Points raised at the Interactive Civil Society Hearing at the United Nations 16th June 2011


Venue : UN General Assembly Hall , United Nations , New York.

Chaired by Mr.Joseph Deiss , President of the UN General Assembly .

 Dear Friends ,

I am honored to be here , &  have few key points  for the special high level, two-day session that UN will convene in September 2011 for addressing the issue of chronic diseases.

I appreciate the point that UN session talks about local issues across regions . I would further suggest the United Nations that , if we want the governments to act on its recommendations , we must go beyond local i.e. get micro . My experience in public policy makes me believe that governments do appreciate and act on recommendations that are local but also focus on micro issues .

We have mega goals but  our actions have to be micro and we must suggest inputs that are local and at  micro level,  for execution.

Also, let us  accept the fact that for this generation , we are late, and we have already missed the bus . What I would not like is, that our next generation sits in the same UN General Assembly hall after 40 years , and discusses the same issues related to chronic diseases , and says that ‘our earlier generation behaved irresponsibly and did nothing for us ! ’. So the time has come for us to distinguish the ‘Urgent’ & ‘Important’ . Urgent is that we must fix the issues related to the chronic diseases now , but it is more Important  that we plan to build a healthier next generation . So my expectation from the UN is,  that  there will be a dedicated session related to Child health at the UN General Assembly in September .

Also that,  the technology is becoming all-pervasive and we must use this UN session to promote the use of  mHealth to address the issue of chronic diseases . I am expecting that the UN general assembly will dedicate a session to mHealth, and how it can help in the delivery of care for chronic diseases.

 Lastly , I would like to run a quick survey on ABCDE of  Chronic Diseases / Healthcare . Where,  A stands for – Asthma/ Arthritis , B stands for Blood Pressure , C stands for CVD / Cancer , D stands for Diabetes & E stands for Epilepsy / Elderly patients ( as 84 % of all the elderly patients are on one or more medications)

If anyone of you or your immediate family members have any of these ABCDE , please raise hands .

The response is unbelievable ! I have made a point . It is not about the 5 or 10 % prevalence rate of chronic diseases. We have just now had the visual proof of the prevalence of chronic diseases , and it is much higher than the figures that we read often .

It’s time to act now .

Thank you.

Rajendra Pratap Gupta

The points i talked about as mentioned above ,were highlighted by Sir George Alleyne , UN Special Envoy in his closing remarks.

Mental Healthcare Act 2010 – Needs revisions


The Population Health Improvement Alliance

 

Rajendra Pratap Gupta

President

Registered Speed Post / E-Mail

Dated: March 24th 2011

Shri. Ghulam Nabi Azad

Hon’ble Health Minister

Government of India

Nirman Bhavan,

New Delhi -110108

Reference: Revision of Mental Health Act 1987 & Mental Health Care Act 2010 ( draft )

Dear Shri Azad ji,

This needs your esteem, kind and personal attention.

I am writing this note on behalf of the Disease Management Association of India – ( DMAI)- The Population Health Improvement Alliance . DMAI works with all the stake holders in the entire continuum of care, for improving the population health of the nation . Over the last few years, we have worked with different stake holders to help define the right priorities in healthcare for the policy makers & the care providers .

Through this note , I am drawing your attention to the revision of the mental health act of 1987 and the proposed Mental Health Care act 2010 (Draft). The process of revision of the Mental Health Act 1987 was initiated about a year back, to make it compliant to the United Nations Convention on the ‘Rights of Persons with Disability’. Disability includes persons with long term mental illness. This convention advocates equal rights for all disabled persons.

Dr Saumitra Pathare ( a private psychiatrist) and Dr. Jaya Sagade (a lawyer) of Pune were in charge of conducting the regional consultations on behalf of the Ministry. Over the last one year, there have been 5 regional consultations with various stakeholders. The major stakeholders consulted have been users, care providers, professional bodies in mental health, mental health institutions and state government representatives. However, it is to be noted that, the Medical Council of India, other specialties of modern medicine, and professional organizations of general health field, have not been consulted. This is important, as the changes which are evident in the draft bill have far reaching consequences in terms of the way the modern medicine is taught and practiced currently.

DMAI- The Population Health Improvement Alliance, is surprised with the outcome of the consultations , and that there was hardly any discussion on the final outcome to patients due to the significant changes which are being brought in terms of the ‘mental health’ field of practice of medicine by way of promulgating this act. Proposed changes are likely to cost human lives , as persons who have not been trained to be physician (Clinical Psychologist, Psychiatric Social Worker, Psychiatric Nurse), will be entrusted with the role of independent examination, diagnosis and admission of patients in mental health facilities. Currently, this role rests with a Psychiatrist who is a medical doctor (MBBS) trained in Psychological Medicine. In modern system of medicine ,only a physician (M.B.B.S )can diagnose a patient, as only he has received training in all the specialties such as Medicine, Surgery, Eye, ENT, Obstetrics & Gynecology, Pediatrics, Orthopedics, Radiology, Dentistry, Dermatology, Anesthesiology, Pharmacology, Preventive and Social Medicine, Pathology, Microbiology, Physiology, Biochemistry, Anatomy etc. , which essentially means, covering all the systems of the body. Unfortunately, Human body cannot be compartmentalized and however we may wish, but we cannot have an Eye specialist who has studied only ‘Eye’ and not done MBBS ( as a basic general qualification and set of skills covering the entire human body system) to examine each and every system of human body. Similarly, we cannot have a Psychologist who has no training of the subjects studied at MBBS level, to diagnose mental disorders by only doing psychological examination!!!!

Only an MBBS trained doctor with the proper understanding of the entire human body system and its functioning, can do a detailed psychological evaluation and come to a diagnosis of whether the patient has a psychological illness or it is some physical illness, which is presenting itself as a psychological illness. In cases of latter, appropriate referral is required and any delay may even be fatal. S/he can also order various tests and imaging and interpret them for aiding in his diagnosis. After a diagnosis is arrived at, s/he can plan and provide physical treatment (ECT), pharmacological treatment or psychological treatment. The role of psychiatric nurse, clinical psychologist or a psychiatric social worker is to assist him by nursing the patient, helping him in psychological interventions, helping him in psycho-social interventions respectively. But the patient is under the overall care of a psychiatrist who is the leader of the mental health team. All the three categories of personnel work under the supervision of a psychiatrist .

 A clinical psychologist, PSW ( Psychiatric Social Worker ) or a psychiatric nurse is not trained to be a physician. They have not studied the human body as an MBBS doctor and cannot do detailed physical or systemic examination, investigations and imaging like a psychiatrist. They are in no position to independently examine, diagnose and advise admission of patient. A PSW and Clinical psychologist have not general training in other subjects of modern medicine. Just by talking to patient, how can a Clinical Psychologist or PSW diagnose a mental disorder? They will be severely restricted by their inability to do general and systemic examination and order and interpret investigations and imaging. A Psychiatry examinee will fail in his examination if he did not touch the patient for examination ; however bright drug treatment he may formulate for the patient ; as without a general and systemic examination, a person cannot make a diagnosis of mental disorder. In many cases special investigations and imaging also has to be ordered and interpreted. As per the diagnostic criteria for mental illness, a mental disorder can only be diagnosed after ruling out that the signs and symptoms are not better accounted for by a medical illness or use/abuse of a substance. In this scenario, without proper validation of the reason for the particular condition , what is the validity of diagnosis of mental disorder by a Clinical Psychologist, PSW or a Nurse ? Even the quacks believe that they can diagnose and treat independently. Each such claim needs to be examined objectively in line of their competence and current practice related to their vocation.

