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India

December 2021 Kolkata

27th January 2022 by newtjoh

This post mixes personal asides and commentary on Indian national and local issues prevailing during a December 2021 visit to the family home of my wife in Kolkata, India.

It is usually an annual event but did not occur last year due to Covid travel bans; my wife, however, did manage to come to the IJK in the summer but had to quarantine in a hotel close to Heathrow.

The autumn relaxation of restrictions lulled me into a false sense of security so when I heard that after a long hiatus India was again granting travel visas, I quickly purchased an Air India ticket consistent with a two month stay, at a bargain price.

What I did not factor-in was that the quick and painless electronic ‘E’ visa, which during my last 2019 visit could even be obtained on arrival without fuss, had not been reinstated.  I had to revert instead to an earlier process: first make a registered on-line application and then an appointment at one of the out-sourced Visa Application Centres located in Islington and Hounslow.

To my horror, the earliest available date for such an interview was weeks away beyond the booked date of my flight departure! Following intensive efforts to get an emergency visa direct from the Indian High Commission, it sent an e-mail that offered me an appointment slot at Hounslow (located in back streets close to the soon-to-be redeveloped historic Hounslow Calvary Barracks) the day before my planned departure.

A false hope. The counter clerk soon disabused me: after collecting the fee he flatly stated that my visa would be ready in four working days and then valid only for travel for 30 days post-entry, not the usual six months.

If I had known that I would have rearranged my outward flight earlier. The resulting late notice counted as a no-show that with the required change in flight dates set me back not far short of £2,000 – more than thrice the cost of my original ticket.

Very frustrating and not the best of starts. I consoled myself that at least I was fortunate that a period of paid employment during the Covid period had allowed me to accumulate savings; and that I only had to bear the costs of changed itinerary for myself only, rather than for a larger family that some of my fellow on-the-day visa-seekers at Hounslow now faced (mainly UK passport holders of Indian origin): swings and roundabouts and all that.

In case you are wandering, this long personal preamble provides an entry into the serious business of politics. The new tight visa regime was limited to UK and Canadian nationals, who consequently took the collateral damage for an apparent tit-for-tat governmental visa dispute.

Ironically later that month it emerged that the latest Foreign Secretary, Liz Truss, the Thatcherite-mantle-bearing wannabe successor to Boris Johnson, wanted to pursue a trade deal with India that involved the easing of visa restrictions on Indians wishing to study and work in the UK with the return expectation that India would ease restrictions on inward British trade and investment into its growing service sectors, such as IT.

I allowed myself a slight sardonic chuckle remembering the not-too-distant times when the Conservatives presented themselves as the party that explicitly favoured white ‘kith and kin’ immigration. A positive but probably unintended post-Brexit consequence that could make easier ‘brown’ immigration from the sub-continent central to the government’s Global Britain mantra. One to track.

Finally arriving in Kolkata early in December, as we travelled along the Airport Road, passing a cheesy replica of Big Ben before hitting the ‘expressway flyovers’ that now traverse the east and south-central parts of the city, its usual cacophony and bustle enveloped the car. Shuttered restaurants and internet cafes suggested that its recovery from India’s previous Covid waves remained uncomplete, however. To see the impact of the first Indian lockdown starting March 24, 2020 on Kolkata view this video.

That said, at the national level, India’s main stock exchange indices continued to spurt in step with a recovery in GDP that is forecast to reach nine per cent for 2021-22, following a seven per cent Covid-related decrease the preceding year.

Such figures at the national level, of course, do not necessarily replicate at the regional or grass-roots level. Incomplete detailed official statistics limits evidence-based interpretation but most commentators believe Indian post-1991 reform development model has skewed GDP gain to benefit of the middle-class and rich with the poor rural and insecure urban wage worker majority benefiting very much less, save for, to my eyes at least, widespread mobile phone usage.

Covid can only have compounded distributional inequality. I was left to wander how workers, such as the neighbourhood cycle rickshaw men, managed to maintain themselves and their families during close to two years of lockdown or muted demand. Apparently local Temples provided some support. I don’t know whether the official cash transfer scheme introduced in March 2020 following the country’s first lockdown percolated to them and their families and for how long along with the overall effectiveness of that and successor schemes.

I received my booster jab the week before my arrival, instilling confidence that I could avoid testing positive preventing my departure from India within my 30-day visa validity, which would be a problematic and expensive eventuality to say the least.

The emerging threat of Omicron provided a growing backdrop throughout my visit. I had not only missed the December exponential explosion in London case-numbers but had arrived in India just in time as inward flights from the UK were banned before the month ended.

On Christmas Eve, we visited Park Street – Kolkata’s West End – enjoying the tremendous festive street decorations, more impressive than in London pre-Covid. The crowds were stupendous, mostly well controlled by a high-visibility police presence enforcing a one-way pedestrian flow with mask-wearing exhortations generally heeded.

But as new recorded Omicron cases ticked up, then began to double in days, many of the large New Year club celebrations were cancelled for yet another year, but this time at the last moment. Even the New year firecrackers seemed more subdued compared to pre-Covid years.

A primary set of themes tend to dominate each annual visit, whether it is demonetisation, mass electronic ID roll out, pollution control, health policy reform, or employment reservation issues.

This time the concerted efforts of the second Modi government, viewed through a Kolkata lens, to impose Hindutva populist cultural nationalism in ideological and policy terms even at the expense of constitutional and democratic norms and values as well as development outcomes was centre stage.

In December the 50-year anniversary of the creation of Bangladesh (loosely translated as the country of the Bengalis) independence passed.

As way of historical background, Bengal and Calcutta was the centre of British colonial power from the late eighteenth century, when Warren Hastings, the first Governor-General with a pan-India remit presided in Calcutta, until 2012 when Delhi replaced it as the imperial Indian capital.

The associated rise and growing self-confidence of a Bengali intelligentsia during the nineteenth century made the colonial city the epicentre of Indian engagement with that same power and later constitutional Indian opposition to it and was where in the early twentieth century organised revolutionary terrorism first reared its head in earnest.

An imperialist viceroy, Lord Curzon, at the apogee of empire in 1904 announced a classic colonial divide-and-rule device to spike such indigenous nationalist  opposition. He split Bengal into separate western and eastern administrative entities. The west in population mainly Hindu, including Calcutta; and the east mainly Moslem, notwithstanding that it included Assam, with the historic Mughal city of Dacca (Dhaka) as its capital.

The idea was that the poorer Muslims, freed from the fear of electoral domination within the existing undivided province and its limited property-based franchise, by the in-built Hindu majority  would ally themselves with the British.

But the change provoked furious Bengali agitation that soon resulted in its reversal, announced no less by the new King George V in his 1911 Coronation Durbar, in tandem with the transfer of the imperial capital from Calcutta to Delhi.

Apart from this giving back to Bengal and Calcutta on one hand and taking away on the other, Britain maintained divide-and-rule by the establishment and entrenchment of separate electorates for Muslims that guaranteed them a minimum number of seats.

The device of separate electorates served to drive a wedge over time between the India National Congress, that since its birth in 1885 had evolved into the paramount national independence party, and the Muslim League (ML) and other parties focused on the Muslim communal electorate and its economic and social concerns.

As independence began to beckon, a brilliant London-educated lawyer, Muhammad Ali Jinnah, revived and mobilised the ML into a mass communal-based political party dedicated to the principle that the Muslims of India to protect their identity and future needed to secure a separate independent nation for themselves, free of Hindu domination: Pakistan – in effect a nation defined by religion.

