The Tribune, Chandigarh, India

OPINION

NON-POLICY ON SRI LANKA
Escapist approach will not do
by Inder Malhotra
LET me cut out the cackle at the outset. A renewed Indian military intervention in Sri Lanka is out of the question, notwithstanding our enormous security stakes in the island republic separated from us by only 21 miles of seawater. The reasons for this are obvious and compelling.

Promises to panchayats or perpetuation of poverty?
by Ram Singh
THE failure of the “top-down” approach through central planning in bringing about a change on the rural poverty front and the consequent debate gave substance to the argument that this approach should simultaneously be complemented by a “bottom-up” one. The consequence was the 73rd Amendment Act. After the passage of this Act, state governments, one after another, are unwinding the “packages” for panchayati raj institutions (PRIs).

MIDDLE

It began with Eve
by Raj Chatterjee
THERE are certain things — simple, commonplace things — that you cannot teach the most intelligent of women, however, hard you may try. Fruit, for example, should always be washed before it is eaten. But what did Eve do? First, she let a total stranger, an absolute snake-in-the-grass, talk her into plucking an apple from the one tree in the garden she should have shunned. Then, without so much as dipping it in the river that ran past Eden, she took an uninhibited bite at it and passed it on to her simple-minded spouse.

WORLD IN FOCUS

Escalating cost of health care
by Professor S.M. Bose
THE steep rise in the health care delivery system seen in the last quarter of the century has been mind boggling. The heavy cost not only leaves one's purse empty but at times it also decides the option between life and death. This is more true in the context of a developing country like India where 40 per cent of the people still exist below the poverty line.

75 years ago

May 11, 1925
Corruption in Police
WHILE the Government cannot absolve itself from its duty of putting down corruption in any of the departments of the administration, it is the obvious duty of the public, as Sir John Maynard pointed out in his speech on Sardar Tara Singh’s amendment in respect of the pay of officers of the C.I.D. at Tuesday’s meeting of the Punjab Council to cooperate with Government in detecting and punishing corruption, and so to fashion their social conduct as to bring it home to all persons inclined to be corrupt that society is not prepared to tolerate their wickedness.

Probe into probe

THE riots which broke out in Delhi and other parts of the country in the wake of the assassination of former Prime Minister Inidra Gandhi on October 31, 1984, have haunted the successive governments as well as certain sections of the public. The happenings were traumatic. They had communal and barbaric overtones. The killing of more than 5,000 citizens should not go unaccounted for in a civilised society. The perpetrators of the brutalities must be brought to book; this is what has not happened so far. The Bharatiya Janata Party-led government gave clear hints of the re-opening of the 1984 riots episode before the last General Election and also after it. The All-India Shiromani Akali Dal (Babbar) stridently asked for "another inquiry commission", accusing the previous commission formed in 1985 and headed by one of our most respected judicial men, Mr Justice Ranganath Misra, rather crudely. At this stage, before welcoming the new probe, it is necessary to remember that Mr Justice Misra, a former Chief Justice of India, acted as the head of a commission just as Justice Nanavati is going to do now. Justice Misra found no evidence of a set planning or instigation in the 1984 gory happenings. The matter needed deeper study and he recommended the setting up of "another committee" "to enquire into such incidents and order the registration of fresh cases, if so desired".

The six-point terms of reference indicate that Justice Nanavati would begin at the beginning. He would look into the causes and the course of criminal violence and the riots. He would study the sequence of events leading to, and all facts relating to, such violence. He, in his wisdom, would also tell the appointing government whether those heinous crimes could have been averted and whether there was evidence of a lapse or dereliction of duty, or of a cover-up bid, by certain authorities or individuals. As usual, Justice Nanavati would be required, after yet another post-mortem, to suggest measures that would "meet the ends of justice". He has absolute freedom to pick up any relevant point. It is true that the two committees, appointed after the Justice Misra Commission submitted its report, did not recommend punishment for a visibly large number of people, including officers and men of the police who were alleged to be involved in the riots. There were many acquittals. Several marked men have either died or retired from service by now. Of the 707 cases duly registered, 374 were chosen for prosecution. As many as 322 cases were treated as untraced or cancelled. Then 320 persons were acquitted. There were only 30 convictions, of which 25 were pending trial. The data do not show spectacular progress by way of intensive enquiry or punishment. However, the Justice Misra Commission's report should be treated with sanctified respect because someone some day might start doubting the adequacy of the Justice Nanavati Commission findings too! Probes which are not judicial must at least be judicious.

