“Indo-Pacific” is in the news. The US has renamed its Pacific Command to the Indo-Pacific Command, the shared regional vision outlined by India and Indonesia has emphasised its centrality, and the region’s political importance to India was at the core of the expansive foreign policy speech delivered by Prime Minister Narendra Modi in Singapore. All of these are a response to the spectacular rise of China. If this points to a future concert of powers in the region to balance Beijing’s power play, it will be an important yet insufficient measure in reaction to the Chinese project that connects Asia and Europe.
Covering 35% of the earth’s surface, Eurasia is home to five billion people living in over 90 different countries and producing nearly 70% of global GDP. For millennia conquest, trade and migration have organically bound Asia and Europe – the ebb and flow of great civilisations across this vast landmass spawned myriad political and economic dynamics of global history.
Only in the recent past, in historical terms, have these been interrupted. The Industrial Revolution in Europe and the subsequent colonisation of Asia and Africa created an artificial divide, concentrating on economic and military power in ‘the West’.
Asia’s contemporary economic ascendance allows people, goods, innovation and finance to flow relatively freely across Eurasia again. But the re-emergence of the supercontinent is not frictionless. New integrative geo-economic forces bring with them new political tensions.
As history repeats and Eurasia coheres, the outlines of a new world order will be defined by who manages it and how it is managed. It is in this supercontinent that the future of democracy, of free markets and global security arrangements, will be decided. And there are three key factors influencing this.
The first, to borrow a phrase from Robert Kaplan, is the revenge of geography. As much as Eurasian integration is organic, its current ‘avatar’ is decidedly Chinese. Having assessed that the divide between Europe and Asia was an artificial, modern and ‘Western’ construct, China is doing what no other power had the appetite for: conceive of, define and then manage Eurasia.
The Belt and Road Initiative (BRI), Beijing’s choice of instrument, is creating sprawling networks of connectivity projects – each designed to embed dependency on China’s economy into this geography. Simultaneously, BRI dilutes the importance of the landmass’s sub-regions, thereby upsetting the settled balance of power arrangements.
India and the European Union (EU), for example, are struggling to curb China’s creeping influence on their sub-regional political, economic and security conversations. A “free and open” Indo-Pacific vision, and nascent coalitions like the Quadrilateral initiative seek to balance China’s rise on the maritime front. The oceans, however, are but one of China’s platforms – and a purely maritime response is inadequate.
China is relentless in pursuing this project: building infrastructure, facilitating trade, and creating alternative global institutions. Surreptitiously, China also exports its political model: “capitalism with Chinese characteristics” – a unique blend of state capitalism and authoritarianism. Unless liberal democracies propose an alternative in Eurasia that effectively addresses the infrastructure needs of countries in Asia and Africa, China’s proposition will succeed.
Here lies the second factor: the revenge of democracy. Whether it is the US, EU or India, democracies are more polarised than ever before. The Pew Global Attitude Survey consistently records that trust in democratic governments is at an all-time low. More than ever it appears that liberal democracies are bogged down by domestic crises, leaving them little energy for strategic planning. At a juncture when China’s timelines are decadal, democracies are struggling to look past their next election.
And the final factor, demography, is a double-edged sword for the entire region –, especially for China. For many Eurasian countries, BRI’s economic benefits are obvious. However, in an era when nationalism is the defining mood of politics, China’s presence can be unwelcome. China’s labour exports create tensions with younger host country populations who must now compete for employment opportunities. There is the risk that BRI will merely create infrastructure networks for extreme and radicalised organisations in unstable countries.
At home, demographic pressures might force Beijing to reconsider its ability to deliver. As younger Chinese move up the income ladder, their expectations from their government will increase. Simultaneously, the preponderance of single young men in urban regions and ageing rural populations makes Chinese society susceptible to violence and unrest. What will these demographic pressures portend for the project of Eurasian integration? Will the Chinese state have the political capital to recklessly buy influence across the world? Will demographic complexities allow others to cobble together a viable counter to the Beijing consensus?
Sitting in New Delhi, it cannot be more obvious that India’s development and security is inextricably tied to Eurasia. India sits at the crossroads of continental Eurasia and the Indo-Pacific – the two regions that will define this century. The US has expended blood and treasure over the past nine decades to maintain its privileged position in these two regions. Russia, the original Eurasian superpower, is reduced to a glorified policeman, or more charitably, a crafty risk management consultant for Chinese expansionism. And EU can either choose to be an actor or be acted upon, one slice at a time.
It is critical that all of them, and more particularly India and the US, imagine an arrangement beyond the Indo-Pacific, into the heart of Eurasia. China’s continental-sized poser requires a supercontinental answer. It is for the liberal world to stand up and be counted, or step aside and let Pax Sinica unfold.
Author: Samir Saran, President of Observer Research Foundation.
Three of the fastest-growing applications of artificial intelligence (AI) today are a manifestation of patriarchal stereotypes – the booming sexbots industry, the proliferation of autonomous weapon systems, and the increasing popularity of mostly female-voiced virtual assistants and carers. The machines of tomorrow are likely to be either misogynistic, violent or servile.
Sophia, the first robot to be granted citizenship, has called forwomen’s rights in Saudi Arabia anddeclared her desire to have a child all in the span of one month. Other robots are mere receptacles for abuse.
The Guardian in 2017 reported that the sex tech industry, including smart sex toys and virtual-reality porn, is estimated to be worth a whopping $30 billion. This is just the beginning. The industry is well on its way to launch female sex robots with custom-made genitals and even heating systems, all in the quest to create a satisfying sexual experience.
The advent of sexually obedient machines – which are designed to never say no – is problematic not just because of the presumption that women can be replaced, but because the creators and users largely tend to be heterosexual men. The news of a sex robot being molested, broken and soiled at an electronics festival in Austria last year should hardly come as a surprise.
While one could argue that the use of sexbots could reduce the abuse and rape of women in real life, it is undeniable that these machines are created to serve some men’s perverse needs. The machine represents a new wave of objectification, one that could potentially exacerbate violence against actual women.
The arrival of lethal autonomous weapon systems (LAWS) or “killer robots”, on the other hand, threatens to de-humanize both the male and female victims of war.
On the one hand, autonomous weapons could reduce the number of humans involved in combat and even decrease casualties. Killer robots could ultimately bring down the human cost of wars. On the other hand, they could downplay the human consequences of combat — and indeed, violence itself — and lower the threshold for armed conflict.
Several states are calling for a pre-emptive ban of killer robots, afraid that they might lead to an AI arms race, one that could raise the risk of a violent clash. Should machines be allowed to make life and death decisions? Or should this choice stay in the hands of humans, however fallible they may be?
Finally, the development of voice assistants and Internet of Things (IoT) devices for the care of children and senior citizens is a market that is expected to expand rapidly in the next decade. The presumption that machines cannot invoke the emotional intelligence that care workers possess is increasingly being challenged with the emergence of smart tracking devices and health monitors that can observe and predict behaviour.
These innovations no doubt share their underlying technology with other voice-driven platforms such as virtual assistants – platforms often designed to mimic servility and subservience. It is no coincidence that voice assistants are often designed to sound and act feminine – take Apple’s Siri (in its original avatar) and Amazon’s Alexa. The more recent development of a ‘male’ option for voice assistants does not change the overall picture of male dominance and female servitude in AI.
When chatbots and voice assistants are fed on a diet of data assembled by male coders, machines perpetuate inequities found in the real world. This can have unintended consequences.
Given the general uncertainty surrounding the impact of AI on the real world, the responsibility of creators as well as broader communities merits all the more attention.
Today, machines reflect regressive, patriarchal ideas that have proven to be harmful to society. If this continues, technology may no longer usher us into a post-gender world. In fact, like all bad doctrines that have held communities back, biased codes may just institutionalize damaging behaviour.
Perhaps the involvement of more women and marginalized communities in the creation of AI agents could deliver the equity that we desire in future machines, and prevent the development of more patriarchal technology. If the machine is patriarchal, do we remove the more systemic condition of patriarchy or reduce reliance on the machine altogether? Both are easier said than done.
To build an equitable world, which will be inhabited by women, men and machines, the global community needs to script norms around the fundamental purpose, principles of design and ethics of deployment of AI, today.
Autonomous systems cannot be driven by technological determinism that plagues Silicon Valley – instead their design should be shaped by multiethnic, multicultural and multi-gendered ethos. AI and its evolution, more importantly, needs to serve much larger constituencies with access to benefits being universally available.
The administration of AI applications cannot be left to the market alone. Experience tells us that the market often fails and is regularly compromised by perversion and greed. History teaches us that when governments control, constrain and constrict innovation, they produce aberrant outcomes that are far from ideal. Norms developed by communities, instead, provide a workaround. We must promote norms that manage these technologies, make it available to those who need it most, and ensure a gendered development of this space led by a multistakeholder community that includes voices from outside the Atlantic consensus.
Samir Saran, Vice-President, Observer Research Foundation (ORF)
In 2005, the Government of India launched the National Rural Health Mission (NRHM), promising to re-imagine primary healthcare and address the under-served needs of rural areas. The thrust of the mission was to establish a fully functional, community owned, decentralised health delivery system with inter-sectoral convergence that ensured parallel improvements in areas that impact health outcomes – such as water, sanitation, education, nutrition, and social and gender equality. It subsequently published the Indian Public Health Standards (IPHS) as a reference point for public healthcare infrastructure planning and upgrade of existing facilities. In May 2013, the Manmohan Singh Cabinet approved the framework, with Rural Health and Urban Health Missions as the two sub-Missions of the over-arching National Health Mission (NHM).
