Who wants to become a doctor?
Evidently, not too many people, as this ToI report notes.

It takes ten years of sustained, punishing, high-risk training of the finest minds to make a trained specialist (obstetrician, surgeon, pathologist); fourteen if you want a 'super' specialist (cardiologist, brain surgeon). The results these days, despite the risk, can be quite impressive.
The only known 'de-risker' we know? The calibre and training of the mind-hand holding the scalpel.

About 15 years ago, Maharashtra created a new 'super-risk': a line of mantris and babus of the command-and-control dispensation, for whom doctors were slave labour.
Clever policies and incentives ensued: mandatory rural postings, endless exams, shifting universities, disappearance of teaching seats, and, of course, increasing reservations.

The finest minds have voted with their feet. Should we be surprised?

Slumdog and Slumbai

It had to happen again.

Some white guys threw a bone in the direction of something indian (i am referring to slumdog millionaire, the movie), and people went into raptures about how the west is 'waking up to india'.

Most people i spoke to called slumdog millionaire a "triumph of the spirit over hardship" or "the never say die mumbai spirit" or something similar and seemingly inspirational.

Friends and colleagues gushed about how the fellow in the movie rose despite the deprivations of the slums and having to dive into human faeces to win some international dole-fest.

Cliches and prejudices aside (brilliantly articulated here), they are to be expected, it is the misplaced joy of the average mumbaikar that is disturbing: not one person found the presence and the continued growth of slums troubling anymore.

Not one person.

The slum -- and the urban planning failure it represents -- is the pink elephant in the room nobody wants to talk about. Just like the pink elephant of islamic terrorism.

It is now part of us, never to be sought to be removed, merely to be accepted and taken in our stride.

However, this pattern of ignore and move on has been going on. For 60 years, year after year (or election after election) we the people of mumbai have consistently voted NOT to fix things, preferring the soporific of rice at 2 kgs (for the masses) or the "wonderful mumbai spirit" (for the chattering classes) to real, painstaking change.

Mumbai is now a city without a collective objective and a collective aspiration.
A city without a future.

Over at Shadow Warrior, Rajeev points out how this is also visible among hindus at the national level. Everyone has a plan for our decimation. We don't even know that we're being hunted.

Medical Education in Maharashtra – 2

A path to resolution.

Now that the stewards of state (of “commanding heights” fame) have completely botched things, how do we reform? Where do we begin? What do we do?

To answer that question, it may be useful to remember the Cheshire Cat from Alice in Wonderland, “[what you need to do] depends a good deal on where you want to go.”

To understand what we need to do, we need to have a suitable vision of where we want to go. We may, for instance, want to “Establish a system to produce world-class physicians and health care leaders to meet Maharashtra’s and India’s demand for talent, while creating economic value via high-quality patient care, research and accelerated job creation.”

Translated into plain English, this means more and better hospitals -- say three times as many, with vastly improved teaching skills and capabilities that directly meet India’s healthcare needs.

It is tempting – but wrong – to conclude that all it will take is more money. If that were the case, the thousands of crores of taxpayer money the government has spent in shoring up Air India and Indian Airlines again and again would not have been as completely wasted as they have been.

No – it’s not more money that is required. What is required is an entirely new system for channelling cash, most of it from private pockets, to create an all new educational system.

There are three big changes the government must drive to make this happen:

1.Create competition in the delivery of medical education by liberalising norms governing setting up of medical institutions

The only way we can have more medical schools is, well, by allowing more people to start medical schools.

Transparent, simple yet stringent norms should be established – and anyone meeting those norms should be allowed to start a medical school. The norms could well cover requirements such as financial stability, experience in running medical schools – perhaps even globally. This is a good way of getting schools like Harvard and Hopkins interested. Incidentally, Singapore adopted a similar strategy to attract Insead Business School and Duke Medical School to Singapore.

Going beyond the school itself, medical institutions should be allowed to select the university with which they choose to be affiliated. Ergo Medicine programs should be repatriated to their parent universities, completely reversing the current trend for sameness. Creating competition – where universities strive to be affiliated to the best schools – is a far more powerful means of creating quality than by obsessing over standardising curricula across the state.

2. Create payment security in Education to attract the best medical schools

While (1) will grab the interest of leading healthcare educational institutions, it is unlikely to keep them from having bouts of attention deficit. To make sure the Harvards of the world come – and stay – the Government will need to assure them of a good return on their investment.