A nuclear counterattack

IN a delayed but uncharacteristically sharp rejoinder, India twitted the nuclear powers for their action and innaction and also their continued refusal to accept it as a nuclear weapons state. In the process, External Affairs Minister Jaswant Singh’s suo motu statement in both Houses of Parliament brought the ongoing NPT Extension Review Conference into media focus. The most striking aspect of the redefined policy is that the country is no more defensive or apologetic about its nuclear status and does not link its demand to be treated as one with talking about building a national consensus on the CTBT. In fact, the CTBT does not even figure in the statement. On the other hand, there is a sharp criticism of the USA, NATO and China for their not-so-subtle nuclear rearmament programme or nuclear weapons-based strategic doctrine. In other words, India exudes more confidence in its capacity to resist the US pressure to roll back the nuclear programme. It is also clear that it has given up believing in building up a sizeable nuclear arsenal to claim the denied status or seek US help to enter the exclusive club. India seeks to build a force big enough to be a deterrent but small enough to reassure non-nuclear neighbours of its peaceableness. India has not said anything new but has stated its position with laser-sharp clarity and firm conviction. It no more talks of universal nuclear disarmament but of carving out nuclear weapons-free zones and wants a conference to realise this goal. It repeats its old commitment not to use nuclear weapons first or against non-nuclear countries, not to help anyone put together a bomb and not to deploy these weapons of mass destruction outside its border.

The departure from the past is in the way Mr Jaswant Singh chose to criticise the nuclear powers. Naturally the USA has attracted heavy fire. Its plans to modernise about 5000 nuclear warheads is setting the clock back. The collective pledge to eliminate such weapons at a future date does not undo the effect of upgrading its nuclear force. Washington’s plans to spend a mammoth $65 billion over the next 19 years to perfect an anti-missile shield is a gross violation of the 1972 anti-ballistic missile treaty. That country shares tactical nuclear weapons with NATO countries and that is a breach of the NPT. The USA and other western countries are known to have helped Israel in making the nuclear bomb and China played a similar role in Pakistan. China is also busy building a nuclear bomb-carrying missile force. The claim by these nuclear powers that the bombs are not targeted at anyone is laughable since it takes only a few minutes to do so. In contrast, India’s track record is impeccable. The assertion that India and Pakistan would never be allowed to enter the NPT as nuclear weapons states came a week earlier and the Indian response has come on Tuesday. The time has been well used to hone the policy positions and direct them at the right quarters.

Towards “Mahajolt”

THE nascent mahajot (grand) alliance is proving to be a non-starter. It was to be tried out in the Panskura Lok Sabha byelection but the Congress has all but dealt it a fatal blow by declaring its own candidate to challenge Mr Gurudas Dasgupta of the CPI, the candidate fielded by the Left Front. There was considerable opposition by a section of the state Congress unit but the will of the high command prevailed and it was decided to field Mr Shubhankar Sarkar, president of the West Bengal unit of the National Students Union of India, to fight the byelection, scheduled to be held on June 5. This is obviously a "symbolic fight" considering that the chances of the Congress winning the election are just about remote. But, as the working president of the state unit of the party, Mr Priya Ranjan Dasmunshi, candidly said, not contesting or joining hands with the Trinamool Congress-Bharatiya Janata Party combine would have affected the morale of the party workers. The West Bengal PCC president, Mr A.B.A. Ghani Khan Chowdhury, was initially against putting up a candidate but later fell in line. The declaration spells trouble for Ms Mamata Banerjee who has suffered serious reverses in the state civic polls recently. She was hopeful because of the dissension within the Left Front. Mr Dasgupta's term in the Rajya Sabha expired last month. There was almost a split in the Left Front following its refusal to allot the Upper House seat to the CPI again. The seat had fallen vacant due to the death of veteran leader Gita Mukherjee who had won it by a margin of 47,000 votes in November, 1999. A common candidate could have helped Ms Banerjee bounce back but that was not to be.