In modern system of medicine, which is regulated by MCI, there is no specialization known as Clinical Psychology, PSW or Psychiatric Nursing. The mandate of ‘Rehabilitation Council’ is limited to rehabilitation of persons with disability and practice of modern medicine under Rehabilitation Council is neither required nor allowed. If at all, new independent specialties such as Clinical Psychology, PSW and Mental Health Nursing without any supervisory role of a Psychiatrist is being planned for modern medicine system, then the whole modern medical system (MCI, Indian Medical Association, Other Medical Specialties) must be consulted .

If we go as per the draft, it means that Clinical Psychology, PSW and Mental Health Nursing personnel are as much a specialist as a psychiatrist and can independently examine , diagnose, admit and treat patients with mental disorders.

It is not understandable why a psychiatrist has to do MBBS (study the whole human body) and then specialize in Psychiatry while for the other persons they need to study only psychology or social work and yet be assumed to be qualified to examine the whole body, diagnose, admit and treat patients (albeit without medicines) . The demand to prescribe medicines by non psychiatrist is also going around (and may be later on this will be also be made possible.) There is no institution in the country where a Clinical Psychologist, PSW, Mental Health Nurse examines patients independently, diagnoses a mental disorders, admits patients and treats them. This amounts to practice of Psychiatry under the modern system of medicine and would invite penal provisions of MCI. The sole aim of drafters is to get the bill through and take credit for drafting the bill rather than have a healthy development of the sector. Nowhere in the country there is a Clinical Psychology ward, PSW ward or Psychiatric Nursing ward. The decision to admit is taken by the leader of the mental health team who is a Psychiatrist and it is the Psychiatrist who is overall responsible for treatment of a patient with mental disorder.

One of the reasons given by the people behind the draft of the Mental Healthcare Act 2010, for giving the role of independent examination, diagnosis and admission in bill, is the shortage of psychiatrist in the country. But if we go by the definition of psychiatrist in the bill which is the same as that in the previous Act, ‘an MBBS qualified person with experience and training in Psychiatry can be designated a psychiatrist’ for the purpose of the Act.

At present , there are about 8 lac medical practitioners in the country and these can potentially be designated as psychiatrist. So where is the shortage for the purpose of the Act ? The only purpose which could be served by giving an independent examination, diagnosis and admission to Clinical Psychologist, PSW, Mental Health Nurse in the bill is to later on claim that if they are capable of doing these jobs, then this means that they can practice their trades independently under the modern system of Medicine. This would mean they will be physicians of mental disorders just like a psychiatrist.

The inclusion of Clinical Psychologist, PSW, Mental Health Nurse for purpose of independent assessment, diagnosis, admission to a mental health facility should be deleted and replaced by ‘psychiatrist’ (an MBBS qualified doctor with some training/experience in psychiatry). After this, there will not be a need for defining mental health professional in the Act. If at all it has to be defined, then Clinical Psychologist and PSW shall be designated as Assistant Mental Health Professional as in the present legislation (Section 22 of State Mental Health Rule 1990) and their role clearly specified as being- to assist a psychiatrist.

Further, the supervision and review of the decision of a psychiatrist by a Clinical Psychologist, PSW, Mental Health Nurse in the mental health review commission is not feasible as review is to be done by practitioner of the same specialty i.e. Psychiatrist. Thus, the provision of Psychiatrist in the review commission should be made mandatory.

In a multidisciplinary team such as a mental health team, each team member has a specific role. If everyone will do the same role, which is to independently examine, diagnose and admit, then there could be no team functioning. Rather the role of each mental health person should be clarified in the Guidelines /Rules clearly, so that there is good team functioning and the public is well informed and is not misguided by manipulative persons. Can we imagine a similar provision for a Nurse specializing in Medical, Surgical, OBG, Cardio-thoracic nursing to independently examine, diagnose and admit patients in Medical, Surgical or OBG, Cardio-Thoracic ward respectively? Then why should we consider similar provision for Clinical Psychologist posted with Neurology department?

Psychiatry is a medical discipline as any other discipline. If Clinical Psychologist, PSW and Psychiatric Nurse want to independently examine , diagnose, admit and treat patients without even having the training and skills for the same and government wants to allow the same, then they should be allowed to start their own wards to do so and be responsible for their decisions. If we allow such changes to be brought, this would mean that a Psychiatrist too does not need to do MBBS. Then all the specialties of modern medicine should have direct specialization rather than first spend 5.5 years to be a General doctor. Human body cannot be divided in a compartments. All organs and systems are interrelated. A stroke can present itself as a depression in a mental health facility. What skill a psychologist or a PSW has to diagnose it without doing a full neurological examination or relevant investigations. They will treat for depression while the patient will die. In my view , compartmentalised knowledge is dangerous for the medical profession and defeats the basis of evidence based medicine

We are trying to make Clinical Psychologist, PSW and Mental Health Nurse into Physicians in mental health by giving the role of a Physician to them under the new draft bill on the pretext of shortage of Psychiatrist. However, there are less than a 1000 Clinical Psychologist and PSW both combined in the country. Further, there is no dearth of Psychiatrist under Mental Health Act, as Govt. can very well designate MBBS doctors with some experience in Psychiatry as Psychiatrist (as per the definition and provision in current legislation and the draft Bill). So even the assumptions for the shortage of psychiatrists is not a right justification for this act

The role given to Clinical Psychologist, PSW and Psychiatric Nurse in the draft bill is ; independent examination of patients, diagnosis , admission and then review of decisions taken by a Psychiatrist. Instead of this, in the draft bill, the role of a Clinical Psychologist and PSW- as a rehabilitation professional , and Psychiatric nurse – as a specialized nurse, should have been clarified and focused.

The position of a Psychiatrist as a mental health team leader should be reiterated and the decision of a psychiatrist should only be reviewed by a board having a psychiatrist. These rules could further be clarified In the draft bill psychiatric social worker and clinical psychologist has been mentioned as mental health professional just like a psychiatrist. However, In section 22 of the State Mental Health Rules’1990 (the existing legislation) the PSW and Clinical Psychologist are referred to as Assistant mental health professional. The change in the draft bill under consideration has been done with a view to make their role fit for independent examination, diagnosis, admission to a mental health facility by the drafters, without any regard to the impact of this on the patient care and safety. If they are full-fledged professionals (as they claim) who can diagnose, admit and treat patients, why do they need to be defined as such in the Act. At no place in the draft bill their role has been mentioned separately. At all places they are bunched as mental health professional with no individual roles. At no place it is mentioned that they will function under the supervision of a psychiatrist. If they independently examine, diagnose and admit patients they are then deemed to have an independent role. This will increase the role conflict which is already very high in the mental health team. So much so that at some places there is no team work. In Kerala High Court, there is a case going on, to allow clinical psychologist to independently practice in community to treat patients of mental disorders.

This is a serious issue and needs to be taken up strongly so that untrained people are not given the role of a physician i.e. to practice independently to treat patients.

