Blissful Life

When you apply skepticism and care in equal amounts, you get bliss.

Year: 2022

  • Finding Direction When Being Pragmatic

    You remember how I embraced pragmatism and started chasing power? There was one problem. When you start chasing power with the idea of wielding it for social justice, when and where do you stop chasing power and start wielding it?

    Take Praveen’s comment for example

    Screenshot of text chat. Pirate ‍ Praveen (he/him) quotes asd's message "Context: https://blog.learnlearn.in/2021/09/power-is-useful.html" and comments "Though this is a slippery slope and one which usually results in concentration of power eventually in most cases, there are exceptions though. When you start making compromises, where do you draw the line? That is not easy." asd: "Hmm. I know that is a valid criticism."  Pirate ‍ Praveen (he/him): "Usually the short term power and sustaining becomes the primary goal and everyone forgets the initial goals. Look at any political parties." 

    One possible answer can be that you start wielding power while you start chasing power – and you chase less and wield more as you go forward.

    Graph that shows on y axis time, x axis "amount of effort in". As time goes forward "chasing power pragmatically" decreases and "using power to reach ideals" increases.

    But going by this, today I should spend lesser effort in chasing power than I spent yesterday. And tomorrow, even lesser than today. That doesn’t quite fit with the idea of chasing power first. Perhaps there is a threshold of power which I should reach before I start using power. Perhaps the graph is more like:

    Similar graph as above. X axis is time. Y axis is amount of effort spent. Towards the beginning on the X-axis of time, the Y axis is completely occupied by chasing power pragmatically for a while. At one point using power to reach ideals starts and then correspondingly chasing power decreases.

    Perhaps that threshold is what is called “the line”. The line that determines when you stop (or decrease effort in) chasing power and start using that power to reach ideals. Drawing the line becomes important once again.

    Let us then try drawing that line.

    How much power is enough power? Is a PhD enough academic power? Is a 20 person company that operates in profit enough entrepreneurial power?

    Read my poem (?) about career advice. Any goal you accomplish will be dwarfed by a bigger goal. No matter how much power you gain, there will be someone more powerful than you.

    Which means that there is no clear way to draw the line on when to stop chasing power.

    But there maybe an alternative that requires us to not draw a line. One in which we can chase power and use power simultaneously with the same effort. That alternative requires us to reconcile pragmatism and idealism. 

    You find a hack to chase power through your ideals.

    That is extremely slow though. Slow and excruciatingly boring.

    Which is why it has to be extremely personal. You have to be very selfish in what you are doing and craft the journey to your likes and desires. Only that can sustain the boredom of that chase.

    (It was Varsha who told me first about entrepreneurship being a very personal journey. This maps on to that. Life is a very personal journey.)

    That also solves a long-running question in my mind. How do you find what direction to go in when you are being pragmatic? What’s the principle with which you make pragmatic decisions?

    The answer is to listen to yourself. To do what feels the most right to you. I know that sounds like profound bullshit (something that internet gurus would say). But it is based on neuroscience and philosophy of knowledge.

    The brain is a rather complicated organ. We can process many more signals than we are conscious about. Even when we think we make decisions rationally, we make decisions based on very many things that we haven’t consciously considered. Read Scott Young’s Unraveling the Enigma of Reason to read more about how our reasons are always post-facto rationalizations.

    And this is tied in the external world to intersectionality. There is no decision on earth that lies on a single dimension. Everything affects everything else and nothing is clear-cut.

    And thankfully these are complementary. It is only a decision making machine vastly complicated like our brain that can consider all the thousand factors that intersect on a decision in the human world. (I express similar thoughts in the earlier post on living with opposition)

    It also means it is difficult to rationalize some of these decisions and generalize them into principles. Pragmatism is the acceptance of this fundamental difficulty and the decision to live within that framework of uncertainty.

    Of course, one has to be widely reading and learning to offset the risks of trusting an uninformed brain. One must be open to unlearning and relearning, criticisms, etc as well. These are the things that will protect the pragmatic person from going in the wrong directions.

    tl;dr? Trust your gut.

  • Scraping the Bottom of the Pyramid in Indian Healthcare

    At least 300 million people in India live below poverty line. And that line is drawn somewhere around an income of ₹1000-1500 per month. If we draw the line double that, the number of poor also doubles.

    That’s the bottom of the bottomless pyramid.

    Half a billion people who earn less than ₹3000 a month.

    If you earned that much, what would your priorities be? Food? Shelter? Financial security? Education for a child?

    What about your own health? 

    Imagine you have diabetes too. The cheapest food you have all around you is rice or wheat based. If you want to decrease carbohydrates and not go hungry, how much can you spend on food? And if your sugars are not under control, would you spend more on a combination of multiple oral hypoglycemic agents that might cost about ₹500 per month?