Complementing NHM at the secondary and tertiary level care is the Rashtriya Swasthya Bima Yojana (RSBY) at the national level, and a number of state-level government health insurance initiatives. However, many big states like Uttar Pradesh do not implement RSBY, and the overall budget for such schemes remains limited. They often offer light financial protection and narrow coverage.
By the time the government established the NRHM, it had also made international commitments to achieve the Millennium Development Goals (MDGs). In fact, the 11th Plan laid out goals and targets that were more ambitious than the MDGs. In 2015, the government ratified the Sustainable Development Goals (SDGs), committing itself to the inclusive and universal development of people and planets through cross-sectoral collaboration for equitable prosperity. Unlike the MDGs, the 17 SDGs and 169 targets announced at the UN General Assembly 2015 were developed by the countries themselves and aim to stimulate action over the next 15 years. Ensuring Universal Health Coverage for all citizens was seen as a critical strategy to achieve the SDGs. The 12th five year plan, Niti Aayog’s Three Year Action Agenda, as well as the National Health Policy 2017 have health targets well in line with the ambitious SDG targets.
The Lancet Commission findings for India revealed that a $1-investment in health would yield a $10-increase in gross domestic product (GDP) by 2035. Over the last eight years for which detailed official data are available, India’s health spending has gone up considerably, as Graph 1 shows. The seemingly sudden decline in the Centre’s share in 2014-15 is due to a change in statistical method – from that year, transfers to states through the treasury route were taken as part of state expenditure. The recent devolution and the changes in the structure of fund flows in the health sector (Box 1) have increased the proportion of money spent on health by the states. However, the increase in public spending on health – when considered as a percentage of GDP – remains more conservative, increasing over the last decade from 1.1 percent of GDP to 1.4 percent.
Box 1: Recent Changes in the Structure of Fund Flows in the Health Sector
India has a federal structure of government, wherein a number of schemes in various sectors (including the health sector) are initiated at the national level and implemented at the subnational level. Till March 2014, the bulk of funds for these schemes were released by the central government directly to implementing agencies without involving the treasuries of the state governments. After March 2014, these funds have been released to the treasuries of the state governments, which in turn release them to state-level implementing agencies. The state-level implementing agencies further release funds to district-level, block-level and lower level implementing units. Public funds therefore, have to flow through multiple levels of governments and administrative units before these can be spent on the designated goods and services.
In 2014-15, the first year in which NHM funds were routed through the state treasuries, the utilisation ratio was much lower in ‘high-focus’ states than in ‘non-high focus’ states. This could possibly be a reflection of relatively weak institutions in the ‘high-focus’ states, which hindered easy adaptability to the change in the mode of fund flows. Source:
Despite the recent successes in disease elimination and the largest ever decadal decrease in neonatal, infant and maternal mortality, a large section of the Indian population still has limited access to quality healthcare. The newly released disease burden estimates underscore the health challenges faced by the Indian people.
Health Challenges for India
Life expectancy at birth improved in India from 59.7 years in 1990 to 70.3 years in 2016 for females, and from 58.3 years to 66.9 years for males. State statistics however showed inequalities, with a range of 66.8 years in Uttar Pradesh to 78.7 years in Kerala for females, and from 63.6 years in Assam to 73.8 years in Kerala for males in 2016.
While the per person disease burden measured as the disability-adjusted life years (DALYs) rate dropped by 36 percent from 1990 to 2016 in India, there was an almost two-fold difference in this rate between states in 2016. Amongst the states, Assam, Uttar Pradesh and Chhattisgarh had the highest rates, and Kerala and Goa the lowest.
For India as a whole, the DALY rate for diarrhoeal diseases, iron-deficiency anaemia, and tuberculosis was 2.5 to 3.5 times higher than the average for other geographies at a similar level of development, indicating that this burden can be brought down substantially.
Source: India: Health of Nation’s States (2017)
The most important health system issue emerging out of the latest disease burden statistics is the considerable shift from infectious and maternal/child health conditions to non-communicable disease (NCD) conditions across states. India’s public health delivery system is still geared towards infectious diseases as well as maternal/child health conditions. There is very little in the existing structure to address emerging concerns like non-communicable disease conditions or mental health. If drastic changes are not made followed by sufficient funding, these emerging challenges will soon blindside India’s economic growth story.
Primary health services remain extremely inequitable within the country, both in terms of access and delivery. For example, according to data from 2017 calculated using the prescribed norms on the basis of rural population from Census 2011, Andhra Pradesh has a primary health centre (PHC) shortfall of four percent, Uttar Pradesh of 30 percent, Bihar of 39 percent and Madhya Pradesh of 41 percent. Overall, the country still has a 19 percent shortfall of sub-centres, 22 percent shortfall of PHCs, and a 30 percent shortfall on community health centres (CHCs).
Access and delivery problems are compounded by severe human resource constraints. Challenges prevail in three aspects of human resources for health: numbers, distribution, and skills. In terms of numbers, the country faces a shortage of physicians and specialists, with a doctor-patient ratio of 0.7 per 1,000. This is significantly lower than the global average of 1.4, as well as that of several other developing countries and emerging economies, including Brazil (1.9), Turkey (1.7) and China (1.5). In March 2017, nearly eight percent of PHCs in India had no doctor and 18 percent were unsupported by pharmacists.
While the National Health Policy (NHP) and its main implementation arm, the NHM, outline an ambitious vision, India’s investment is healthcare remains low. The majority of the population continue to bear the brunt of healthcare costs with limited accessibility to quality health services.
Indeed, despite a rapidly growing economy, government expenditure on health has seen no significant increase for a decade (2005-2014). It hovers between 1.1–1.4 percent of GDP, significantly lower than that of Nepal (2.3 percent), Bhutan (2.6 percent) and Sri Lanka (two percent), and shamefully lower than the global average of six percent. While the NHP talks about an increase to 2.5 percent by 2025, there is no clarity on how much the increase will be on an annual basis. The 2.5 percent allocation is despite the increase to three percent of GDP by 2022 recommended by the High-Level Expert Group (HLEG) on UHC set up in October 2010 under the auspices of the previous Planning Commission, and takes no cognisance of a study conducted by Ernst & Young which estimated that government expenditure on health will need to account for 3.75-4.5 percent of GDP by 2022. As a result of the low priority given to public healthcare spending, Indians on average have a very high burden of out of pocket (OOP) expenditure on health (Graph 2).
Graph 2: Public Health Expenditure and Out-of-pocket Expenditure
The poor availability and quality of public health services is forcing people to seek care in the private sector. In India, the private sector provides more than 80 percent of outpatient care and 60 percent of inpatient care. With no widespread financial protection scheme in place, private spending on healthcare negatively impacts the financial stability of millions of Indians every year. Latest research using National Sample Survey Office (NSSO) data from 2014 found that the percentage of Indian households that fell below the poverty line due to OOP health expenditure was seven per cent of the total; this is a massive number. OOP expenditure remains alarmingly high at 62.4 percent, as already discussed. Based on NSSO 2014 data, of all health expenditure, 72 percent in rural and 68 percent in urban areas was on buying medicines for non-hospitalised treatment.
Against this backdrop, Global Health Strategies (GHS), in partnership with the International Vaccine Access Centre (IVAC), Johns Hopkins Bloomberg School of Public Health, and the IKP Trust, undertook a study to evaluate public financing mechanisms capable of sustainably delivering UHC in India. The key recommendations of the study were that India urgently needs to re-examine both the provisioning and financing of healthcare. In terms of provisioning, the government should aim to universalise free primary healthcare at the point of service. This will ease the load on the secondary and tertiary care centres. To finance this provision, a higher proportion of GDP will need to be allocated from tax revenues. There should be a national social health insurance (SHI) covering secondary and tertiary care for the entire population. Additionally, supplementary taxes such as sector-specific taxes, so-called ‘sin’ taxes, corporate social responsibility (CSR) contributions, tax-free bonds and trust funds could also be explored for specific health interventions over short periods of time.
The GHS study report was drawn up through literature review, interviews with experts and a high-level, national consultative meeting. This Special Report builds on the findings of the study and presents recommendations for a policy audience.
Why the Public Sector Must be Involved in Healthcare
Nobel laureate Kenneth Arrow had laid down the reasons why healthcare cannot be treated simply like any other commodity, to be sold and bought at prices determined solely by market forces. His argument was that the very unpredictability of health needs and expenses makes people less likely to provide for future health expenses than, say, for future housing or clothing needs—a phenomenon that he called ‘hyperbolic discounting’. A healthy person tends to think that health lasts forever. Access to health information is limited, making the patient dependent on doctors for crucial decisions about treatment and that too at a time when s/he is physically and mentally vulnerable and extremely easy to exploit. Trust is therefore the most important component of the doctor-patient relationship. Unpredictability of health outcomes, and the fact that patients are billed once a non-refundable service has been delivered, means that it is not possible to shop for health services the same way as one would shop for, say, toothpaste. There is also a demand-supply gap: the number of doctors available is limited; years of study and a licence to practice medicine are entry level barriers and justifiably so. That again makes it different from shopping for toothpaste because, in theory at least, there is no limit to the number of companies that can manufacture toothpaste.