DMAI insists that the Medical Council of India, Indian Medical Association & patient groups & DMAI needs to be taken in confidence and consulted, as independent examination, diagnosis and admission and also treatment by psychological or psycho-social means is practice of psychiatry under modern medicine and could not be allowed to be done by persons who do not even have a MBBS degree, in view of patient safety and care.

All health personnel shall work within the limits of their competence. In section 43 and 45 of the draft bill related to admission in a mental health facility: a mental health professional (i.e. Clinical Psychologist, PSW, Psychiatric nurse) has a role to examine a person suspected to be mentally ill independently, assess mental illness and its severity and advise admission. This is a role which goes beyond their competence. There are already instances of Clinical Psychologist practicing treatment of mental disorders independently as isolated examples. There is growing demand from clinical psychologist to allow them to practice independently the treatment of mental disorders. This change in the draft bill will allow them to be recognized as persons who can independently examine, diagnose, and admit patients, which will substantiate their claim to practice independently in community rather than under the supervision of a psychiatrist. It’s altogether different matter that they are not trained to examine and diagnose mental disorders as it requires ruling out other physical disorders as well and it requires a person to be a physician to do that. In section 22 of the draft bill : Constitution of district panels of mental health review commission , two members could be mental health professionals (i.e. Clinical Psychologist, PSW, Psychiatric nurse) which may not include a psychiatrist if he is not available, but then how the commission can judge the decision of a psychiatrist if no psychiatrist is in the commission? One needs to have knowledge of psychiatry to assess the correctness of the decision of a psychiatrist in a particular case. Provision of a psychiatrist in the review commission should be mandatory rather than being replaced by non-psychiatrist personnel Mental disorders are medical disorders and should not be treated by non-medicos .

I am quite sure that you will intervene and ensure that the corrective measures are taken to address the lacunae in the bill Also,

DMAI- The Population Health Improvement Alliance has initiated a ‘NCD Policy of India’ initiative, and would be glad to have the views of the ‘Ministry of Health’ involvement on the initiative

I am quite convinced that committed leadership will take cognizance of this note and take measures to implement the suggestions after a debate with all the stake holders in the continuum of care.

Should you need any assistance at my end, do let me know.

With best regards

Rajendra Pratap Gupta

CC. Dr.Manmohan Singh, Sonia Gandhi ,Rahul Gandhi , Dr.Syeda Hameed, Dr.Murli Mahohar Joshi , Montek Singh Ahluwalia ,Shri Dinesh Trivedi , Sitaram Yechury,  Members of Parliament , Sam Pitroda , Secy-Health & Family Welfare , GOI,  Dr.K.Srinath Reddy, Debasish Panda , Secretary (ME) Governors , MCI DGHS,MOHFW, Dr.Sudhir Gupta , CMO, NCD-MOHFW ,Dr. Suman Sinha, Psychiatrist,  IMA , Chief Minister’s of States

Include Homeopathy in National Health Schemes


DMAI wants the govt to give due weightage to homoeopathy in NRHM

Suja Nair Shirodkar, Mumbai Wednesday, March 30, 2011, 08:00 Hrs [IST]

The Disease Management Association of India (DMAI) has recommended the Public Accounts Committee (PAC) of the central government to increase the role of homoeopathy in the National Rural Health Mission (NRHM), especially for acute illness.

At present homoeopathy is not being leveraged properly under NRHM in spite of it being the cheapest way of treatment in the country. Rajendra Pratap Gupta, president and director DMAI pointed out that the homoeopathic medicines are cheaper and much more accessible to patients thus it is only natural that its potential should be utilised properly under NRHM.

Though the treatment used in homoeopathy is superficially similar to the medicines prescribed by a conventional doctor it differs in their source, preparation and dosage. He observed that in spite of having enough qualified homoeopathic physicians in the country the government is not giving them enough chance to play any role in the national health program. “Today there are  hospitals and colleges that cater to homoeopathy and encourage its use then why isn’t the government utilising these resources to increase the demand for homoeopathic medicines among the rural population.

The government should take step to ensure that the people in the rural India can also benefit from this system,” he pointed out. He said that the demand for homoeopathy has increased over the years as more and more people are adopting homoeopathic treatment due to its effectiveness compared to other available methods. Thus it should be put to use more effectively. He added, “Homoeopathic medicines are very cheap, in almost two rupees a patient can get a weeks worth of medicines which will be a great support to the rural population, it would provide them with cheapest alternative that assures best treatment.”

Homoeopathy is a system for the treatment of illness that is based both on the recognition of patterns within the symptoms of the illness and a wider consideration of how the individual is as a person. Although conventional medical assessment also takes these issues in to account, the homoeopathic approach integrates personality type, previous experiences, emotional state, the influence of the environment and other social factors to a greater degree than is usual with standard medical practice.

http://www.pharmabiz.com/NewsDetails.aspx?aid=62119&sid=1

Rajendra Pratap Gupta

DMAI wants the government to extend the NRHM till 2017 with radical operational changes


The Population Health Improvement Alliance                                                                                                                                                                                                                  

The Disease Management Association of India (DMAI), a non-profit organisation propagating disease management concept and tools in the country, has urged the Public Accounts Committee (PAC) of the central government to reconsider its recommendations for scrapping of National Rural Health Mission (NRHM) as the NRHM has made an impact on the lives of the rural population in the country.

The DMAI suggestion in this regard was put forth by the DMAI president and director Rajendra Pratap Gupta in a letter addressed to PAC chairman Dr Murli Manohar Joshi recently.

The NRHM was launched in the country on April 12, 2005 for a period of seven years i.e. from 2005 to 2012 for providing integrated comprehensive primary health care services, specially to the poor and vulnerable sections of the society. It means that NRHM will get expired by 2012. However, seeing its impact on the rural population, the government is thinking of a possible extension for another five years. In this regard the government had asked PAC to review the NRHM. However, in its reports the PAC has recommended on scrapping the NRHM scheme.

However Gupta suggested, “NRHM is a very useful programme and has been successful in having its presence felt even in the remote parts of the country. However, there are many radical administrative and operational changes needed to be made in the present format of NRHM.”

He suggested that with proper administrative and operational tactic, this programme certainly will have the power to create desired impact in the rural health scene. In his recommendations to the planning commission on the changes needed in NRHM for the 12th five year plan, Gupta suggested that technology must be leveraged in NRHM for accountability, transparency and telehealth and that 12th five year plan must consider opportunities to digitise NRHM in all spheres of its implementation.

He said, “There are many important changes that needs to be undertaken in the NRHM, but of all changes the first and foremost change should be to improve the quality of medicines that is being supplied at the NRHM centres. Secondly, minor surgeries are not allowed in Primary Health Centres (PHCs) as of now. This should be changed and the government must allow minor surgeries in the PHCs as it would help reduce a lot for hassles for the villagers and bring revenue for the government as well.”

Other issue that he had highlighted in the letter was on the inadequate fund flow on time which could lead to corruption among the people working at the lowest level in PHC and sub centres.

“I have met people who were not paid salary for months, and also discovered the fact that the funds that were supposed to be sent for 2010 were received by the centres in mid January 2011. Such delays must be stopped with immediate effect as this clearly will encourage and lead to corruption as people drawing a monthly salary of Rs.5000-8000 won’t be able to sustain their family without salary for months. Either they will resort to bribing, selling the government supplies or starts absconding and working for employers in parallel. Thus I suggest that the fund meant for a sub centre or PHC must be transferred in advance for the quarter if not half yearly,” Gupta points out.

