Blissful Life

Category: economics

  • What’s the Most Important Scientific Research?

    Post-facto rationalization. That’s something human beings are good at. If you decide to do research in a specific field, you’ll come up with hundred ways to justify why that research is important, if not the most important.

    I have been listening to Ravikant Kisana the last couple of days. In the podcast episode about Chandrayaan, RK calls Chandrayaan “completely useless”. A summary of the episode is the description of the episode: “Buffalo wonders what the Chandrayaan benefits are, while pondering over the crumbling education system. We take a moment to acknowledge the hot mess that is Gen Z.”

    Palani Kumar makes a very similar point in the talk about manual scavenging in CMC Vellore. “We have too much technology, we have lots of technology, we went to moon also, the other side of the moon, we haven’t saved anyone’s life among manual scavenging people”.

    I’m part of Sarvatrika Arogya Andolana – Karnataka which makes the consistent demand that we need to put more money into primary healthcare and have free medicines in government hospitals and so on.

    That’s the context in which I come across this thread by Nandita Jayaraj about a couple of breakthrough researches. Before I finished reading the thread I tweeted about it: 

    “Reading this thread made me think about how scientists in their lab coat are viewed in a very neutral or positive way by me whereas some of them are quite cunning and will do anything to get funded. 

    There are so many scientists hyping up rare diseases because that is where they get money to play with genes.”

    I hate universities. A lot.

    It is easy to argue with me by saying that universities are important and they create safe space for learning and that I can reject universities because of my privileges, and so on. But my intense hatred for universities has been validated by Ravikant Kisana in the Mind Your Buffalo podcast about institutional murders. The universities and the academia and the intellectual elite of this country are indeed a big part of the problem.

    And that’s where I come from. A position of intense hatred for scientists for their ignorance of how they’re part of the problem.

    And then these people who are held in high regard, in general, by journalists, people, and everyone, talk about research. From their pure and apolitical viewpoints. All I can hear when they open their mouth is “I want money. I am so smart. I do the most important work on Earth. Give me money.”

    Let us set all of that aside and look at this question “objectively”. Isn’t this sort of a trolley problem? You’re forced to choose between space science and sanitation technology. You’re forced to choose between rare diseases and common diseases.

    One could say “let us put some money in everything” because that’s one way of thinking about it.

    One could also think in purely utilitarian ways and calculate the cost (somehow) of each and measure benefit and do some kind of optimization.

    One could operate purely on empathy. But that has its own problems (Malayalam talk).

    Anyhow, answering this question is very hard. But it is indeed possible to look at it from a lens of caste, privilege, etc as seen above in RK’s podcast.

    (more…)

  • By Doing “Government’s Work”, Are We Making It Easier for The Government and Worse for the People?

    At the end of the CHLP session today Akshay (not me) asked something like: “When we do work that the government should be doing, are we making it easier for the government in some ways, and also making it more difficult to hold the government accountable?”

    This is a question that only someone who is truly invested in community work can ask. They are worried that the government is going to invest less in that particular problem, that in the long run it becomes harder and complicated because of the reliance on “bespoke” solutions. (The example given was how government relies on the voluntary effort of data by covid19india.org / covid19bharat.org to get COVID related counts and how there is no other system to track these counts)

    I do not claim enough experience to answer this question.

    But if we break down this question, the concerns we have are:

    1. How sustainable are such bespoke solutions? If we could keep doing it forever, then why should we not do it forever? Should government ever take over?
    2. Are such bespoke solutions less effective than more universal solutions? If yes, are we causing a less than optimal outcome? If no, are we preventing a scale-up of these solutions by the mere fact that it came from outside the government?
    3. Does access to and/or existence of such bespoke solutions make it difficult to demand more universal solutions from the government? (Either by making people reticent or by making the demand look less urgent)

    A few counter points are:

    1. But how long should I wait for the government to do the right thing?
    2. Who is at the receiving end of our desire to wait for a universal solution? Who suffers when we wait?
    3. Let’s say I don’t attempt the bespoke solution. What do I do now? Should I now force the government to build a solution?

    The way I avoid these questions are by thinking:

    • The government is a huge, inefficient, highly hierarchical organization with not much capability to build innovative solutions. Therefore, expecting government to come up with a good solution is pointless.
    • I should do things that give me joy, not what brings joy to the world. If bringing joy to the world in certain ways brings me joy, then so be it.
    • The second-order, third-order effects of our actions are very very hard to predict. No matter how much we “calculate”, not much is going to come out of the calculations. We have no way to say that any particular action is what is going to help the world. We just do what we want to do and hope that it turns out to be a good thing. Often, there is no way to actually say whether something turned out to be good either.
    • If we are creating value, putting value out into the world, it is more likely than not that we’re doing something right. The value will compound in ways we cannot anticipate. Always.

     If you are reading this and you have answers to some of these (existential, sorta) questions, let me know.

    Update

    I sent this to Tanya and Prashanth. Prashanth tried to add a comment and failed. That comment is:

    “This is an important question to “struggle” with especially for those
    (like me) who are involved in such “solutions” that are often not only
    outside-the-box, but also as rightly pointed out, being designed outside
    the “public” system. For an individual like me for whom, working with
    indiviudals/communities/populations is coming from an ethical
    imperative and from wishing to move our society towards health equity,
    there is – I confess – no other way. What do we who do not wish to work
    within governments for various reasons do? I think what we can do is
    build coalitions, networks and allies which nudge/push/critically
    demonstrate the need for public services and systems to do more. And for
    me, such efforts are ways of showing that more can be done. Another
    reason to do this is to address the inertia that sometimes develops at
    middle level institutions (like districts) where the glamour of
    word/jargon based policy vocabulary is not there and the fatigue of
    under-resourcedness is a daily reality. So, I believe such efforts can
    hopefully spur creative thinking within public systems, build allies
    within the system and who knows…knowing the complexity and unintended
    effects these things have…some things stick…some things
    flourish…improve? But, certainly there ought not to be a claim that
    such accomplishments (if they are such) will automatically result in
    “systems change”….these are some of my thoughts. “

     

    Prashanth also got Werner Soors involved. You can read W’s comment below this post. To me, W has more or less arrived at the crux of the dilemma. The struggle is related to the dichotomy created by the ideal government and the real government. But as W points out, it maybe worth trying to become part of the government through becoming part of the people.

    Coincidentally, I saw this video by The Ugly Indian today

  • 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.