The jumping into the fray by the Congress may still lead to some disgruntled party elements joining hands with Ms Banerjee. She is also hoping for defections from the Left ranks. But if the Congress somehow manages to relegate the TMC to the third spot, the switchover of cadres from the Congress to the TMC might come to an end or at least slow down. Now that the Congress has entered the contest, its sole hope lies in trying to grab the coveted second position. It is virtually the Congress versus the TMC for the runners-up place in the constituency because the BJP hardly has a presence there. The difficulty of the Congress is that it is neither in a position to shake the Left Front from its perch on its own nor is it capable of wooing back Ms Banerjee. A charismatic party president might have pulled off at least the second option but Mrs Sonia Gandhi does not have that kind of political acumen. Whatever political consequences, the forthcoming byelection signals the end of the mahajot experiment for now.

NON-POLICY ON SRI LANKA
Escapist approach will not do
by Inder Malhotra

LET me cut out the cackle at the outset. A renewed Indian military intervention in Sri Lanka is out of the question, notwithstanding our enormous security stakes in the island republic separated from us by only 21 miles of seawater. The reasons for this are obvious and compelling.

In the late eighties the Indian Peace-Keeping Force (IPKF) was sent there at the express invitation of the then Sri Lankan President, J.R. Jayewardene, to fight the battle for that country’s survival in one piece. It was almost literally stabbed in the back by his bigoted successor, R. Premadasa. More than a thousand gallant officers and soldiers had made the supreme sacrifice.

However, since the LTTE, hell-bent on Tamil Eelam, is perilously close to conquering the whole of Jaffna peninsula in the north, Sri Lanka does need help. Indeed, this need is accentuated because nearly 25,000 Sri Lankan troops with apparently no will to fight are bottled up in the Tamil majority region. They can be evacuated only by a Dunkirk-like operation. Couldn’t some surgical air strikes of a very short duration be made to relieve the pressure on the beleaguered Sri Lankan forces? Alternatively, arms and ammunition, including aircraft, desperately needed by the neighbouring country, could be sold to it.

Unfortunately, both these options are also ruled out. For, the Tamil allies of the BJP, headed by the Tamil Nadu Chief Minister, Mr M. Karunanidhi, are bitterly hostile to the very idea of any kind of military help to the Sri Lankan government. They don’t want any Indian contribution to be used against any Sri Lankan Tamil, including the fascists of the LTTE. All that the Vajpayee government is able to offer Ms Chandrika Kumaratunga, the Sri Lankan President, therefore, is "humanitarian aid". But what good is this if a large part of the Sri Lankan army is either destroyed or humiliated? In any case, the AIADMK supremo, Ms Jayalalitha, in an apparent attempt to upstage Mr Karunanidhi, had demanded that humanitarian aid should be routed through the Red Cross, not sent to Colombo or Jaffna directly.

Under these circumstances, one would have thought that New Delhi would adopt a policy of creative diplomacy with three clear aims in relation to a country that really is India’s security backyard. First, preservation of Sri Lankan unity and territorial integrity on the one hand and a fair and equitable settlement of the prolonged and excruciatingly painful ethnic conflict there, on the other. Secondly, to see to it that powers hostile to this country do not fill the vacuum created by Indian inability to intervene. Thirdly, and no less importantly, to maintain India’s leadership role in the region, and not allow it to be eroded.

Alas, there is no sign of such a policy prescription. What we have instead is a non-policy, composed of a few slogans and shibboleths without any recognisable plan for action. South Block does swear by the dual objective of securing justice and fairplay for the Tamil minority within the framework of a united Sri Lanka. It then goes on to make an extraordinary declaration: India would neither intervene in Sri Lanka itself, nor allow anyone else to do so.

Pray, what is Sri Lanka expected to do if Tamil Eelam looks like becoming a reality, especially if the LTTE, intoxicated by its easy victory, refuses any kind of negotiations? Wouldn’t it desperately look for military assistance elsewhere? Indeed, it did turn to Pakistan after India’s refusal. Had the Pakistanis agreed to fish in Sri Lanka’s troubled waters India would have had to react very sharply for obvious reasons. However, even under a military regime, Pakistan knows its limitations and has refrained from flying out its crack battalions to the Sri Lankan war zone though it is bound to make whatever capital out of the curious situation it otherwise can. China, if asked, is likely to be even more reluctant than Pakistan to send its troops into the jungles of Jaffna.

It is in this context that reports have come in about Israel’s military help to Sri Lanka although even the Israelis can only supply equipment, including perhaps Kafir strike aircraft, not men. Whether this arrangement has tacit Indian support or not has yet to be established.