The Second World War provided conditions opportune for its propagation. Congress leaders were put in prison, as Britain focused on the war effort. In 1943 over a million of the Bengali rural poor were starved by a famine caused by structural inequality and official mismanagement and negligence rather than the shortage of food, per se – what the Bengali economist Nobel Prize winner, Amartya Sen, summarised as lack of entitlements of exercisable claims to available food.

The wider uncertainty that reigned as to the what the precise political future for India held other than ultimate divestiture of colonial power fuelled growing mistrust and latent fear between the two communities. It increasingly led to communally motivated riots and acts of violence, whether precipitated by a small-scale row or brawl that escalated, religious music or processions that antagonised one or other of the communities, or simply a wish by local wannabe gangsters to loot or to take advantage of disorder. Bengal and Kolkata in the 1940’s doesn’t seem that dissimilar to Ulster and Belfast in the 1970’s.

In August 1946 this culminated into mass communal riots and organised killings that resulted in the slaying of many thousands, often by the hatchet and club, known as the ‘Great Calcutta Killing’ that stopped only at the behest of Mahatma Gandhi threatening to fast to death, if it didn’t.

A Calcutta University historian, Suranjan Das, back in 1990 differentiated it in scale and character from earlier communal riots, thus: “It was more organised, more directly concerned with institutional politics (the establishment of ML government in Bengal; the growth of Hindu revivalist organisations linked to Congress; the impact of propaganda for and against Pakistan) and hence in the prevailing climate more exclusionary related to communal politics …. and identities rather than cross-communal leftist and nationalist consciousness”.

Job, well done, Curzon!

The following year British India, amid deadly communal strife and massive population movement, was partitioned into two separate independent and sovereign nations, India and Pakistan: ‘freedom at midnight’ for most; communal-based death and destruction for the multitude victims of the ‘ethnic-cleansing’ of mixed Muslim and Hindu communities either side of the new border drawn through Punjab in the west and Bengal in the east.

Although the Muslim population, representing around a fifth of the total erstwhile undivided Indian population, was concentrated in those two provinces, it was also dispersed throughout the continent (communities often included descendants of the administrators of the Mughals).

Muslims, according to the 2011 Census, still account for over 14% of the total Indian population, by far the largest religious minority to the 80% majority of the population reported as Hindu. Christians the next largest but only accounted for 2.3%, followed by Sikhs, 1.7%.

Pakistan was bifurcated into West and East Pakistan, separated by over a thousand miles of continental India.

East Pakistan was the successor to Curzon’s east Bengal. Bengali Muslims comprised the majority population, which also included poor Muslim migrants from east India, predominately Bihar, who spoke Urdu rather than Bengali, while a Hindu landowning and commercial Hindu minority that remained accounted for around 10% of its total population at its 1947 inception. West Bengal became the Indian state of West Bengal.

The power and resources of Pakistan was concentrated in West Pakistan. The Punjab and Punjabis were hegemonic in the government and the military. They treated the Bengalis of East Pakistan more as colonial subjects than equal citizens; effeminate inferiors to the martial Punjabis; clerks rather than warriors.

Bengali nationalist discontent grew in response. It flared to a head when the Awami League (AL) – created in 1949 as a Bengali nationalist party – in the 1970 national election won 167 of the 169 East Pakistan seats. To avoid the AL exercising its majority in the national assembly, the West Pakistan-resident Pakistan President declared martial law.

A bloody guerrilla war involving atrocities on both sides broke out in March 1971 – a war that India under Indira Gandhi soon joined for its own strategic security reasons. It ended nine months later with the marooning and surrender of the Pakistani army and the establishment of the independent state of Bangladesh, jettisoning East Pakistan into the dustbin of history. Their Bihari local allies, became stateless, confined to squalid refugee camps.

Up to ten million Hindus over the next two decades also sought refuge in India including in squatter settlements around Kolkata and its surrounding rural hinterland. Other households encroached on vacant plots before going on to establishing themselves in emerging suburbs, such as Tollygunge, Chetla, and New Alipore, and across former rural areas absorbed progressively into the Kolkata metropolitan area.

Bangladesh itself was over-populated and confined in part to the Ganges delta prone to both cyclones and flooding, which could and did wipe out its means of agricultural subsistence. Shorn of industry, trade, and resources by previous British and Pakistani overlordship, it lacked an economic base to support its rapidly rising population, threatening a twentieth century Malthusian outcome that Europe the previous century had escaped through industrialisation and urbanisation.

It was a state born in blood with dismal prospects of nemesis rather than peace and prosperity. Certainly, the newly born Bangladesh was one, if not the, poorest country of the world and almost immediately became synonymous with floods and famines, making Henry Kissinger’s epithet ‘basket-case’ appear apt at the time given the new country’s dependence on external official and charitable aid. A memory of my early teenage years were newscasts of famine relief efforts that underscored homilies about not wasting food.

Yet the country survived, stabilised, and even began to prosper, despite periods of political turbulence and intolerance not prevented by weak democratic institutions that remain fragile.

A key landmark was the strategic decision taken in the eighties to develop a comparative advantage in cheap manufactured clothing to provide the primary route to export-led industrialisation. The industry has provided employment to up to four million workers, with the female proportion estimated to be as much 80%, foreign exchange, as well an impetus to invest and innovate, although concerns about child working and other working condition abuses persist. In parallel an indigenous Grameen micro-finance initiative and other social welfare advances provided springboards for a steady improvement in social welfare indicators.

Remarkably, given its inauspicious start, the World Bank  in April 2021 reported that despite its per capita GDP ranking tenth lowest in the world in 1971, Bangladesh had reached lower-middle-income status in 2015, and is expected to graduate from the UN’s Least Developed Countries (LDC) list in 2026. Poverty declined from 43.5 percent in 1991 to 14.3 percent in 2016 based on the international poverty line of $1.90 a day (using 2011 Purchasing Power Parity exchange rate).

Looking forward, according to the Asian Development Bank, expected per capita GDP growth for Bangladesh is 5.5% in 2021 and 5.8% in 2022. It is now higher than India’s according to some commentators who make the case that its growth is broader-based and comes attached with better human development outcomes, vindicating its ‘bottom-up’ development trajectory. That said, the above statistics should be considered with caution given problems of collection, definition, and interpretation. Political and climate change risks remain.  Its economy could become over-dependent on the garment sector.

Undoubtedly there was much for Bengalis to celebrate, and even more to ponder, on its fiftieth anniversary, not only in Dhaka but in Kolkata, a city, as we have seen, so scarred by the 1947 partition that in one stroke rent asunder its natural geographical and economic hinterland causing it to swell with refugees during the ensuing years – an experience repeated in 1971.

Calcutta – as it was then still known – itself had become a synonym for ‘third world’ poverty, squalor, and hopelessness, political violence, a period vividly captured in Geoffrey Moorhouse’s book of that name and period.

Such depictions were and remain resented locally, however; in fact, considerable progress in bustee slum improvement programmes began and have continued, even though the number of huts without a concrete roof during the post war period increased in both absolute and proportionate terms to approach 50% in 1981 – the product of not just of uncontrollable refugee and rural migration, but natural population increase.

Today the typical Kolkata home seems to be a flat in the high rises that increasingly dominates the cityscape. My walks around the local suburbs of New Alipore and Behala, at least, indicate ‘slums’ – as its middle-class term – although often hidden down an alleyway do appear integrated into its neighbourhood and provided with facilities consistent with permanence and the seeking and maintenance of employment and participation in society. Informal settlements without such facilities, along railway lines and without watercourses and close to concentrations of low paid informal employment remain, however.

