Tuesday, May 30, 2000, Chandigarh, India
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Air-India
privatisation |
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PRIVATISATION
OF MEDICAL SERVICES
From
darkness to light
Over
to the countryside
Military
schools in Punjab
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PRIVATISATION
OF MEDICAL SERVICES A FEW years ago, an eminent surgeon working at the Post-Graduate Institute of Medical Education and Research, Chandigarh (PGI), took early retirement and started private practice, I asked him why he had done so. His brief reply was, Its money. He was confident of earning much more money as a private practitioner. He is indeed earning more now. There are quite a few such examples. Many medical experts do not join government institutions at all. It is not only money that is responsible for such a phenomenon. There are many other well-known dysfunctions of hospitals in the government/public sector that push efficient doctors out. News of highly competent, upright and committed doctors being superseded by less competent ones in government institutions is common. Every individual faces alternatives. If he chooses one alternative, he foregoes others and, thereby, their associated benefits. These forgone benefits are called opportunity cost of his choice. A doctor is also an individual. He tends to calculate this opportunity cost when he chooses to work in a government hospital rather than join the private sector. More competent a doctor, more is his opportunity cost. No doubt, government jobs provide greater security, but an efficient person does not really need to bother about job security. His competence and skill give him the best security. The opportunities thrown open both within India and abroad by the process of globalisation, liberalisation and competition in the last two decades have caused increasing brain drain from the government to the private sector. It must be recognised that a good number of doctors working in government hospitals are committed to serving humanity. They do so against all odds within their work place and temptations from outside. Once I saw a professor of the PGI walking towards his residence with a kilogram of pumpkin in his hand. I enquired, you went yourself to buy only this much of vegetable. He replied seriously, we dont have a servant and on the last day of the month I can afford to buy only this much of the vegetable. On another occasion, he narrated another story. His college-going daughter wanted him to purchase a scooter for her. He showed his inability to do so because of paucity of money. Then she informed him expressing her anger that only two girls of her class came to the college on bicycles. One was she herself and the other a daughter of a peon! This doctor is second to none in his area of specialisation. He could have earned a lot to live lavishly as a private practitioner or as a retainer in a private nursing home. Yet, he continues to serve the PGI on a fixed salary. There are others like him. But, unfortunately, the breed of such doctors is declining fast. Perhaps, they are more obstinate than rational in todays society! The point is very clear: Government hospitals in the country are losing good doctors to the private sector. Let us look at the feelings and responses of the users of medical services. A friend of mine took his 10-year-old son, who had fainted without any apparent cause, to a government hospital. After a long wait a doctor saw him and advised certain neurological tests. The laboratory gave a date for the test that was after a month, even though it was a case of emergency. So, he took the boy to a private hospital where the tests were promptly done. The attitude of the doctors and the supporting staff at this private hospital was so good and caring that my friend decided to get his son treated in the same hospital. There are umpteen examples of painful experiences of the user public, of inadequacy and poor quality of service in government hospitals, long waits and harassment at the hands of the personnel. Thus, people are forced to search for alternatives. And such alternatives are becoming increasingly available in the private sector. The rich are willing to pay a higher price for quick and quality service. Even people belonging to weaker sections are seen in a significant number getting treated by private practitioners. The reasons are harassment of all kinds, negligence, etc, in government hospital. These add to the real costs of medical service at the government hospitals. It is a pity that the poor have to suffer these costs more than the rich. Thus, the total real cost of a medical service at a government hospital becomes more than that at a private nursing home, particularly in the case of the poor. Consequently, there arises demand for the medical service in the private sector. The private entrepreneur seizes this opportunity. Attracted by the large demand, the corporate sector is also diversifying into this area. There is shift from other professions, even from farming, to starting a nursing home. What is the reason for the poor quality of service in the government/public sector? The agency cost (the inability of an organisation in effectively achieving its objectives such as profit, shareholders value, or social welfare, etc, due to the pursuit of self-interest by the employees, particularly, by the top management of the organisation) is too high. There must be other factors, such as lack of funds and political interference, causing deterioration in the quality of service in the government hospitals. However, the agency cost is the most important cause. The real threat to the government/public sector does not come from the policy-makers who have a bias for the private sector, private entrepreneurs, or capitalists. It originates in the private