He put special stress on telehealth adoption goals for NRHM and other healthcare projects, as setting up and manning the physical infrastructure with qualified professionals at remote places is nonviable. To stress the importance of telehealth adoption in the country the Telemedicine Society of India (TSI) is organising a three-day conference Telemedicon’ 11 in Mumbai from November 11 to 13. TSI is completely dedicated to the promotion of telehealth in India and is being organised at a time when there is a big push from the government and private players in the field of telehealth in India.

Rajendra Pratap Gupta

http://www.pharmabiz.com/NewsDetails.aspx?aid=61977&sid=1

www.telemedicon11.com

Worst Prime Minister India has ever had & the worst President Congress ever had


A few days ago , the Prime Minister defended that, during the appointment of the Chief Vigilance Commissioner (CVC ), he was not aware of any charge-sheet against him , this is despite the fact that, Sushma Swaraj clearly raised an objection to the  appointment of Mr.Thomas as CVC  based on the charge-sheet.

Now ISRO says, that it had kept the cabinet in dark on the deal with Devas. This office is with the Prime Minister . I am sure that all of us realize by now that , this Prime Minister is no more than a rubber stamp of Sonia , who has no inclination to go into facts and take action . In fact, this is the worst Prime Minister India has ever had , and Sonia is the worst President Congress had ever had .

Sonia is Queen of Corruption and mother of all scams & Manmohan is a lame duck PM 

Both must resign and go

Rajendra Pratap Gupta
www.rajendragupta.wordpress.com

Re-structuring Healthcare in India – 12th Five Year plan – NRHM , ICDS & Malnutrition


 

 

January 31, 2011.

Dr.Syeda Hameed

Member

Planning Commission

Government of India

Yojna Bhawan,

Sansad Marg, New Delhi- 110001

Reference: Inputs on the 12th Five year plan W.R.T. (1) Eradicating under-nutrition and malnutrition in India through restructuring of ICDS or other means and (2) Suggestions for improvement in the present structure of NRHM. 

 

Dear Dr. Hameed,

I am sure that this finds you doing well.  This has reference to the mail from your office on 5th January 2011, requesting me to provide inputs on the 12th five year plan w.r.t.(1) Eradicating under-nutrition and malnutrition in India through restructuring of ICDS or other means and (2) Suggestions for improvement in the present structure of NRHM. 

At the outset, let me put my deep appreciation for the NRHM (National Rural Health Mission) and its positive impact on the healthcare of the rural population. I had a chance to visit many rural pockets over the past few years, and my inputs are based on the reality as seen by a commoner, and I do hope it is insightful along with being helpful.

Policy Changes:

To me, there appears to be no single prescription for addressing the diverse healthcare needs of this country, which is as big as a continent, but NRHM has made its presence felt even in the remote parts of the country.  Seeing that the NRHM was launched only in April 2005, and would be around till 2012, with a possible extension for another five years , one of the key policy action items that might be worth considering to create a pro-active Rural healthcare system in another six years ( assuming that the NRHM is discontinued in its current form by 2017 ), is to be able to sensitize the population on the adoption of basic standards of personal hygiene , nutrition & lifestyle necessary for fitness  ( wellness) that makes our population less dependent on hospital care . This should be one of the key goals of the NRHM for the 12th Five year plan .The current NRHM has put the onus & financial burden on the centre, as the centre and state partnership in terms of the financial outlay is 85: 15 . Second important consideration , this also must get a key policy shift for the 12th five year plan which should have one more stakeholder i.e.  center : state : Beneficiary .

Funding for NRHM:

  

We need to see a financial participation from the beneficiaries of the NRHM, as they would have got used to the services offered via NRHM centers ( ASHA , ANM, Sub Centers , PHC , CHC & District hospitals ) , and the value of offering would have increased through NRHM centers. In addition to this, per capita income will also go up in the next five years if the country continues to grow at the current pace. So we must consider if we can increase the fees for basic services towards the 10th year of NRHM; even a token increase by one rupee can deliver a quantum leap. Besides, we must keep reducing the financial incentives gradually every year to phase it out eventually. Still, the people would enjoy the safe healthcare services which are subsidized or offered at a very low cost. Villagers are getting used to these services , and I am sure that in the 10th year of NRHM , it might be a right time to bring down some of the subsidies and incentives , as the trust would have built up considerably .

NRHM should welcome ‘tax free’ donations from individuals and corporates: This should be publicized and could become a good way to raise funds in a step towards building a financially sustainable healthcare model for rural India

With a gradual reversal in the expense funding between center and the state, the expense part needs a micro planning as, though the hard infrastructure expenses might not be as high as it is now (since we are constructing sub centers & upgrading some existing centers ), but the maintenance of the infrastructure built will become a huge financial burden, and  knowing that the divestment & auctions are not routine incomes for the government, this would lead to a huge deficit in the budgets over the next six years if financial planning of NRHM is not planned and managed well.

Also, one of the key considerations for the policy makers is to look at  converting NRHM into NHM ( National Health Mission ) , as the conditions remain deplorable for urban poor , and the private facilities are not going beyond tier 1 &  2 towns .

 

Structural changes:

It would be worth considering replacing the hierarchical designations to functional designations to have a clearly defined role and an outcome driven responsibility

Mission Steering Group (at the Centre) could consist of the following :

Director for Planning & Forecasting,

Director for Strategy 

Director for Analysis & Research (One who looks into the regular reporting & review)

Director – Innovation & Program improvisation (Program will certainly improvise with regular feedback & inputs)

Director – IT

Director – Procurement

Director – Logistics

Director – Finance & Accounts

Director – Standards – Medical Protocols, GCP (Good Clinical Practices) & Quality Control

Director – IM (Infant Mortality)

Director – MM (Maternal Mortality)

Director – Nutrition 

Director – Immunizations

Director – Preventive Care

Director – Mental Health

Director – TB- DOTS

Director – ART

Director – NCD

Director – Anemia & Related Disorders (This needs a special focus, as more than 50 % of women are Anemic)

Director – Oral Care

Director – De-addiction (De-addiction must also be a focus area, as the consumption of alcohol has been on constant rise, and wife beating is prevalent in most of the households)

Director – Ophthalmology

Director – Ambulatory services

Director – Pharmacy

Director – NGO & Alliances

Director – Media & Communication

Director – Human Resources & Training

More people can be added depending upon the focus areas for NRHM. In fact, I would strongly recommend that all the national health programs be merged with the NRHM one by one  to ensure that health & wellness issues are addressed holistically in rural India

The reason I am recommending a dedicated resource for each action area like Director – MM, Director IM etc. is that, then we have people with specific deliverable, and outcomes would be better. Currently, at the centre, we have four Joint Secretaries and four directors with multiple responsibilities . These might leave them with delivering outstanding results in some areas, and with serious gaps in some!!

The above mentioned Central Committee (Mission Steering Group ) , should be overseen by the board or committee which has members from Public Health, doctors from modern medicine, Ayush, Nursing, Public representative, patient groups & people from different walks of life, who bring diverse capabilities to the team with proven competence in envisioning and executing projects on mass scale or of making a social impact. 1/3rd of these representatives must change every two years (rotating public participation). 50 % of the members must be from the government and 50 % from the private sector. Also, of the total members, 50 % must be practicing doctors and remaining non-medicos.

