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इतिहास का बदला: यूरेशिया का उदय

Samir Saran

क्या भारत 21वीं सदी को परिभाषित करने वाले यूरेशिया और हिंद-प्रशांत के दोराहे पर खड़ा है?

भारत, 21वीं सदी, यूरेशिया, हिंद-प्रशांत, समीर सरन, चीन, संतुलित, सहमति, एशिया, एकीकरण, सांस्कृतिक, आर्थिक, सैन्य, बीआरआई

नासा का ब्ल्यू मार्बल प्रोजेक्ट

“हिंद-प्रशांत” खबरों में है। अमेरिका ने अपनी प्रशांत कमान का नाम बदलकर “हिंद-प्रशांत कमान” रख दिया है, भारत और इंडोनेशिया द्वारा रेखांकित साझा क्षेत्रीय विज़न इसकी केंद्रीयता को प्रमुखता देता है और भारत के लिए इस क्षेत्र का राजनीतिक महत्व सिंगापुर में प्रधानमंत्री नरेन्द्र मोदी के विदेश नीति से संबंधित भाषण का केंद्र था। ये सब चीन के हैरान कर देने वाले उदय का जवाब है। यदि ये सब क्षेत्र में चीन के प्रभुत्व को संतुलित करने के लिए विभिन्न ताकतों की भविष्य में बनने वाली सहमति का संकेत है, तो यह उपाय महत्वपूर्ण भले ही हो, लेकिन एशिया और यूरोप में फैले चीन के प्रोजेक्ट के लिए नाकाफी है।

धरती की सतह के 35 प्रतिशत भूभाग को कवर करने वाला यूरेशिया 90 से ज्यादा देशों में रहने वाले 5 बिलियन बाशिंदों का घर है, जो वैश्विक जीडीपी के 65 प्रतिशत के लिए उत्तरदायी हैं। सहस्त्राब्दि भर से फतह, व्यापार और प्रवासन ने एशिया और यूरोप को मूलभूत रूप से बांध रखा है — इस विशाल भूभाग में फैली महान सभ्यताओं का उतार-चढ़ाव अनगिनत राजनीतिक और आर्थिक गतिशीलताओं का परिणाम है।

अभी हाल तक, ऐतिहासिक संदर्भ में, यह सब निर्बाद रूप से जारी था। यूरोप की औद्योगिक क्रांति और उसके बाद एशिया और अफ्रीका में उपनिवेशवाद ने ‘पश्चिम में’ आर्थिक और सैन्य ताकत एकत्र करते हुए क्षेत्र में एक ऐसी कृत्रिम दरार उत्पन्न कर दी जिसका कोई भौगोलिक वजूद नहीं था। यह समुदाय दूसरे विश्व युद्ध का विजेता बनकर उभरा, जिसने केवल सत्ता के इन ढांचों और क्षेत्रों को संस्थागत रूप प्रदान कर दिया।


एशिया का समकालीन आर्थिक उत्कर्ष और उसके अपने समुदायों तथा बाजारों का एकीकरण तेजी से इस यथास्थिति को तितर-बितर कर रहा है। मौजूदा दौर में एक बार फिर से पूरे यूरेशिया में लोगों, वस्तुओं, नवाचार और वित्त का प्रवाह अपेक्षाकृत मुक्त रूप से हो रहा है। लेकिन इस सुपर कॉन्टिनेंट का नए सिरे से उदय टकरावों से अछूता नहीं है। ये नई एकीकृत भू-आर्थिक ताकतें नए राजनीतिक तनाव अपने साथ लेकर आईं हैं।


जिस तरह इतिहास खुद को दोहरा रहा है और यूरेशिया एकजुट हो रहा है, ऐसे में नई विश्व व्यवस्था की रूपरेखा इस आधार पर परिभाषित होगी कि इसका प्रबंधन कौन करेगा और इसका प्रबंधन किस तरह होगा। इसी सुपर कॉन्टिनेंट में लोकतंत्र, मुक्त बाजारों और वैश्विक सुरक्षा प्रबंधों का भविष्य तय होगा और इस परिदृश्य में तीन प्रमुख कारक आकार ले रहे हैं।

पहला, रॉबर्ट केपलान का यह कथन उद्धृत करना होगा कि यह भूगोल का बदला है। हालांकि यूरेशिया का एकीकरण स्वाभाविक है, लेकिन उसका वर्तमान ‘अवतार’ निश्चित रूप से चीनी है। यूरोप और एशिया के बीच की दरार को कृत्रिम, आधुनिक और “पश्चिम” द्वारा बनाई गई मानने के बाद चीन ने यूरेशिया को समझने, परिभाषित करने और फिर उसका प्रबंधन करने जैसे ऐसे कदम उठाए, जिन्हें करने का उत्साह किसी अन्य ताकत ने नहीं दिखाया।

यूरेशियाई सुपर कॉन्टिनेंट का विचार अपने आप में नया नहीं है: 1904 में, हेल्फोर्ड मेकिंडर ने अनुमान व्यक्त किया था कि पश्चिमी नौसैनिक श्रेष्ठता का युग ताकत कायम करने की राह तैयार करेगा, जिसमें यूरेशिया — “मुख्य केंद्र” — विश्व वर्चस्व का आधार होगा।

ब्रिटिश, अमेरिकी, जर्मन और रूसी रणनीतिकार लम्बे अर्से से इस विचार द्वारा प्रभावित रहे हैं। ज्बिगनीव ब्रेजजिंस्की ने लिखा कि सोवियत संघ को नियंत्रित करने का आधार “यूरेशिया की बिसात पर” अमेरिकी प्रभाव का विस्तार करना था। जबकि रूसी दार्शनिक अलेक्सांद्र दुगिन का विचार था कि रूस के नेतृत्व वाला यूरेशिया नेटो की “अटलांटिकवाद” की साजिश को प्रभावशाली ढंग से नाकाम कर देगा। प्रत्येक मामले में, विषय स्पष्ट था: भूमि आधारित सैन्य आपूर्ति श्रृंखलाओं के माध्यम से प्रतिस्पर्धी ताकतों को संतुलित करना।

चीन की योजना अलग है — भूराजनीतिक ब्लॉक्स की बजाए सुविधा पर आधारित गठबंधनों द्वारा परिभाषित परस्पर निर्भर वैश्विक अर्थव्यवस्था में, चीन का विस्तार ऊर्जा की आपूति, कच्चे माल और बाजार की तलाश में मल्टी डॉलर वाली भूराजनीतिक प्रेरणा से परिभाषित है।


चीन की पसंद बेल्ट एंड रोड ​इनिशिएटिव है, जिससे कनेक्टीवि​टी प्रोजेक्ट्स का विशाल नेटवर्क तैयार हो रहा है—उनमें से प्रत्येक की इस सुपर कॉन्टिनेंट के भूगोल में चीन की अर्थव्यवस्था पर अंतर्निहित निर्भरता है।


चीन की प्रेरणा का आधार विचारधारा नहीं, बल्कि दोबारा प्रचलित होने तथा विश्व में सांस्कृतिक, आर्थिक और सैन्य केंद्र होने की अपनी ऐतिहासिक स्थिति का विस्तार करने की इच्छा है। चीन के आर्थिक महत्व के साथ ही साथ यह अभियान साधारण रूप से संतुलन बनाने वाली रणनीतियों के स्थान पर अपने यूरेशियाई विजन को महत्वपूर्ण रूप से और ज्यादा प्रबल, दूरदर्शी तथा स्थायी बनाता है।

ऐसे में कोई हैरानी नहीं कि बीआरआई उप-क्षेत्रों के भूभाग का महत्व कम करता है, इस प्रकार स्थापित सत्ता संतुलनों को अस्थिर करता है। मिसाल के तौर पर भारत और यूरोपीय संघ (ईयू) यूरेशिया की राजनीतिक, आर्थिक और सुरक्षा वार्ताओं में चीन के धीरे-धीरे बढ़ते प्रभाव पर काबू पाने की जद्दोजहद कर रहे हैं।

मुक्त और खुला” हिंद-प्रशांत विजन और क्वाड्रीलैटरल इनिशिएटिव जैसे नवविकसित मंच सामुद्रिक मोर्चे पर चीन के उदय को संतुलित बनाने के लिए प्रयास कर रहे हैं। महासागर, हालांकि चीन का महज एक मंच भर है और ऐसे में विशुद्ध रूप से सामुद्रिक जवाब नाकाफी है।

चीन बेहतरीन तरीके से इस प्रोजेक्ट: बुनियादी ढांचे का निर्माण करने और व्यापार को सुगम बनाने तथा वैश्विक संस्थाओं का विकल्प तैयार करने में अनवरत रूप से जुटा हुआ है। चीन लुके-छिपे ढंग से अपने राजनीतिक मॉडल: “चीनी विशेषताओं से युक्त पूंजीवाद” — सरकारी पूंजीवाद और अधिनायकवाद के अनोखे मिश्रण का निर्यात भी कर रहा है। जब तक उदार लोकतंत्र यूरेशिया में — एशिया और अफ्रीका में बुनियादी ढांचे और शासन की जरूरते प्रभावी ढंग से पूरी करने वाले ​विकल्प को प्रस्तुत नहीं करते, तब तक चीन का प्रस्ताव कामयाब होता रहेगा।

यहीं दूसरे कारक की बारी आती है: लोकतंत्र का बदला। चाहे अमेरिका हो या यूरोपीय संघ या भारत, लोकतंत्रों का पहले से कहीं ज्यादा ध्रुवीकरण हो चुका है। द प्यू ग्लोबल एटीट्यूड सर्वे लगातार यह दर्ज कर रहा है कि लोकतांत्रिक सरकारों का विश्वास अब तक के सबसे निचले स्तर तक पहुंच चुका है। ऐसा लगता है कि पहली बार उदारवादी लोकतंत्र इतने जटिल हालात में पहुंच चुके हैं कि उनके पास रणनीतिक योजनाएं बनाने के लिए ज्यादा ऊर्जा ही नहीं बचती। ऐसे समय में जहां एक ओर चीन का दस साल का घटनाक्रम है, वहीं लोकतंत्र अपने अगले चुनावों के लिए संघर्ष कर रहे हैं।