motive of the persons who man the government/public sector and make decisions on their behalf. The real privatisation of a public sector or government organisation begins when its management starts thinking in terms of its own self-interest at the cost of the organisational goals. The worst happens when the management uses the organisation for its own sake. This is the extreme form of agency cost responsible for the deterioration of an organisation. Given the same environment and budget, a hospital in private sector provides better service, and more efficiently, than a government hospital. One can see the mushrooming of private nursing homes in a city like Chandigarh, which has the prestigious PGI and a modern government hospital. It would be tantamount to complacency if one thought that the growth of private nursing homes in the city was only due to the increased demand for medical service that government hospitals were not able to cope up with. There is a definite shift from government hospitals to the private sector. It appears that the privatisation of hospitals too is imminent. If a well-established government hospital is not running properly in the same city where private hospitals are thriving, it is natural to think of privatising the hospital as a feasible solution. The change of ownership per se does not increase organisational efficiency or effectiveness. The implicit assumption behind the privatisation of a public sector unit is that the change in ownership will ensure improvement in the managerial performance and worker productivity. What is the logic of an increase in efficiency and effectiveness due to the change in the ownership, from government to private? Governments finance capital either from taxing the public, or through deficit financing or borrowings whose burden is borne ultimately by the public. The risk taker in the case of public investment is, therefore, the public at large. However, since the risk is spread over a large number of individuals, it can be proved mathematically that the cost of risk bearing, as perceived by society, approaches zero. In the case of the private sector, the risk is borne by the limited number of shareholders. The cost of risk bearing is significant for each one of the shareholders. Often people make laughing reference of failures of a public sector unit. But the same people lose their nights sleep if the share value of a company in which they are stakeholders declines. The risk of inability to achieve the objectives of an organisation in the private sector keeps the shareholders, at least the major ones, alert and, thereby, there is constant pressure on the management to perform. Just like the burden of the loss, the joy is also shared by a few in the private sector. So, the shareholders are willing to reward good performance as much as they are to punish the bad performance. The accountability of the management does the trick. We are in the age of competition. The service providers in the private sector compete among themselves and also with the government/public sector. Huge investment is being made in purchasing state-of-the-art machines and equipment. Highly skilled doctors and the supporting staff are being employed. Ultramodern facilities are being created. Customer satisfaction is considered as the ultimate route to profitability. As a result, the quality of service in the private sector has been improving. Let me hasten to add that there is a lot to be desired as regards the quality of service in the private hospitals too. The hygiene and infrastructure facilities in the best of the private hospitals in the country are poor as compared to the international standards. The point to be made is that the quality of service is improving in the private sector through time vis-a-vis the government sector. Privatisation is not a matter of ideology, as many people, particularly politicians of leftist orientation, seem to believe. It is not a matter of legal definition. It is not a matter of procedure either. It is a consequence of market mechanism and the underlying real forces that determine the supply and demand. Any ideological debate should favour a system that is organised around the principle of supremacy of the societal interest rather than on the principle of maximisation of individual self-interest. Economists have known since long that the conditions for self-interest-motivated market mechanism to maximise social welfare are too stringent to be applicable in the real world of market distortions. Such systems ignore the interest of the poor and the weak, and, most important, of future generations. Future generations belong to society but do not exist in the present to reveal their preferences in the market. An extreme case of inter-generation inequity takes place when an unborn is killed through abortion on the basis of the revealed preference of the present generation. Thus, theoretically, there is a strong case for public sector hospitals as against private sector hospitals. Yet, the reality is that there is a reverse trend. And it must be emphasised that any trend towards the privatisation of hospitals becomes a matter of concern in view of the increased probability of neglect of the poor and the weak who cannot afford to pay. It must be appreciated that not all the hospitals in the private sector run on profit motive. Nor all the private practitioners have only money as motive. There are private practitioners fully dedicated to serving the poor and the weak. There are hospitals that aim at serving humanity free of cost. They generate funds through donations. The hospitals run by voluntary agencies and welfare organisations are among the top institutions. Indeed, providing medical service to the needy is on top of the agenda of a large number of non-profit organisations not in the government sector. These