Further, a similar structure needs to be set up at the state level.  At the District level, the work gets delivered via same field workers.

While the PHC’s & Sub centers are done up very well, some gaps remain, like;

  • There is a mismatch in the requirement & stocks of medicines. All the PHC’s get similar stocks of medicines irrespective of the load in OPD. So , whereas  some PHC have more stocks ,  some have stock outs – More of Forecasting and logistics issue
  • Supplies of nutrients is insufficient & inconsistent –  Once we have a focused resource ( Director – Nutrition , Director – Forecasting & Director – Logistics ), these problems would reduce drastically
  • Need is for three doctors instead of the two currently at the PHC, so that the load can be handled well. Currently, at times, the wait period for a patient to be seen could go beyond 4 hours at times in OPD. Also, with this, the PHC can operate           24 X 7 , since doctors can do an 8 hour shift each
  • It would be good to have the doctor’s residence attached to the PHC
  • Biomedical waste disposal has to be given priority to avoid infections in villages.

 

Challenge: Nutrition given during ANC / PNC is consumed by the family and not by the mother.

Solution: If ASHA can monitor this during visits or otherwise, it would be effective or the gender specific nutrition packs could be made to ensure that the females consume what is meant for them. Self Help Groups have emerged as the new power centers in the villages and every village has Self Help groups. ASHA’s must work with SHG’s to address this issue and oversee that the diet meant for the lactating mother is given to her in presence of a SHG member

Challenge: Electricity – Load shedding in villages: This leads to lack of storage conditions in PHC’s & Sub centers

Solution: India has adequate sunshine for 9-10 months in a year, for rest of the months, the load shedding is less, so it is worth considering having solar panels as an integral part at all the PHC’s & Sub Centers for generating electricity needed for storage and other requirements

 Challenge: Poor Quality of Medicines: It is observed that the qualities of medicines are poor, and it is procured by the district Health committee. Poor quality of medicine is a serious issue, as the patients are given medicines for treatment, and if the medicines are not effective, it will lead to mistrust in the entire system, and the poor people will have to move towards private practitioners or quacks and suffer more

 

Solution: Since all the companies in pharmaceuticals have national level operations, it will be good  if the national level tie up is done for procurements of medicines at the NRHM rates, and the order, supplies & payments happen locally. With this, we will be able to get the best rates and also give the best quality of medicines to the needy poor patients. Also, generic medicines should only be allowed to be used under NRHM. This will help to save enormous costs to the government. Also, all the PHC’s & sub centers must set up ROP’s (re-order points for all the requirements, factoring in the time lag for supplies based on past trends. This will ensure that there are near zero stock outs).

It was observed that the specialists (Gynecologist ) in one of the model PHC (Wardha district) comes only for two hours and that too, to direct patients to private practice. This must be avoided at all costs, as this will eventually make ASHA’s & ANM’s, agents for private clinics for all the wrong reasons & erode the trust in the NRHM

Challenge: Absenteeism in PHC: It is a common problem to see that doctors are missing or come only for a few hours or few days in a month.

Solution: It is suggested that the entire NRHM attendance moves paperless (biometric attendance be made compulsory). With this, the problem of absenteeism will come to an end

Challenge: Preparing reports and paper work takes most of the productive time of the health workers

Solution: With the advent of low cost tablet PC’s & low price 3 G enabled phones; it might be worth considering giving these devices to health workers like ASHA’s. Also, if these mobiles / tablets have a GPRS connection, it can mean live data updates, thereby, reducing the three month gap between the village data entry and the central review points at Delhi

When I visited the residence of one ASHA worker, she had more registers to maintain records then her daughter would have used in her studies! In all, she had about six registers to maintain records and spent 2-3 hours daily to just fill in her records. I believe that just one register should have been good enough ,  with name of the beneficiary , under which head ( disease or operation ) ,  visit for the purpose of , repeat visit , action taken, next steps, and next due visit etc…….The register given by NRHM was in English with words like Vulnerable men / women . I believe that the language used should be bilingual and not just in English …. This needs immediate attention. Digitizing the records through mobile phones would be great, as has been done in Wardha district for IM & MM programs. The data is updated live and the impact is significant with no chances of multiple entry and errors, and also real time actions happens due to SMS based follow up and care.

Ground reality: I visited one centre in a rural area, and I was surprised to see the PHC decked up to welcome the Health & Sanitation committee that was to visit the centre. I was told by the centre staff that they have been waiting since past one week, expecting this committee and they had bouquets etc ready to welcome them. Such visits do not reveal anything and add no value to the working of the village sub centers or the PHC but work only for photo-ops!! Only surprise visits must be under taken with no formal information given in advance, so that the right picture is presented during the visit, and the action oriented steps can be taken to fill the gaps, if any.

Pharmacies are present in every part of India .It is believed that India has about 7.5+ lac pharmacies across the country, and most of the villages have a pharmacy. All the

Pharmacists must work as ASHA support systems due to their knowledge and skills, being the trusted touch point for basic health problems. Focus through pharmacists should be on chronic diseases and paternal care, and through ASHA’s on child and maternal health

Medicine kits given to ASHA should have all the instructions in English, where as all the pharmaceutical companies are expected to carry the same bilingually (English & Hindi).  For NRHM supplies, pictorial presentation along with bilingual labeling must be mandated.

Tribals & Upper caste: Despite the best efforts of the government, tribals are still called the ‘Black castes’ and live in a separate area demarcated for them. One of the biggest challenges is that ASHA from a lower caste would still find few takers amongst upper caste households, and vice versa. This is one issue that needs to be addressed. It would be wrong to create two ASHA’s and further the divide , but some really significant  work can be given to ASHA , so that it appears to be compelling enough for everyone to seek ASHA’s assistance- Like the entire village birth certificates must have ASHA’s signature etc.

Changes in the delivery of services

 

New Opportunities: 

Community Radio: This is being experimented in Baramati, and must be looked into. Similar services can be started in villages to drive healthy behaviors. I had visited a few villages in north, where a simple awareness campaign (pictorial & through songs in local dialect) have reduced the maternal mortality by 93 %. The expenses in this project were not more than Rs.5000.00 per village. Such models need to be adopted

Toll free based IVR Multilingual helpline:  NRHM must initiate this to help reach the right people for the right inputs

m-Health based Jeevandaini scheme : This has been piloted in Wardha district , with good results in institutional deliveries and drastic improvement in MMR.  The simple mobile based applications have lead to live data upload and follow up via SMS, leading to good compliance amongst ANM’s & ASHA’s . This health based model needs to be made an essential part of NRHM . Since 3G & WIMAX is now a reality , the rural health information flow and delivery of few basic services must be done adopting m-Health ( mobile health platform ).