और अंतिम कारक, जनसांख्यकी है, जो समूचे क्षेत्र, खासतौर पर चीन के लिए एक दोधारी तलवार की तरह है। बहुत से यूरेशियाई देशों में, बीआरटी के आर्थिक लाभ जाहिर हैं। हालांकि ऐसे दौर में, जब राष्ट्रवाद राजनीति का मूड परिभाषित कर रहा हो, ऐसे में चीन की मौजूदगी अप्रिय हो सकती है। चीन का श्रम निर्यात युवा आबादी वाले मेजबान देशों में तनाव उत्पन्न कर रहा है, जो अब रोजगार के अवसरों के लिए प्रतिस्पर्धा कर रहे हैं। इस बात का खतरा है कि बीआरटी अस्थिर देशों में केवल उग्र और कट्टर संगठनों के लिए बुनियादी सुविधाओं के नेटवर्क तैयार करेगा।

घरेलू स्तर पर, जनसांख्यकीय दबाव चीन को अपेक्षाएं पूरी करने की उसकी योग्यता पर पुनर्विचार करने के लिए मजूबर कर सकते हैं। जैसे-जैसे चीन की युवा आबादी आमदनी की सीढ़ी चढ़ेगी, अपनी सरकार से उनकी अपेक्षाएं बढ़ेंगी। साथ ही साथ, शहरी क्षेत्रों में अकेले युवाओं की अधिकता और उम्रदराज होती गांवों की आबादी के कारण चीन के समाज में हिंसा और अशांति का खतरा उत्पन्न हो जाएगा। ये जनसांख्यकीय दबाव यूरेशियाई एकीकरण के प्रोजेक्ट के लिए क्या पूर्वाभास देंगे? क्या चीन के पास दुनिया भर में प्रभाव को अंधाधुंध खरीदने के लिए राजनीतिक पूंजीवाद या पॉलिटिकल कैपिटल होगी? क्या जनसांख्यकीय जटिलताएं अन्य देशों को बीजिंग सर्वसम्मति से निपटने की जल्दी से कोई व्यवस्था तैयार करने की इजाजत देंगी?


भारत में, यह बात इससे ज्यादा स्पष्ट नहीं हो सकती कि भारत का विकास का मार्ग जटिलता से यूरेशिया से बंधा है। भारत 21वीं सदी को परिभाषित करने वाले यूरेशिया और हिंद-प्रशांत दोनों क्षेत्रों के दोराहे पर है।


भारत, हालांकि ऐसे देशों के समूह में से एक होगा और उनके विजन के अनुसार खुद को ढालने, और तो और उस विजन को आकार देने की उसकी योग्यता आने वाले दशकों में यूरेशियाई वार्ताओं को प्रभावित करेगी।

रूस, जो अपनी आर्थिक जरूरतों और अमेरिकी ताकत के प्रति साझा नफरत के कारण चीन से कमजोर स्थिति में है, चीन के प्रति प्रतिकूल संबंध रखता है। इस वास्तविक यूरेशियाई सुपर पॉवर की हैसियत इस समय गौरवशाली पुलिसकर्मी — या ज्यादा उदारता से कहें तो चीनी विस्तारवाद के लिए चतुर जोखिम प्रबंधन सलाहकार — से ज्यादा नहीं है।

जिन दो आर्थिक विजनों को वे एकीकृत करना चाहते हैं वे — बीआरआई और यूरेशियाई आर्थिक संघ हैं, जो विविध तर्कों के अंतर्गत ऑपरेट करते हैं। इनमें से पहला चीन को व्यापार के वाहक के रूप में स्थापित करने की मंशा से बाजारों को नए सिरे से स्थापित करना चाहता है, जबकि दूसरा रूस के सीमित आर्थिक प्रभाव का विस्तार करने के लिए एकल बाजार का निर्माण करना चाहता है। साथ ही, रूस की चिंता का सम्मान करते हुए, चीन अब तक क्षेत्र में कड़ी सुरक्षा प्रतिबद्धताओं को टालता आया है — जिसका दीर्घकाल तक टिकाऊ रह पाना मुश्किल है।

रूस की साधारण क्षेत्रीय क्षमता और चीन की बहु-महाद्वीपीय महत्वाकांक्षा के अंतर से यह प्रश्न उठता है : क्या हो अगर दोनों स्वायत्तता और भौतिक रूप से यूरेशिया के दो अलग विजन्स तक पहुंचे? या उन दोनों के बीच प्रतिस्पर्धा पहले से ही अस्थिर क्षेत्र में जटिल सुरक्षा गतिशीलता की रचना कर दें?


दूसरी ओर, यूरोपीय संघ यूरेशिया को मुश्किल मान रहा है। एशिया की राजनीतिक अस्थिरता से अलग-थलग, यूरोप ने सत्ता की राजनीति को छोड़ दिया है और अमेरिकी सुरक्षा की छाया तले बहुसंस्कृतिवाद का अपना विजन विकसित कर लिया है।


हालांकि पश्चिम एशिया में फूट के कारण, शरणार्थियों की भीड़ पहले से कर्ज में डूबी ​अर्थव्यवस्थाओं में जा पहुंची है, जिसने यूरोपीयनों को महाद्वीप के साथ अपनी निकटता याद दिलाने के लिए बाध्य कर दिया है।

अब यूरोप भीतर और बाहर से टूट चुका है। यहां तक उम्रदराज होते यूरोपीय समाज प्रतिक्रियावादी लोकप्रियता और सुस्थापित राजनीतिक और आर्थिक सर्वसम्मति के विघटन से जूझ रहे हैं, उनकी सीमाएं बेल्ट एंड रोड इनिशिएटिव द्वारा धीरे-धीरे नष्ट हो रही हैं। यूरोपीय संघ को अब हर हाल में कुछ मुश्किल फैसले लेने होंगे: या तो अपनी एजेंसी के संरक्षण और विस्तार में जुटना होगा या एक समय पर एक ही काम करना होगा।

अमेरिका ने, अपनी ओर से पिछले नौ दशकों के दौरान, इन दोनों क्षेत्रों में अपने लिए विशिष्ट स्थान बरकरार रखने के लिए रक्त और धन बहाया है। हालांकि, रूस और चीन को संतुलित करने के प्रयास और “आतंकवाद के खिलाफ युद्ध” करने में उसकी ताकत और प्रभाव नेटो, केंद्रीय कमान और हाल में नए नाम पाने वाली ‘हिंद प्रशांत’कमान के बीच बिखर कर रह गए हैं, जिनकी अपनी रणनीतियां और विरासत हैं। क्या अमेरिका, अब अनपेक्षित रूप से आर्थिक राष्ट्रवाद के साथ खिलवाड़ करते हुए, जवाब देने की अपनी संस्थागत क्षमता से ज्यादा तेजी से संयुक्त और एकीकृत हो रहे विश्व में नेतृत्व का दावा कर सकता है?

महत्वपूर्ण होगा कि सभी और ​खासतौर पर भारत और अमेरिका, हिंद-प्रशांत से परे यूरेशिया के केंद्र में व्यवस्था की कल्पना करें। यह कल्पना लोकतंत्र के मानदंड संबंधी विचारों को नजरंदाज करते हुए, यूरेशियाई भूराजनीति वित्त और प्रौद्योगिकी के प्रावधानों, सम्पर्क तथा व्यापार तथा विविध राजनीतिक व्यवस्थाओं को समायोजित करने की इच्छा द्वारा परिभाषित होगी।

ये लेखक के निजी विचार हैं।

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Liberal world must stand up and be counted, or step aside and watch Pax Sinica unfold

Samir Saran

“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 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 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.


This commentary originally appeared in The Times of India.

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Indo-pacific, Uncategorized

Eurasia: Larger than Indo-Pacific – Liberal world must stand up and be counted, or step aside and watch Pax Sinica unfold

Original article 

“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.

 

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Globalisation and the celebration of unique cultures work together within BRICS

Samir Saran

The BRICS today is a manifestation of a post ideology world — a world that can coalesce on principles, not necessarily based on political theologies.

BRICS 2018, BRICS Academic Forum, Samir Saran, Johannesburg, South Africa, ideology, digital

Opening address by ORF President at the BRICS academic forum, 2018.


It is my honour to be here and share this dais with you all, my esteemed colleagues — Dr. Ivan Oliveira from Brazil, Professor Georgy Toloraya from Russia, Ms. Dong Weihua from China and lastly of course Professor Ari Sitas who is the host and leading the South Africa team. Thank you, Professor, and a thank you to your excellent team. Please accept our congratulations and gratitude for your exceptional hospitality and for the curation of an excellent agenda for this forum.

We’ve already had a great start to the academic forum — thank you Minister Pandor for your insightful opening address touching on key issues that will shape the world and our common futures over the next three decades.

Personally, I am delighted to be back in South Africa. For many of us in India, travelling to South Africa is like a journey home. Our modern history was scripted by a noble soul who found his calling on this soil. It was in South Africa where the most significant modern Indian project was born and visualised by the father of our nation, Mahatma Gandhi.

We are at an important juncture in world history, in African history and certainly in the brief BRICS journey. We are now entering the second decade of BRICS and the next decade could see the grouping play a decisive and compelling role — a constructive role in a world characterised by disruptions and despondency that looks ever more parochial and partisan and seeks new energy and leadership if it is to continue to work together, grow together and prosper together. South Africa is a perfect venue for us, academics from the BRICS countries to commit ourselves to offer ideas for our political, business and civil society leaders to consider.


We are at an important juncture in world history, in African history and certainly in the brief BRICS journey. We are now entering the second decade of BRICS and the next decade could see the grouping play a decisive and compelling role — a constructive role in a world characterised by disruptions and despondency that looks ever more parochial and partisan and seeks new energy and leadership if it is to continue to work together, grow together and prosper together.