have well-defined objectives and the management and functionaries are accountable. There is no place for those in these organisations who even slightly deviate from the organisational goals.But the general model of the private sector is that of profit motive and competition as presented in the above paragraphs. The obvious lesson for the government hospitals is then to develop a system of accountability,and reward and punishment. Today the good are being weeded out from the government system. The need is to weed out the bad. The lesson is obvious. Yet, I do not think, it will be learnt. The future, therefore, is that of private sector hospitals. Due to competition the quality of medical service is expected to improve to a satisfactory level for those who can afford to pay. The future of medical service for the teeming millions below the poverty line (and one should not believe that those above the poverty line are not poor) is indeed bleak. Even if the blissful world of perfect competition prevailed, in distant future, where the services would be produced and sold at a level of prices equal to the marginal revenue equal to the minimum marginal cost, the poor would still not adequately be served. That level of minimum cost too would be too high for them to afford. (The writer is
Professor, University Business School, Panjab University,
Chandigarh). |
Why tinker
with history? HISTORIANS dont make history. Most of them are mere tools to tinker with the past events. This precisely has been the irony of the historical discipline. It is high time responsible intellectuals stemmed the ongoing efforts of painting the past so that we didnt lose the spirit of our history. Any historical analysis ought to be based upon objective interpretations and not wishfully induced ideologies. There is no doubt that we have complaints with our past record. But shall fabrication yield anything? It is a fact that during the times when foreigners ruled here history was written by our ancestors and also by those who ruled over them. Some might have been hired to write history. However, must be bitterly complain that our achievements were excellent but were shown shoddy by those who doctored history? That they passed on to us lopsided historical analyses and wrong interpretations so as to suit their ends and to keep us down. Is the current hue and cry about tinkering with history without any basis? But what is intriguing is that in independent India with constitutionally guaranteed freedoms and our much touted intellectual liberties, the modus operandi of the colonial rulers should be in vogue. Must the works of objective minds be confined or controlled? Objective and scientific recording of history demands that we lay bare all that is there. If we pick and choose and delineate what suits us, we shall be branded suitably. What is the rationale of the psyche that if one paints ones past bright ones present and future shall automatically become so? Historical writing, though it can encompass all psyches, cannot change the course of bygone events. Why do some of us dig the sands of time to search for the golden dust? Can any country claim that its past was all golden? Let us not falsify the fact that some invaders defeated India and ruled here. We cannot change our history in our fantasies as many would wish. A fanatical play with the historical past is akin to playing with fire. The current efforts of a particular sect of historians to exclusively own Indian history shall be counter-productive. All Indians can take pride in being part of the common heritage. Certain committed writers shall still continue to rake controversies. And the unique thing about historical controversies is that no matter how much the contemporary historians fight to the gallery, these shall reveal the motive. Most of the historical works have been thus lopsided, subjective and at times contrived. No history is true history. All governments make efforts to defend their instruments. But must the particular days government fend for the wrong-doings of the party persons. Most of the blatant espousers of the fundamental ideology, in the forefront now, are mere weathercocks. It would be worth the effort to shuffle through their feathers. Many of the yes men of yesterdays regime are todays cronies. Their motivation is profit and opportunity. Many of these swans can crow again. Ina country as ours, this has been the bane of our history. The country is not the foremost for many. If that had been the case many of our ills would not have been there. The irony of our times is that our elders who were 20 years plus at the time of Indias independence are still in the saddle of power and are running the country as the colonial rulers. There cannot be any sacrosanct history of the Indians by the Indians for the Indians providing Davidians the rationale of the past. Even the officially supported ideologies and their narration cannot provide us the sure signposts of the past. But the mending of history must not be allowed. The study of our history is of invaluable importance. But neither the Spencerian nor Marxist models of the study of history can do us any good. These are alien approaches. Even the imagined and concocted history, which may have the potency to provide stimuli, is no solution for a people who have got their track record as well as its history wrong. (The writer is
Director, Indian Council of Historical Research, New
Delhi). |
From
