Thursday, October 6, 2011

Free Drugs for All

I am just returning “home” to my flat in Delhi after more than a month of travels. I covered a lot of ground and ideas. Highlights include time with the Gandhi scholars in Ahmedabad, a 10 day retreat at Gandhi’s Sevagram Ashram in rural Maharashtra, a short time at the beach on the Arabian Sea in Diu, researching a water conflict between farmers and industry in the remote villages of southern Gujarat, guest lecturing at Sir Padampat Singhania University in Udaipur, and spending three days with a high level Indian Administrative Service (IAS) officer in Jaipur. It is this last experience that I will briefly reflect upon in this entry.

First, a bit of history on the IAS. In the 19th century, the British Government inherited a well-formed public administration system from the East India Company called the Indian Civil Service (ICS), which in 1853 had instituted a competitive examination for highly sought after appointments. After independence in 1947, the IAS was formed and took over the functions of the ICS. There is still a competitive examination for which approximately 300,000 sit annually to win one of 850 positions. Those who don’t make the cut in the top IAS selection can go to other government services such as the Indian Foreign Service, Indian Police Service, Indian Audit and Accounts Service, etc. But in my experiences teaching young people in India, the IAS is, undoubtedly, the place where the best and brightest hope to land a job. Ask why the IAS, one student answered me, “Because that is where I can have the most impact on changing society and making it better.”

In July, I was introduced to Dr. Madhukar Gupta by a friend who suggested that, having written his Ph.D. dissertation on water conflict, he might be a good resource for my research. Dr. Gupta invited me to Jaipur, the capital of Rajasthan State, where he serves as Divisional Commissioner. His wife, Kiran Soni Gupta, an accomplished artist with an international reputation (, is also a high-level IAS officer serving as Principal Secretary of General Administration and Chief Protocol Officer for Rajasthan. Dr. Gupta and his wife both have degrees from the Maxwell School at Syracuse University and Harvard’s Kennedy School of Government. They have a daughter who is studying at Wellesley College in the Boston area (where my wife, Aviva Segall, went to school) and a son in the 10th grade.

Dr. Gupta was a gracious host during my time in Jaipur. He set up meetings with water experts, arranged my accommodations and meals and took me out for a day in “the field” with him. We went to an event at a government hospital, a visit to a district police station, a university celebrating its anniversary, an advance team to where the Chief Minister would visit the following day and a women’s college which Dr. Gupta was instrumental in starting. Being an IAS Divisional Commissioner, he was treaty as a dignitary wherever we went. His jurisdiction includes the metropolitan area of Jaipur and five adjacent districts which have a population of about 17 million people. He oversees all government programs and personnel in this division.

The day I arrived, the Government of Rajasthan launched a scheme in which all citizens visiting government hospitals, clinics and pharmacies will receive free prescription drugs. Over 200 medicines are on the currently approved list. The state government will pay the bill. Some commentators say this is a way for the current Congress-led State government to win the goodwill of voters. There is resistance to this program from some doctors who think that their professional judgment will be constricted by having to prescribe generic medicines as opposed to branded medicines. Critics claim that because doctors are getting kick-backs from drug companies for prescribing their brands, the real resistance is because the doctors will lose that source of income once this program is implemented. There is also obvious resistance from pharmaceutical companies who will lose revenue when cheaper generic medicines are used. And there is resistance from some pharmacists who are making a higher profit margin on branded medication than on generics.

We traveled on bad and bumpy rural roads about two hours north of Jaipur where we met the Gujarat State Minister of Health, Members of the Legislative Assembly for Gujarat and local Panchayat leaders at an event to launch this free drugs scheme. Dr. Gupta used to serve as District Collector, the top government officer, in Sikar District where the event was held, so he knew a lot of people there.

I had an opportunity to interview the Rajasthan Minister of Health, E. A. Kahn (called by his nickname “Durru Mian” by all), after the event. He gave me some history of this initiative to provide free drugs to the people. The National Rural Health Mission was a scheme launched in 2005 as part of the 11th Five Year Plan (India has had these 5-year plans from its independence). Under the NRHM, there were 15,000 medical units supported in rural Rajasthan. Already free medicine is provided for families “below the poverty line,” pensioners and pregnant women.

The expansion of offering free drugs for all at government hospitals the Health Minister estimated will cost the State government about 100 crores Indian rupees (US $20.4 million) although the media reports were estimating expenditures of 200 crores. Rajasthan is the 14th state in India to take up such a scheme, and the Health Minister claimed it has succeeded everywhere. I asked him about the resistance from doctors, pharmacists and drug companies. He said, “I appealed to NGOs and civil society to become more active in pressuring these doctors and corporates to do what is right for the poor people. Some doctors say that generics are no good, but civil society must pressure them to still prescribe these to the patients.” 

I also interviewed Ms. Rita Singh, the District level Panchayat leader, called a Zilla Pramuch. Besides her elected position, she is also working on her Ph.D. on feminist writer Gertrude Stein. She said she was elected because 50% of panchayat seats are reserved for women. Her in-laws are a political family and her husband was an elected official before her. I asked whether she had higher aspirations and she said, “Maybe MP for this district. Then I can really work for the people.” I asked her about the challenges of implementing this free drugs scheme, “How will the government ensure that the right people get the right medicines at the right time?” She answered, “It is my duty to ensure correct delivery.” But I was left wondering how she or her small staff could ever dream of overseeing such a massive job.

Dr. Gupta knew the people and places everywhere we went and was treated like the dignitary he is. There is already a certain amount of traditionalism and formality to much of Indian society and it is greatly increased when dealing with government officials. Many would touch his feet as a sign of respect when they greeted him. He has a full-time car and driver along with a police officer who accompanies him everywhere for security purposes. On four different occasions during our day in the field, caravans of police and lower-level government officers would meet us on the roadway and usher us – with flashing lights and speeding SUVs – to the venues. And at the district police station where we stopped for tea, the red carpet (well, blue carpet) was literally rolled out for our visit.

I asked Dr. Gupta, “How do you keep your ego in check when you are treated like a rock star everywhere you go?” He laughed and answered, “After 25 years of this, I have accepted that this is my duty and there is a particular formality that goes along with this position.” Later in the day, when we were surrounded by two dozen police officers and another two dozen government officials who were reviewing the hospital that the Chief Minister of Gujarat would visit the next day, Dr. Gupta would quietly tell me, “This is really overkill. It is a waste to have this many police and officials here.”

The protocol that was evident in all we did came naturally to this 50 year old man from Punjab, where his father was the Chief Engineer for that state. Dr. Gupta was polished and professional, treating all with respect, from the highest government minister to the lowest chai-wala who served us tea. He was a soft-spoken man who gave public speeches three times that day which contrasted the bombastic politicians’ volume and style. Dr. Gupta’s deliberate cadence and thoughtful words – all in Hindi or the local language – were that of a public administrator. And even in our far-ranging conversations during the six hours we spent together in the car, this erudite man would calmly quote Shakespeare and Indian gurus, speak of macro-economic theory and South Asian diplomacy, talk of art and basketball, and come back frequently to his loving concern for his daughter who he sent away to college in Boston last month and to her future.

I have thoroughly enjoyed meeting the people and going to the places I have here in India. Next week, I am going to Sri Lanka for seven days. I won a special travel grant offered to Fulbrighters to present lectures or workshops in adjacent countries. I will give a paper and guest lecture on water conflict resolution at my host institution, the International Water Management Institute ( outside of Colombo. This is an incredibly exciting opportunity for me to go back to a beautiful country that I visited 20 years ago, and to learn from the top water experts in the world! 

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