International examples bear out Arrow’s argument that governments need to be the actively involved in healthcare, as it is not a standard market good. In Japan, for example, 82 percent of all health expenditure is publicly funded. The Organisation for Economic Co-operation and Development (OECD) countries’ average is 72 percent. Japan has a mandatory health insurance scheme, with premiums based on the socio-economic status of beneficiaries. Healthcare in Sweden is primarily funded by the government, which raises money through taxes. At 11.9 percent of GDP, the Swedish government’s spending on healthcare is one of the highest in Europe. International precedents show that when public spending on healthcare rises to around six percent of GDP (the global average for UHC systems) OOP payments fall below 20 percent of total health expenditure.
In India, the over-reliance on a largely unregulated private sector is fraught with risks of unnecessary costly interventions being chosen over more cost-effective options. That this is already happening is clear from National Family Health Survey 2015-16 (NFHS-4) data that shows that approximately twice the number of babies are delivered by Caesarean section (C-sec) in the private sector as compared to the public sector. While World Health Organization (WHO) guidelines suggest that C-sec should be prescribed within the range of 10-15 percent of total births, private sector rates range from 87.1 percent of deliveries in urban Tripura (compared to 36.4 percent in the public sector) to 25.3 percent in urban Haryana (compared to 10.7 percent in the public sector). WHO also says that while C-secs can reduce chances of maternal and child mortality, there is no evidence of any extra benefits if the rate rises above 10 percent in a population.
The quality of care in the private sector is not always up to standards prescribed by Indian Public Health Standards (IPHS). A study in rural Madhya Pradesh found that only 11 percent of the sampled health-care providers had a medical degree, and only 53 percent of providers had completed high school. Thriving quackery, not just in rural areas but also in urban pockets, is an open secret. Recent examples from Delhi private hospitals show that high-end, expensive hospitals can also have uninterested and callous administrations, thus not necessarily providing quality care to paying patients. Big hospitals may not be available near most rural or low-income communities, being concentrated mostly in urban areas where people have the capacity to pay high amounts. However, what keeps the private sector hospitals – which are a highly differentiated set in terms of size, quality and cost – receiving the bulk of the patient load is that they are available round the clock, at close proximity to the community.
This is not to say all private sector hospitals are bad and should be done away with. They have an important role to play in a country with a large population and limited government intervention. The problem is an over-reliance on the largely unregulated private sector where payments are mostly out-of-pocket and high. This can and does result in negative conditions of over-treatment, poor quality, selective care, and cost escalations.
India Needs to Spend More and Spend Better
Health is a state subject. Yet it is the Centre that is the prime mover behind the National Health Mission, which is a core central scheme. Despite the focus on healthcare in the Budget 2018, the actual allocation for NHM decreased from INR 31,292crore in 2017-18 (revised estimate) crore to INR 30,634 crore (budget estimates) in 2018-19. This is a decline of about two percent from the revised estimates of 2017-18.
In addition to the inadequacy of funds, the inconsistency in the timing of funds released by the Centre to state governments has contributed to inequity in terms of service delivery across the country. On average, there were more unutilised funds at the end of the year in the states that needed them most. A 2017 study by the influential National Institute of Public Finance and Policy (NIPFP) and WHO India on utilisation, fund flows and public financial management under the NHM found that at the state level, a file with a request for release of funds has to cross a minimum of 32 desks while going up the administrative hierarchy, and 25 desks on the way down. The study recommended streamlining processes to ease the rigidities of the state treasury system.
One of the primary operational hurdles that the NHM faces is the absorption of funds by states because of their erratic periodicity of release. Sometimes this can be a chicken-and-egg situation. In the first quarter of 2015-16, for instance, 57 percent of NHM allocations were released. However, the corresponding figure was 29 percent in 2014-15 and 46 percent in 2013-14. Similarly, analysis by CBGA shows that while the overall central health budget in 2018-19 was increased, allocation for , Reproductive and Child Health (RCH) component in 2018-19 (budget estimate) has in fact declined by 33 percent from 2017-18 (revised estimate). Along with this , the allocation for Pradhan Mantri Matru Vandana Yojana (PMMVY), which was earlier called the Maternity Benefit Scheme, has also decreased by eight percent over 2017-18 (RE)
It is believed that strengthening health systems will increase the states’ capacity to absorb increased allocations, and should be prioritised, particularly in high-burden states and districts. Poor absorption and distribution of funding at the state level leads to an accumulation of unspent resources each year. This lack of absorptive capacity at the state level has been used both as a justification for the Centre’s non-release of funds, as well as an argument for decreasing overall funding for healthcare.
Primary-Care Network: The Gatekeeper
For India, both generating resources for UHC and designing health systems to implement it are challenges. The best solution to both may be for a comprehensive and quality primary care network to act both as the preventive pillar of the health system and also as a gatekeeper to higher levels of care. Patients need not reach secondary and tertiary care centres without being referred there. This primary care network has to be accessible to all, and free at the point of access so that the OOP expenditure problem can be dealt with. There are international precedents of such an approach. Spain, Thailand, Kyrgyzstan and Colombia have successfully rationalised hospital care through referral management. In Thailand, a gate-keeping system prevents patients from going directly to general or regional hospitals without a referral from district hospitals (except in an emergency or when paying OOP directly). Today 45.3 percent of patient visits are to healthcare centres, 37 percent to district hospitals, and only 17.8 percent to tertiary care centres. The National Health Accounts (2013-14) showed that of the overall expenditure, primary care took up 45.5 percent, secondary care 34.8 percent and tertiary care 16.1 percent. 
A study by Harvard University in 2017 on state-level, primary-level expenditure trends found that among the 16 states studied, some poorer states have already started focusing on primary care, and that states like Chhattisgarh, Rajasthan and Assam spend more on it in per-capita terms than better-off states like Kerala or Gujarat. However, the study also found that the primary care expenditure as a percentage of total government health expenditure has either plateaued, or shown a downward trajectory for the last three to four years in 11 out of the 16 states. It is well established that a functioning primary-level care delivery system can take considerable patient load off the secondary and tertiary hospitals. There are yawning gaps in the existing primary care network with some states being far better organised than others. Addressing the infrastructural and human resource gaps in primary care will go a long way in addressing overcrowding in urban hospitals, as well as controlling household costs.
The private sector’s focus on costly tertiary interventions rather than primary prevention has given rise to a situation where the limited number of doctors available crowd these better paying centres while there are few doctors to be found for primary care. This pushes people to seek treatment at the tertiary centres. Investment in primary care therefore has benefits at multiple levels: prevention, gate keeping, and putting an end to the crowding at tertiary care centres whether public or private.
Medical education in India is currently geared towards producing specialists rather than family physicians who are the bedrock of primary care. Every year 60,645 medical graduates qualify to be part of the public health system but opt out of it for a variety of reasons – poor pay, remote locations, and lack of facilities. Across the world, countries have tried to contend with this problem in their own way, but for India, perhaps, the best option could be for the government to train non-physician medical providers like nursing practitioners (with BSc Nursing degrees), Ayurvedic practitioners (with Bachelor of Ayurvedic Medicine and Surgery degrees), and Dentists (with Bachelor of Dental Surgery degrees), all of whom would require additional training and formal certification in allopathic primary care. The Supreme Court, in its ‘Dr. Mukhtiar Chand & Others Versus the State of Punjab’ judgment in 1998, acquiesced in legal feasibility of such an approach, specifically for BAMS doctors, who are in adequate supply. In this vein, the National Medical Commission Bill, 2017, has suggested a bridge course to enable practitioners of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathic (AYUSH) systems to practice modern medicine, despite widespread protests from professional associations. Given the limited MBBS output, the best solution here too may be focused training of MBBS doctors, rather than looking at the long-term option of increasing post-graduate seats in medicine.
CASE STUDY: Immunisation
Every dollar spent on vaccines in low-income countries yields a $16 return in direct costs and a $44 return in indirect costs within a decade. It is one of the most cost-effective options of preventive health. India has its own vaccine success stories. It followed up its 2014 achievement of polio-free certification, with the elimination of maternal and neonatal tetanus in 2015. It owes both these achievements to a concerted immunisation effort. However, children in India continue to die of vaccine-preventable diseases. It has the largest number of under-five deaths in the world, at 1.2 million, comprising 20 percent of the global total. India’s share of pneumococcal, rotavirus and measles deaths is 25.6 percent of the global toll. India’s per capita immunisation spend is just $8.88, far less than Bangladesh ($34.61), Nepal ($29.96), China ($22.09) and Pakistan ($13.14). It was among the last four countries to approve Haemophilus influenza type B (Hib) vaccine to prevent pneumonia, along with Indonesia, Belarus and South Sudan, and it has only recently introduced the vaccine in its immunisation programme.
Recent data shows that India’s performance in ensuring immunisation coverage has been slow, with worrying reversals in some key states. Research by Observer Research Foundation has shown that prior to the NRHM, full immunisation coverage in India improved at a sluggish pace from 35.4 percent in 1992-93 to 42 percent in 1998-99 and 44 percent in 2005-06. NFHS-4 found that immunisation coverage had increased to 62 percent in 2015-16. Although post-NRHM, the pace of immunisation has accelerated, the improvement is far less than, for instance, in the case of institutional births (births taking place in a medical institution rather than at home) which grew from 39 percent in 2005-06 to 79 percent in 2015-16. The following graph shows the current levels of full immunisation coverage across Indian states and UTs.