Securing a true evidence-based up-to-date picture requires hard investigation into hard data from available sources. A possible task for the future.

That Dhaka, the capital of Bangladesh, is less than 160 miles (as the crow flies: less than the distance between London and Manchester) away from Kolkata; the close linguistic and commercial ties between the cities; the legacy of the pivotal involvement of the Indian army in the freedom struggle to create the country; and that the AL – historically sympathetic to its Indian neighbour – has been in increasingly-entrenched power for nearly a decade – all might suggest that ruminations of Bengali (Bangla)-based affinity should accompany Bangladeshi’s fiftieth birthday, encouraging some resurrection of discussion on regional economic and social co-operation, at the very least.

Yet the anniversary passed with muted local notice. Why?

Cultural and class affinities tend to trump any shared ethnic and linguistic identities. Kolkata Bengalis predominantly are Hindu upper caste and middle-class; Bengali-speaking Bangladeshis are mostly Muslim (historically some were lower caste converts to the faith) and working-class.

The long and insecure land border between India and Bangladesh has encouraged focus on illegal cross-border immigration rather than closer economic integration, especially in Assam and neighbouring states, whose indigenous communities frequently react to the economic and cultural threat of Bengali Muslim migration by agitations that sometimes turn deadly violent.

Despite the linear closeness of the Kolkata and Dhaka, such political, as well as geographical – the indented and heavily forested Gangetic delta (the Sunderbans) – factors have mitigated against the development of direct fast rail, road, or ferry links between them, making flying more convenient for travellers that can afford that mode. And, in any case, few Kolkata Hindu households have family left in Bangladesh, their grandparents abandoning ancestral pre-partition lands and houses, as did my wife’s family.

More recently, Narendra Modi’s re-election as Indian Prime Minister in 2019 marked a sharp shift towards Hindutva-based nationalism of an increasingly communal colour, making the national political environment of December 2021 hardly conducive to pan-border or Greater Bengal economic integration and co-operation: something that surely should increase the GDP of both West Bengal and Bangladesh.

Modi’s government ended the special status of the State of Jammu and Kashmir (up to then, India’s only Muslim-majority state) split it into two Union government-administered territories as an obvious ploy to reduce the prospect of potential future Muslim political influence: Curzon revisited.

The Citizenship (Amendment) Act 2019 was enacted, providing  a path to Indian citizenship for  Christian, Sikh, Buddhist, Parsi, and Jain  migrants  that migrated after suffering  persecution in  Pakistan, Bangladesh, and Afghanistan before December 2014, but technically came as illegal immigrants. Such eligibility, however, was denied for Muslim illegal migrants from those countries, making for the first time an individual’s religion an overt criterion for citizenship under Indian law.

During December Modi’s government even revoked the foreign exchange licence of the late Mother Theresa’s world-renowned Kolkata-based ‘Missionary of Mercy’ charity, apparently taking account of accusations that it encouraged poor Hindu recipients of its help to convert to Christianity, blocking it from receiving funds from abroad.

This was in tune with a tide of rising intolerance towards Christians in India, where churches and priests have been subject to physical attacks by local Hindu mobs for allegedly encouraging conversions to Christianity, when in most cases they appear simply to have been practising quietly their own religion.

Even more concerning were frequent reports of Hindu extremist groups spreading inflammatory anti-Muslim propaganda. Even when these went as far as exhortations to kill Muslims, the silence from government suggested silent acquiescence by the ruling Bharatiya Janata Party’s (BJP) top brass to their use at the very least as a dog-whistling tactic to browbeat the main minority.

It recalls Modi’s pronouncement when Chief Minister (CM) of the western state of Gujarat in 2002 in the wake of a firebombing by a Muslim mob of a train causing the death of around 70 Hindu pilgrims at Godra that the “people need to vent their anger”. Hindu mobs massacred 2,000 Muslims in the riots that followed.

The BJP had burst into political prominence three decades back through focused and concerted campaigns to exploit a nascent majoritarian reaction against the purported – but often fake or self-interested – socialist secularism of the Congress Party, the post-independent hegemonic political force, dominated by the family descendants of its first Prime Minister, Jawaharlal Nehru (Harrow and Cambridge), with its associated regional power brokers.

Nehru’s daughter, Indira Gandhi (she married Feroze Gandhi (LSE) – no relative to Mahatma Gandhi), was the prime minister that ordered the Indian intervention instrumental in the creation of Bangladesh. Despite the hiatus of the ‘Emergency’ that she instigated later in that decade and its political fallout, she remained India’s dominant political figure until her assassination by a Sikh bodyguard in 1984.

Her own son, Rajiv Gandhi, Cambridge-graduate and former airline pilot, inherited the her mantle and won the election that followed on a sea of sympathetic outpouring for his mother, but after five uneven and difficult years in power lost the 1989 general election.

In 1991 he also, tragically, suffered assassination, this time by a female Tamil Tiger suicide bomber. Soon afterwards Congress re-assumed power with the multi-lingual South Indian Narasimha Rao as Prime Minister, who appointed Cambridge economist Manmohan Singh as his finance minister.

His government was a key watershed one in the trajectory of post war Indian economic history but it managed less creatively and resolutely the Ayodhya controversy.

It was there in the sixteenth century that the conquering Mughal emperor, Babur, had demolished a centuries-old temple to build an eponymous mosque on the same site. Hindu activists/pilgrims now camped in the town agitating for that Babri Mosque (Masjid) to be demolished and for the temple that it had replaced – purported by them to be the birthplace of Rama – to be re-built. In 1992 they succeeded in demolishing the mosque during a disorder that claimed more than 2,000 lives.

The Yatra Chariot marches that BJP leaders orchestrated and led across India in 1990 proved a key turning point in the demise of Congress as the national hegemonic political power: the BJP leadership saw and took the opportunity to harness its potential to symbolise the side lining of Hindu religious-cultural-nationalist sentiment by the Congress and the political establishment/elite.

When Congress was reduced to a seat tally of 140 out of 543 in the 1996 general election, Rao soon resigned as party leader.  An unstable period of coalition government followed but a conclusive 1999 general election then allowed Atal Bihari Vajpayee, leader of the BJP, to serve a full five year term as prime minister within a National Government Alliance (NGA) coalition.

Meanwhile Congress power brokers had asked Rajiv’s widow, the Italian-born Sonia Gandhi, to become Congress president in the hope that the Gandhi name would help to rally electoral support. After a tricky start she soon learnt to navigate the Indian political jungle, in spite of her gender and foreign origin, asserting herself over the Congress power brokers, as had her mother-in-law two decades before.

She pulled the Congress strings at state and national level as its president during the period of opposition to the  NGA government and then the technocratic edifice of Manmohan Singh’s premiership of a Congress-led coalition that was in power from 2004 until Modi’s 2014 first general election victory, when Congress was reduced to a rump of 44 Lok Sabha seats.

Her son, Rahul Gandhi (Cambridge) was elected to the Indian parliament (Lok Sabha) in 2004 for the family seat of Amethi, progressed through Congress, elected its president in 2017, but resigned in 2019 in the wake of that year’s general election defeat when he lost his Amethi seat.

He continues to make public speeches and to campaign for Congress as does his sister, Priyanka Gandhi. Either could re-emerge as Congress leaders with their mother back as Congress president.