darkness to light MY despondent colleagues might envision the doom of our university and lament its quality of leadership, though I notice a rare briskness in its pace to replace darkness with light. Until two or three years ago one campus corner looked like a virtual pit of reptiles where sat in the dark a bunch of rogue dogs who would start snarling at the approaching shadow of a morning walker. This was right in the porch of the main library which I never saw lighted at night during my 37-year stay on the campus. It was a fearsome patch which prompted some of my friends to buy bludgeons, both long and short, to safeguard their legs and ankles from those bloodhounds. Once or twice I suggested to one dynamic dean that he could ask the library guards to check the morning menace. A few days later he reported that being equally scared of those wild creatures they didnt have the heart to open the door and face them. Very coolly he advised me to keep off the killing field and choose a different route for the walk. But how could I abandon the beaten track fringed on both sides by some of the most majestic trees mango, gulmohar, Ashoka, palms and amaltas? Well, just to preserve my self-esteem, I pulled out my Baltimore baton from a carton and walked at my own risk. I would hurl a loud no at those advancing rowdies, show them my secret weapon and keep moving to complete the campus round. That ghoulish spot that turned back many a walker, now uplifts my spirits. Gone are the savage sounds. The killing field offers now a contrasting sight with those young students walking up and down, revising their lessons and priming themselves for the trials. They study all night in the reading room and come out in the morning to energise themselves both with the fresh air and a bit of coffee from the joint that never existed until two years ago. The well-lit area has vanquished the fear that for decades had haunted the walk-addicts. Putting it plainly, a feat of transformation. Whoever thought of
brightening the portico of the library, keeping the
reading room open at night, and setting up of the coffee
outlet at a need-based location deserves my salute. |
Over to
the countryside OVER to the countryside has been an old Mao Ze Dong dictum to his communist cadre. His much acclaimed revolutionary guerrilla strategy was based on first capturing the countryside and then prepare for protracted assaults on the city areas. Half a century later, Indian Naxalites too are replicating the same old strategy and with fairly good results. But now our modern capitalists both the dying tribe of desi and the all-powerful MNCs have it all reverse. The business has begun invading the countryside in a big way. Big and small players planning their market strategy to penetrate into what they hope the booming rural market. While doing so, they also aim at ousting the tiny sector which now meet the limited rural needs. All sorts of fancy figures are being bandied about the potentials of what was once derisively dismissed as upcountry market. Market surveys like the election predictions by similar research agencies are highly prone to exaggeration depending on who charters them. One such survey recently predicted that in the next six years, the low income households in the rural areas will be down to a merely 16.5 per cent of the population. If one takes such rosy predictions at their face value, in two years, proportion of the high income rural households with earnings of over Rs 1.25 lakh per annum has gone up from 0.3 per cent to 2.3 per cent. Thus they predict that by 2006, the population of the rural consuming class will be 43.3 crores or over 75 per cent of all households. For the market, this is quite an inspiring figure considering the fact that Indias middle class consuming population itself was put at 30 per cent and on which the whole marketing strategy has been drawn up. And to cap it all, 42 per cent of the rural households own TV sets. What else you need for turning the entire rural India into a booming market? Such rosy visions apart, the rural market has over the years acquired importance, both quantitatively and qualitatively. In fact, even in the first half of the last century, rural India had an important share in the sale of consumer durables of the era. In the absence of a wide network of outlets, rural sales were through short newspaper advertisements and sent through VPP. Rural landlords and well-to-do sections bought the prestigious West End watches, clocks, kerosene lanterns, petromax and gramophones and displayed them as status symbols. Thus rural India as a potential market for manufactured goods is not a discovery of the new market wiz kids. Shorn of the myths and heady hypes, the rural market has come to play an important role in Indias consumer sales. The urban market has its own definite characteristics and limitations. It cannot be defined as one single segment. It has layers after layers depending on the purchasing powers of the respective sections. It is highly region specific. Unlike the pre- World War II rural market, the present boom is confined to a few prosperous areas which have been benefited from the green revolution, cash crop and the limited percolation from the nearby cities. For the new marketers and strategy planners, rural market includes all areas beyond the existing marketing network centred on the major consuming conglomerates. This includes the mofussil towns some of them as big as the cities and the areas served by the distribution centres therein. The shop owners even in interior villages collect their merchandise from such centres. Incidentally, even during Mahatma Gandhis childhood, the concept of self-sufficient villages, which used no consumer items produced outside, had ceased to exist. The new consumer boom is a continuation of an old process but in a quicker pace with organised efforts driven by a budget of several million. Segmentwise, on the top is the highly affluent farming class with huge surplus funds and tremendous purchasing power. Products of green revolution, in most places they own large tracts of land alienated from the marginal farmers in the process. Among them, a new generation with modern education and high consumer aspirations has