In the last few years, there have been many additions to the Universal Immunisation Programme (UIP), and Mission Indradhanush – introduced in 2014 – which aims to fully inoculate all children under the age of two with seven essential vaccines by 2020. Pneumococcal Conjugate vaccine (PCV) was introduced in 2017; Inactivated Polio Vaccine (IPV) has been rolled out nationally; rotavirus vaccine is available in nine states, and Japanese Encephalitis (JE) vaccine in all priority districts. However, the projected cost of these vaccines will have to be taken into account as India increases allocation to healthcare as it has committed to do in the NHP. The procurement cost for these life-saving UIP vaccines is expected to go up 6.5 times, from $88 million to $565 million for complete scale-up of Pneumococcal Conjugate Vaccine (PCV), Rotavirus, Measles Rubella (MR), Inactivated polio vaccine (IPV) and Pentavalent vaccines as per the comprehensive multi-year strategic plans (cMYP) costing and financing tool for immunization. With a forecasted budget increase from $694 million to $1.44 billion, the funding gap for UIP is set to rise to 37 percent of total programme costs, or $534 million. For now, the Global Alliance for Vaccines and Immunisation (GAVI) has contributed $500 million but it is targeted only at poor countries; and as India graduates to middle-income country status by 2021, it will no longer be eligible for GAVI support. Sustainable domestic funding options will have to be explored. India has historically never rolled back a vaccine once it was introduced in the UIP.
At a high level national consultative meeting organized by GHS, a panel of experts recognised that maternal and child health have to be seen as an investment rather than expenditure and the most cost-effective intervention, vaccination, is a priority investment for the nation’s future. It should also therefore be classified as capital expenditure rather than revenue expenditure.
Financing Options for UHC
In most countries in the world that have managed to implement UHC, the bulk of the funding comes from general government revenues (tax financing) and public contributions towards a social health insurance programme. In India, general tax revenue is the source of 90 percent of public health funding, but the low tax to GDP ratio (17.7 percent) is the spoiler. However, countries with lower GDP growth and economic potential than India have done it. Mexico moved towards UHC by increasing public spending on health from 1.9 percent in 1996 to 3.25 percent of GDP in 2014. Thailand doubled its public expenditure on healthcare from 1.66 percent in 1995 to 3.2 percent of GDP in 2014. Both countries have a tax to GDP ratio almost identical to India’s, although both are much richer.
While increased allocations from the general tax pool could help finance primary healthcare, supplementary resources will be required to fund secondary and tertiary healthcare. No examples of a universal healthcare system funded purely by general taxation exist anywhere in the world. Even the National Health Service (NHS) in the UK is funded by a combination of general taxation (around 80 percent) and national insurance contributions (close to 20 percent). The UK’s tax to GDP ratio is around double that of India’s but public funding on health is more than five times (as a percentage of GDP). That is why a mandatory social health insurance may be a good option; however the relatively small size of India’s organised sector may prove a roadblock. The effort should be to pool the already large OOP expenditure on health into pre-payment pools and enable users to spread the expenditure over a longer time-frame by pooling of risks.
Statutory health insurance (SHI) schemes function by mandating payroll contributions from workers, pooling the resources collected, and earmarking them for a comprehensive health benefits package for all. Risk pooling is a mechanism by which revenues are aggregated to spread financial risk of health expenditures across individuals and over time. Pooled revenues are used to pay for healthcare needs of individuals, reducing or eliminating the need for OOP expenditure at the point and time of service. It is also essential for a universal care package to be clearly defined and to include outpatient services, cost of medicines and a continuum of care feature.
Mandatory health insurance contribution may have political implications in a cost-sensitive society like India. However, if the resources raised by the government are effectively earmarked for healthcare, the willingness of the middle and higher income-groups to contribute will be higher since their expenses would then amount to an investment with a clear return. There are some existing insurance schemes like the Employees’ State Insurance Scheme (ESIS) for factory workers and the RSBY for the informal sector workers, which are now being planned to serve as blueprints for wider health protection schemes. In the Indian context, a national social health insurance scheme should cover the entire population, where the government pays for the poor and vulnerable, the formal sector pays through mandatory payroll contribution, and innovative mechanisms are explored to charge fees from the informal sector. The current UHC plan of the government seems to be around National Health Protection Scheme (NHPS), which is an enhanced version of the RSBY.
Nearly 22 percent of Indians live below the national poverty line, and the poorest 40 percent have access to only 20 percent of total income. Reaching these sections will involve substantial administrative costs. Community outreach may be an important first step before moving on to more sophisticated tools to decide eligibility. In 2012, both Turkey and Indonesia replaced community targeting based on local expertise, with rigorous registry through a clearly defined methodology, with increased and more equitable enrolment success. The Philippines also initially used community-based targeting where local governments identified beneficiaries, enrolling millions of people identified as poor in a health insurance scheme financed by the central government. But in 2009, the central government imposed a more rigorous methodology through the National Household Targeting System. The new system revealed that only 800,000 of the beneficiaries qualified as poor and were thus eligible for subsidies, and that many households that were poor had not been enrolled in the subsidised health insurance programme. Given such inclusion and exclusion errors, any such mechanism should have the required flexibility and consider the households that fall into poverty every year due to health related expenses.
What kind of money can mandatory payroll contributions generate? An early estimate based on income-tax collections in 2014-15 of INR 284,266 crore (PPP $160 billion), shows that between INR 14,000 to INR 34,000 crore (PPP $7.7 billion to $18.9 billion) could be raised, with contributions ranging from 5-12 percent. This figure would provide a significant contribution to the NHP target of 2.5 percent of GDP for universal coverage, equivalent to 25 percent of the current shortfall in spending.
Reaching informal sector workers may prove to be the real roadblock for India in rolling out an SHI. The informal sector employs 91 percent of the workforce in India. However, countries like Vietnam (68.2 percent in the informal sector) and Thailand (42.3 percent) can serve as models. Vietnam uses tax funding to reduce the premium for the informal sector by 50 percent, while Turkey employs a sophisticated system to determine appropriate premium payments for informal sector workers through scoring estimated income, property value and car cost. Multiple governments, including those of Colombia, Mexico and Thailand, originally charged the informal sector for participating in health insurance schemes, but have since extended full subsidies to these populations. For India, the platform of Jan Dhan, Aadhaar and extensive use of mobiles could provide the building blocks for identifying and enrolling the target population.
General tax revenues and SHIs can be supplemented by sector specific taxes. The erstwhile education cess, for example, was instituted to fund the government’s Right to Education (RTE) obligations; the National Clean Energy Fund was set up to tax INR 200 per tonne of coal imported or produced in India. There is also the Central Road Fund since 2000, to improve road infrastructure, which taxes petrol and diesel, and which was increased in 2015 from INR 2 per litre to INR 6. The existing 3 percent education cess on personal income and corporation tax was converted into a 4 percent “health and education cess” by Budget 2018 to fund the initiatives for families in rural areas and those below the poverty line. The increased cess is expected to collect an additional ₹11,000 crores per year, and be a main source of funding for the proposed National Health Protection Scheme (NHPS). The education cess had increased total allocation for elementary education from INR 5,000 to INR41, 000 crore between 2004 and 2013. Another source of funding could be “sin” taxes, a concept that currently applies to tobacco and alcohol in India, though such taxes are not a sustainable long-term source. . A tax on aerated sugary drinks and junk food can be considered, with the added advantage of thereby reducing their consumption and impacting NCDs in the process.
The CSR contributions of the private sector too could be harnessed for health purposes. Section 135 of the Companies Act 2013 made India the first country in the world to legislate for mandatory CSR contributions. All companies with a net worth above INR500 crore, or a turnover above INR 1000 crore or an annual net profit of above INR 5 crore are required to spend 2 percent of their net profit on CSR related activities. The Act lists a series of legitimate recipients of CSR contributions, including campaigns such as reducing child mortality and improving maternal health.
The scheme stands to raise a significant amount of money for development projects. In the first year of implementation in 2014-15, Indian companies paid out around INR 6,400 crore in CSR payments. Reliance Industries Ltd was the top contributor, funding approximately INR 761 crore of the total collection, followed by the state-run Oil and Natural Gas Corporation Ltd with INR 495.2 crore. However, in 2015, KPMG found that more than half the 100 largest Indian companies had failed to meet their targets. CSR contributions, along with funding by the government, could possibly help strengthen the primary care network. Tax free bonds and trust funds too could generate some funds, though CSR may be the most promising option.
Budget 2018 as an Ambitious Foundation for the Way Forward
Budget 2018 with the proposed Ayushman Bharat initiative is a landmark moment in India’s healthcare policy. After the launch of NRHM, it is perhaps for the first time that health is getting such attention in the union budget. However, despite the ambitious beginning, NRHM (now NHM) failed to improve the primary healthcare infrastructure in any substantial way. GHS (2018) found that more than 80 percent of the increased service provision under the NHM was attributed to just 20 percent of health facilities. In 2017, only 11 percent sub-centres, 16 percent primary health centres (PHCs), and 16 percent community health centres (CHCs) were found to be functioning as per Indian Public Health Standards (IPHS) norms.