That leaves only big powers, acting on their own or under the umbrella of the UN, who can take any decisive action. So far the UN Security Council has kept only an eye on the dangerous and deteriorating situation. But should it decide to take up the matter formally, what is there to prevent it? Both India and Sri Lanka have good reasons to keep the UN away from what is essentially an internal conflict. But that can be ensured only if New Delhi and Colombo act in concert to put in place a viable alternative.

What can such an alternative be? The answer to this gnawing question lies in the crucial fact that Sri Lanka, India and the USA have declared the LTTE to be a terrorist organisation that also engages itself in the smuggling of narcotics to finance its nefarious activities. Surely, the three countries can cooperate to deal with a grim crisis that India should have handled on its own but evidently cannot.

This, of course, is easier said than done. For despite the upswing in Indo-US relations, especially after Mr Bill Clinton’s visit to this country, the foreign policy establishment remains deeply suspicious of American presence within Indian security parameters. Changed circumstances haven’t altered the old mindset. In any case, the policy of masterly inactivity, combined with the firm opposition to any other country taking the necessary action, makes no sense at all. For it can only lead to Tamil Eelam which, as we are rightly shouting from the housetops, is against India’s highest interests.

Maybe, a way out of the present policy paralysis can be found in stages. To begin with, the navies of Sri Lanka, India and the USA can surely patrol the international waters around the emerald island to prevent supplies and reinforcements from reaching the LTTE. Even Mr Karunanidhi cannot object to this because, on second thoughts, he has allowed the Vajpayee government a "free hand" in pursuit of national interest.

Moreover, both the Americans and the Israelis, apart from giving the Sri Lankan government the weapons it needs can provide it with invaluable military advice and intelligence. After this state of affairs is reached the remaining requirements of the situation can be reviewed trilaterally. Not to adopt this approach would be an invitation to disaster.

This column is being written well before the Prime Minister’s meeting with the leaders of Opposition parties to which the BJP’s ally, the Telugu Desam, that hasn’t joined the government, has also been invited. But this get-together is not going to make much of a difference to the situation as it exists.

All major parties, barring those that cannot look beyond their collective nose, have already spoken. It was amusing to watch Congress leaders declaim on TV that while their 1987 decision to send the IPKF must not be criticised, the present government should not send in any troops to Sri Lanka. The BJP is content to go on reaffirming that it "will not go the IPKF way". This kind of political oneupmanship is no substitute for policy.

Promises to panchayats or perpetuation of poverty?
by Ram Singh

THE failure of the “top-down” approach through central planning in bringing about a change on the rural poverty front and the consequent debate gave substance to the argument that this approach should simultaneously be complemented by a “bottom-up” one. The consequence was the 73rd Amendment Act. After the passage of this Act, state governments, one after another, are unwinding the “packages” for panchayati raj institutions (PRIs). The latest contribution to the rhetoric of “development via the empowerment of PRIs” are the commitments made by the UP and Haryana governments. Unfortunately, these “packages” have turned out to be long on words and short on substance invariably. There are structural and functional anomalies infesting the PRIs and other rural development agencies. These anomalies should be identified and sorted out without delay. Otherwise, not only the desired results will not be achieved, the very objective of the Act will be defeated.

At present, the PRIs face both managerial and structural problems. For one, the PRIs are ill-equipped to mobilise and manage the funds needed for rural development. Secondly, the important developmental agencies like the District Rural Development Agencies (DRDAs), try to undermine the PRIs’ role rather than complement their efforts.

There are only a few states like Madhya Pradesh, Karnataka and Kerala where the PRIs are mobilising the needed resources and implementing various development schemes effectively. Otherwise, in states like Bihar elections for local bodies have not been held for more than 10 years. In the states where there are duly elected PRIs in place, these are ineffective.

The PRIs lack power, expertise as also funds which are pre-requisites of poverty eradication. The grant-in-aid received by most of the PRIs is barely sufficient to meet their administrative expenses. That is why — due to the paucity of funds — no development programmes are undertaken by gram panchayats and particularly zila parishads (ZPs) in most of the states. The condition of ZPs in the newly created districts is more miserable because unlike the ZPs in old districts these have no earning assets such as buildings, shops, land and fixed deposits. These ZPs are completely at the mercy of the governments’ grant-in-aid even for their administrative expenses. Given this sordid picture, the decision of the Haryana government to raise the limits on spending by panchayats from Rs 25,000 to Rs 1.25 lakh and to Rs 5 lakh with the permission of ZPs can be described as myopic.