Modi in 2021 seized the opportunity of the inauguration of  the Kashi Vishwanath Mandir (Kashi Temple) corridor project in Varanasi to re-spin the BJP Ayodhya narrative that the Muslim Mughals were alien invaders whose actions and institutions were inimical to time immemorial Hindu culture and society.

Another Mughal Emperor, Aurangzeb, this time had had in the holy city of Varanasi (Benares) demolished a historic temple and replaced it with a mosque, leaving remnants of the previous temple in situ.  Its reconstruction on a nearby site with a clear vista to the Ganges opened-up through the removal of an intervening warren of lanes and alleys, was described by Modi on 13 December thus:  “ the long period of slavery (that) broke our self-confidence in such a way that we lost faith in our own creation”, going on to present the Kashi Temple corridor as both a tangible and symbolic manifestation of India modernising in step with its Hindu cultural heritage: “Today from this 1,000 year old Kashi I call upon every countryman – create with full confidence, innovate….”. Put another way, India’s development must sit within a Hindutva cultural superstructure.

Modi’s second term has shifted away from development towards an ideologically led project to underscore that India and Hinduism is culturally and politically indivisible. The logical adjunct to that is the political neutering of India’s Muslim population and their portrayal as a product of an invasion that was not only military, administrative, but also culturally, alien.  Modi advances that project using the tools of majoritarian political populism

In that light,  Alastair Campbell, Tony Blair’s former spin-doctor, in his Review of 2021 for Tortoise Media posited that a populist demagogic political leader can be recognised by these characteristics:  propaganda is more important than policy;  simple untruths beat complex realities;  you must demand loyalty of others, but not give it yourself;  stirring up division is vital, and good; build slavish media backing and sectarian support; develop a unique way of speaking, rich in imagery and the exploitation of emotions and symbols; rewrite national history; say unsayables; use baseless claims and insults; ignore conventions; weaken Cabinet, Parliament and bodies that threaten ‘the will of the people’, as you define it; never admit you’re wrong; never accept your opponents are right; and, finally, always blame others if things go wrong.

Campbell, drawing-on Populismus für Anfänger (Populism for Beginners) authored by two Austrians, economist Walter Ötsch and journalist Nina Horsczek, concluded that Donald Trump and Boris Johnson “ticked-all the (populist) boxes”. Well, the glove fits well also on Narendra Modi, first elected as India’s Prime Minister in 2014, as it does on Turkey’s Recep Tayyip Erdoğan, in power since 2003, or on Brazil’s, Jair Bolsonaro, who said last August that he sees only three possibilities for his future: “death, prison or winning the 2022 presidential elections”.

All have doubled-down on authoritarianism, chiselling-away at the weakening foundations (or their barest semblance in the case of Vladimir Putin of Russia) of their respective nation’s increasingly fragile democratic institutions, when they can or must to keep in power.

However, compared to Trump or, less starkly, to Johnson, the charge of sado-populism – implementing policies contrary to the material interests of their own electoral popular base – fits less comfortably, however, on the Indian premier.

To retain power, the BJP, depending on and varying with the regional and local political context, must assemble and maintain lower caste and Dajit (‘untouchable’) vote-banks, underpinned by the promise and delivery of jobs, security, and development to their members.

To that extent, development must accompany the practice of Hindutva as otherwise a split vote in the Hindu wider community – defined by socio-economic and historical cultural characteristics than by religious observance, could allow the Muslim vote to assume potential electoral importance: anathema to Modi and his cohorts.

What is most worrying and potentially tragic on a world-scale, is that India with its huge and rising 1.4bn population, its sustained success in escaping colonialism to become the world’s largest democracy, its emergence as an economic global colossus despite its diversity, rising population and continuing mass poverty, has fallen to the populist bug – regressing towards discriminatory communal-based narrow nationalism, leaving its main minorities, at best, marginalised and insecure, and at worst, in physical danger, contrary to the Indian constitution as constituted in 1947 which, however, included ‘paper’ rights such as universal access to health care.

Modi and his closely-knit inner circle (Amit Shah, currently Union Home minister, and Jagat Prakash Nadda, BJP president) during 2021 certainly shunned India’s parliament as they endeavoured to cow its democratic institutions as much as they could. They, however, met humps going down that road.

His government’s dilatory and negligent preparation and response to the Covid second wave that hit India during the spring and early summer of 2021 overwhelmed its health services, shortages of oxygen, mass burial, and even the dumping of bodies in streets, causing the government to lose its sheen of competence.

Concerted and high-profile demonstrations by Indian farmers, infuriated by the lack of consultation and preparation that preceded and accompanied hastily enacted and implemented agricultural reforms, forced their abandonment and repeal less than a year after their enactment. The BJP also lost the West Bengal state assembly elections badly.

These reverses may partly explain Modi’s doubling-down on Hindutva cultural nationalism in the approach to the 2022 state assembly elections. The most populous state, Uttar Pradesh (UP), the Hindi heartland home to more than 200m people, whose current CM is even more of a Hindu militant than Modi, as well Punjab, Goa, and Uttarakhand states will go to the polls this year.

Enter Mamata Banerjee, the CM of West Bengal since 2011. Her portrait blandishes every party and official poster with any exceptions tending to prove the rule, making unmissable her face, endorsements, and homilies wherever you travel in Kolkata.

Her back story illustrates the capriciousness and factionalism of Indian politics. She first came to national prominence as a firebrand young radical in the Congress Party, initially locally and then nationally. Following her election to India’s parliament in 1984, her political career progressed to the point that she held twice the Union government Railways Minister and other key second rank cabinet posts, displaying a dissident streak driven sometimes by policy issues but often by factional personality/power clashes that both induced and accompanied the fragmentation of Congress into national and regional coalitions.

By the nineties Congress was mostly a spent force in Kolkata and West Bengal. She accused it of becoming stooge of the Communist Party of India (Marxist), which, following an unstable period in coalition with Congress had won control of the West Bengal state government in 1977. Through rural land reform and development, trade union links and tightly knit party organisation, it consolidated its electoral reach and hold to the point that it retained control over the West Bengal state government for over 30 years.

Led by the legendary communist, Jyoti Basu, for most of them, as time went on the growing corruption and hubris of the CPI(M) administration opened-up potential space for a well organised opposition to become sufficiently electorally popular and strong enough to withstand and then overcome the powers of patronage and intimidation that ruling parties in India tend to enjoy and employ.

Mamata (as she is known locally) filled it by creating a new party: the Trinamul (meaning: springing from the grassroots) Congress (TM). It focused on addressing state-wide and local issues at such a grassroots level. Spearheading and galvanising opposition to confiscations of rural land that the CPI (M) was instigating to attract international industrial investments into designated Special Economic Zones, proved a vote winner, putting her back into national prominence.

Like her CPI(M) and Congress CM predecessors she is Bengali upper caste. Jyoti Basu spent five years in London as a student in the thirties before qualifying as a barrister, while his son accumulated a business fortune, allegedly helped along the way by the state government.

Following-on from its state assembly poll victory that halted Modi’s electoral juggernaut, the TC won a landslide of seats in the 2021 December Kolkata Corporation elections. Although fiery loudspeaker speeches and processions of a “we will vanquish our enemies” slant and tone interrupted the peace of a couple of evenings, the polling was surprisingly peaceful on the day.

Canvassing and polling booth practice, indeed, proved a near replica of UK election practice and ambience – at least it was where my wife’s family voted, save that the polling station record for the family address included a photograph of an unknown male, leaving some potential scope for voter substitution malfeasance.