The ambitious National Health Protection Scheme (NHPS), which promises to expand insurance cover from current low levels to a substantial 100 million households is expected to improve access to secondary and tertiary healthcare tremendously. Building on the gains of the past decade, India continues to follow a two-pronged strategy of demand side as well as supply side interventions in healthcare. The Empowered Programme Committee of NHM approved ₹1,200 crore for 2018-19, and ₹1,600 crore for 2019-20 for setting up 1.5 lakh health and wellness centres. This means that the sub-centres, the lowest rung of the NHM structure, will for the first time, move beyond providing antenatal and postnatal care, and immunization services. The Finance minister in his budget speech confirmed this commitment this year. If implemented well, this initiative will take comprehensive primary healthcare services closer to the people who need them the most. It also has the added benefit of taking some burden off the secondary and tertiary care delivery system. However, per sub centre, current year’s allocation translates to only ₹80,000, which may prove to be inadequate given the ambitious objectives.
The Budget 2018 makes it clear that India’s medium-term pathway to UHC is a continuation of the last decade’s strategy of provisioning-insurance mix at an expanded scale. It will be key how the government addresses the severe health workforce shortages in the public hospitals so that part of the huge insurance bonanza (amounting to INR 15000 Crores) flows back into the public healthcare delivery system and rejuvenates it. It is expected that the proposed merger of three unlisted public sector general insurance companies will help keep the insurance premium within NHPS substantially low compared to RSBY. The rapid expansion of the insurance coverage is also expected to kick in economies of scale and help keep costs low. Yet, offering a substantial health insurance cover of INR 500,000 for 100 million households with the available resources will be a big challenge within the current cost parameters.
Increase in government investment in healthcare is the most preferred option on the road to universal health coverage. This is not just because it has the highest benefit to cost ratio, but also because increased public sector investments would better enable a significant section of the population to access improved healthcare. This would also enable emerging lower middle-class groups that demand better healthcare but find the rates in the private sector unaffordable. However, apart from looking at increasing the spending on health, India also needs to look at more efficient means of spending that money. This can be achieved by prioritising high impact system design changes and interventions like immunisation which give the biggest impact for every rupee spent.
The focus has to be on improved, accessible and quality primary care. To chalk out the implementation blueprint, a committee of diverse stakeholders and policy makers needs to be established to further evaluate these recommendations and use them to develop implementable guidelines. Given the potential of rapid expansion of fiscal space, it should be possible for India to eventually bring in the remaining 150 million households into a truly universal system, which integrates NHPS with the primary healthcare delivery system in the medium run. How a diverse India choses to do it will offer lessons to dozens of other countries who plan to make UHC a national mandate and expand health coverage to yet uncovered population groups.
About the Authors
Anjali Nayyar is Executive Vice President, Global Health Strategies. Dhruv Pahwa is Senior Director, Global Health Strategies. Samir Saran is Vice President, Observer Research Foundation. Oommen C. Kurian is Fellow, Observer Research Foundation.
 Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of under-5 mortality in 2000-15: An updated systematic analysis with implications for the Sustainable Development Goals. Lancet 2016.
‘India has both the capacity and the moral authority to shape a global digital economy’
ndia is fast becoming the indispensable nation of cyberspace. The Indian market could decide the future of many technology giants. As such, she can be seen as a policy pioneer.
In November, Ajit Pai, Chairman of the US Federal Communication Commission, announced the rollback of the Obama-era rules on net neutrality. As the historic architect of the internet and arbiter of its values of openness and freedom, the US appears to be ceding its normative influence over the medium.
Meanwhile, the EU’s misgivings about US technology corporations have driven it to enact a new data protection regime that sets its own highly restrictive standards on digital markets, content regulation and privacy. This is par for the course for a community that is looking increasingly inward, and no longer sees itself as a model for other countries.
Farther east, China has outright rejected the West’s open model for the internet and has outlined a vision to become a cyber superpower premised on state sovereignty and control.
Thanks to such developments, leadership in cyberspace is contested and a new global regime will follow the model that best balances several competing priorities. With a 450 million strong – and growing – online population, India is capable of exercising considerable heft in shaping the future of the internet. India’s multiple identities only add to this weight: as the world’s largest democracy, it commands the legitimacy to shape an open and free internet; while its role as a developing country ensures it will account for what matters to the global south, such as affordable access, local content generation and platform security.
Two recent events have further bolstered India’s leadership in cyberspace claim. The first was the Telecom Regulatory Authority of India’s (TRAI) recommendation that access to the internet must not be restricted by discriminatory measures from service providers. Even though some rough edges remain, such as the role of the proposed multi-stakeholder ‘advisory’ body and the regulation of Over the Top Services, the TRAI has done well to endorse the principle of net neutrality in its proposals to the Department of Telecommunications.
Despite increasing convergence with the US on information technology issues, New Delhi was not swayed by America’s deliberations. Instead, the TRAI chose to endorse a pragmatic model that would balance commercial imperatives against consumer interest. In this process, it has also given New Delhi the ability to claim moral leadership over the principles that define the internet.
The second development was the publication of the Ministry of Electronics and Information Technology’s consultation paper for a Data Protection Framework for India. Prompted by the Supreme Court’s verdict in the Puttaswamy case, the Indian government is now working to protect individual privacy in the digital world. While the final law will undoubtedly generate debate, the report notably makes it clear that India will balance civil liberties, security and data-led innovation.
No country has yet managed to strike a perfect balance. In countries like China, privacy has been subsumed in favour of national security. In democracies like the US, social media platforms have been left vulnerable to foreign influence; and in the EU, stringent data protection laws might stifle innovation. If India can fine-tune its own design for a data-driven economy while protecting the rights and security of its citizens, it will have created a prototype that is at once unique, and yet replicable.
Both these developments highlight something significant: India is carving out its own unique position in cyberspace, one that is likely to be emulated by emerging markets. With multiple institutions – from courts to political leadership to civil society – actively contributing to a diversity of opinion, the shape of an Indian consensus on cyberspace is slowly emerging. The Digital India initiative could culminate in a distinctive offering that will not only invigorate India’s economy but also serve as a model for other countries, including the industrialized West.
The internet is provoking new debate about the emerging social contract between citizens, businesses and the state. These debates will eventually find their way into international norms and regimes. To prevent the emergence of a “splinternet” and to preserve the democratic nature of cyberspace, India must proactively tell its own digital story.
India already has a rich history of safeguarding the global commons by blending idealism with pragmatism. Speaking at the Paris Conference in 2015, Prime Minister Modi recognized that more than 300 million Indians do not have access to energy. Despite this, India was determined to ensure that access does not come at the cost of the environment. This determination, said Modi, was “guided by our belief that people and planet are inseparable; that human well-being and nature are indivisible.”
India’s position on cyberspace is equally progressive. As things stand, India has both the capacity and the moral authority to shape a global digital economy. At the Global Conference on Cyber Space in New Delhi, Prime Minister Modi believed that the internet validates the ancient and inclusive Indian philosophy of “Vasudhaiva Kutumbakam” – the world is one family. “Through technology, we are able to give meaning to this expression, and indeed to the best of democratic values,” he continued.
A democratic, innovative and secure cyberspace is consistent with both India’s ancient moral values and its modern economic imperatives. India’s recent policy actions on net neutrality and data protection are a step in the right direction. New Delhi must now craft a narrative around India’s digital economy that appeals to the rest of the world.
Over the years, many observers have expressed skepticism about the BRICS (Brazil, Russia, India, China and South Africa) initiative – and skeptics within the BRICS member states perhaps outnumber those outside.
The reason is a clear lack of traditional logic behind the coming together of these countries. They are dispersed geographically, their economies are in different stages of development and there is a fair degree of ideological dissonance between them. And unlike other economic associations, BRICS does not seek to set up any common political or security architecture.
However, this should not obfuscate the fact that the purpose of BRICS was clear from its inception: to form a convenient and pragmatic 21st-century relationship that pools the influence of its members in order to achieve objectives agreed to by all five countries. In a multipolar world in which economic and political power is rapidly diffusing, the BRICS nations seek to influence and shape the norms of global governance, which have been fashioned by the Atlantic system in the past. BRICS, then, is a coming together of nation states at a particular geopolitical moment to achieve a set of goals.
Each member of BRICS also has their own reason to sustain this plurilateral movement. Russia sees BRICS as a geopolitical counterweight to the eastward expansion of the Atlantic system. For South Africa, BRICS is a means to legitimize its role as a gateway to and powerhouse of the African continent. BRICS allows Brazil to collaborate in the shaping of the Asian century, despite its geographical location. China participates in the forum because it recognizes BRICS as an important vehicle for fashioning governance systems in which its political influence is commensurate to its growing economic heft. Finally, for India, BRICS is a useful bridge between its rising status as a leading power and its erstwhile identity as the leader of the developing world.
The first decade of BRICS
BRICS’ first decade saw each of the members laying down groundwork for cooperation, from identifying areas of convergence on political issues to improving economic ties. The level of engagement between its members, ranging from high-level summit and ministerial meetings to various working groups and conferences, has only deepened over that time.
Today there is a fair degree of cooperation on issues such as trade, infrastructure finance, urbanisation and climate change. Moreover, the five members have made modest progress in people-to-people connections. Platforms such as the BRICS Academic Forum and Business Council have proved to be useful in improving their understanding of each other’s industry, academia and government.
Undoubtedly, the two most notable achievements of the BRICS have been the institutionalization of the New Development Bank (NDB) and the Contingency Reserve Arrangement.
The importance of these institutions cannot be understated. For one thing, they mark a shift from political rhetoric to delivering concrete results, alleviating some of the skepticism surrounding the BRICS initiative. More importantly, they represent a partial fulfilment of BRICS’ core raison d’être: to offer credible alternatives to the Atlantic system of global governance.