South Africa is turning a new chapter. Its institutions have valiantly defended democracy and these institutions and associated laws have allowed the country to tide over some of its most difficult moments. I’m a big believer in President Cyril Ramaphosa and I’m a part of “Ramaphoria”. This is a special moment for this very special nation and we are all with you.

I believe the blueprint for Africa may well be scripted by this new administration and I am also convinced that this new administration will infuse greater energy into South Africa’s international engagement not only in this forum but also in forums such as IBSA. It is evident that South Africa is important to the world and the world is important for South Africa. The next ten years may well see South Africa take a leadership role in ideas, innovation and sustainable development — not only for its own communities and people, but also by creating a template for the entire continent.

The South African leadership of BRICS therefore comes at an appropriate time. The world is struggling with democracy and South Africa has shown us how democracy can be preserved, how peaceful transition of power can be achieved, how bitter political contests can use democratic means to discover resolution. As such, in a world where pluralism is being threatened, South Africa is a shining beacon for this continent and much of the world.

As South Africa moves to version 2.0 and renews its journey, economic and political, the second decade of BRICS will deeply benefit from this. In the 90’s South Africa promised the world a new charter for itself and a vision for a New Africa. It has more than delivered — yet, as with all our nations, there remains more to be done.


As South Africa moves to version 2.0 and renews its journey, economic and political, the second decade of BRICS will deeply benefit from this.


Even as we discuss issues on health, gender, social protection, security, education and research, economics and finance, and energy and resources, each of these themes are and will be implicated by three overarching global realities that are shaping communities, politics and societies.

The first reality is that of identity – and imbedded in this identity debate are issues around nationalism, race, ethnicity. Technology has spawned digital communities that are shaping and challenging traditions and indeed our interactions with the “other” and with ourselves. Globalisation itself has disrupted notions of who we are. We are today all global citizens with unfettered exposure to our surroundings — near and far. Yet, we are increasingly seeking old anchors in uncertain times.

The BRICS project in many ways can help us un-clutter the identity challenge. While this group adopts an increasingly outward looking approach, the collective remains deeply cognisant of its own individual cultural and historical moorings. Globalisation and the celebration of unique cultures and diversity work together within BRICS. It is not necessary for global citizenship and local cultures to be in contest — rather they can work well together and serve the larger common purpose.

Yet, as we seek globalisation, we must ensure it is a version that leaves no person behind. We must seek globalisation that serves diversity and unique perspectives that make this world richer. We must seek technologies that serve humankind and are not designed only to further wealth and prosperity for a few. We must seek global institutions that serve people and not just those who fund them and create them.


As we seek globalisation, we must ensure it is a version that leaves no person behind. We must seek globalisation that serves diversity and unique perspectives that make this world richer. We must seek technologies that serve humankind and are not designed only to further wealth and prosperity for a few.


21st Century identity challenges are shaped by the residues of the past and are further compounded by today’s complexities — issues pertaining to technology, financial access and intellectual property.

For instance, with the advent of the Fourth Industrial Revolution, we experience a reconfiguration of traditional social and economic classes. The farm, factory and office are no longer the nodal point of economic activity and human interaction. As the importance of traditional workspaces erode, we have seen a regression to social, political, and religious beliefs of yore. The future of the work space, and work, then, will implicate our imaginations of our selves.

The BRICS community and the BRICS academic forum with their inherent diversity should provide a new template that is better able to address the challenge of identity in this digital age.

The second is the challenge of inequality. While the world has rightly focused on the undeniably important challenge of poverty eradication — it has not done enough on devising policies to respond to growing inequality. This single factor is implicating political and social stability all over the world. Inclusivity is not only about lifting individuals out of poverty but also about providing the same opportunities to all. The contours of inequality today are complex — there is inequality around access to resources, infrastructure, health and education. There is inequality around political agency. There are deeply embedded biases that prevent women leadership of political, social and economic spheres. There is inequality that still lingers from racial divides and colonial legacies.


The BRICS community and the BRICS academic forum with their inherent diversity should provide a new template that is better able to address the challenge of identity in this digital age.


The BRICS academics gathered here must take leadership in developing ideas and solutions that serve the purpose of equality and equity. We have an opportunity to be propositional and assume thought leadership on this most important risk and opportunity of our times.

Which brings me to the last challenge, that of ideology. The BRICS project of the next decade must take into account the ideological challenges arising from identity and inequality. How do we move from the development of women to women led development? How do we move from affordable housing to housing that affords basic dignity for all? How do we move from education for all to economic agency and upward mobility to all? How do we create financial models of investments that do not prey on people and countries? How do we invest in technologies that serve aspirations of all rather than scavenge data from people?

One of the pitched debates today is on the management of data. If data is to drive economic growth in the future, then data inequality must also be addressed. While the rich may be able to safeguard their data, the poor cannot afford the same luxury. Further, most of our data is housed outside of our borders, across the Atlantic. The question then is, how do we ensure the fair use of data and confer its ownership and benefits to the owners themselves. Perhaps the BRICS can provide a model for the rest of the world — it is replete with alternate solutions. Take for example the Aadhaar platform of India, the Chinese BAT framework, the Russian comparative advantage in mathematics and cryptography, the South African experimentation with financial inclusion and technology and, of course, Brazil, which pioneered the Bolsa Familia program of social inclusivity. These all offer templates that are non-Atlantic and more importantly templates catering to a whole new class of people. In our own experiments we have a treasure trove of successes and failures and we must share and then together shape a new ethic of digital growth devoid from the 20th century dogmas around socialism or capitalism, market or command economy. We must work with ideas and solutions that serve us and we must devise a new template for a digital world that makes ideas richer and ideologies weaker.


The BRICS project of the next decade must take into account the ideological challenges arising from identity and inequality.


The last decade of contemporary history has seen a vigorous renewal of ideology — from religious to economic to ethnic beliefs and cultural ecosystems. We have seen how each of them have had a significant impact on political systems and political outcomes. The digital revolution and social movements based on hashtags are creating new mobilisations that are challenging the normative order of the past, the implication of which are still unknown.

The BRICS today is a manifestation of a post ideology world — a world that can coalesce on principles, not necessarily based on political theologies. The Russian democratic system, the Chinese socialism based on new characteristics, the Indian model of political and economic choice, the South African experience and the Brazilian politics are all shaped by different histories and experiences. As an academic community it is important for us to catalogue and map these diversities of systems and to tease out and define the principles that have allowed us to work together.

The plurilateral BRICS club is proof that ideas can trump ideology. BRICS is an ideas project and the academic community must be in the driver’s seat of the ideation process. We can’t let our today restrict us from visualising a fairer and better tomorrow. Progress will not happen by chance — rather it will require the world’s collective efforts. Let us commit to this today at the summit of BRICS academics and with this spirit engage in informed debates and exchanges this week among this wonderful BRICS family.

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Xi dreams: A roadmap for Pax-Sinica

Samir Saran| Akhil Deo

This paper studies the motivations behind the Communist Party of China’s decision to abolish presidential term limits and the implications of this decision not only for China, but for India and the world. The paper argues that this development stems from Xi’s conviction that only a stable leadership can help achieve the “China dream”. The contours of Xi’s vision include the erosion of the erstwhile “collective leadership” that has traditionally managed the affairs of the party and state. It also involves a more prominent role for China in international affairs; and the Belt and Road Initiative (BRI) is a bold statement of Xi’s attempt to reshape the global order. This will create new contradictions in China’s domestic landscape and increasingly position the country against the US. Further, these shifts will create new anxieties in China’s periphery, including with countries like India. ‘Communism with nationalist characteristics’ will now be pitted against the brand of nationalism that is sweeping across many parts of the liberal world.

Introduction

Located at the western edge of Tiananmen square in the heart of Beijing, the Great Hall of the People is from where China shows itself to the world. The Great Hall is where the People’s Republic of China government performs state functions, hosts foreign dignitaries, and organises various activities that project China’s power. It is also where the National Party Congress takes place every five years. The Congress itself is about people and policy: it reviews the party’s initiatives for the past term, outlines key priorities for the next five years, and appoints a new Central Committee. The 19th iteration of this event, held on 18 October 2017, may yet be the most important in the country’s history.  For the past five years, President Xi Jinping had sought to transform both the party and the state: he cemented his political power through an expansive and ruthless anti-corruption campaign; placed himself in key positions to influence the party, military and state; and extended the party’s authority over every aspect of the country’s governance. Xi is, without a doubt, China’s most powerful leader since Mao. However, unlike Mao, who governed a poverty-stricken China, Xi commands an economy that is today a driver of global economic growth.

Xi has been instrumental in securing for China an increasingly influential position in the international community. At Davos in January 2017, Xi Jinping disavowed protectionism and championed free trade and globalisation. It did not escape observers that Xi’s public pronouncements stood in sharp contrast to those of US President Donald Trump. On climate change, too, China has emerged as the most important actor—not only promising to cut down on emissions, but also investing in technologies, supply chains and markets that are critical for achieving the promises of the Paris Agreement. In Eurasia, the Belt and Road Initiative (BRI) is expanding Chinese influence through a series of infrastructure initiatives that Beijing claims will be the engine of the next wave of globalisation and connectivity. Xi has also pursued a more nationalist foreign policy. One month after Xi took charge of the military in November 2012, Chinese aircraft encroached on Japanese airspace for the first time since 1958.[i] At the same time, the construction of artificial reefs and shoals in the South China Sea, along with the overall militarisation of the region, have received top priority under Xi. Indeed, President Xi appears to be stubbornly departing from Deng Xiaoping’s maxim—”Observe calmly, secure our position; cope with affairs calmly; hide our capacities and bide our time; be good at maintaining a low profile; and never claim leadership.”[ii]

Which is why all eyes were on President Xi last year, at the 19th National Congress of the Communist Party of China. Delivering a marathon three-and-a-half-hour speech, Xi was bullish about his country’s future. “This is a new historic juncture in China’s development,” he declared, and the country must now “strive for the great success of socialism with Chinese characteristics for a new era, and work tirelessly to realize the Chinese Dream of national rejuvenation.”[iii] Xi undoubtedly saw himself as central to this effort. Having christened himself “core leader” in 2016, a designation first given to Chairman Mao, he inserted a new ideological guide to China’s destiny: “Xi Jinping’s thought on socialism with Chinese characteristics for the new age.” This placed Xi in the pantheon of China’s greatest leaders, adding to what was already a lengthy preamble which takes, as its guide to action, “Marxism-Leninism, Mao Zedong Thought, Deng Xiaoping theory, Theory of the Three Represents, and the Scientific Development Outlook”.