Discussing “returns on investment” in education is typically considered inapplicable – heretical even.

I disagree.

An education – in particular, a degree from a reputed college – is highly monetisable. When an average IIM-A student gets a starting salary worth 10 lakh, the market deems the worth of that “student+degree” combination to be worth at least as much. So, if an IIM-A student is charged Rs. 5 for a degree, s/he should not really be bothered – s/he will still be, economically speaking, better off.

So, in a nutshell, the government must give full freedom to medical schools to charge market rates for their fees.

And, instead of controlling fees, mechanisms should be established whereby the poorest of the poor have access to the capital required to fund this education. A cornucopia of solutions – from student loans to vouchers as suggested by Friedman – are possible. The government can, in fact, “fund” the education of students from whichever caste/creed/demographic/electorally useful group of people it wishes to pamper by directly paying the school the full cost of their education.

Such a move will have an altogether salubrious effect on the schools themselves. Forced with having to compete for the student’s rupee, colleges will have to offer better facilities, higher teaching standards and resources to attract students and value –added services – like career counselling and placements. The motivation for becoming distinctive will also incentivise them to establish tie-ups and alliances for research and development.

Existing shackles that prevent these relationships from emerging should also be removed.

3. Ensure public safety by establishing an independent regulatory authority.

While (1) and (2) may be adequate in other sectors, it is certainly not enough in medical education. After all, is it safe to leave the licensing of physician to a bunch of colleges that is interested in a 100% pass rate?

This is a legitimate concern, but effectively solved by establishing an independent regulator.

In the United States for instance, all physicians – even those from the best schools –must pass stringent licensing examinations administered by an independent licensing authority.

India too has successfully established ombuds and regulators such as the TRAI, indicating the viability of the concept. This regulator should be kept independent of the government (which means the Ramadoss or Grand poobah of the time should not be allowed to meddle in its operations). It should also be made financially secure by providing it with ring-fenced government funding and “licensing fees” collected from students and medicall colleges.

This independence and financial stability is crucial to staff the regulator with high quality experts – and not some spineless lackeys beholden to the present Minister.

Details about how we can make this regulator – indeed any institution – at arms length from political vicissitudes is matter enough for a separate post.

So there we have it – a framework to pull Maharashtra back from its state of self-inflicted medical decline and place it firmly onto a growth trajectory.

Of course, several operational issues remain unanswered – such as how do we ensure that these medical colleges have the right kind of teaching hospitals available? This one is easy: allow hospitals to forge alliances with existing hospitals to upgrade them into teaching institutions. Give incentives for adopting and transforming poorly run government hospitals and so on.

Some questions are harder – such as how do we get the best here? How many medical schools are enough? How expensive is too much?

They are all valid and important.

However they are also amenable for resolution under the umbrella framework of the three shifts listed above: competition, payment security and outcome regulation.

So, why have we not started as yet?

Unfortunately, like most changes – this change too has to start from the government. Babus have to go from thinking of themselves as thekedaars and maay-baaps of the sector to facilitators and nurturers.

They have to realise that this sector is too important to be held ransom to their petty egos.

Alas, the recent fracas with Ramadoss and the AIIMS demonstrated how far the sarkar is from this realisation.

Einstein had once said that a problem can only be solved at a level of consciousness higher than at which it was caused.

Our netas and babus need to raise their levels of consciousness pretty significantly to embrace such radical change.

Cold comfort, that we need to wait for our Netas and Babus to think differently.

Perhaps they should begin their journey by reading Alice in Wonderland.

Reforms -- a means to an end

It’s been 30 months since I moved from the United States back to Mumbai to start my first real job. So it was with much excitement that I was looking forward to visiting the United States again.

The America I left in 2003 was swaggering and strutting, buoyed by the confidence of a rebounding post 9-11 economy (concerns about being "Bangalored" notwithstanding). It was also the America that had, with impressively little effort, pulverized the Taliban that had successfully kept the Soviet war machine busy for over a decade.

Against that memory, America 2007 felt palpably different to me. The swagger had given way to a shuffle –The war on terror in Afghanistan still lingered and continued to add to the body count. Worse, the invasion in Iraq had gone horribly wrong, costing billions and killing thousands of troops. Scanners, metal detectors, x-ray machines and ID checks were everywhere, constant reminders of the here-and-now nature of terrorism.