That peace quite possibly, or even probably was deceptive, unfortunately, simply reflecting that the TC confident of victory instructed its workers not to conduct any unnecessary electoral infractions or acts that could consequently provoke complaints potentially queering its victory glow. Things can turn out differently during close contests when the stakes are higher.

Yet Indian democracy tends to work, not because it is pristine in process, but because at the political macro level it provides a mechanism for the registration of an overall popular verdict that in response to gross governmental hubris and abuse of authority can presage a legitimate and accepted change-over in power. It also has proved over time a relatively effective channel to balance, sublimate or accommodate the different grievances and aspirations of the manifold ethnic, linguistic, and caste groups that India comprises. Even the bribery and patronage received and deployed by candidates at the micro level can serve to increase their responsiveness to local concerns and priorities.

Modi’s crusade against religious minorities in general and Muslim communities in particular risks removing that safety valve, creating discord to the point that it could make the pre-partition assertion that the founder of Pakistan, Mohammad Ali Jinnah, that Hindu and Moslems cannot live as equal citizens in India, a self-fulfilling prophecy, 75 years after partition.

Perspective, however, is called-for. Indian democracy has suffered even more stark, immediate, and deadly attacks, yet survived. Indira Gandhi’s Emergency during the seventies invoked the cessation of democratic institutions and norms and even countenanced mass forced sterilisation programmes. Her assassination set in train massacres of Sikhs in Delhi, at worst with official Congress sanction and at best with indifference. New Delhi’s treatment of Kashmiri Muslims has long blighted India’s human rights record. Communal strife stoked by continuing illegal migration is a long-term problem in Assam and neighbouring states. Closer to home in Britain our treatment of minorities and migrants often have and remains less than sublime under far more relaxed socio-economic conditions, while, of course, the populist Boris Johnson from the beginning of his premiership unashamedly upended or disregarded constitutional and parliamentary conventions.

Economically, Congress during the post-war period with its ‘licence raj’ prior to the liberalisation reforms of the nineties, generated an anaemic – nicknamed the ‘Hindu’ – rate of growth that between 1950 and 1990 averaged less than 4 per cent per annum, lower than that most of its less developed country comparators achieved during that era.

Although that rate did begin to fitfully accelerate in the eighties when concurrently across poor countries in Africa it stagnated or even declined, India’s growth during the worst years of economic under-performance barely kept pace with population increase and consequently contributed to swelling ranks of the Indian poor.

The social programmes and anti-caste pronouncements of Congress often were also more rooted in rhetoric than substance, serving to disguise the continuing dominance of the upper castes and the economically advantaged across society and their growing share of national income.

The advent of Modi, born into an economically backward caste, who served tea (chai) at the local railway station in comparison to the elite private and university education enjoyed by the members of the Nehru-Gandhi political dynasty, represented in that sense a potentially egalitarian refreshing break or even liberation from the feudal-like paternalism of Congress.

National tax and sales tax harmonisation, grassroots sanitation and social protection programmes increasingly based on the digital Aadhaar Card, conducive to the targeting of direct cash transfers, and the rolling-out of extended publicly-supported health insurance, were all steps in the right direction, as was discussed  here. The tension between his pursuit of Hindutva and broad-based development aims seemed to tilt towards the latter during his first term.

Development momentum has been retarded or swamped by the hard Hindutva focus of his successful second term campaign and subsequent record in office, however.

Modi and his close cohorts need to re-orient back to a development focus and away from using Serbian-type recourse to centuries-old historical events as a populist backstop to promote their Hinduvta cultural-nationalism agenda.

Yet, their united and closed mindset, forged by decades of committed apparatchik activity in sometimes secretive and legally proscribed extremist communal organisations, and their probable equation of their populist political methodology with continuing electoral success, appears increasingly to make that a forlorn and optimistic hope.

The future of Indian democracy requires a united opposition imbued with refreshed ideals fused with pragmatic inclusive goals that can effectively engage with the toiling Indian masses, holding the Modi’s BJP to effective real account.  A tough call given the tendency of oppositions in India to fragment into factions. Mamata Banerjee, for instance, would need to join hands with the Congress leadership and regional leaders from other parties.

Rahul Gandhi in December made a stab in differentiating a tolerant and inclusive Hinduism from Hinduvta in December, but in his usual partial and dilettante way.

The development and systematisation of an compelling alternative narrative to Mod’s hard Hinduvta, focused on the inclusive upliftment of the poor majority, regardless of caste and religion, capable of popular translation by a broad range of coalition partners, awaits.

Hopefully, necessity forges progress in 2022.

 

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Filed Under: India Tagged With: Kolkata, Modi

Indian Budget 2018: development watershed or politics as usual?

26th March 2018 by newtjoh

In 2014, the Bharatiya Janata Party (BJP) became India’s governing party after winning an absolute majority of the seats in lower house of the Indian parliament, the Lok Sabha. Its nationalistic religious socio-cultural based (Hindutva) electoral platform has always been controversial. Its leader, Narendra Modi,  was prevented entry to the US  after his alleged complicity in the 2002 killing of 2,000 Muslims during communal riots. But, as Union prime minister, he has eagerly availed himself of opportunities to bestride the world stage, basking in his international superstar, rather than his past pariah, standing. In January 2018, for instance he addressed the annual economic gathering in Davos, Switzerland where he enjoyed the company of the western financial and political elite. He  began his life’s journey as a lower middle-class tea seller, then deserted his wife to become a monk, before working his way up the party apparatus by dint of sheer single-minded focus and ability to become chief minister in his home state of Gujarat, one of India’s most economically advanced states.

Indeed the BJP’s overarching Hinduvta platform is sometimes tempered,  more often  paralleled, by its development one.  In the Budget that the Union Finance Minister, Arun Jaitley, presented to the  Lok Sabha on the 1st February 2018, the latter development driver tended to  overshadow Hindutva, although as  it will be the last one covering a full year before the next Union election takes place in May 2019, preceded by a number of State Assembly elections, the electoral dimension also loomed large.  And, BJP  deployment of Hindutva still continued, with, for instance, the Union Home Minister waving off yet another BJP-promoted religious march or ‘Rath Yatra’ later in the same month: this time to collect water and soil from all four ‘holy’ corners of the nation.

The BJP’s 2014 platform included pushing up India’s real GDP growth performance back again to beyond  the 8% per annum achieved between 2003-11, when the  post-1992 liberalisation of the licence-quota-control Raj really began to bear fruit.  During earlier decades this had evolved into economic calling card of the hegemonic post-independence dynastic, but ostensibly secular and socialistic, Congress Party. But by  the eighties, the party began slowly to embrace market reform, responding to annual growth rates that in the 60’s and 70’s were sometimes barely above the rate of population increase. The watershed was the 1991 crisis, when India nearly ran out of foreign exchange, after which reform became a driving force, with both the BJP and Congress, as well as other parties aspiring to political power, competing to become holder of the development mantle.   Congress  remains the BJP’s main electoral rival under the fresh leadership of Rahul Gandhi, son and grandson of  former prime ministers, Rajiv and Indira Gandhi, respectively, and the great-grandson of Nehru, India’s first and renowned post-independence leader.

In practice, post-2014  economic performance under BJP stewardship has continued to be relatively sluggish. 6.5% growth was registered in 2016-17, amidst fears that the delayed result of the November 2016 demonetisation measure could continue to hinder growth into 2017-18. Investment levels remain stuck at levels below the near 35-40% of GDP that were recorded pre-Global Financial Crash (GFC).