Not only that at present the PRIs lack recourses, the fact is that even in the future if funds are made available the PRIs will not be able to manage them and supervise the implementation of their schemes successfully. As a recent study on Haryana shows, most of the ZPs do not have a proper accounts section, and the staff is both inadequate and untrained.

As regards the undermining of the PRIs, though these are supposed to be effective instruments of socio-economic development, as in the past so even today most of the schemes are implemented through non-representative development agencies like DRDAs which are riddled with inefficiency caused by long bureaucratic chains. The same study shows that in Haryana either the post of Accounts Officer is lying vacant in many DRDAs or there is a shortage of the supporting staff. This means that there is no proper accounting and auditing of the funds spent.

Funds for various rural development-cum-poverty eradication schemes are passed on through the DRDAs to the implementing agencies such as BDPO and NGOs. Funds for various subsidy schemes are kept with the banks as advance subsidy for the loans to be given to the potential beneficiaries. It was found that usually a significant section of the needy population is ignored in the disbursement of subsidies. Huge amounts remain with the banks at the end of the financial year because the required loans are not sanctioned by banks to the targeted groups. These funds remain unadjusted for many months and are used by banks for lending purposes to other clients. No interest is paid by the banks on these funds. This practice, apart from creating difficulties in bank reconciliation and auditing, leads to avoidable misutilisation of the poor people’s money.

In order to remove these anomalies last year various schemes for rural development were merged together to form a unified scheme called Swarnjayanti Gram Svarozgar Yojana. To ensure people’s participation under the scheme, the gram sabha is given an important role. To ensure that development funds are not used for administrative purposes, as it happened in past, under this scheme, the DRDAs are to get money for such expenses separately. But as yet most of the DRDAs have not received funds for administrative expenses and their salary and other such expenses are being met from the funds exclusively meant for rural development.

At the implementation level, fund mismanagement is caused by the poor maintenance of major accounts books such as the muster role and measurement books — the accounting registers for the labour employed, wages paid and the details of the work undertaken by the implementing agencies. Frequently false entries regarding the employment of labour and the work undertaken are made in these books.

To avoid these problems via popular supervision the new guidelines mandated the transfer of funds for some schemes directly. But this has not taken place as yet, and the PRIs remain completely neglected. Admittedly, the state politicians and bureaucrats who have complete control over the agencies like the DRDAs have lesser sway over the PRIs and hence are unwilling to share funds. The new guidelines provide for the staff for the formulation of plans and projects for effective eradication of poverty through employment generation. Though the staff is provided to each DRDA and ZP for this purpose, the finalisation of plans/projects is a mere formality to be done occasionally. No importance is given to the local availability of resources and the market potential of the activities to be undertaken by the beneficiaries.

The experiences of the states where the PRIs are given financial powers show that the problem of rural poverty can be solved only if more and more development schemes are implemented through popular participation. Therefore, if a government is sincerely interested in rural development, instead of engaging itself in rhetoric such as raising limits for funds, it should strengthen grassroots democracy by implementing schemes through the PRIs. The schemes related to social security and employment generation should best be implemented through the PRIs, mainly the ZPs. Also to enable the PRIs to manage funds properly it should provide them with an efficient and transparent accounts section.

The writer is a faculty member, Haryana Institute of Public Administration, Gurgaon.

It began with Eve
by Raj Chatterjee

THERE are certain things — simple, commonplace things — that you cannot teach the most intelligent of women, however, hard you may try.

Fruit, for example, should always be washed before it is eaten. But what did Eve do? First, she let a total stranger, an absolute snake-in-the-grass, talk her into plucking an apple from the one tree in the garden she should have shunned. Then, without so much as dipping it in the river that ran past Eden, she took an uninhibited bite at it and passed it on to her simple-minded spouse.

Ever since then Man has had to eat apples and pears unpeeled (the skin is full of vitamins) and probably unwashed, the cook being a laggard.

Try driving a car in a crowded bazaar with demented taxi drivers overtaking you from the left, jet-propelled scooters bursting your eardrums, emaciated cows meandering across the road and a fat Bahmini bull blocking your path. Try, at the same time, to approve the curtain samples that have been fished out of a shopping bag. I say “approve” because it is simpler, and safer as far as you and the bull are concerned, to do so even if the colours give you a pain in the belly.