America had also suffered multiple domestic body blows. Katrina had severely shattered America’s confidence. As New Orleans plunged into sub-saharan African style anarchy, the world saw the soft underbelly of the sole superpower.

America’s vaunted healthcare system also seemed to be misfiring – with medicare bankruptcy within the next 10 years a real possibility.

Was this it, then? The beginning of end of the American century? The end of Pax Americana as we know it?

My guess is probably not – for while the damage was visible, what was also starting to show was an acceptance of the problem and a resurfacing of the “we shall overcome” spirit.

A store clerk in LA quipped to me that “The climate is changing, we’ve done something wrong and it aint what it used to be.” Another man noted how in his home town in Colorado, they had snow in February for the first time in over years.And it was not merely in words – for the first time I was seeing words like hybrids, low emissions, green housing and sustainable buildings in American newspapers. In general, the focus had shifted from an analysis of what is broken to what is needed to fix it. On healthcare too, the debate was rapidly shifting to systematically controlling costs and ensuring coverage. America seemed to be waking up and smelling the coffee.

I had noted this behaviour during my days in Boston in 2001-2003. Those were the days when Americans were afraid of being "Bangalored" -- their jobs vacuum cleaned to Indian shores. I remember Wipro’s Azim Premji having to take some tough questions at MIT in late 2003 (he dispatched them with panache).

The breast beating lasted all of a few weeks. The American people accepted it, hunkered down and began reskilling to live in an outsourceable world.

And then it struck me. America -- and Americans are a resilient lot.

They see change -- and adapting to it -- as a pre-requisite for continued prosperity and growth. For instance, America has taken to green technology not because it is "good for mother earth" but because sustainable energy usage is vital if America has to continue to enjoy economic growth and security.

It is this resilience, this willingness to change to reach a higher goal that has made America a leader among nations.

So what does all of this mean for a resurgent India?

Should a nation that is only just learning to sprint slow down to a shuffle again, as she was shuffling under the weight of the Nehruvian Penalty*?

Hardly. Like America, India too needs to realise that reforms are necessary to ensure future prosperity and security. There are plenty of "bumps" in the road India has chosen -- bumps that can prevent india from getting into her stride. It is in her best interest, therefore to remove these bumps.

One of the biggest bumps facing India are her dismal education system. If India has to leverage her much touted “demographic advantage” over China and continue growing for the next 50 years – her education system needs to be nursed to fitness pronto.

Murli Manohar Joshi may have missed the point by asking for IIM fees to be dropped, but Arjun Singh’s "Mandal 2" crusade and re-establishment of an educational license-raj, with the government as lord and master, can potentially nuke it to the dark ages.

To fix this problem, Indian education needs radical surgery. As a first step, we should shutter (ideally nuke) the Ministry of Human Resources. Second, we should liberalise education delivery and allow any player -- private, public or charitable -- to start educational institutes. Finally, to ensure standards are met and enforced, an independent regulator should be established. This regulator should be staffed by experts (not babus), and may be funded by levying nominal charges from all institutes and users to ensure impartiality. A supporting framework to finance education for the 'meritorious poor' will also be required to ensure that no one is left behind.

In addition to fixing the system, the content our system imparts needs to be reformed as well. Education needs to be freed from the clutches of the 4Ms (Marxists, Mullahs, Missionaries and Macaulay-followers). Issues like Article 30 of the Indian Constitution that exclude Hindus also need to be scrapped. All that is another story, for another entry.

Such educational reforms will not come without pain -- Indians have grown used to the concept of "nearly-free" education paid for by someone else's money. Migrating to a system where you have to pay for the education you get is not likely to be an easy transition. The biggest opposition is not likely to come from the sadharan Indian -- he already pays for sundry coaching classes and "donations". It is likely to come from the Marxists and the JNU types.

They should be ignored.

In sum, if India wants to become prosperous, she needs educated professionals. Paying for making those professionals is a key means to that end. Like the Americans say, there aint no free lunch!

With India going through ebullient times, then, reforms need to be hotfooted (not backpedalled as MMS and co. are doing) – the pain will be easier to bear.

And seriously, good times or bad, will anyone really miss Arjun Singh?

***

* Incorrectly known as the “Hindu rate of growth”. India's poor rate of growth from independence to the 80s is attributable to Nehru and his policies, neither of which were Hindu. The term is © Shadow Warrior; see rajeev2004.blogspot.com for more.