Job creation  and rural incomes, especially in the rural areas, have also stagnated under the BJP watch. This has led some rural caste groups wielding vote banks significant at the local and state levels, such as the Patidars (one who owns a strip of land) in Modi’s home state, becoming politically unsettled, see, https://economictimes.indiatimes.com/news/politics-and-nation/the-day-of-the-patidars-why-their-votes-matter-in-gujarat-election/articleshow/61994403.cms. 

Against that backdrop, Jaitley’s budget measures were focused across three main inter-related areas, in agricultural and rural development, in extending access to universal healthcare, and in improving infrastructure.

Agriculture and rural development
Two thirds of the 1.3 billion Indian population still live in villages or rural areas, despite urbanisation proceeding steadily  and the urban population rising to 380 million.

Agriculture remains India’s largest economic sector in terms of the number of people who rely on it for income and employment,  in contrast to value-added. Most villagers still eke out a precarious and uncertain living from agriculture or related occupations. 50% of crops grown remain rain-based: a failed summer monsoon can mean no crops to sell; while a good one can lead to over-supply, which then pushes down prices and incomes. Rural incomes therefore are still highly dependent on the climate or ‘the gods’, and, unsurprisingly have lagged post-reform urban incomes.  in the early post-1991 reform period to the mid-2000’s rural incomes stagnated, as they done since 2014.  Such cold reality provides the sobering backdrop to the BJP’s promise to double rural incomes by 2022 from their 2017 level, while increasing rural employment.

It provides the political context to Jaitley’s budget announcement to increase the minimum price support (MSP) for Kharif crops (those largely sown in the summer monsoon, such as rice) to a level of 150% of their production cost, mirroring the support levels already prevailing on other Rani crops. He also unveiled measures to support the development of employment-generating food processing industries, the further rolling-out of institutional credit and marketing infrastructure, and of the lifting of restrictions on agricultural exports.

In addition, his  budget included a commitment to build one crore (10m) new homes, under the banner of “a home for all ‘poor and homeless’ households”, along with an additional 4 crore electricity connections. And, in a country where only c30% of the rural population is estimated to have access to an in-situ toilet,  an additional 20m toilet connections were also announced.

These proposed measures reflect the electoral significance of rural voters, as well as the lobbying strength of organised farmer lobbies. With respect to the latter, the BJP continues to face pressure from organised farming lobbies to maintain not only price support for agricultural goods, but also untargeted subsidies on inputs, such as on fertiliser, on farm machinery, on irrigation, as well as on electrical power.

On the debit side,  farm price MSP support can  encourage corrupt rent-seeking activity by agents best placed to exploit the system for their own, rather than officially defined, ends. Setting administrative, rather than market-based, prices apart from pushing up food prices and hence inflation, can incentivise farmers to grow supported crops, leading to over-dependence and an ‘eggs in one basket’ exposure that risks future loss of livelihood.

Its distributional impact  is unclear, although it can be expected that the more productive framers cultivating intensively larger landholdings for market distribution will benefit most through higher profits, with some gains trickling down to increased wages. A stated aim of the government is to encourage consolidation and higher productivity agriculture. That, however, implies the exit of more marginal smallholders, the further capitalisation of the agricultural sector,  with the pace of migration of the rural poor to the urban centres, consequently, quickening.

Infrastructure
Although about one-third of India’s population is urban,  two-thirds of gross value-added (GVA) within the economy is urban-based. Construction is India’s second largest economic sector in terms of its contribution to GDP. It also is employment-intensive, employing around 52m people in 2017.

Smart investment in productive infrastructure that improves connectivity by reducing the costs imposed on capital and labour by congested city streets, by inadequate and antiquated railway, road, and aviation links, and by patchy and unreliable digital services, should  help to push-up the growth rate, as is desired by the government.

The official national education aim is to ensure inclusive and quality education for all and to promote life-long learning. In that light education is slated to receive an additional one lakh crore rupees until 2022 with up to 13 lakh new teachers trained with blackboard and digital skills, referenced to a wider aim to extend the duration and improve the quality of education received by the growing number of school-age children. The National Apprenticeship Scheme is also to be expanded .

The Budget also announced higher investment outlays on railway rolling-stock, line-doubling, and wi-fi availability along with expanded aviation capacity in regional and sub-regional hubs, and of broadband access in the rural areas.

Rolling out universal health-care (UHC)
70 years after independence, less than 20% of Indians are covered by health insurance or have access to affordable health care, despite the 1947 Constitution promising universal access to affordable health care. Most households today risk incurring health costs that can be financially catastrophic, with seven per cent of low-income households – around 63m people- pushed into poverty by such costs each year.  Many others, of course, die or suffer life-changing disabilities because of their lack of access to quality health care or because of poor sanitation, in particular within the rural areas. The impact of mortality and morbidity rates, of poor sanitation of inadequate, and of inaccessible primary and secondary health services, and their associated economic costs are unquantifiable, but are likely to be huge.

As way of background, an official report (the Srinath report, https://www.slideshare.net/anupsoans/universal-healthcare-dr-srinath-reddy-report-to-planning-commision ) in 2011 recommended to the previous Congress government that annual public spending on health care should be raised from 1.2% to 2.5% of GDP by 2017, and to 3% in 2022,  in order to eliminate the need for user charges. The report noted that  per capita government spending on health in India (at purchasing power parity:PPP)  at $43 was significantly lower than was the case in Sri Lanka (PPP$87), in China (PPP$155), and in Thailand (PPP$261), as well as across most other low to middle-income countries.

Srinath urged  that the existing national – Rashtriya Swasthya Bima Yojana (RSBY) – and similar state publicly-financed health schemes should be merged and their scope considerably expanded in order to create a viable UHC model in India, funded from general tax revenues,  rather than ‘unsteady streams of contributory health insurance which offer incomplete coverage and restricted services’. Instead all citizens should be guaranteed access to essential primary, secondary and tertiary health care services. This UHC  model, it proposed, should be provided by a mix of public and contracted-in private providers, with 70% of the increased funding devoted to primary care, reversing by 2022 the current mix of public and private funding to one instead two-thirds publicly-financed.

In 2017 total combined public and private spending on health care totaled 4.5% of Indian GDP (well below international averages). Publicly financed health expenditure remained at the particularly low-level of 1.3%. Private spending was more than double that. User-payments for hospitalisation, for drugs and for other medical expenses and  private insurance premiums continue to constitute the main sources of national total health financing, although with central and state governments reimburse insurance funds for costs they incur on eligible publicly-covered insured persons. Only 23% of total government spending on health is actually directed at the provision of public health care facilities.

The main proposal made in the Budget was for 10 crore poor households, or an assumed 50 crore people living in such households (one crore = 10 million, so 10 crore is 100 million, 50 crore is 500 million), to be provided with up to around five lakh rupee  hospitalisation insurance cost cover per household. This compares to  to the three lakh cover currently provided by the main RSBY and its state-level current equivalents. (One lakh is 100,000, so  five lakh is 500,000 rupees: at prevailing rupee-sterling exchange rate (85-90 rupees = £1), the proposed NHPS  will offer each eligible household broadly between 5,500 and 6,000 pounds insurance cover for hospital-related costs).