The 19th National Congress was also supposed to perform another function: that of elevating a successor. The 15th party congress in 1997, for example, named Hu Jintao and Wen Jiabao as successors to Jiang Zemin and Zhu Rongi, respectively. And Xi Jinping and Li Keqiang were elevated at the 17th party congress in 2007. Therefore there was much anticipation, both within China and around the world, about who Xi would name as his successor at the 19th Congress. He would speak no words about any succession. Less than half a year later, Xi confirmed what many had already suspected. In March 2018, China’s parliament overwhelmingly voted in favour of a proposal abolishing presidential term limits—essentially making Xi the chairman of everything on an open-ended basis, and entrusting him with the great concerns of party, military and state. Of the 2,964 votes that were cast, 2,958 were in favour of the amendment, one vote was invalidated, and “the identities of the five dissenters is—and will almost certainly remain—a mystery,”—as The Guardian puts it.[iv]

Again, in doing this, Xi broke from convention that had been established by Deng, who prioritised economic development and warned against “the excessive concentration of power” of the kind China saw in the Mao era, and the violence of the cultural revolution that followed. The reaction from global audiences was immediate: “a new emperor” and “president for life” were common headlines across newspapers. Even in Beijing, the signs of discontent became immediately obvious. China’s censors worked overtime as soon as the news broke out.  An assortment of phrases such as “constitution amendment,” “re-elected,” “proclaim oneself as emperor,” and “two term limit,” were erased from Weibo—China’s equivalent of Twitter.[v] All references to the popular Disney character Winnie the Pooh—to whom Xi bears a resemblance, according to Weibo users—were erased as well. In some universities abroad, posters with the phrase “Not my President” were plastered on campus walls by anonymous Chinese students.[vi] Perhaps the one censored phrase which indicated both disgruntlement in China and paranoia of the authorities was: “I disagree.”[vii]

Ironically enough, the only person who seems to have praised Xi Jinping was President Trump, who was quoted to have said “it was great” that Xi was now president for life. “We’ll want to give that a shot someday,” he added.[viii] The key question, however, is if President Xi is just another power-hungry dictator. The answer is complex. It was not truly necessary for Xi to abolish constitutional term limits for the presidency; in fact, real power rests with the Party Secretary and the Chairman of the Central Military Commission, which have no limits in the first place,[ix] although still largely subject to the informal 10-year transition rule that has been in place since Jiang Zemin’s regime. Instead, it would be correct to assume that Xi believes that predictability and stability are key for China’s emergence as a great power. Apart from rising domestic expectations, the international climate can be far more hostile to China’s growth.

This paper discerns the motivations and implications of ‘Emperor’ Xi in the context of China’s political economy, his ambitions for China’s place in the international system, and the Sino-Indian relationship. At home, Xi is aware that Chinese society is undergoing a significant transition. A prosperous middle class begets new expectations, and the Party must adapt to serving new demands. The statist nature of collective leadership in the Hu Jintao era must have weighed heavily on Xi, because he now believes that what China requires is a stronger Party, with himself at its core. Simultaneously, China’s economic rise and social stability must require it to play a greater role in international affairs—commensurate with its history and current heft. To achieve this, Xi will seek the erosion of the artificial borders of Asia, Europe and Africa, and intend for China to emerge as the sole arbiter of political, economic and security decisions in these regions. For India, Xi’s ambitions can only mean greater rivalry. As an emerging power that harbours its own global ambitions, India cannot constrain itself to playing second fiddle.

The Principal Contradiction

Xi Jinping has outlined the “China Dream” explicitly: a “moderately well-off society” by 2021 and a “democratic, civilised, harmonious, and modern socialist country” by 2049.[x] Central to achieving this vision, is what the Chinese understand as resolving the “principal contradictions” of a state. By identifying and resolving these contradictions, society is able to develop peacefully. This line of thinking formed the crux of Mao’s influential 1937 essay, “On contradictions”, where he identified  an irreconcilable class war between the proletariat and the bourgeoisie as the two opposing social forces.[xi] Intent on preventing the horrors of the cultural revolution that followed from this thought, as well as on generating wealth, Deng Xiaoping described the principal contradiction in 1981 as the one between “the ever-growing material and cultural needs of the people and backward social production.”[xii] By framing the problem in this manner, Chinese leaders could justify market reforms and reconcile the tenets of socialism with those of a market economy, thus giving birth to what would be known as “socialism with Chinese characteristics.”

Nearly four decades later, the results are clear enough: with a Gross Domestic Product (GDP) of US$11.2 trillion, China is today the world’s second largest economy and continues to climb up the industrial value chain;[xiii] ranked 22nd on the Global Innovation index, it is home to some of the world’s most competitive technology giants such as Alibaba and Tencent;[xiv] by 2014, China was trading nearly US$4.3 trillion of goods and services, making it the world’s largest trading nation;[xv]and it now boasts one of the world’s most advanced military, allotting nearly US$175 billion on the forces’ modernisation in 2018.[xvi] This trailblazing economic growth, however, has come with social costs, such as huge inequity: as China boasts over a million millionaires, the richest one percent of households own one-third of the country’s wealth.[xvii] Urbanisation is also taking its toll: nearly 200 million rural migrants travel across China in search of factory jobs that offer poor pay and hazardous working conditions; and many of China’s major cities, most prominently Beijing, are enveloped in dense smog for many months of the year. There is also the problem of corruption, with Transparency International’s Corruption Perceptions Index ranking China 77th out of 180 countries.[xviii]

A survey by the Pew Research Center in 2015 showed that the Chinese people viewed corruption, pollution, and inequality as their country’s most pressing problems.[xix] Unsurprisingly then, President Xi has reframed the principal contradiction as the tension between “unbalanced and inadequate development” and the “people’s ever-growing needs for a better life.” This includes, in Xi’s words, “demands for democracy, the rule of law, fairness and justice, security, and a better environment.” This is the crux of the “New Era” that President Xi promises. In essence, he recognises that economic growth alone is not enough; rather, the party must embrace “well-rounded human development and all-round social progress.” While the idea of solving contradictions itself is ambiguous, the importance of this framework on both the direction of the state, and Xi’s own personal ambitions, are momentous. What Xi is saying is that he alone can provide what China’s increasingly ambitious middle class expects: clean governance, efficient provision of government services such as education and healthcare, affordable housing, and a cleaner environment. The text of his report at the 19th Party Congress is a key indicator of his intentions: the phrases “rural rejuvenation”, “ecology”, and “environment” were mentioned more times than “market” or “economy.”[xx] It is unsurprising, then, that Xi, who The Economist called “the world’s most powerful man,”[xxi] spent the better part of 2017 talking about toilets, describing them as a “concrete part of advancing our country’s revitalisation.”[xxii]

This restatement of the Chinese society’s “principal contradiction” will have enormous implications: it signals Xi’s personal ambition of being the president that will turn China from a poor middle-class country, to a prosperous society that forms the backbone of a new great power. It also validates the criticism of former Premier Wen Jiabao, who warned in 2007 that the Chinese economy was increasingly becoming “unstable, unbalanced, uncoordinated, and [ultimately] unsustainable.”[xxiii]Many believe that Xi now has the power and authority to correct this; according to Moody’s,  Xi’s consolidation of power “could advance the process of economic reform and rebalancing, because one obstacle to reform has been the misalignment of incentives between the central leadership and other officials.”[xxiv] Deng, who was the principal architect of China’s economic reforms beginning in the late 1970s, saw “the separation of the party and government” as key towards rejuvenating the economy. President Xi sees things differently. In an allusion to Chairman Mao, he had once said: “Party, government, military, society and education, east, west, south, north, the Party governs everything.”[xxv]

Xi now faces the enormous challenge of making the right choices for China’s economy. In 2013, Xi promised to give the market a “decisive role” in the economy. Five years later, it is apparent that Xi has done with the economy what he has done with the rest of China: he has elevated the role and power of the Communist party. As the goal of doubling the 2010 GDP of China by 2020 remains a policy priority, Xi has called on the “national champions”—or State Owned Enterprises of China—to fulfil this role. Xi has also mandated the presence of Party members in almost every commercial venture in China, giving them key management and investment decisionmaking powers. Moreover, its action plan for what it calls “Made in China 2025” puts to rest any notion that the country might now be looking at liberalising its economy. The plan envisions China emerging as the industry leader on high-technology manufacturing and advance technologies such as robotics, artificial intelligence, and genomics. It seeks to indigenise and relocate global supply chains to the Chinese mainland with generous support from the state in the form of easy credit, domestic procurement clauses, and trade barriers. For now, Xi has made it clear that any real market reform that would reduce the Party’s influence is undesirable.