Take the joint account. You are going out on a business trip and expect to be away for long. You don’t want your wife to run up bills or borrow money from your neighbour. So you get a duplicate cheque book from your bank. You transfer a certain figure from the stub of your cheque book to the stub on hers.

All she has to do is to keep a running total — just make a deduction each time she writes a cheque. You come back in a fortnight’s time expecting to see a nil balance in her cheque book.

Instead, you see more than a month’s salary staring you in the face. Your fault, of course, for having said “running total.” You always add, don’t you, to make a total?

Despite your several reminders, it is the end of November and those Christmas cards to old friends abroad have not been dispatched. In desperation, you undertake to type the names and addresses on the envelopes and leave them on your wife’s desk so that she can write her tender messages on the cards — and your names.

A week later you pick up the bunch and ask if she has done her part of the job. A muffled sound comes from the bathroom which you take to be an affirmation. You spend a small fortune on air-mail stamps at the P.O. You get rid of the lot with a sigh of relief. You come back home to face a hullabaloo. Where are the cards? Your wife was just going to write the messages — and your names!

Escalating cost of health care
by Professor S.M. Bose

THE steep rise in the health care delivery system seen in the last quarter of the century has been mind boggling.

The heavy cost not only leaves one's purse empty but at times it also decides the option between life and death. This is more true in the context of a developing country like India where 40 per cent of the people still exist below the poverty line.

Gone are the days when health was a state subject and government hospitals and dispensaries used to treat patients free of cost. I recall my years of medical studentship and surgical residency in government hospitals where everything was available free of cost to all the patients in the general wards. If some costly medicine or disposable item was not available, one had only to request the Medical Superintendent and it was promptly supplied. Today, hardly anything is available in the hospital. There is a vast difference in the quality of health care services provided to the rich and the poor.

"Health for all by 2000" is still a distant dream. As a matter of fact, the Central and state governments are forcing the hospital authorities to raise their revenues by charging patients for everything. This happens not only in bigger institutes like the PGI and the AIIMS but also in state owned medical college hospitals. These charges are unrealistic; in many instances even higher than those in average private hospitals and nursing homes. For example hospital room rent the PGI in Chandigarh is higher than in any private nursing home in the city.

The cost of coronary angiography as per the hospital charge sheet may be only Rs 2500 but the hidden charges of Rs 8000 to Rs 10,000 for the material that have to be procured is extra. No government hospital price list mentions this and no hospital administrator is willing to admit this.

For operations in a government hospital, the patient not only pays the scheduled operation charges, but also brings in all the material required for the operation, even basic items such as syringes, I.V fluids, cannulae, catheters, ECG leads, gloves, sticking plaster, plastic sheets etc. At times he may even be asked to bring sutures, disposable diathermy connecting leads, suction tubes etc. Impersonal and callous attitude of the hospital staff, multiple trips to the market, delay at every step, are the bonus that a patient and his relatives get from a general hospital.

The cost of coronary bypass operation in a private hospital like, Apollo and Batra of Delhi is approximately Rs 1 lakh to 1.5 lakh and it almost comes to the same if not more in government hospitals like AIIMS, PGI etc. The same holds true for simple operations like removal of gall bladder (cholecystectomy), hernia repair etc. The operation fee for a simple groin hernia in the general ward of the PGI is Rs 5000.

In the present generation, even if one earns 15,000 to 20,000 per month, one is just having a hand to mouth existence and is not able to save substantially. How can such persons afford unexpected expenditure that runs into four or five figures?

I have seen a number of patients forced to leave the hospital because they could not continue to afford the treatment. I am sure more patients keep suffering in their homes, as they cannot afford hospitalisation.

The expenditure is particularly very high in major illnesses like heart attacks, candidates requiring ICU care, multiple trauma cases, liver and kidney failures, major operations involving heart, lung, liver, pancreas, brain etc. Liver, lung, heart and kidney transplantation cost a lot a money. One liver transplant costs a minimum of Rs 10 lakh to perform and another Rs 10000 per month for maintenance.

Cancer patients pose special problems, which are not only professional, but ethical also. The biological behaviour of cancer is such that the outcome of treatment is not predictable. Two patients suffering from the same cancer, at the same stage, given the same treatment respond differently.