If, and when, it is implemented, this National Health Protection Scheme (NHPS) – the Ayushman Bharat in Hindi – will become the world’s largest health insurance scheme, administered by a dedicated and new National Health Authority of India. Its second plank is to expand and improve the currently chronically under-resourced public primary health sector. Currently each village should have  a sub-centre provided with one multipurpose health worker covering an average 5,000 people. The next tier is the primary health centre equipped with basic operating, lab, and lest one doctor and other supporting staff, with the community health centres and district hospitals providing in-patient and some specialist  care. However many supposed sub-centres do not exist; while those that do, inevitably, vary in quality and effectiveness. Many villagers have to travel some miles to find a working one. It is proposed that the sub-centres are converted into wellness centres, equipped and resourced to diagnose and treat illnesses, such as diabetes and hypertension, with 150,000 to be rolled out by 2023.

Central and state governments (with a 60% central, 40% state  apportionment) are expected to pay the insurance premiums of the additional 100m households covered by the NHPS, or to otherwise set up an alternative institution or fund to defray claims. As discussed above,  the future actual cost of NHPS premiums, and whether the government will, or can, meet them, remains to be seen. As way of  comparison, premiums charged for a household of five in a private scheme vary on average between 12,000 and 24,000 rupees annually. Assuming a 12,000 rupee annual cost would imply a Rs. 1.2 lakh crore public budgetary cost. This compares to the actual budget of Rs. 2,000  allocated in 2018-19, the initial rolling-out year.

The low distribution costs and economies of scale that large-scale bulk purchasing of insurance cover could potentially offer,  has led some insurers to project that the premiums could fall to Rs 5,000 annually, reducing the public budgetary requirement to 50,000 crore, of which the national share at 60% would be Rs.30,000: that sum is still, however, fifteen times the 2018-19 allocated amount. Government officials project that the premium cost could drop to as low as  Rs 1,000 to 1,200, but that appears very optimistic.  In order to demonstrate commitment to the effective execution and implementation of the NHPS in line with stated aims, rather than lip-service to another aspirational policy designed with more of an eye on short-term electoral impact, the government needs to show the colour of its money in terms of future year budgetary allocations .

Another issue relates to the selection and  targeting of  scheme beneficiaries. It is proposed that they will be identified from the 2011 Social and Economic Caste Census.  Such a form of election, however, is subject to definitional and recording error, as well as to corruption and fraud.

Even if fully implemented, the NHPS  will cover only around 40% of the population, leaving many  households with low to moderate incomes, as well as poor people, uncovered and exposed to an associated higher risk of morbidity and/or of catastrophic health costs. It  has attracted the epithet ‘ModiCare’, derivative of the US insurance support MediAid scheme for the poor and uninsured. It will need to overcome  similar problems to those that beset the US system, related to its reliance on a predominately privately provided hospital sector to provide secondary and tertiary health care to the population in general. Such a reliance is questionable in terms of both effectiveness and equity outcomes, touched on in https://www.asocialdemocraticfuture.org/personal-experience-indian-private-health-sector/ .

Certainly it is not clear that entrenching an insurance-based system is the best strategic route to  a viable and sustainable Indian UHC system, to the more universalist  approach recommended  by the Srinrath report and other  health and development experts.

Conclusion

The overarching issue concerning India’s post-1991 development is whether and to what extent that the substantial leap in GDP has benefited or percolated down to the majority of the population, the poor and those with low and moderate incomes. The rise in per capita average GDP achieved indicate that household per capita income should have more doubled since 1991, and if continued should double further every 12-15 years. Although the proportion of the population defined as living in poverty, as measured by a very low consumption strict subsistence-related standard,  has fallen, it remains highly doubtful that the actual household and per capita incomes  of the majority of the population have risen anywhere near that implied rate, with the incomes of the rural poor and some of the urban poor remaining stagnant. Most of the GDP gain has been secured by higher income and educated groups  employed in buoyant  market  sector, such as IT, and by those in a position to extract or colonise economic rents linked to rising land values. That  increased numbers of individuals belonging to disadvantaged caste and other groups have been able to make good financially, perhaps, perhaps serves to cloud dramatically increasing inequality and that, according to National Sample Survey data, per capita expenditure only rose on average by 0.1% per year between 1993  and 2010.

Related and ancillary to that is that social welfare outcomes as measured by nutrition, educational and health indicators have not improved significantly, and in some cases have actually regressed, resulting in India falling behind countries with lower levels of GDP per capita, such as Bangladesh, in child mortality and immunisation  rates per 1,000 population, for example. Impressive economic growth has not gone  hand-in hand with social welfare advancement in post-reform India.

Given India’s robust and effective democracy, one would expect rising and strong pressures for improved social outcomes and compressed income inequality. These pressures, however, are mediated by and on cross-cutting caste, communal, and regional lines within India’s gigantic, awe-inspiring, and complex democracy. In order to secure and maintain power, parties at both central and sate level must succeed in building up electoral coalitions of support across such lines, rather than rely on broad development programmes.

The 2018 Budget  evidenced that in relation to its MSP measures, while also responding to competitive populist pressures to improve access to health care through the NHPS in a grandstanding and bold manner, clearly designed to attract attention during a year preceding the 2019 general election.

That said,  the focus on rural development, connectivity infrastructure, and on health, which despite massive under-provision relative to need and latent demand, health is still India’s third-largest economic sector, makes sense, in GDP value-added, employment, as well as in social welfare terms. As ever, the acid test of progress will be their focused and effective implementation and measured outcomes.

 

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Filed Under: India Tagged With: health services, India, public finance and budgets

A personal experience of the Indian private health sector

13th March 2018 by newtjoh

I stayed in Kolkata, the erstwhile colonial capital of imperial British India, for three months this year, at my wife’s home in New Alipore.

Halfway through my stay, a family crisis erupted when my sister-in-law aged 69, was taken dangerously ill. A doctor summoned to her home advised that she needed urgently to be admitted to a specialist hospital  due to complications connected to severe abdominal pains. Otherwise she would likely die.

That day she was admitted to the intensive care unit (ICU)  of the Charnock Hospital – a well-equipped private facility, with facilities akin to UK and American standards, located on the Eastern By-pass. It is a super-speciality hospital providing in coronary, stroke, critical care, as well as gastroenteritis services: http://www.charnockhospital.com/charnock-hospital-aboutus.html.

Fortunately she was covered by comprehensive health insurance, by dint of her husband’s former and her son’s current employment by the local Airports Authority.

The next day family members, including myself, went to the hospital in order to  find out her diagnosis and prognosis.  We arrived at around 11am and waited in the modern, almost sleek, waiting area to await information on her condition.

Whilst we did, occasional raised voices could be heard from the payments desk, the most active reception booth, which was shrouded by information boards setting out the price list for different types of treatments. These concerned the need for patient families to pay in advance for continuing treatment, and  about the precise amount demanded. Wads of notes were paid over by family members of patients or ‘customers’ without applicable insurance cover – the majority –  who were required to pay in cash up-front for treatment.

Their alternative,  if they could not or were not willing pay the prescribed charges, was to take their relative to an overcrowded general public hospital, where facilities would be much more limited, much more chaotic, with much less prospect of the delivery of suitable and timely specialised care. Indeed during that same week, a number of cases were reported in the local press where seriously injured or ill patients  were unable to access the care they needed from public hospitals that resulted in their death or were forced to seek private care instead. Another motorcyclist, for instance, who had suffered a  head injury in rural West Bengal was  unable to a obtain treatment due to a lack of neurological resources, was forced to travel first from  his  district hospital to the regional Medical College nearly two hundred miles away, before being referred to a specialist neurological unit  at one of  Kolkata main public hospitals, another three hundred miles, where he had to wait over 14 hours to receive treatment on a corridor bench, before direct representations by his relatives to the hospital superintendent secured his admission.