Mobile Sub centers: Sub centers are built at a cost of Rs.8.5 – 13.5+ Lacs. It might be worth considering to set-up mobile sub centers( Mobile Vans ) that can go across to the remotest areas and conduct outreach programmes. So the cost of operating the sub center ( rental , electricity etc ) gets consumed in the form of fuel expenses for the mobile health center and also, these sub centers can be used as an ambulance in case of medical emergencies . Thus it would save Rs.300 that is given for transferring patients to the referral centre. The cost of  mobile centre is expected to be much lower than the cost of a physical centre. Location of PHC’s & Sub Health Centers is mostly around a few Km’s from the residential areas, and this needs to be corrected or filled up with such mobile health center

Digital Training of Health workers: It might be worth considering creating a TV programme on doordarshan modeled exclusively for training ASHA, ANM & for increasing awareness amongst NRHM beneficiaries. Also the same should be made available through mobile phones as 3G is now a reality. Expecting mothers must be able to see the demo & programme clippings via their handsets or through ASHA’s handsets, which could be upgraded to a 3G enabled mobile handsets for live reporting or for delivering video content for various programmes.

Technology must be leveraged in NRHM for accountability, transparency and telehealth. 12th five year plan must consider opportunities to digitize NRHM in all spheres of its implementation

Minor surgeries in PHC: Now that that PHC’s have facilities for delivery, minor surgeries must be allowed in the PHC. So far, minor surgeries are not allowed in PHC. This is one important decision that can help save a lot for hassles for villagers and bring revenue for the government. The PHC’s can enroll patients for minor surgeries, and then get a surgeon on call for a day from a nearby town and complete the minor surgeries at the PHC to function as day care centers .

Reporting of NRHM across states should be on the same format as of KPI’s (key performance indicators) so that it leads to apples to apples comparison and this could be on these indicators

  • Structural : Setting up and maintenance of the facilities
  • Functional : Human resource management and flow of instructions and funds
  • Fund utilization: special focus must be paid as to why the funds could not be used, as the money is meant to be spent with an outcome allocated to every rupee spent.
  • Outcomes :  Measurable outcomes in improvement in the village / Taluka health must be done every quarter

 

Reporting and review must be

  • Weekly for Talukas
  • Fortnightly for Districts
  • Monthly for states
  • Quarterly at the centre

 

This timely reporting will itself bring out better outcomes. It was sad to learn that during the mid-term review of the 11th five year plan in July 2009, the ministry of health & family welfare was not even aware of  any targets. The reality is that, the files from the planning commission were not even looked into by the ministry of health & family welfare until the mid-term review of the plan started. One of the senior official of the MOHFW had revealed to me that rarely MOHFW looked into the files from the planning commission , and they were not even aware of any targets set by the planning commission , and that if the MOHFW did not respond to the plan targets set by the Planning Commission , the planning commission assumed the targets as accepted by the Ministry of Health & family welfare .This is a structural and procedural lacunae and needs to be addressed from the planning stage for the 12th five year plan , so that the ministry does not question in the meeting who set the targets for them ??

Administrative changes:

 

Financial planning and flow of funds:  The fund flow on time is the biggest problem. I have met people working at the lowest level in PHC & Sub centers, where the salary has not been paid for months, and the funds for 2010 were received in mid – Jan 2011. This clearly will encourage corruption. People drawing a monthly salary of Rs.5000-8000 cannot sustain their family without salary for months. Either they will resort to bribing; selling the government supplies or starts absconding and working for employers in parallel. The fund meant for a sub Center or PHC must be transferred in advance for the quarter if not half yearly. This is one single biggest action item to make a sub center or PHC Staff working 6 days a week

Referral centre: It has been found that the referral centre in Panvel (district Raigad) does not even accept patients & turns them away from the door itself ( this is a reality ), and the patients are routed to the Alibag referral centre. Such centers must be a common occurrence across India. Government is paying for them, but they are operational only on paper. Such center must be tracked down, and either made fully operational or closed down. As not only they cause a loss of money to the exchequer, but also diminish the trust of the common man in government’s flagship schemes like NRHM

Why programmes succeed or why they fail- Lessons to learn:  Let’s take a look at the successful programmes like NACO for Aids, National TB control programme & the Pulse Polio programmes. All these programmes have worked well because of  the fact that they have proper structure and resources allocated.  In the ministry of health & family welfare, the programmes are fantastic announcements, but the human resources required are not properly allocated in the ministry to handle such programmes; only the funds are transferred in the bank for the programme. So the department handling the programme is under resource crunch , they do not even have people to handle the communication , and most of their time goes in reporting ; Result – the funds remain un-utilized and are returned back in case of calamity announcement from the PM’s fund or for other reasons and thus programmes fail to leave an impact . Planners must study the success of National TB control programme & NACO and implement the learning’s in all the programmes for Health & family welfare

Incentive to health workers ASHA’s ANM’s & other Sub center & PHC staff: It is expected that since ASHA’s and ANM’s are incentivized for institutional deliveries, referral etc. The incentive might also make them turn to private practitioners over a period of time, as the lure of money will drive them to recommend private gynecologists & give less focus to home visits and counseling, and this might be happening even today as well. It is suggested that the ASHA’s & ANM’s must be incentivized for counseling, home visits, immunization  & preventive checks as a routine part of their job and the incentive must be paid for each home visit ( even Rs. 2 to Rs.3 per visit is good enough ) .  This will lead to a fixed remuneration to ASHA’S & ANM’s. Certain Evaluation parameters for the success of an ASHA must be established like how many households are aware of sanitation, hygiene, preventive health and healthy lifestyle.  Since the NRHM has a huge outlay of funds for the national healthcare, a ‘dip–stick’ audit using random sampling must be done with the households, and this must be done every quarter across the states where NRHM is currently operational.

ASHA is not paid a salary but is paid incentive for institutional deliveries (Rs.100), DOT treatment (Rs.250), meetings for once a month (Rs.150, out of which Rs. 100 is for travel and Rs.50 for refreshments). A supervisor is above ASHA’s and she handles about 30 ASHA’s. She is paid Rs. 3000.00 per month. She is supposed to be meeting two ASHA’s a day. Since both the ASHA’s and Supervisor have to travel long distances by road , and keep in constant touch with each other , I would recommend free local roadways pass to NRHM workers , and a mobile connection with CUG ( Closed user group , that allows free calls between users ) for NRHM staff.  The cost of which could be less than Rs.75 per month

NRHM Handbook : Since the NRHM programme is the biggest healthcare programme so far,   it is imperative that a detailed multi lingual NRHM Handbook, manual or ready reckoner be brought out for all those involved in the programme  , covering  basic protocols,  bio medical waste disposal , do’s & don’ts  dealt with FAQ’s . Also, the digital version must be available on mobiles and internet.

1-3 months rural posting of nurses, pharmacist and doctors must be made mandatory for the courses to fill the resource crunch, and the professionals must be remunerated for these postings along with free accommodation on site at the sub center and PHC.

Awareness & sensitization: Since NRHM is addressing the key areas when it comes to health and hygiene, it is imperative that a chapter on NRHM is added in secondary education (class 6th onwards). This will lead to awareness and sensitization amongst children to adapt to healthy habits

Role model & Case studies approach: People believe in facts, and the case studies & success stories of ASHA & ANM’s must be shared nationally to make the acceptance more impactful for behavioral change. I must share with you something interesting that I witnessed in north India. I was visiting rural belt in north India, and came across an ancient custom called ‘Shourey pratha’. Under this , when the lady delivers a child , she is confined to a room for 40 days , and cow dung is plastered on the walls ,and baked cow dung cakes are burnt non-stop to fumigate the room, automatically the mother and child suffocate to death . Now we can well imagine why the IM &MM (Infant Mortality & Maternal Mortality) was very high in the rural belt in north India. With simple explanations and scientific explanations with the help of  the Self Help Groups (SHG’s), this tradition is on its way out. SHG’s is the most powerful change agent in rural India and the NRHM must use this channel to drive a behavioral change in rural India.