This is hardly surprising. Whenever he speaks at home, he extolls absolute loyalty to the Party. The Party itself under Xi, however, has undergone a massive transformation. Since at least the 1990s the PRC has embraced the idea of “collective leadership”. In 2007, a communique issued by the Party Congress stated that collective leadership is “a system with a division of responsibilities among individual leaders in an effort to prevent arbitrary decision-making by a single top leader.”[xxvi]Various analysts have said that the pillars of China’s “authoritarian resilience” were “Intra-Party Democracy”, merit-based recruitment, delegation of power, and consultative decisionmaking. Deng Xiaoping himself once argued that “the key to China’s stability lies in the collective leadership of the Politburo, especially its Standing Committee.”[xxvii] Under Hu Jintao, however, this principle was severely tested. During a period referred to as “the lost decade”, Chinese society was marred by corruption and social unrest; it was when Chinese politics was at its factional worst between the elitist group who “generally represented the interests of entrepreneurs and the coastal region”, and populists who “represent the interests of the labouring classes and the inland region.”[xxviii] At the same time, the same decentralisation that characterised the Deng era came to represent a disconnect between Beijing and local officials in the provinces—a divide captured aptly by the Chinese proverb: “The mountains are high and the emperor is far away.”[xxix]

Perhaps aware of this reality, Xi has eroded this consensus. According to a Party source interviewed by the Nikkei Asian Review in early 2018, “Xi is now aiming to be free of China’s collective leadership system. His ideal is to have strong powers similar to those granted to a U.S. president.”[xxx] The complete centralisation of power under Xi bears testament to this desire: not only is he President, General Secretary of the Party, and Chairman of the Central Military Commission, but Xi also chairs the Central Leading Group for Comprehensively Deepening Reforms as well as the National Security Committee—two of the most important decisionmaking bodies in China. Simultaneously, he chairs several leading groups on internet governance, military reform, and foreign affairs, among other aspects of governance. Many of these leading groups are also staffed by Party officials who worked with him during his younger days in provinces such as Zhejiang and Fujian—in other words, their loyalty is beyond question.[xxxi] What surprised many was Xi’s absolute control over the People’s Liberation Army (PLA). Writing for The Wall Street Journal, Andrew Erickson notes that Xi’s “ability to impose his will on the PLA… is a skill that his predecessor Hu Jintao lacked utterly and that Jiang Zemin wielded inconsistently.”[xxxii] During a high-profile address to Chinese troops stationed in Hong Kong  to mark the 20th anniversary of the British handover, Xi reportedly asked them to refer to him as “Chairman”—a break from the conventional “leader” that troops otherwise use, and a powerful indication of his domestic strength and complete control over China.[xxxiii]

At the heart of Xi’s so-called “new era” for both society and industry, then, appears to be more centralised Party control. Indeed, it does not seem likely that the intimidation of human rights activists, dissenters, and religious minorities will subside. At the same time, Xi will preside over the creation of the Orwellian social credit system, which will track citizens’ behaviour in astonishingly granular detail using artificial intelligence, Big Data, and the Internet of Things. As Elizabeth Economy writes in her new book, “The Third Revolution”, Xi Jinping’s call for the “rejuvenation of the Chinese nation” is not entirely novel. Both Hu Jintao and Deng Xiaoping have in one way or another called for the “invigoration” of China. Xi, however, has “elected a way forward that largely rejects the previous path of reform and opening up: instead there is reform without opening up.”[xxxiv]It is this new framework that will guide China’s political economy. Over the past decade, Beijing has attempted to enact several reforms that would address its persistent domestic imbalances. Ultimately, Xi’s power grab alters the political ecosystem within which they will operate. This system is “party first”, with core leader Xi at the helm.

Everything Under the Heavens

Of course, China’s economic rise and stability will have major implications on how it reshapes the world order. “The great rejuvenation of China”— Xi’s nationalist calling card—is an appeal to the country’s historical place in world affairs. Ever since China’s last imperial dynasty was defeated by the British Navy in the mid-19th century, the quest for wealth, power and international prestige has preoccupied China’s elites. Indeed, Xinhua notes, “By 2050, two centuries after the Opium Wars, which plunged the ‘Middle Kingdom’ into a period of hurt and shame, China is set to regain its might and reascend to the top of the world.”[xxxv] The sheer number of foreign trips that Xi Jinping has taken since becoming president is a testament to this belief: nearly 28, covering 56 countries across five continents—the highest number for any Chinese leader.[xxxvi] Xi is aware that China’s global power ambitions could not have come at a better time. Indeed, the 19th Party Congress report notes that “relative international forces are becoming more balanced.”

This was a slightly nuanced recognition of the perception that Western powers are unable to anchor the post-World War II international order. The United States (US) and the European Union (EU) have both faced a succession of economic and social troubles over the past several years. For the first time since the end of the Cold War, an American president is speaking of economic protectionism, disavowing multilateral diplomacy, and demanding more from military alliances. The EU, on the other hand, is gripped by a crisis of identity as an inflexible Brussels struggles to manage economic inequality along with integrating the millions of migrants from the Middle East, thus putting to test the values of multiculturalism and liberalism that defined post-war Europe. These turmoils have left a leadership vacuum in terms of the global economy, epochal ecological change, and collective security. It is in this vacuum that President Xi sees opportunity: by the middle of the 21st century, Xi boasts, China would have become “a global leader in terms of comprehensive national power and international influence.”

Yet by any measure, China is already a global power. During Xi’s 2012 visit to Washington, D.C. as vice-president, he called for a “new type of great power relations” between the US and China. Elizabeth Economy writes that such ambitions reflect Xi’s confidence that China is in a position to shape the international order—or capable of “constructing international playgrounds” and “creating the rules” of the game, as he would later say in a speech in 2014.[xxxvii] China’s ambition, as journalist Howard French notes, is deeply historical. “For the better part of two millennia,” writes French, “the norm for China, from its own perspective, was a natural dominion over everything under the heaven, a concept known in the Chinese language as tian xia.”[xxxviii] Xi has been masterful in his employment of history to stoke nationalism among his people. “Only by having a correct recognition of history,” he once said, “can it be possible for us to open up a better future. Forgetting history signifies betrayal.”[xxxix]

The first major flashpoints of this invigorated nationalism are likely to be the South China Sea (SCS), where “steady progress” in the construction of islands and reefs has been highlighted as a major achievement by Xi; and Taiwan, which Xi claims must be reunited with the mainland to achieve the great rejuvenation of the Chinese nation. As French notes: “Everything about its diplomatic language says that it views the Western Pacific as it once did its ancient known world…and that it intends for this region to return to its status as a place where China’s paramount standing goes unchallenged.”[xl]This is another key reason for Xi to remain in power: Since 2012, he has reformed and rationalised personnel management, reorganised the military into “theatre commands”, created new units to develop and deploy advanced technologies, and promoted a younger generation of military elite.[xli]However, these upheavals have created certain efficiency problems, including the dislocation of units, anxiety amongst senior officers and unfamiliar organisational structures.[xlii] Xi intends to power through these reforms and oversee a streamlined military that will achieve full modernisation by 2035. He wants to ensure that the PLA becomes a global top-tier fighting force capable of winning wars by mid-century. In the SCS, China has adopted a strategy of “active defence”—otherwise referred to as anti-access/area denial (A2/AD), which involves utilising long-rage precision missiles, active control over contested waters, and denial of navigation to preclude American intervention in the region.

Taking note of this, US Admiral Harry Harris has already called Beijing’s militarisation of the South China Sea “a coordinated, methodical and strategic” attempt to “erode the free and open international order;” he warned that “China’s impressive military build-up could soon challenge the United States across almost every domain.”[xliii] Further, the US National Security Strategy now refers to China as a “revisionist power”, and the US Senate recently passed the Taiwan Travel Act, clarifying that it “should be U.S. policy” to allow American and Taiwanese officials to meet for high-level talks.[xliv]On 16 April 2018, President Xi sent a clear message to the US and the world by ordering live fire drills in the Taiwan Strait, only days after he presided over a large-scale naval display in the SCS that involved “more than 10,000 naval officers, 76 fighter jets, and a flotilla of 48 warships and submarines.”[xlv]

Nearly three years ago, Graham Allison wrote that when a rising power confronts an incumbent superpower, war ensues.[xlvi] He titled the book “Thucydides trap” in memory of the Athenian historian who analysed this dynamic between Athens and Sparta nearly 2,400 years ago. Whether or not the Thucydides trap plays out in the SCS region may be uncertain, but the signs are ominous.

The real concern, however, is China’s Belt and Road Initiative (BRI). This dense network of infrastructure projects, energy lines, supply chains and trade routes, intends to erode the artificial political geography of Asia and Europe. Again, Xi has been masterful in employing history to court support for the BRI: “More than 2,100 years ago,” he said, “during the Han Dynasty a Chinese envoy named Zhang Qian was twice sent to Central Asia,” and journeys would “start the Silk Road linking the East and West, Asia and Europe.”[xlvii] From railway lines in South-East Asia, to the comprehensive China Pakistan Economic Corridor (CPEC) in Central Asia, to a military base in Djibouti, Africa, and onwards to the Greek port of Piraeus—President Xi has staked his legacy on being able to integrate Asia, Africa and Europe into one overarching political, economic and military architecture with Beijing as its central node. Foreign Minister Wang called it “the largest international cooperation platform in the world and the most popular international public product.”[xlviii] The word “cooperation,” however, is often loosely thrown about by Chinese officials. A recent review of eight countries that have signed on to the BRI revealed what countries like India already knew: the projects are financially unsustainable, the trade imbalance with Beijing is too high, environmental costs are ballooning, and strategic assets are being collateralised for debt.[xlix] When asked why Sri Lanka had handed over the strategically located Hambantota port to China for a 99-year lease, Mahinda Samarasinghe, Sri Lanka’s ports and shipping minister, answered woefully: “We had to take a decision to get out of this debt trap.”[l]

China is now wary that a counter-mobilisation of other regional powers is taking place against the BRI. Beginning with a speech by former US Secretary of State Rex Tillerson in October 2017, who criticised the BRI for its “predatory economics”,[li] like-minded ‘Indo-Pacific’ democracies have begun to align their normative interests, economic statecraft and military postures to prevent Beijing from unilaterally shaping Asia’s governance architecture. While the US, Japan, India and Australia all have their own axe to grind with China for various political and military reasons, they are well aware that faulty economics could be the Achilles’ heel of the BRI. The signs of discontent are already apparent in many parts of the world—protests against Chinese investments have erupted from Kazakhstan in Central Asia, to Kenya in Africa, Bangladesh and Sri Lanka in South Asia, and in parts of South East Asia as well. Accordingly, members of the renewed Quadrilateral Initiative (i.e., India, Japan, Australia, the US) are creating new synergies in their economic statecraft: the US’ “free and open Indo-Pacific” strategy, the Indo-Japan Act East Forum, and the new Asia-Africa Growth Corridor. In each case, these states are raising capital to meet the connectivity requirements of developing countries and pushing for better qualitative economic frameworks and transparent investment standards.