emerged. Frequently exposed to high living and lifestyle of the urban centres, they bring along the best vehicles, clothes and gadgets to their rural estates. In their craze for showing off their acquisitions among their village clans, they even display cell phones which cannot in any case work in the interior regions. Recently, some automobile giants have claimed that many of their highest priced cars had their buyers among this rural nouveau riche. Freed from the control of the old miserly generation, some of them are reckless spenders. Vagaries of agricultural income make them less bothering about credit which they could clear after the next best crop. In some parts of Punjab and cash crop rich Guntur, it is claimed, the young farmers vied with each other to acquire the latest model of tractors and farm equipment. Farmers from far away UP and Bihar go to Punjab villages to buy the sparingly used second-hand tractors. Thus this section has emerged as the prized target of the high-priced consumer durables. Market promotion shows are held in such rural centres exclusively for this segment. Some market strategists have even come out with slightly modified versions of urban products (like cars and washing machines) to suit the rough rural setting. But in many cases, such exclusivist strategy boomeranged as the rural rich insisted on the same city versions. The neo kulaks lack of vision and enterprise to divert their surpluses to new profitable ventures like rural industries turn them mad spenders. Luxury cars as dowries is quite common among certain prosperous regions. This lucrative but extremely narrow section apart, there are clear signs of an emerging rural upper middle class market. Several factors have contributed to this process. Residuary effects of the green revolution a sterling contribution of the much maligned Nehruvian planning and the urbanisation process, rather than the percolation of reform and globalisation, seem to be at work. Spread of TV-induced consumerism and urban saturation for many products have encouraged the market men to invade the rural upper middle class market in a big way. Change in price structure of many essential items has been another factor. Detergent is cheaper than washing soap. In prosperous rural areas with a fairly developed bazaars, well stocked smart shops are slowly coming up side by side with the old banias dukan with teraazu as symbol. MNCs, and not our own corporates, were the first to sense the significance of this market. As early as 1994, this writer was witness to a large group of small industrialists being taken to Narasimha Rao by Murli Manohar Joshi to complain against the intrusion of the MNCs into the rural market. L.K. Advani too had met them at Parliament House. They had specially mentioned cases like the cheaper Wheel brand detergent launched by an MNC as their rural version detergent just to oust the tiny producers. It is another matter if the wheel has now turned a full circle and the two Union ministers no longer bother about the SSIs. At the lowest level is the vast backward rural tract, far away from the farm revolution and steeped in penury. The market has little interest in this vast region with stagnated agriculture sans little capital formation, large marginal farmers and jobless agricultural workers. It is a rural version of the north-south divide. The schism is not only between the tiny pockets of prosperity and the vast backward region but also within the former. Two different kinds of markets exist side by side in the prosperous pockets as the booming shopping centres and the humble dukans in the dingy lines of the mazdoor bastis behind the posh flats. The most important implication of the increasing business interest in upmarket or urban sectors will be a sudden change in the governments rural policies. Already, corporates are showing more interest in rural development programmes in selected areas. Some are planning to launch their own NGOs with ample funds. Apparently, all this is much more than mere philanthropy. Generation of more rural income among those sections with more purchasing power means deeper market penetration. Board rooms have begun keeping closer watch on such aspects as agricultural production, impact of farm prices and subsidies on the purchasing power of the rural market. Business writers are already betraying signs of confusion. If subsidies can boost sales of both desi and MNC it can boost production and generate services. And so goes the debate well behind the pink pages. For the corporates, it is not just a notional issue. For well over a decade, the index of industrial production depended on the performance of agriculture. A direct correlation has been established between the fall in agricultural income and overall sales of the manufactured goods. Industrial growth depended not on factors linked with industry but behaviour of agriculture. Even if farm output was stagnant but farm prices went up substantially, it will boost industrial production. This is extremely
necessary for the industry to plan their production.
Papers for the board rooms have established that there is
usually a one-year time lag for the agricultural
performance to reflect on the industrial production. In
1994-95, it is pointed out, farm output went up by 4.5
per cent and farm prices by 15.7 per cent. The next year,
industrial production rose from 9.8 per cent to 13.8 per
cent. A similar correlation was seen in 1997-98 and the
subsequent year. The better industrial performance in
1999-2000 was attributed to the bumper harvest of
1998-99. Thus the severe drought raging the country this
year is bound to adversely affect the demand for
manufactured goods, especially consumer durables. The
result will be a corresponding fall in industrial
production next year. |
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