While such institutions are unlikely to ever replace the IMF or the World Bank, they represent a fundamentally different governance paradigm. By giving equal voting rights to its founding members and improving reliance on local currencies, the BRICS members are attempting to create a new, non-Bretton Woods template for the developing world to emulate.
The end of innocence
Despite achieving a moderate level of success over the last decade, two recent events have brought the divergence between the BRICS members into sharp focus.
The first is the recent military standoff between India and China on the Doklam plateau, which has effectively brought to an end the naive notion that a comfortable political relationship is always possible amongst the BRICS members. The second is China’s efforts at creating a ‘BRICS plus’ model, a thinly veiled attempt to co-opt nation states, which are integral to its Belt and Road Initiative, into a broader political arrangement.
Both of these events highlight how the foundational principles of BRICS – respect for sovereign equality and pluralism in global governance – are liable to be tested as the five member countries pursue their own national agendas.
However, instead of derailing the BRICS project, these developments are likely to inject a level of pragmatism into the initiative. While BRICS itself is unlikely to form the lynchpin of foreign policy for any of its members, it will continue to be an important instrument in their toolkit.
Essentially, the BRICS members are now likely to realise that the group itself is a ‘limited purpose partnership’ in which political barriers will always limit the partnership’s full economic potential.
The next decade?
If BRICS is to remain relevant over the next decade, each of its members must make a realistic assessment of the initiative’s opportunities and inherent limitations.
BRICS did well in its first decade to identify issues of common interests and to create platforms to address these issues. However, new political realities require the BRICS nations to recalibrate their approach and to recommit to their founding ethos.
For one, they must reaffirm their commitment to a multipolar world that allows for sovereign equality and democratic decision-making. Only by doing so can they address the asymmetry of power within the group and in global governance generally. Only this approach will strengthen multilateralism.
Second, they must build on the success of the NDB and invest in additional BRICS institutions. It will be useful for BRICS to develop an institutional research wing, along the lines of the OECD, which can offer solutions distinct from western-led knowledge paradigms and which is better suited to the developing world.
Third, they should consider a BRICS-led effort to meet their commitments under the Paris Agreement on climate change and the UN’s sustainable development goals. This could include, for example, setting up a BRICS energy alliance and an energy policy institution. Similarly, the NDB in partnership with other development finance institutions could be a potent vehicle to finance progress towards the sustainable development goals amongst the BRICS members.
Fourth, the BRICS nations can also consider expanding the remit of their cooperation to address emerging areas of global governance such as outer space, the oceans and the internet.
Finally, the BRICS members must encourage direct interactions between their constituents. In the digital age, seamless conversations amongst people, business and academia can foster relationships, which are more likely to cement the future of this alliance than any government efforts.
For the first decade of its existence, the group was powered by a top-down approach with large investments of political capital. The second decade must ride on the energy and entrepreneurship of the citizens and communities that reside within the BRICS countries.
Samir Saran, Vice-President, Observer Research Foundation (ORF)
The views expressed in this article are those of the author alone and not the World Economic Forum.
India will have to learn the fine art of staring down the dragon to preserve its political space, while embracing China for some important economic opportunities. At Doklam, it did the former; will a different India turn up at BRICS?
PM Modi with Russian President Vladimir Putin, Brazilian President Dilma Rousseff, Chinese President Xi Jinping and South African President Jacob Zuma after the welcome ceremony at the 7th BRICS Summit in Ufa.(PTI)
Leaders of Brazil, Russia, India, China and South Africa (BRICS) have gathered this past weekend for the ninth annual BRICS summit in Xiamen, China. The prolonged Himalayan standoff between India and China will cast its shadows on this meet and will certainly add a new dimension to discussions on the future of this plurilateral.
The BRICS emerged out of a global order dominated and managed by the United States (US) post the break of the Soviet Union. The US led institutions catalysed global trade and financial flows, which in turn also helped in the organic growth of most of the BRICS economies. Despite their growth, their marginal role in management of key global institutions created an undesirable asymmetry in world affairs. BRICS came about as a vehicle to respond to this, and together they hoped, they would be able to loosen the vice-like grip the Atlantic system had on existing governance institutions.
There were two unstated principles that shaped the ethics of the BRICS formation. First, each nation placed a premium on sovereignty and its importance in the conduct of world affairs, and second, each state sought greater pluralism and equity in decision-making processes in a multipolar world.
The China and India standoff at Doklam compels us to revisit these organising principles. The Doklam incident was a contest around sovereign concerns. These concerns are rooted in history and muddied by China’s determination to implement a political and economic arrangement across Asia that is insensitive to the territorial rights of India. The Belt and Road Initiative (BRI) and the associated China Pakistan Economic Corridor (CPEC) are but thinly veiled attempts to shape an Asian order that plays by the Chinese rulebook alone. While BRICS symbolises a multipolar world, BRI and CPEC are the harsh face of an undesirable and unipolar Asia.
Further, China’s latest attempt at creating a ‘BRICS Plus’ platform, comprised of states who happen to be key actors in the BRI, makes it clear that it sees BRICS as an adjunct of the BRI and merely as a vehicle to catalyse its larger ambitions.
These events make it clear that we must shed the romantic notion that ideological convergence is possible within BRICS. Each member must see the group for what it is—a twenty first century ‘limited purpose partnership’ among states to achieve specific sets of outcomes. There is nothing inherently improper about such an alliance, however, if progress is to be made, it will be predicated on creating effectively designed institutions.
The most successful BRICS endeavour has been the creation of the New Development Bank. The time has come to build on this initiative and focus on creating more institutions for greater cooperation in issues such as finance, urbanisation, sustainable development and the digital space. This could include setting up a BRICS credit ratings agency, a BRICS research institution and institutionalising the process of managing the global commons such as the oceans and outer space.
It is obvious that each of the BRICS members will have their own reasons for being at Xiamen. Russia continues to see it as a geopolitical bulwark against the US, all the while tacitly acquiescing to Chinese leadership. South Africa will present itself as the leading voice of the African world and will raise issues of peace and development for the continent at the summit, while Brazil, which is undergoing a period of domestic turmoil, is unlikely to be too innovative or demanding. China is far more certain of what it seeks.
For India, this year’s summit becomes important. India will have to learn the fine art of staring down the dragon to preserve its political space, while embracing China for some important economic opportunities. At Doklam, it did the former; will a different India turn up at BRICS? Forums like Xiamen allow India and China the chance to begin anew.
As we enter the second decade of BRICS, Xiamen would have to be the arena where the members recommit to upholding the founding principles of the BRICS. Thereafter, they must chart a new roadmap for greater institutionalisation of the group’s interests.
Samir Saran is vice president at the Observer Research Foundation and tweets at @samirsaran
(From Left) Brazilian President Michel Temer, Russian President Vladimir Putin, Prime Minister Narendra Modi, Chinese President Xi Jinping and South African President Jacob Zuma, at BRICS summit, Benaulim, Goa, October 16 (PTI)
Heading into the BRICS summit in Goa last weekend, Indian diplomacy sought four key objectives. First, use the forum to strengthen bilateral relationships with all four countries, especially Russia and China. BRICS as a grouping will undoubtedly be served well, and its mandate strengthened, as a result of political exchanges at the bilateral level. Second, stabilise the BRICS regime at a time when some of its major constituents have been perceived as disruptive forces in the international order. Third, leverage the platform to highlight concerns of cross-border terrorism emanating from Pakistan, and lend momentum to India’s efforts to promote a comprehensive, multilateral instrument to tackle terrorism. And fourth, consolidate and build on the institutionalisation of intra-BRICS initiatives, aimed mainly at promoting economic growth.
All four objectives were materially advanced by New Delhi at the summit, with varying degrees of success. At a time of general turbulence in the international system, whether it is armed conflict in Syria, contestation in the South China Sea or the imminent overhaul of global climate and trading regimes, India can take credit that the summit concluded on a sober, even footing, without letting the political predilections of each power holding sway over the group.
On the subject of terrorism, the Goa declaration strongly endorsed multi-national efforts to tackle the spread of terror networks, and specifically urged countries to crack down on terrorist organisations designated by the United Nations Security Council. It is frankly besides the point that groups based in Pakistan. such as Lashkar-e-Taiba and Jaish-e-Mohammed did not find mention by name in the declaration, since they are groups that are listed by the UNSC under its anti-terror sanctions regime. The references to terrorism in Afghanistan in particular are significant, as they cast a shadow over Islamabad’s conduct in preventing its neighbour from pursuing its “independent political and economic course”. India’s pointed references to Pakistan’s less-than-constructive role in tackling home grown terror networks indicate New Delhi is prepared to sustain its recent efforts to draw ever more global attention to the subject.
The conversations on terrorism in Goa, however, should not detract from the substantial progress that BRICS countries have made in the last year in charting a common economic narrative. Thrown into sharp relief by Britain’s exit from the European Union, the diminishing appetite for integrated markets and indeed, globalisation as we know it, has not deterred BRICS countries from pushing ahead with key economic initiatives.
The Goa declaration correctly highlights the critical role of the New Development Bank (NDB) in attracting foreign investment and supporting renewable energy and infrastructure projects in the global South. Consensus on a BRICS credit rating mechanism was not forthcoming at the 8th summit, given that a consolidated view on perception of financial risk and regulation is a sensitive matter. It is worth noting here that the NDB itself was the product of many such BRICS meetings, both at the level of leaders and sector experts. The credit ratings mechanism is an important initiative that should be pursued with vigour when BRICS finance ministers, industry associations and independent experts now meet over the course of the calendar year to flesh out its details.