To address these concerns, President Xi is placing his bets on a new agency for international development which will  “give full play to foreign aid as a key means of major-country diplomacy,” enhance its coordination and “better serve the nation’s diplomatic strategy” including the Belt and Road project, according to State Councillor Wang Yong.[lii] This new agency is significant as it indicates that Beijing is aware that it must create a more equitable economic framework to manage its investments and quell the discontent in target regions. However, Beijing’s “major country diplomacy,” at least when it comes to those states that are hesitant about the BRI, often involves coercion.  For the most part, Southeast Asia has had to bear the brunt of China’s heft. China has used its loose purse strings to effectively “divide and rule” the ASEAN. Despite having suffered the worst of Beijing’s land reclamation policies in the South China Sea, for example, Rodrigo Duterte of the Philippines is confident that he can come to an arrangement with China—a view undoubtedly buttressed by nearly US$24 billion in investment proposals promised by China.[liii] For the same reasons, successive ASEAN communiques have failed to explicitly highlight Beijing’s militarisation of the SCS. Not that this behaviour is limited to Asia: In 2016, both Hungary and Greece—major beneficiaries of Chinese investments—refused to adopt an EU statement on the South China Sea, and have fought hard to prevent any major overhaul of investment policies that would limit Beijing’s financial offerings.[liv]This, in fact, is a key overarching objective of the BRI: to erode the autonomous politics of various subregions around the world through economic statecraft, military coercion, or both. Only by ensuring that regional blocs do not cohesively act as one unit can the Belt and Road succeed. Xi has staked his personal legacy on this.

The BRI is also important to China because it ultimately paves the way for Xi’s institutional statecraft. President Xi wants China to emerge as the next driver of globalisation—however, he wants to do this in a manner that is distinct from the ‘Washington consensus’ that was based on transparent free markets. In its place, Xi will sell “socialism with Chinese characteristics”; a unique blend of state control over industry and capitalism—or what India’s former Foreign Secretary calls “non-market economics”.[lv] Today’s global institutions, such as the World Bank, are dominated by America’s economic model—and China seeks to supplant these institutions with those that support the ‘Beijing consensus’, such as the BRICS New Development Bank (NDB), the Regional Comprehensive Economic Partnership (RCEP) trade agreement, and the Asian Infrastructure Investment Bank (AIIB). China is even setting up new “international tribunals” to manage trade and investment disputes arising from the BRI. However, it is unclear what standards of dispute settlement will be employed, and which law will be given precedence. The most obvious implication of this new institution is to prevent disputes involving the BRI from being settled under the legal system of potential competitors. Ultimately, these institutions bolster Beijing’s influence in recipient countries; give China leverage over other multilateral institutions; and enhance Beijing’s global leadership status. If China succeeds in this endeavour, it will fundamentally alter the nature of global relations. For nearly 70 years, the combination of political liberalism and economic free markets succeeded in the global marketplace of ideas. As Wang Yi states, “…the most essential and meaningful results of China’s diplomacy as a major country with Chinese characteristics” is that China can now “provide a new path for all developing countries to modernization.”[lvi]

As Elizabeth Economy states bluntly: “China is essentially, an illiberal country claiming leadership in a liberal international order”[lvii]—another contradiction it undoubtedly seeks to resolve. And it has found a willing partner in Moscow. In 2016, former Chinese Vice Foreign Minister Fu Ying wrote in Foreign Affairs, that it would be incorrect to characterise the Sino-Russian relationship as one that is a “marriage of convenience”; instead, she writes,  “changes in international relations since the end of the Cold War have only brought the two countries closer together.”[lviii] The official was essentially blaming Washington’s unilateralism’s for bringing them together. Today, both Moscow and Beijing remain convinced that the centre of gravity in international politics is drifting from the Atlantic to the Eurasian system—a geography they are both particularly well-placed to influence. While ideologically and economically whittling away at the EU—through Russian support for far-right parties and China’s financial offerings, both these countries have enhanced economic cooperation through interaction between the BRI and the Eurasia Economic Union (EEAU); and are coordinating security and governance policy under the Shanghai Cooperation Organization (SCO). At the same time, both countries have often taken similar positions at the United Nations, such as on the Syria crisis, and have stepped up military exercises in disputed areas such as the South China Sea. Russia is merely China’s most influential partner in what is otherwise a concerted effort to build a coalition of states who are no longer willing to subscribe to the notion that domestic development and global governance is only achievable under the conditions of democracy and free markets.

In 1949, Mao achieved the goal of independence; in the 1980s Deng set China on a path that would make it wealthy; and Xi believes that the time has now come to build a “community with a shared destiny for mankind” and fulfil the objective of ensuring that “China will continue to play its part as a major and responsible country, take an active part in reforming and developing the global governance system, and keep contributing Chinese wisdom and strength to global governance.” Whether or not President Xi will say so explicitly, he intends to attempt what no modern Chinese leader has accomplished:  the revival of the ancient Chinese system of Tian-Xia—a worldview as old as the Han Dynasty that places China at the apex of a network of political, cultural, economic and military regimes—or as Xi notes, “ever closer to centre stage in global affairs.”

From the Himalayas to the High Seas

To be sure, there are several irritants to Xi’s ambitions—and none more persistent than India.  During the last five years under Xi, tensions between the two countries have only exacerbated. For example, China has repeatedly blocked efforts at the United Nations to list Pakistan-based Masood Azhar, mastermind of the Pathankhot attack, as a “global terrorist”. In June 2016, China vetoed India’s bid to become a full-fledged member of the Nuclear Suppliers Group (NSG). In April 2015, Beijing announced the China-Pakistan Economic Corridor, which passes through Pakistan Occupied Kashmir. China has also steadily increased its presence in India’s neighbourhood, both economically—through BRI projects in Bangladesh, Nepal, Bhutan, Sri Lanka and Afghanistan, as well as strategically–by increasing the number of military deployments in the Indian Ocean Region. Understanding why is not that difficult: India and China are now structurally set to collide. They are the world’s largest democracy and autocracy, respectively; they both are expected to become part of the three largest economies in the coming decades;  they are home to a couple million of the world’s millionaires, and hundreds of millions of the world’s poor; they host two of the largest militaries in the world, and have two of the highest defence expenditures; and, most importantly, they both harbour ambitions of becoming a global leader. Indeed, the wealth and power of the world is inextricably moving eastwards towards Asia. India and China are in a race to define the contours of this region’s governance.

If China likes thinking of the world in contradictions, then it only needs to look at its relationship with India. The fundamental contradiction is how each nation views its role in Asia. Just like for China, India’s rapid economic rise will reshape the global balance of power in the coming decades. Unlike China, however, India is defined by a vibrant democratic political system, and an economy that largely relies on private-sector entrepreneurial dynamism. Indeed, at the World Economic Forum in 2018, Indian Prime Minister Narendra Modi made it clear that India’s democracy is a “force for stability” in an otherwise global state of uncertainty and flux.[lix] Just as China employs history in defining its relationships, India believes that “Asia’s re-emergence is the greatest phenomenon of our era”—as Modi declared at the 37th Singapore lecture in late 2015. India’s reintegration with a broader Asia, he said, was a “return to history,” announcing that India is “retracing our ancient maritime and land routes, with the natural instincts of an ancient relationship.”[lx] China understands that if India can succeed in lifting millions of its people out of poverty, and emerges as a new engine of global economic growth, it will provide an alternative development model to the developing world—one that is completely different from Beijing’s preferences and equally attractive.

Perhaps the most obvious indication that India and China are on a collision course is New Delhi’s opposition to the Belt and Road Initiative—President Xi’s signature initiative. India has always been reluctant to remain a “passive recipient of outcomes”—as former Foreign Secretary Jaishankar said.[lxi] Following Modi’s state visit to Beijing in May 2015, where New Delhi expressed irritation that it was not privy to conversations on the “One Belt One Road” initiative (as it was known then), India has emerged as a forthright critic of the BRI, calling it Beijing’s attempt to “hardwire influence” in Asia.[lxii] At the same time, India is also ramping up its own connectivity projects, such as the India Myanmar Thailand Trilateral Highway; the Chabahar Port with Iran; along with the International North South Transportation corridor with Russia. Further, India is partnering with Japan to launch the Asia-Africa Growth Corridor (AAGC) which seeks to propel growth, investment and connectivity between the two regions. Similarly, In December 2017, India hosted the ASEAN-India Connectivity Summit in a bid to offer alternatives to Chinese investments in the region. In terms of geography, these projects seek to connect the Indian Ocean, the Persian Gulf and Europe—almost exactly the regions that the BRI will target. However, India is decidedly a different power. By articulating its own norms, and aligning with like-minded partners under the Quadrilateral Dialogue, India is making it clear that it will not rely on “predatory economics,” and will instead attempt to foster a “rules-based order” that ensure financial sustainability and good governance in relation to connectivity initiatives.

Under Xi’s command, such disputes over economic relations and global leadership have also spilled over into military conflicts that now extends from the “Himalayas to the high seas.” Despite the fact that the Doklam standoff had ostensibly come to an end in August 2017 following a “mutual withdrawal” ahead of a BRICS summit a month later, Chinese forces remain in the region and do not appear ready to withdraw yet. In a series of reports for The Print that have caused embarrassment to New Delhi, retired Colonel Vinayak Bhat has used satellite imagery to detail the build-up of PLA forces in and around Doklam, including helipads, concrete fighting posts, and new trenches.[lxiii]China’s Foreign Affairs spokesperson in fact made clear that China would  “continue with its exercise of sovereign rights” in the disputed area.[lxiv] At the same time, Maldives President Abdulla Yameen has declared a state of emergency in a country that is traditionally considered a part of “India’s backyard”, and has refused to yield to calls from the international community, including India, to restore democracy. His only friend so far has been China—and understandably so. Beijing has invested nearly US$1 billion in investment projects in the island state; has obtained the lease of the “uninhabited island Feydhoo Finolhu for tourism use for 50 years”; and is now the Male’s largest creditor, accounting for nearly 70 percent of the state’s debt.[lxv] Ominously, even as the tropical island was under a state of emergency and India’s next moves were yet undecided, eleven Chinese warships sailed into the East Indian Ocean early this year, in what was undoubtedly a form of soft signalling to New Delhi. [lxvi] In a story that is now familiar across the South Asian subcontinent, China’s hard economic power, coupled with its rising military profile, is eclipsing India’s historical civilisational ties and its recent commercial outreach.