Newer and newer chemotherapy drugs are coming to the market everyday and these drugs cost quite a lot. Some even cost Rs 30000 to 50000 for a single course of treatment and one may have to give a number of courses. But the dilemma is that the response rate may be only 20 to 30 per cent i.e 20 per cent to 30 per cent of the patients will only respond to this treatment and prior to the treatment there is no way to find out which patient is going to respond. The big question , therefore, remains. Should one spend so much money and then pray to the Almighty for a favourable response or should one forgo the chance and save the money for the dependants, particularly if the patient happens to be the bread-earner of the family? This is more relevant because these chemotherapeutic agents only prolong the life of the patients for some more time. These drugs usually do not cure the disease, at least not advanced cancer.

The same problem one faces while treating a patient of brain death on ventilator as every passing day will cost about Rs 10000.

High tech and the present generation of doctors are the biggest culprits in escalating the cost of the medical delivery system.

Costly investigations, repetition of investigations and unnecessary investigations are factors that contribute to cost escalation. C.T. scan, MRI, Gamma Camera, colour doppler etc. have come as a boon to the medical profession but they have also proved to be a curse. Surgeons and physicians used to treat all sorts of cases without these sophisticated, time consuming and very costly investigating facilities. But today no specialist will like to treat even a simple case without having these investigations. Cost is no consideration in a majority of the cases. However, for a simple head injury, a neurosurgeon, whether he is practising in a government hospital or in a private clinic, will order a CT scan even before thoroughly examining the patient. The minimum cost of a CT scan of the head is about Rs 1000. But it is also not fair to blame the doctors only (who seem to be forgetting the art of clinical medicine) as the Consumer Protection Act will definitely blame a doctor for not getting a CT scan done in case of a mishap.

It is not the radiological investigations alone which are excessively carried out but all sorts of investigations — biochemical, serological, radio isotope scannings are being frequently done without any consideration. If an investigation is available in the hospital that does not mean that the patient should have it, but unfortunately the discretion is disappearing fast.

Repetition of investigations is the other major cause of the escalating cost of treatment. Most of the clinicians feel that unless indicated (e.g. in case, some new development has taken place in the intervening period) investigations need not be repeated within six months. The cost of medicines have gone up beyond imagination; it runs into hundreds and thousands. Take for example the cost of antibiotics. An ICU patient, on an average, may require antibiotics worth Rs 1000 to Rs 2000 per day, the cost of parenteral nutrition per day is about Rs 1500 per day. A bottle of 100 ml of Albuminal required to compensate hypoproteinaemia (a common problem amongst our patients) is Rs 3500. And these items are necessary if you want to pull out a seriously ill patient. Clinicians have to compromise all the time because cost is a major consideration and hence a major constraint while we are treating a seriously ill patient.

Medicines have to be prescribed but then the cost in many cases can definitely be reduced by sound judgement. It is felt that in a large number of cases antibiotics are used indiscriminately, in wrong combinations and for a much longer duration than required. It is not uncommon to find a patient on three or four antibiotics for seven to 10 days. After a simple, clean operation although it has been clearly shown that antibiotic prophylaxis can be achieved in a majority of cases by a single shot or at the most by a 24 hour regime.

It is equally true that appropriateness is the single most important factor in the selection of the antibiotic and not its cost. Unfortunately, the drug manufacturers seem to be calling the shots and it has become a fashion to prescribe the latest and the costliest antibiotic to fight infection, whereas the same results may be achieved either by prescribing no antibiotics or by ordering an antibiotic which may cost only one-tenth.

A large number of medicines are prescribed empirically, i.g, without having the established evidence of benefit. Vitamins, tonics, trace elements, enzyme preparations, and many other drugs come under this category of drugs.

Liberalisation of the import policy has opened the flood gates and chemist shops are packed with foreign goods. As in other walks of life, there is a belief that imported medicines are better than indigenous ones. Use of costly equipment, instruments, suture material and other disposable items has definitely escalated the cost of health care delivery system 10 fold, if not more. Many of these are essential but a large number of them are also avoidable.

In our quest for providing five star health care, we should not forget that even in the USA the health care system was crumbling because of cost escalation and they had to tighten the noose. After all we should always remember that we live in India, and every penny conserved is definitely a saving for better things.