 

 

Eradicating under-nutrition and malnutrition

 

The issue of under-nutrition and malnutrition is not just an issue associated with poverty . If I were to say that malnutrition is also prevalent due to the lack of sanitation facilities, people would not believe it, leave alone talking about linking the two.

Here is an interesting linkage : Females in the village have to defecate in the open , and for that , they either go out in early mornings or late evening when it gets dark . To avoid going in between , the women not only eat little , but also feed children just good enough so they do not go out and defecate too often , and this has been a cause of malnutrition and under-nutrition . There is a common habit amongst girls studying in schools with no proper toilets that , they seldom drink water during school hours to avoid going to toilet !! Strange but true . Similarly , mal-nutrition and under-nutrition has become a sanitation issue . This calls for the involvement of the ministry of rural development to address the sanitation issue in rural India to completely address the issue of malnutrition & undernutrition . Also, the ministry of food processing to work with the players for producing locally fortified foods to reduce the cost of  ready-to-use therapeutic foods (RUTF).

Nutrition is often overshadowed by other medical conditions, like malaria or diarrhea, despite the fact that malnutrition, combined with these conditions, can more often be fatal.” A “severe acute malnourished child” is more than nine times more likely to die than a well-nourished one, & malnutrition from any means retards normal growth .

Besides sanitation , societal traditions that female child is a burden still plagues the nation ,and there is a bias towards the male child who is treated as an inheritor and an insurance in the old age for parents .  Government needs to step its machinery on all fronts . It is a known fact that,  a weak female will never bear a healthy male child , and this should form the basis of the Healthy India campaign as the discrimination against the  female child is rampant in every part of the nation . The issue needs to be attacked multi-fold ;when the mother is expectant , post child birth , adolescent years, post puberty age in girls . Special focus has to be given to the female child , who bears a male child in future .

One of the key pillars of NRHM must be eradication of anemia amongst women with the focus on the girl child. Special fortified biscuits or snacks with calcium, iron and zinc need to be made  available for the girl child ( developed specially for females, so that male child is not given those products ! ) and separate packing for boys to be given as mid day meal or as packaged snacks made especially for children fortified with nutrients ; ready-to-use therapeutic foods (RUTF). For boys, the nutritional support must continue till the age of 6 years but for females , this support must continue till 16 years in age

The deficiencies varies with the region , like Vidharbha region has a severe issue of sickle cell anemia , and this is becoming a serious genetic health issue . Similarly, deficiencies in every region needs to be addressed region-wise.

Diet charts are as important as immunization charts and needs to be given together during child birth based on the physique of the newly born

RDDA’s ( Recommended Daily Dietary Allowance ) should be worked out specific to each child . The role of the nutritionist gains significance in NRHM and is  central to the issue .  The diet plan must be made for each new born and followed under the directions of ASHA locally . So far, I have not seen a prominent role of a dietician in either the sub center or the PHC

I would recommend national health planners to tie up with WFP ( World Food Programme ) to provide daily nutrition for as low as Rs.5 per day . Even companies like Unilever are working on creating BOP Healthcare ( Bottom of Pyramid Healthcare ) models focusing on healthcare basics for the rural masses. It might be worth exploring PPP ( Public Private Partnerships ) to address this issue & come out with ready-to-use therapeutic foods (RUTF)

Indian Pediatrics has brought out a Special Issue (August 2010) on Severe Acute Malnutrition, which deliberates in detail on the global and national evidence relating to pertinent issues on this subject.

Severe acute malnutrition (SAM) in children is recognized as a major underlying cause of death amongst under-five children. These deaths are preventable provided timely and appropriate actions are taken.

According to National Family Health Survey-III, conducted during 2005-2006 in India, 6.4% of children below 60 months of age were suffering from this malady . With the current estimated total population of India as 1100 million, it is expected that there would be about 132 million under-five children and amongst these about 6.4% or 8.1 million are likely to be suffering from SAM.

With the emergence of home based management approach for SAM children, which includes the use of Therapeutic Nutrition (TN) as part of Medical Nutrition Therapy (MNT), it is possible to address this issue in a cost-effective manner. More than 85 % of total SAM cases are without medical complications and can be identified through active case finding in community to be successfully managed at the home level. Global evidence suggests that with integrated management of SAM children, case fatality rates can be reduced to less than 5 percent. Short-term therapeutic nutrition for 6-8 weeks is an integral component of home-based management of SAM. There is an urgent need to develop an indigenous preparation of therapeutic nutrition in the country and operationalize the community management of SAM. Exploring a tie up with WFP / Unilever might be a good start. Also NRHM can start a mission GYM ( Grow Your Medicines) at the PHC , Sub centers and in every households ,as most of the green vegetables and fruits can be grown locally , and can be used for fighting mal nutrition and under nutrition .  On one side ,  fortified snacks could be given , and also the NRHM can distribute seeds for growing vegetables and fruits that can mean  much cheaper source of right nutrition .

Height weight charts must be distributed in all households to keep them aware of age- weight –height ratio and the relation to malnutrition . Automated SMS based service could help in ensuring compliance as seen in the case of Wardha pilot for MM /IM.

Awareness and sensitization must happen through short films and pictorial comics about the deficiency of Iron & Calcium in females

ICDS : Policy makers must consider merging ICDS with the NRHM , as it might be worthwhile to double the number of ASHA’s and allocating more high priority job to  ASHA’s.

Health Fairs must be organized locally to create awareness on the issue of malnutrition . Those parents who have the healthiest girl child must be made ‘Role Model’s’ for others to follow . A ‘healthy girl child award’ must be instituted in each village ( Say Rani Laxmi Bai Award ,Sarojini Naidu or Indira Gandhi award  etc) , and the government must recognize the mother and father ( Good Parenting ) for healthy upbringing of the female child ,along with a cash award of say Rs.1000.00 , or other incentives like 2 KG extra ration at the PDS shops, free bus travel for parents for one year in ST ( state transport ) bus , 50 % fee reduction in graduation of the child ,if studying in government college  etc, could also be considered depending upon the consensus of  the relevant stake holders.  This can be a good competition to start with, which will drive home the message that bringing up a healthy girl child is beneficial in the short run and in the long run & the responsibility of the parents , with the Government acting as an enabler for this . To start with, if each of the 6 lac + villages gives this award to one girl ( parents ) , and each encourages 10 people to take care of their girl child , we would have got 6 crore healthy females in the next 10 years !!  If we want faster results , we can fix the criteria for a healthy girl child for the age group 1- 16 years , all those who qualify can get incentives for the healthy upbringing of the girl child like free travel on ST bus etc . Ministry of women and child development might like to take this up in the 12th five year plan.

NRHM must insist with the ministry of education to include in the curriculum few chapters  on micro nutrients and their role in healthy living , and this should start from class eight onwards.