To quell some of these tensions, Modi and Xi met for an “informal summit” at Wuhan in the last week of April. Coming ahead of Modi’s visit to China for the Shanghai Cooperation Summit in June, expectations were uncertain about the two-day meeting that would see both leaders “walk by a lake, visit museums, and even take a boat ride.”[lxvii] The first sign of this rapprochement was Foreign Secretary Vijay Keshav Gokhale’s note to the Cabinet Secretary that senior leaders from government must not attend a public event organised by Tibetan leaders to thank India for hosting them for nearly 50 years now.[lxviii] That same month, India reportedly informed their Chinese counterparts that it will not intervene in the Maldives, and that it expects China to reciprocate this measure of “strategic trust” by not crossing certain “lines of legitimacy.”[lxix] Chinese Foreign Minister Wang Yi, for his part, has resorted to clichés, suggesting that “the Chinese dragon and the Indian elephant must not fight each other but dance with each other. If China and India are united, one plus one will not equal two but 11.”[lxx] The results, ultimately, were underwhelming: apart from calls to accelerate economic cooperation, and the possibility of exploring joint development partnerships in Afghanistan, neither country could agree on key bilateral irritants, such as the Belt and Road Initiative, Pakistan, or Indo-Pacific security. Rather than the results of the summit itself, the analysis around it gave far more illumination. Some believe that the summit was a product of “Asia’s imbalance of power”—a weaker India seeking reprieve from a domineering Beijing.[lxxi] Others believed that “Trump is driving Xi into Modi’s arms”—alluding to global economic tensions that have arisen as a result of Trump’s trade posture against China, and its consequent search for alternate partners.[lxxii] In truth, both from India’s and China’s side, the overtures are temporary: New Delhi is gearing up for national elections in 2019, and Beijing is in the midst of a potentially costly “trade war” with the United States—and neither of them are keen to manage another flashpoint.

Prior to the visit, Modi tweeted in April that he would be visiting Xi to “discuss our respective visions and priorities for national development, particularly in the context of current and future international situation.”[lxxiii] Unfortunately, the fact remains that these visions are at odds with each other. In the long run, the India-China relationship runs on multiple faultlines: civilisational, historical, economic and military—and Xi Jinping intends to tip the scales in favour of China before India can catch up. The central problem is that Beijing refuses to recognise India’s influence, power or prerogatives, in its own neighbourhood and in the extended region. From claiming that India behaves as a hegemon in its region, and telling New Delhi that the Indian Ocean does not belong to India, Beijing is repeatedly dismissive of India’s great-power ambitions. The military and economic disparity between the two countries only bolsters Beijing’s confidence. Indians are acutely aware of this reality—in 2017, a survey by the Pew Research Centre found that  only  21 percent of Indians surveyed had confidence in Chinese President Xi Jinping to “do the right thing.”[lxxiv] As China’s immediate neighbour, and a diverse and chaotic democracy with its own global ambitions,  India is facing the obvious implications of Xi Jinping’s extended presidency: greater turbulence in the near future.

The Paradox of Power

Clearly, the import of Xi Jinping’s power grab is enormous. In a world that is “in the midst of profound and complex changes,” as the 19th Party Congress report notes, Xi now enjoys political stability to oversee China’s rise as a global power, and by extension, emerge as the greatest Chinese leader in modern history. He must deal with a hostile United States, while managing complex social, economic and ecological problems at home. His decision to remain Party President beyond 2023 only serves to show that Xi believes in his own ability to steer China through these headwinds.  For political systems with shorter timelines and democratic constraints, this is an impossible task. For Xi, it is within reach.

At home, it remains to be seen whether or not Xi can fundamentally alter China’s social contract. A larger, more prosperous and more technology-savvy middle class will place new types of pressure on China’s governance system. If Xi can successfully deliver on his “better life” agenda, he will truly have a new model for development. China will become the first high-income autocracy, an achievement many considered impossible. This will have tremendous spillover effects in the international system. Already, Xi has made it clear that the revival of the Middle Kingdom will be accompanied by the redrawing of geographical borders, a transformation of the global institutional landscape, and the death of diversity in China’s periphery. If Beijing can provide an alternative to liberal democracy, the normative foundations of the international liberal order will stress considerably. For emerging democracies such as India, this is a fundamental challenge. Competition with China will not merely be geographical, or economical, but ultimately ideological, too—India must not only provide a bulwark against Beijing’s militarisation, but should now prove to developing countries in Asia and Africa that liberal democracies is a fundamentally more utilitarian political model.

However, Xi must solve a paradox for himself. Without having a clear map for political succession, Xi risks facing the ire of not only China’s ordinary citizens, if he fails to deliver on his promises, but also the disenfranchised Chinese elites, of which there are many given his anti-corruption programme and consolidation of power. Indeed, under Xi, expenditure on domestic security has increased exponentially, touching nearly US$200 billion in 2017 alone[lxxv]—in what is perhaps an indication that he is concerned about unrest at home. On the international front, Xi’s renewed nationalism and assertiveness is facing resistance from a variety of fronts. As the implications of investments under the BRI become more apparent, developing states are becoming increasingly wary about political pressure from Beijing; if the economic premise behind these investments begin failing, Chinese firms have the most to lose. At the same time, the US is now preparing for great-power rivalry with China—breaking from nearly two decades of doctrinal emphasis on terrorism as the primary threat to American security.  Both the United States’ National Security Strategy 2017 and the National Defence Strategy 2018 have singled out China (along with Russia) as “revisionist powers”, claiming that they  seek to “shape a world consistent with their authoritarian model — gaining veto authority over other nations’ economic, diplomatic, and security decisions.”[lxxvi]  In tandem, regional powers such as India, Japan and Australia are curtailing Beijing’s ability to act unilaterally, and are increasingly creating networks of partnerships that will increasingly coalesce with the objective of preventing the rise of a China-led order in Asia.

For now, Xi remains popular with the Chinese masses, and increasingly the most important actor in the international system. However, while autocratic politics may deliver some economic benefits and consistency in international relations, absent any checks and balances, the threat of overreach, conflict or collapse remains persistent. What tends to follow the collapse of these systems is a period of turmoil and conflict—something China and the world cannot afford.

To read the full issue, click here.

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Cyber Security, Uncategorized

AI has a gender problem. Here’s what to do about it

World Economic Forum, 16th April 2018 

Original here

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 for women’s rights in Saudi Arabia and declared 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.

Robots are expected to replace workers around the world.

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.

Authors 

Samir Saran, Vice-President, Observer Research Foundation (ORF)

Madhulika Srikumar, Junior Fellow, Observer Research Foundation

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Uncategorized

Xi grabs power to resolve current contradictions, but could trigger new ones

Samir Saran

Xi’s consolidation of power likely has two objectives. The first is personal — Xi seeks to cement his legacy. The second is great power ambitions.

 BRI,Chinese Dream,Communist Party of China,Xi Jinping
Photo: GCIS — Flickr/CC BY-ND 2.0

“The superior man,” says the Analects of Confucius, “cannot be known in little matters but may be entrusted with great concerns.” As an ardent scholar of Confucianism, it appears that President Xi Jinping has taken this advice to heart. In March, Xi orchestrated the abolition of constitutional term limits for assuming presidency effectively making him the “chairman of everything” for life and entrusting him with the great concerns of party, military and state.

Xi’s consolidation of power likely has two objectives. The first is personal — Xi seeks to cement his legacy. Since Mao, no other Chinese leader has crafted such a cult personality. Having christened himself “Core Leader” at the 18th Party Congress in 2016, he has now firmly entrenched “Xi Jinping Thought” in the constitution, placing him on par with Mao Zedong and Deng Xiaoping.

The second is great power ambitions. Xi has set very clear timelines for achieving the “China dream”; otherwise known as the “two centenaries” — “moderately well-off society” by 2021, and a “democratic, civilised, harmonious, and modern socialist country” by 2049. By mid-century, Xi intends for China to become a “a mighty force” that would be an active “constructor of global peace, contributor to the development of global governance, and protector of international order.”

Xi has set very clear timelines for achieving the “China dream”; otherwise known as the “two centenaries” — “moderately well-off society” by 2021, and a “democratic, civilised, harmonious, and modern socialist country” by 2049.

Xi is aware that China is at a critical juncture. He believes the time is right for China to reclaim its place in the world; and to supplant Western powers — especially America — as the leader of the international system. To view Xi’s power play as selfish dictatorial ambition, then, is superficial. Instead, it has more nuanced implications for China and the world.

First, Xi understands that the Communist Party requires a new social contract with its citizens. Over the past 30 years, China’s trailblazing economic growth has created a prosperous middle class and skilled professionals — many of whom now demand a better quality of life over high growth rates alone. Secure with his own position, Xi might be in a position to experiment with political reforms that could address this contradiction, and advance his “better life” agenda — including improving “deliberative democracy” by politically empowering local officials and creating new channels for public accountability.

Second, the pace of institutional reform will increase exponentially. As China becomes a global power, Xi understands that “going out” will require new standards for transparency, governance and performance in the economy if he is to sell “socialism with Chinese characteristics” to the rest of the world. Already, the National People’s Congress is assembling to consider enacting such reforms this year. Perfecting a unique blend of state control over industry and free markets will require painful and complex restructuring of administrative and economic institutions — and Xi wants an uninterrupted stint to see these reforms through.