Among the biggest takeaways from the summit’s deliberations is BRICS’ continued willingness to take on the unfavourable economic headwinds together, whether by pushing towards greater integration of its markets, facilitating the mutual ease of doing business or providing accessible capital to its businesses. India’s hosting of the BRICS and BIMSTEC summits helped in highlighting that trade ties need to be significantly enhanced, not just among BRICS, but also between BRICS and BIMSTEC countries. On this count, the declaration’s heightened attention and call to build the capacity of micro, small and medium enterprises to ensure they are included in global value chains are significant as they are crucial sources of employment.
The summit declaration also brought the focus back to international norms that promote stability and inclusion in common spaces. At a time when mega-regional trading agreements have significantly altered the discourse on cross-border trade, the summit stressed the need for co-operation in crucial matters relating to Intellectual Property Rights and the digital economy. BRICS members have always attributed a position of “centrality” to the WTO-led trading system, but their endorsement this year is significant.
The Goa declaration reflects an important moment in the group’s history, which has seen the “alternative” powers weighing on the side of liberal, multilateral trading institutions that were conceived by the West. References to the “open and non-fragmented” nature of digital spaces should not be viewed from the prism of Internet governance alone. It is also a pointed reference to the need to keep cyberspace open for commerce, and prevent its “stratification” by exclusive trading regimes.
The BRICS summit in Goa reinforces India’s position as a “bridge” between the liberal institutional order and the potential disruptive impulses of major powers that have opened up the possibility for contestation. Its concurrent hosting of the BIMSTEC heads of state meeting allowed New Delhi to raise the grouping’s profile, and signal its importance to India’s neighbourhood diplomacy in the days to come.
As for the Goa declaration, India may not have had its way on every issue – this is only natural, just as New Delhi sought to moderate the influence of Moscow’s holding the pen at the BRICS Ufa summit last year, the gives and takes of diplomacy ensure a document that is acceptable to all. The Goa declaration ensured the BRICS ship continues to sail steady, and remains on course for bigger and more effective projects in the years to come.
Samir Saran is vice president, Observer Research Foundation, New Delhi
While the state continues to exercise its regulatory capacity over digital spaces — a task it will likely keep in the coming years — the internet has magnified the rights and responsibilities of the private sector and end users across the world.
The interaction between states, non-state actors and transnational corporations necessitates the creation of a regime complex that clearly outlines their respective roles. This paper is a first step in that direction, articulating norms that may serve as the baseline for legal and political agreements on cyberspace. Inter-governmental gatherings like the UN Group of Government Experts have largely focused their efforts on the security of networks and ICTs. Multistakeholder organisations and platforms like the Internet Governance Forum, the Internet Corporation for Assigned Names and Numbers, and the Internet Engineering Task Force, have begun to re-orient their mandate, with a view to make their governance more inclusive and accountable.
The set of seven norms and their corollaries identified in this paper may inform the functioning of both intergovernmental and multistakeholder processes. This document also attempts to chart the role of the private sector in digital governance. The end user today is valuable to internet companies, since the data collected from consumers directly contributes to the creation of revenues. If user data is the basis of wealth generation, internet giants have a responsibility to invest in the user by offering local content and innovative technologies that are contextual. This is particularly true in the case of emerging economies and developing countries, where internet businesses should tailor to the unique needs of the next billion users.
This paper argues that effective internet governance requires shifting the locus of digital debates from the Atlantic to the Asia-Pacific and bringing in new voices and views of a new constituency of stakeholders. Similarly, all stakeholders must work towards building the capacity of growing digital economies and first-generation internet users. Efforts to fragment digital spaces by creating alternative “internets” must be avoided. Just as regimes that curtail the freedoms of internet users are undesirable, actions that raise the cost of local innovation and increase barriers to the unrestricted flow of technology, and thereby quality of access, should also be discouraged. These norms are a work in progress, and the author reserves the right to refine them through continued consultations with stakeholders across the spectrum.
1. Online = Offline + more
The protection of rights over the internet requires mechanisms that are unique, contextual and transformative. Rights on the internet should not be limited to those offline, and must build on the edifice of free speech and expression that already exists. Similarly, current regulatory frameworks must evolve in response to the digital medium. Just as traditional broadcasting regulations have become inadequate to regulate online speech, outmoded censorship laws often constrain free expression and impose a chilling effect. Contemporary conversations on privacy must reflect the need to protect sensitive data, while acknowledging its importance for technological innovations that benefit local communities.
NORM: Realising the transformative potential of the internet requires progressive online freedoms that move beyond rights granted offline.
COROLLARY: Real-world regulations must not constrain the advancement of technology; rather, they must evolve in response.
2. Let data flow
Affordable, universal and high-quality access to the internet is among the top policy prerogatives of governments today. Access will require substantial investments in the form of local data centres, internet exchanges and last-mile connectivity. As net exporters of data, developing countries represent a robust market for internet companies. For their digital economies to expand — thereby increasing the share of the global pie — the free flow of trans-boundary data must be coupled with the unrestricted flow of technology. Custodians of data should orient their research and development towards local solutions, and foster domestic entrepreneurship. Data flows, however, should respect the sovereign imperative of law enforcement and security.
NORM: The global free flow of information must necessarily lead to universal access to the internet in emerging economies that is affordable and qualitatively rich.
COROLLARY: Free flow of data must be complemented by free flow of technology that is tailored for local innovative solutions.
3. Living in an encrypted world
Governments around the world are locked in debate with industry bodies and civil society for the right to access encrypted communications. Backdoors and forced localisation of data, however, can decrease the overall standard of security in the market, curtail free speech, and violate the integrity of data. Governments should welcome technological developments that incorporate security by design, with a view to preserve the integrity and stability of digital networks.
NORM: Encryption must be the norm.
COROLLARY: Decryption of data must be subject to rigorous standards of judicial review.
4. The responsibility to inspect?
States are faced with increasingly dangerous and sophisticated threats from state and non-state actors in cyberspace. The technological and legal capacity for dealing with these threats is often disparate, caused in part by lack of access to proper forensic, investigative and prosecutorial tools. It is the sovereign function of a state to protect its own citizens and infrastructure from such threats, without undue interference or intervention in its affairs. The interconnected nature of the internet demands that governments and businesses across geographies cooperate towards norms of cooperation that mitigate the risk of conflict.
NORM: The responsibility of states to protect cyberspace is a sovereign function, commensurate to their capacity.
COROLLARY: The collective responsibility for protecting cyberspace requires global investments for building capacity in developing countries.
5. Strengthening the base
The ubiquity of low-end smartphones, the growth of affordable data networks in emerging economies, and the relative lack of awareness of cyber vulnerabilities among users leave networks and individuals vulnerable to exploitative practices. Enhancing cyber hygiene among internet users in emerging economies can help substantially decrease the vulnerability of the global digital space as a whole.
NORM: Cyber security must account for, and address technology limitations of the end user at the bottom of the pyramid.
COROLLARY:Local communities must be at the forefront of articulating policy solutions for cyber security.
6. Three rules for internet governance
Despite attempts to decentralise and diffuse the management of global internet governance institutions, there are inadequacies in revised accountability mechanisms. The locus of internet governance must shift from big transnational corporations to start-ups, medium and small local enterprises, from governments to multistakeholder communities, and from trans-Atlantic conversations to Asia-centric debates.
NORM: Multistakeholderism should be institutionalised by accounting for diversity in gender, geography and sectors.
COROLLARY: International internet governance must undertake three transitions and accommodate new stakeholders:
States → Communities.
Trans-national corporations → Small & Medium Enterprises and Startups.
Atlantic → Asia and Africa
7. Against the Splinternet
The Domain Name System (DNS) represents a stable and contiguous platform of unique identifiers, comprising numbers and names. Attempts to fragment the internet by creating an “alternative” system or through interference in the functioning of the “root” should weigh its potential impact on internet users, businesses and governments. Just as technical efforts to create a parallel DNS should be discouraged, trade regimes around the digital economy should consider the effect of fragmenting the internet into differential pricing regimes. Affordable and universal internet access can be realised by removing policy barriers to the creation and strengthening of ICT infrastructure.
NORM: The internet should remain unfragmented.
COROLLARY: Differential trade regimes should not raise the cost of doing business in the digital economy nor impede low-cost connectivity to users in Asia and Africa.
In the digital age, data is currency and information is the energy that drives the 21st century economy. Today, 46.1 percent of the world’s population is online. These 3.4 billion Internet users collectively generate a significant amount of commercial and personal data that can be stored, collated, and analyzed. This data is the lifeline that charts users’ online identities: it can also be monetized by Internet service providers, social media platforms, and end user applications. As a necessary corollary, control over data and the flow of information has become highly politicized. One who controls this data retains the power to shape the global geopolitical order.
Data is intrinsically valuable. Data grants access to an individual’s online activity, lifestyle choices, consumption patterns and so on. It is for this reason that states have been vying to gain access to vast amounts of data either through legal mechanisms or surreptitiously. It is also the backdrop for the evolving global norms around encryption. In many ways, this conversation is reminiscent of the adage of energy politics of the 20th century: he who controls the oil controls the world. There is, however, one central difference: today, every Internet user is the owner of an unending oil field and every Internet non-user is sitting on a potential reserve.