Back at Charnock, at around lunchtime her son and daughter–in law were summoned to the ICU, where they were advised  that their mother’s most pressing problem was  a ‘leaking’ gall bladder with some element of typhoid fever also apparently present. Medicine had been ministered in an attempt to resolve or manage the problems, but the medical representative advised that in the event of  a full X-ray denoting that surgery was required, the urgency of the situation meant that it may be needed to be undertaken as early as tomorrow morning,  and would involve an element of potential risk to the patient.

Asked to come back early next morning, they went home in order to complete a forest of forms connected to their mother’s insurance cover to be submitted as required to the hospital in lieu of up-front-payment.

They returned to Charnock next day at 5AM. It turned out to be a very long and stressful day for them. They were told that the specialist surgeon whom would have operated could not do so as he himself had to  support a sick relative, and that, accordingly, they should transfer the patient to another private super-speciality hospital  – the largest such one in Kolkata – nearby: the  Apollo Gleneagles.

Their next tasks were fourfold; first, to arrange transport for their mother; second, to complete the forms connected to that transfer; third, to collect the MRI scan and other test results  conducted on their mother;  and third, to fourthly her  admission at the Apollo. This was on top, of course, the continuing uncertainty and the increasing criticality concerning their mother’s treatment plan: in short, was surgery required and what risks would it entail? After all, if the gall bladder was actually leaking,  surgical intervention was needed without any further delay; on the other hand, if the problem was one of infection and fever, drug therapy might be  safer and less risky  compared to intrusive surgery on an elderly patient with heart problems, which could lead to the infection spreading through the blood and ultimately to sepsis: https://en.wikipedia.org/wiki/Sepsis.

Meanwhile the patient’s brother, whom I was staying with in New Alipore,  had a contacted his own diabetes specialist who an Apollo consultant, to expedite the emergency  admission. He  promised to  contact a colleague who he felt was best suited to conduct any needed surgery.

The hospital transfer to the Apollo Accident and Emergency department had only just been effected when we arrived at around 5PM.   I was surprised that visitors such as ourselves were allowed  to mill around the beds of this busy 20-bed emergency department, while doctors and nurses scurried around in order to respond to monitor warning bleeps or to conduct examinations, without challenge.  There appeared to be a rapid through-put of patents as some were transferred to wards to be replaced by new arrivals. This churn, however, was not always quick enough, with one case reported that morning of a 54 year-old man dying in an ambulance parked outside the ward due to a bed not being immediately available.

Bad news about our family member was received that the Charnock Hospital apparently had lost the MRI results of the patient or some reason could not provide it to  her son and daughter-in-law, who understandably were becoming increasingly stressed.  Another problem that was communicated to me by my wife was that the resident on-call staff at the Apollo conducting the initial examination appeared to resent the fact that the family contact consultant had assigned the case to a particular  surgeon.  They made the case-owner consultant was a diabetes, not a gastroenterology, specialist, but my wife expressed concern that the real problem was that this meant that they would not have a claim on the insurance monies linked to the case. Apparently there was competition between doctors to ‘control’ cases for that reason, sometimes to a point where it became an organised scam.

The good news was that my sister-in-law was surprisingly lucid given her condition suggesting that the medication was working, and that the assigned surgeon arrived soon afterwards to conduct his own examination, which he proceeded to do carefully and professionally.

We went outside in the corridor to receive his feedback, which he gave in  a measured and respectful manner. In essence, he advised that if the cause was a diseased or leaking gall bladder, which was the most likely cause on the evidence available, its source could be missed by limited micro-surgery; accordingly, that the safest course of action was to conduct the next day a full surgical examination and to proceed to the removal of the organ as found necessary,  as the gall bladder itself was not a vital organ, but such surgery would be high risk.

This seemed to make sense to us, and we went home relieved that at least a course of action had been mapped out and would be undertaken by a by a dedicated professional who looked and acted the part.

The operation, indeed, took place next day. We attended in a dedicated waiting room provided to relatives of those having surgery, where electronic screens reported on the progress of each operation: all mod-cons, like much of the activity of the hospital. After about two hours, the surgeon called us to the theatre entrance, where he showed us  gall bladder he had successfully removed from my sister-in-law and in particular  its diseased ‘mouth’, which was black,decayed, and horrible. He was hopeful that the cause of infection had been removed, but cautioned that post-surgical bleeding could follow and that she was not yet out of danger,  and needed to be transferred to the high dependency unit.

Fortunately she did continue to recover slowly and was able to return home after a fortnight.

That was not the end of my unplanned brush with the Indian private medical sector insofar that a friend of the family was reaching a tipping point in the treatment of his son’s kidney failure. He needed a transplant but his father’s  employment-related insurance cover no longer covered his son, as had attained 25 years of age.  Because the cost of kidneys to be used for such purposes was extremely high – Indian culture is not supportive of deceased family members donating their organs after death, while a public donor bank suffers from public administrative and other failures related to a lack of a national health service. Organs needed to be purchased often from living donors, which could push the costs beyond the means of a retired – albeit high-ranking – policeman, such as in this case. He thereby  enlisted the support of family members  to draft  a letter to his insurance company requesting that he donate the needed kidney to his son conditional on compatibility checks.

What lessons were drawn from these events?

First, of course, class, money, and location counts: unless you possess the benefit of employment-related, or were able to purchase  private health insurance at an annual premium cost reported cost between 12,000 to 24,000 Indian rupees per annum for a family of five (roughly £150 to £300), or had enough savings to pay for treatment as needed, if you suffered a  serious accident or illness you would need to rely on the grossly under-resourced  public hospital sector and take your not too bright chances accordingly. In fact 86% of rural, and 82% of urban, Indians are reported not to have any such access to insurance, explaining why 63 million of them are pushed into debt by unplanned healthcare spending each year.

Whilst not seeking to minimise the current crisis of the NHS (which also suffers from rationing, distributional, and informational issues) universal and accountable provision by the State does offers clear equity and efficiency advantages, as well a value-base or footing geared to individual need, even though that value-base can be perverted for provider and political ends as well.

Second, there is no guarantee of excellent or good treatment within the private hospital sector. Treatment is still often reliant on personal contact and power and the ability to navigate an often rigged and corrupt system where corporate and personal profit, rather than patent need, can prove paramount. Patients must rely on family members to either activate insurance policies or to negotiate payment at a time of high stress and uncertainty. The hospitals secure super-profits from the charged use of drugs and sundries in treatment, sometimes as much as 1000%.  Hospitalisation costs are outstripping premium incomes.

Third, the problem of asymmetric information between provider and patient and their family members comes into particular play within such a private system: you must rely on medical advice that particular treatments are appropriate and needed given the particular circumstances of the case; the suspicion is that sometimes the treatment follows the payment schedule  based on inputs rather than customised to individual need and circumstances, and best outcomes.

Fourth, and related to the third, while overall the health services are massively underfunded in India, with public health expenditure accounting  at less than 1.5% of GDP, adversely impacting on both preventative and curative care outcomes, private health expenditure reimbursable from insurance and user charges continues to escalate. private providers prioritise screening consultations – with pictures of young ”yuppie- families, captioned, for example, that is never too early to prevent cancer, that inevitably result in unnecessary or over-prescribed treatments that yield additional income to the associated tests and examinations involved, which themselves often represent a diversion of scarce medical resources from alternative and more effective preventative ends. See, for example, http://apollogleneagles.in

 

 

 

 

 

 

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Filed Under: India Tagged With: health services, India, private health insurance

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