Third, Xi has staked his legacy on the Belt and Road Initiative — the key instrument for his ambition of integrating Asia into a governance architecture that is more politically and economically cohesive than its sub-regions. The BRI must overcome several regional competitors to achieve its ultimate goal: creating new markets for high end Chinese goods in Europe. And Xi has made it clear that he is willing to use coercive statecraft to achieve this objective: ranging from Doklam-esque standoffs with India to “debt trap diplomacy” with smaller neighbours. With Xi at the helm, Asia must brace for a forcible attempt to reconstitute its geographical, political and cultural borders.


Xi has staked his legacy on the Belt and Road Initiative — the key instrument for his ambition of integrating Asia into a governance architecture that is more politically and economically cohesive than its sub-regions.


Fourth, Xi sees the reunification of democratic Taiwan with the mainland as a critical pre-condition towards achieving the “great rejuvenation of the Chinese nation.” Already, Taiwan is a souring flashpoint between the incumbent super power — America, which recently voted to increase government and civil society interaction with Taipei — and China’s rising ambition. Xi’s consolidation of political power, coupled with his agenda for institutional and functional modernisation of the army, and militarisation of the South China Sea point towards rising tensions on this front.

Finally, Xi faces the Putin paradox: massive concentration of power creates political losers; many of whom will often seek to exact violent revenge. Xi’s expansive anti-corruption drive, renewed political interference in companies, and rigid ideological control over public spaces have not all gone down well with China’s elites. At the same time, Xi will now also be seen as singularly responsible for policy failures — ranging from the economy to foreign affairs. Having amassed enormous power he must somehow craft a successful model for political transition when he does step down; or else face dire consequences for himself and for China’s stability.

Xi’s power grab will likely be a turning point in history. It brings stability at a time when China’s comprehensive national power is at its highest since ancient times; even as America and other Western democracies struggle to manage the international order they created. Simultaneously, China is a state and society in flux — high economic growth has created new political expectations and demands; and China must now shed its export led manufacturing strategy to embrace a new investment led model for the economy.

“Our mission is a call to action,” declared Xi at the 19th Party Congress, “let us get behind the strong leadership of the party and engage in a tenacious struggle.” If Xi can carry out his mission, he will not only oversee the arrival of China as a great power, but will also emerge as arguably the greatest leader China has ever known in modern history.


This commentary originally appeared in The Times of India.

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Health, Uncategorized

The road to universal health coverage

Global Health Strategies, ORF Special Report

Original link is here 

Introduction

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).[1]

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.[2] 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.

# Expenditure by the centre includes central ministries such as Ministry of Health, Defence, Railways, Labour and Employment, Science and Technology, Mines and Post
Source: https://www.mohfw.nic.in/documents/publications

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.[3] 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.[4]

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:

http://www.nipfp.org.in/media/medialibrary/2017/11/WHO_PFM_Report_ Sep_2017.pdf

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.[5]

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.[6]  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).[7]

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).[8] In March 2017, nearly eight percent of PHCs in India had no doctor and 18 percent were unsupported by pharmacists.[9]

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,[10] 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

Source: http://globalhealthstrategies.com/wp-content/uploads/2017/11/Financing-UHC-in-India-GHS-Nov-2017.pdf

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.[11]  OOP expenditure remains alarmingly high at 62.4 percent, as already discussed.[12] 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.[13]

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.[14] 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.[15] 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.[16] 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.[17]

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.[18] 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.[19]

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)[20]

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.[21] 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. [22]

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.[23] 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.[24] 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.

Human Resources

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.[25]  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.[26]  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.[27] 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.[28] The following graph shows the current levels of full immunisation coverage across Indian states and UTs.

Source: NFHS 4

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.

Supplementary Funding

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.[29] 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. .[30] 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.[31]

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.[32] 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.[33] 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.


Endnotes

[1] NHM includes six financing components:

  1. NRHM-RCH Flexipool,
  2. NUHM Flexipool,
  3. Flexible pool for Communicable disease,
  4. Flexible pool for Non communicable disease including Injury and Trauma,
  5. Infrastructure Maintenance and

Family Welfare Central Sector component

[2] Planning Commission, G. o. (2007-2012). Eleventh Five Year Plan

[3] https://cdn1.sph.harvard.edu/wp-content/uploads/sites/2031/2017/01/Government-financing-of-health-care-in-India-since-2005.pdf

[4] https://data.worldbank.org/indicator/SH.XPD.PUBL.ZS?end=2014&start=2005

[5] icmr.nic.in/publications/India_Health_of_the_Nation’s_States_Report_2017.pdf

[6] https://nrhm-mis.nic.in/RURAL%20HEALTH%20STATISTICS/(A)RHS%20-%202017/Rural%20Health%20Infrastructure.pdf

[7] Ibid.

[8] WHO Global Health Workforce Statistics – 2011. Accessed from http://www.who.int/hrh/statistics/hwfstats/en/

[9] https://nrhm-mis.nic.in/RURAL%20HEALTH%20STATISTICS/(A)RHS%20-%202017/Health%20Manpower%20in%20Rural%20area.pdf

[10] India, P. C. (November, 2011). High Level Expert Group Report on Universal Health Coverage for India

[11] Ravi, Shamika; Ahluwalia, Rahul; Bergkvist, Sofi (2016). “Health and Morbidity in India (2004-2014),” Brookings India

Research Paper No. 092016.

[12] World Health Organization Global Health Expenditure database. Accessed from http://data.worldbank.org/indicator/SH.XPD.OOPC.TO.ZS

[13] http://www.livemint.com/Politics/30z97MDZDMewkJHsfM5D6I/Medicine-costs-form-bulk-of-outofpocket-health-expenses-N.html

[14] http://globalhealthstrategies.com/wp-content/uploads/2017/11/Financing-UHC-in-India-GHS-Nov-2017.pdf

[15] While this also is an indicator of availability of health care infrastructure, there is disturbing data to show the increase in C-sections that may not have been required

[16] Patel et al. 2015. Assuring Health Coverage for All in India. The Lancet 386: 2422-35.

[17] http://www.cbgaindia.org/wp-content/uploads/2018/02/Of-Hits-and-Misses-An-Analysis-of-Union-Budget-2018-19.pdf

[18] Centre for Policy Research. Accountability Initiative. Review of intergovernmental Fiscal Transfers for health: Lessons learned and Looking ahead

[19] http://www.nipfp.org.in/publications/reports/1405/

[20] http://www.cbgaindia.org/wp-content/uploads/2018/02/Of-Hits-and-Misses-An-Analysis-of-Union-Budget-2018-19.pdf

[21] Patel et al. 2015. Assuring Health Coverage for All in India. The Lancet 386: 2422-35

[22] https://mohfw.gov.in/sites/default/files/89498311221471416058.pdf

[23] https://cdn1.sph.harvard.edu/wp-content/uploads/sites/2031/2017/01/Government-financing-of-health-care-in-India-since-2005.pdf

[24] Ibid.

[25] Mor N, Some Thoughts on Health Systems Design in India

[26] https://www.ndtv.com/education/ima-opposes-bridge-course-nmc-bill-black-day-declared-tomorrow-1794459

[27] 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.

[28] http://www.orfonline.org/expert-speaks/immunisation-coverage-india-far-away-from-meeting-targets/

[29] Global Health Strategies (2018), Budgeting for Health: India’s 2018-19 Union Budget, GHS, New Delhi

[30]Global Health Strategies (2016). Financing Universal Health Coverage in India, GHS, New Delhi

[31] Global Health Strategies (2018), Budgeting for Health: India’s 2018-19 Union Budget, GHS, New Delhi

[32] Global Health Strategies (2018), Budgeting for Health: India’s 2018-19 Union Budget, GHS, New Delhi

[33] https://economictimes.indiatimes.com/industry/banking/finance/insure/government-to-merge-3-general-insurance-companies-list-subsequently/articleshow/62739074.cms

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India’s Role in a Liberal Post-Western World

After a period of significant gains, achieved largely through the establishment of institutions that promoted international liberalism, the global order today finds itself at a crucial juncture. Rising inequality, the proliferation of nationalist politics, technology-induced disruptions and the resurgence of zero-sum geopolitics, are all beginning to shake the foundations of the global governance architecture built assiduously over the past 70 years. It is clear that the liberal order, as it is frequently referred to, will not be able to sustain its influence in the 21st century unless it finds new torchbearers in Asia, where politics and economics are scripting a story very different from that of post-war Europe. To some, it is evident that India, which has successfully combined economic growth with its own liberal traditions, will indeed be the heir to and guarantor of this system as an emerging and leading power.

Read the full article here. 

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The road to universal health coverage

Anjali Nayyar|Dhruv Pahwa|Oommen C. Kurian|Samir Saran

Introduction

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).[1]

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.[2] 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.

# Expenditure by the centre includes central ministries such as Ministry of Health, Defence, Railways, Labour and Employment, Science and Technology, Mines and Post
Source: https://www.mohfw.nic.in/documents/publications

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.[3] 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.[4]

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:

http://www.nipfp.org.in/media/medialibrary/2017/11/WHO_PFM_Report_ Sep_2017.pdf

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.[5]

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.[6]  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).[7]

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).[8]In March 2017, nearly eight percent of PHCs in India had no doctor and 18 percent were unsupported by pharmacists.[9]

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,[10]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

Source: http://globalhealthstrategies.com/wp-content/uploads/2017/11/Financing-UHC-in-India-GHS-Nov-2017.pdf

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.[11]  OOP expenditure remains alarmingly high at 62.4 percent, as already discussed.[12] 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.[13]

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.[14] 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.[15] 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.[16] 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.[17]

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.[18] 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.[19]

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)[20]

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.[21] 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. [22]

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.[23] 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.[24] 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.

Human Resources

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.[25]  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.[26]  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.[27] 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.[28] The following graph shows the current levels of full immunisation coverage across Indian states and UTs.

Source: NFHS 4

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.

Supplementary Funding

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.[29] 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. .[30]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.[31]

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.[32] 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.[33] 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.

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