Despite of the Internet being touted as a great “equalizer,” these global conversations are often skewed in favor of the countries that generate data or possess the technological capability to access it. The encryption debate in countries with advanced technical capacities is very different from the countries without them. Until recently, countries with strong technical capabilities were also the most ardent advocates of encryption. This approach was fueled by the belief that the state’s interception capability would always outpace the individual’s encryption capability. Increasingly, this notion is proving to be false. Even the United States realizes that impenetrable encryption could wrest control of data from the hands of the state. It is this insecurity that is causing the pitched battle between Silicon Valley’s encryption evangelists and U.S. law enforcement officials. This insecurity, however, is not unique to the West. Governments in Asia and Africa also drive their own encryption debates out of a fear of losing control over the social order and their capability to monitor their citizens. At the same time, these issues’ importance is also accentuated by the looming threat that their countries’ data will be gathered, stored, and exploited across oceans in another continent.
Cyber diplomacy and geopolitics in these nations is therefore determined by the need to retain control over information emanating from within their countries and the anxiety of this data’s potential misuse by actors outside their borders. As with the conversations around the erstwhile frontier technologies in the nuclear and space domain, this too has a strategic dimension. Unfortunately, these strategic necessities are often responsible for constraining the development of privacy and data protection norms governing the Internet. States insist on perceiving the control of data as a zero sum game. Encryption is perhaps the centerpiece of the falsely dichotomous conversation around security and human rights. Encryption, however, must fundamentally be about human rights.
Encryption is an idea that is grounded in the principles of data integrity and data ownership. The right to encrypt communications is central to the autonomy that we offer all citizens over their own data and who can use, analyze, and access that data and under what conditions. This right automatically grants them the opportunity of determining who can commercially exploit their data. While most of us are comfortable exchanging our personal data for services over the Internet, this decision does not automatically nullify our right to choose how our personal data is used. Naturally, this autonomy must be subject to certain exceptions for law enforcement purposes. However, these exceptions must be considered, pragmatic, and mindful of the human rights imperative. They must not be driven by paranoia and the need for absolute control.
Another noteworthy dimension in this debate is the commercial opportunity that encryption presents. Encryption technology is big business. If data is the new currency then encryption solutions are the new Swiss banks and the market leaders in the tech space like Apple, Facebook and Google are all vying for recognition as “digital Swiss banks.” They are cognizant of the need to protect data, but equally conscious of its commercial value. While they refuse encrypted information to law enforcement agencies, apps and platforms in Google and Apple’s ecosystems innovate and thrive on the availability of big data. It is not public policy that is driving this harvest of data. It is, ironically, the “privacy policies” of major players. Across the pond, European regulators have failed to distinguish the false choice between public and private data with potentially negative consequences for innovation. Indeed, European Internet providers have themselves demanded that privacy norms reflect the need to innovate digitally.
All this is not to question the assumption that the state constantly seeks to monitor digital networks. But the growing trend towards protecting data from the prying eyes of the state poses another important question: is encryption the end of innovation? Increasing law enforcement requests for data retrieval and the myriad ways in which the state collects data en masse are leaving the private sector apprehensive of collecting big data that they may later be required to give up. While this may sound good prima facie, it has a serious downside. Without access to data, the private sector has no means to innovate and tailor their products to the market. The boom in the app economy was fueled largely by creating markets for products and services based on data analysis. Is it possible that the ubiquity of that very data is foretelling the collapse of the market that trades in information?
Ultimately, the debate on encryption must keep three vertices in focus: law enforcement, data privacy, and innovation. The legal standards around data protection and surveillance may vary across jurisdictions—as will the ability of start-ups to innovate—but any policy measures on encryption must arrive at a floating median between these three indicators.
While droughts can be written off as an ‘act of god,’ the fact that the ongoing drought in India has acquired its current intensity is a reflection of the sorry state of economic governance and planning in this country.
This state of affairs has its origin in four structural problems that plague India’s political-economic system at large, and are of immense consequence when it comes to managing India’s water:
The continued use of government-mandated support prices and subsidies for farm produce and farmers.
The de facto orientation of infrastructure projects towards industry, and not for lifeline support.
The perverse effects of the rural employment guarantee schemes.
The absence of innovation and finance around fresh-water recycling, desalination, and river-linking schemes, as well as the continued dominance of revenue expenditure over capital expenditure for the rural sector.
The negative externalities of agricultural subsidies
India is the second-largest producer of sugar in the world after Brazil. Last November, India’s cabinet approved a US$173 million subsidy for sugar cane producers supplying mills that export sugar and produce ethanol. This subsidy would, in effect, make sugar and ethanol produced in India cheaper relative to other countries, and thus make it more competitive at a time when the global commodities super-cycle is at an all-time low.
Such subsidies, along with mechanisms like government-guaranteed minimum support prices for agricultural products, incentivise producers to cultivate commodities that are natural-resource intensive. It is not an accident that Maharasthra, India’s biggest sugar-producing state, finds itself hit the hardest by the current crisis. The drought in the district of Marathwada, a region which accounts for 25% of the state’s sugar output, is the worst since 1972.
Temples for the few, and the lucky
India’s first Prime Minister, Jawaharlal Nehru, once called dams the temples of modern India. It now transpires that these temples only serve a select few through a system of rent-seeking and patronage. The Jayakwadi dam in Maharastra is one of the largest of its kind in Asia. It was created in 1965 with the express purpose of providing relief to the drought-prone Marathwada district. Instead it seems, as India’s Agriculture Minister has claimed, that the biggest beneficiary of this dam is the sugar industry. Meanwhile 89 irrigation projects in the state have been on hold for more than 20 years.
It is not uncommon in India for these projects to be approved to placate certain sections of the population. Synching the approval and completion of lifeline projects to the electoral cycle leads to the kind of unmitigated disaster India is witnessing today. This electoral pandering, coupled with abysmal short-sightedness, leads to a situation whereMaharastra has 1845 dams (35% of all dams in the country), yet only 18% of agricultural land is irrigated (compared to the national average of 47%).
Wither rural employment guarantees?
But construction of dams and other large-scale irrigation engineering projects is only part of the solution. A sustained effort must be made to renew and rejuvenate traditional water bodies and harvesting systems.
The previous government’s much-vaunted rural employment guarantee (MNREGA) scheme took as its goal the provision of employment to the rural poor by directing surplus labour towards infrastructure projects. In principle, MNREGA should have been the perfect vehicle through which traditional water works could have been maintained. Instead, MNREGA has distorted labour markets by disincentivising rural industries and jeopardising the income potential of the most vulnerable. Meanwhile, the scheme continues to bleed money. In 2006-07 (the first year of the scheme’s implementation), MNREGA allocation stood at US$1.53 billion. By 2010-11, the heyday of last government’s populism, it had reached an astonishing US$6.2 billion. The Modi Government seems to have fallen for the same trap: MNREGA’s budget estimate for the current financial year stands at US$5.8 billion.
The sad fact is that despite India’s considerable success in achieving food security (through the Green Revolution), very little effort has been made since to push India’s agricultural products up the value chain, which would have increased rural income as well as reduced the vulnerability of India’s farmers to climatic shocks such as the ongoing drought. Instead of infusing private capital and public infrastructure into the sector, a system of patronage through doles and waivers continues, which seriously compromises the very people it ostensibly seeks to protect. The archaic mechanism of minimum support prices continues to drain the exchequer while insufficiently contributing to the laudable goal of subsidising food. In 2011-12, the procurement subsidy accounted for 85%1 of all food subsidy. Under the Modi Government, this has come down to 43%2, a worthy first step.
Meanwhile, rural capital expenditure has fallen from US$71.3 million3 in 1999-2000 to a measly US$9 million4 in 2015-16. The sharpest drop happened between 2006-2007 and 2008-2009, from US$49 million5 to US$14.6 million6 — not surprising since between these two years, MNREGA allocations jumped three times. Even in irrigation and flood control, revenue expenditure growth overwhelmingly dominates capital expenditure growth: between 1998-1999 and 2015-2016, the former grew by 21%7 while the latter grew by 4%8 .
The need for large-scale innovation
A key challenge of a rapidly growing urban India will be the sustainability of its cities.
Modern India has never shied away from espousing faith in technology to meet its national challenges – a legacy of Nehru’s vision. However, as is the case with most ambitious national projects, the time-lag between announcing a vision and actually implementing it is often unacceptably large. An ambitious project to link 37 of India’s rivers in the north and the south is a case in point. First announced in 1982 by then Prime Minister Indira Gandhi, this project had laid dormant for more than 33 years, to be once again taken up by Prime Minister Narendra Modi last year. But opposition remains rife, from the usual coterie of nay-sayers who have a vocal anti-technology stance in the name of environmentalism. This view carries political weight in India.
It is estimated that India’s water demand will rise to 1180 billion cubic litres by 2050, more than 1.6 times the current consumption. The increase in demand for fresh water will be exacerbated by the dwindling water table. A government that plans for the future ought to incentivise the entry of the private sector into large-scale desalination plants that caters to cities along the coasts. For this to be commercially viable, the target cities should be empowered to generate more revenue. Industrial demand for fresh water is increasing at 8% annually while India’s large cities alone generate close to 40,000 million litres of sewage every day. Recycled water can also be directed towards agriculture as Israel does with 86% of its waste water contributing to farm irrigation.
If the government’s ambitious renewable energy targets are an indication of national will, large-scale deployment of desalination technology may not be out of reach.