       ***

    Scraping the bottom of the pyramid works beautifully in consumer goods. You build something dirt cheap for the poor. Take a ₹2 shampoo sachet. You can cut down the size of the sachet to make it even cheaper.

    You can’t sell half a metformin tablet to a poor diabetic.

    You can’t prescribe a 1 day course of antibiotic.

    You can’t cure pain with an injection.

    But you can. Indeed that’s the kind of healthcare that those at the bottom of the pyramid currently receive. Sub-standard, inappropriate, and incomplete.

    Because healthcare, unlike consumer goods, doesn’t become cheaper at the bottom of the pyramid. It actually becomes more expensive due to the intersection of vulnerabilities.

       ***

    There is simply nothing to scrape at the bottom of the pyramid for healthcare.

    Someone else has to pay.

    A third party.

    Could be the government. Could be charity. Could be grants.

    But hey! If someone is paying, does it matter whether it is the beneficiary or a third party? 

       ***

    That’s the logic with which most NGOs in health and government facilities work.

    Three boxes. Right most one says "govt, others". Arrow from that which goes to the second one reads "pays". Second box reads "Healthcare". Arrow from that to the first one says "gets". First box says half a billion.

    Say you’re a doctor in a PHC. The government pays you. You deliver healthcare to the poor. Simple economics.

    Where does the government get money? It raises money through taxes, etc.

    What if you’re a non-governmental organization? You get donations/grants in what is called “fund-raising”.

    (There’s of course a cross-subsidization model which may look different superficially, but isn’t very different in the larger scheme of things)

    Is this any different from first party payment?

    Similar figure as previous. Only two boxes here. First box says "those who afford". Second box says "healthcare". Arrow in between to both sides - "pays" and "gets"

    Very different!

       ***

    The first issue is that of accountability. Accountability lies where money flows from. If my healthcare is paid for by someone else, my healthcare provider isn’t accountable to me.

    Public health facilities are not accountable to the poor that it serves healthcare to. They are only accountable to the hierarchy above them.

    NGOs are not accountable to the poor that they serve healthcare to either. They are only accountable to funders. (Typically NGOs which are able to diversify their funding source is able to decrease the power that funders have to some extent by dividing the funders into many).

    Why, though? Because accountability without control doesn’t work.

    If you want to hold someone accountable, you have to be able to control them in some way.

       ***

    When there is no accountability, the next issue is that of quality.

    In first party payment, quality assessment is decentralized. Every individual makes their own assessment about the quality of care they receive. And this instantly translates to payment, recurring visits, etc.

    In third party payment, quality assessment is different. It uses “metrics”. And metrics are difficult. Funders typically look at fancy metrics like “decrease in maternal mortality rate”. The problem with such “key” metrics are that they capture very little nuance and sometimes no meaning.

    To government, for example, where the whole hierarchy is just supplying metrics to someone else, it becomes a complete number game. (Recommended reading: Chasing Numbers, Betraying People)

    To NGO funders who have a bit more involved staffing structure it goes beyond numbers to also include “reports” filled with presentation-worthy photographs.

    It no longer matters whether the individual receives quality healthcare as long as the metrics and reports are looking good.

       ***

    Now let us look at something totally different. The CSR sector spent about 2600 crore rupees in health in 2020-21 FY. That’s about 1% of India’s national health budget. As per national health accounts 2017-18, the combined contribution of NGOs, corporates, foreign aid, etc to India’s health expenditures is less than 10%. 

    By all means, the government is the single largest provider and payer of healthcare for the bottom half of India’s pyramid.

       ***

    If you read all of this together, there are certain insights to be gained about why certain things are the way they are.

    Why do NGOs build/research “models”? Because the kind of money it takes to deliver care to a population larger than what “model”s serve is hard for NGOs to come by.

    Why does everyone want to build software? Because software can (theoretically) “scale” to large populations without a lot of money.

    Why do NGOs focus on showcasing “reach”? Because numbers mean impact for funders. And creating the impression of quality is more important than quality.

    Why does public health system get away with delivering poor quality healthcare? Because there’s no real way citizens can hold health system accountable. The constitutionally mandated way they can do so has been hijacked by issues like religion, party, and war.

       ***

    What to do about all this?

    1. Look deeper than numbers – everywhere. In fact, don’t look at numbers, at all. Numbers are meant to hide and deceive.
    2. Think critically. Especially on stories around impact. Reach isn’t impact. Touch-points aren’t healthcare. Technology can’t solve problems that technology can’t solve. Innovation is a buzzword unless and until innovation leads to inclusion.
    3. Be political. In thoughts, actions, and choices.
    4. Be aware, call out, and discuss things like above with raw honesty. Reality is shaped by what we accept silently.