I do hope that these inputs are of some help .I remain at your disposal should you need more inputs on other aspects of healthcare & rural economy

With best regards

 Rajendra Pratap Gupta

Office@rajendragupta.in

Give us a Prime Minister – Manmohan Singh is a good professor but certainly not a PM material


Dear Mrs.Sonia Gandhi,

Since you are the President of Congress party , please look into this email

Over the last few years , we have tried to accept Dr.Manmohan Singh as our Prime Minister , but his performance as a congressman might be good , but he has failed completely as a Prime Minister . Congress has been blinded by Gandhi dynasty to such an extent that it has become poor in chosing the right people for the right job. May be that your and Rahul’s intellect is not upto the mark where you can choose competent people .

Over the years , congress government under your Presidency has become a government of faulty planning , false promises , blaming coalition for your failures and blame free investigations in most of the scams 

  •  This government has too many highly educated people, economists & NRI experts & advisors , but still the wisdom to understand the problems and give exact solutions is missing .
  •  Every time your Congressmen give a new date about controlling inflation , and every time they miss it . When the inflation is perpetually high , you blame coalition politics for it. So why do Indian’s pay a price for your forming the government ?Dissolve the government and go for fresh elections .
  • You are not able to judge the talent and most of your ministers are highly inefficient and corrupt , and we were hoping that Sharad Pawar would be removed so that he could focus on the ICC world cup in 2011( Which he will do anyways !!), but he seems to have hypnotized you !! He is still around !
  • Your party believes that , by revealing the names of those who stole the government money and deposited them in Swiss Banks , would pose a security risk ! So you are trying to tell India that, majority of your office bearers are Swiss account holders !! And that their getting caught would mean that the government would collapse !! Anyways , Julian Assange is on the way for dropping a few names , and I do hope that they are not from India & Congress !!
  • Industrial growth has been reduced to 2.7 % , lowest in the past 18 months . Would like to answer it why ? Rather , I must ask you if your people know at all why it happened ? 
  • People are very bullish about rural India, and every major FMCG , White good & vehicle manufacturing company is over- joyed with the growth coming from rural India in terms of the purchases being made . Let me take you through a very dangerous & disturbing development in rural India – I call it Rubble ( rural bubble ). I have been visiting rural India and talking with villagers . Here is what I want to tell you. Let’s take the example of Chavane village in Raigad. The village has changed dramatically in the past 3 years. It is great to see concrete (Pucca )houses with two wheelers parked in front of the houses. As you dig deeper , the facts reveal that people sold their land to MHADA for Rs.30,000.00 per acre for SEZ, and with sudden flow of funds, the thatched roof houses got converted into Concrete (Pucca ) houses, and two wheelers were also purchased along with some jewellery . Villagers had for the first time seen so much money, so instant money that came by selling land was used to make aspirational purchases , and it is over now , lands are gone as well !! What will the farmer do ? What will the farm labourers do ? How will they earn their living ? Let’s take another village 80 Kms from Nagpur , where Lanco plant is being built . Villagers have sold land for the rates as high as Rs. 25 lac per hectare . In India , average size of the land holding would be around 5-7 acres. Selling the entire land would fetch Indian farmers between Rs. 1.25 lac to 1.75 crore depending upon the size of the holding and the rate paid by the acquirer. On these lands , manufacturing plants would come up. We would never see greenery again. And farmers and their children who do not have jobs and land to do farming will be the next anti social elements or naxalites !! With land not available for agriculture , inflation would be higher than what it is today . Today farming is seen as a disdainful activity , and people want to do a job of Rs. 4000 but do not want to work in farming . Your congress government has kicked the ass of 100’s of millions of farmers over the past 60 years , and we are on a temporaray rural growth that I call as a rural bubble – Rubble !! India is headed for a major crises , & all because of the faulty policies of successive congress governments focused just on building billionaires , industries and encouraging FDI !! Get retail FDI in India , and see how the 12 million kirana stores and their families will starve to death . I have had discussions with the Parliamentary Committee of Commerce , Chairman in 2009 , Dr.Murli Manohar Joshi , and have given him in detail the reasons why we need to avoid FDI for the next 5 years at least !!
  • For price rise , last year ,Manmohan ji said that it was due to poor rains , in 2010 we had good rains and good crop , so why the price rise ? Kindly explain 
  • I was in Nagpur on 17th / 18th , and I read in one of the news papers about the fact stated by none other than Mr.Subramanian Swamy that, your bank balance was about Rs.10 crore some twenty years back , and now it is Rs.80,000.00 crore !! I think that this shows that inflation is very high at 10, Janpath . Please clarify if you actually made 60 % money in the 2G scam or this money came from abroad ? You are answerable 
  • Ironically , in the current times , we have a strong opposition but a weak ruling party . How can this government run ? If BJP comes down on its demand for JPC in budget session, Indian public will assume that it ‘settled’ the matter with congress and will never let them win again the seats that they are looking for, and if they keep their agitation on like the winter session , your government will have to go , and India will see a sign of relief !! 
  • Madam, congress might be your personal fiefdom , but not this country . You have created multiple power centers more powerful than the PM , like Rahul , NAC etc….You are the worst Congress President in the history of this country . But usual , we have a saying ‘Andhon main Kane Raja’ So you are the right person for the congress, which does not have any talent left !!
  • We have an outdated finance minister , unfit Agriculture minister , Hyper environment minister and an ineffective Person on the seat of the PM. All along, I have heard that we need 100 good people or 1000 good bureaucrats etc. But the fact is that , we just need one right person : at the seat of Prime Minister . One right person will change the future of this nation , and Manmohan certainly is a disaster at the cost of people . At this time , we cannot afford to have a lame duck as a Prime Minister of this youthful nation . Please give us a Prime Minister , we do not need a professor !! 
  • A suggestion for controlling food inflation : Please ask the government to start a daily free ( even if you charge the farmers for this service,  it is fine ) truck service from the remote villages to cities , where only farmers can come directly to the market and sell their products, rather than selling through agents , mandis or APMC . This will ensure that the person who adds maximum value and takes maximum risk for growing the produce ( farmer ) should also get the maximum profit . The profit at every point of sale post the harvestor ( farmer) should not cross 15 % , and this will bring down the prices to reasonable levels permanently . I read Subbarao stating that the government is desperate to control inflation and will raise the base rate , I heard Chidambram that government is clueless about the tools to control inflation , Sharad said that he cannot control what the farmers want to grow and so he cannot control food inflation . All these stupid statements come because you have bookish professors and so-called highly placed intellectuals and NRI & outdated advisors , who have no connection to ground reality . I do not understand how will raising the rates decrease inflation ? You have been doing this for the last two years and the result has been same – inflation has only increased . Do we need such economists who do not have answers to the common man’s problem ?
  • Do you never apply your brains about this fact that, the prices of the grains and vegetables are sky-high , still the farmers are committing suicides ? Does this not help you understand the problem and get an answer ? You all must be high level fools then !! 
  • In addition to high prices of food stuffs, by increasing the price of petrol again you have signaled the common man that ‘do not eat , do not go to work’

 Nitin Gadkari ji , please take up these matters with utmost seriousness , as congress is forcing the poor people to take to suicides by failing to control prices . If BJP does not take the matter seriously , the people of India will feel betrayed. Congress is fast becoming a failed party under you Sonia Gandhi ! Please either give us a PM or you and PM can go now ….. do not let this great country go to dogs !! This email is marked to Sharad, your dear son , FM , HM etc. to do some soul-searching and step down

Rajendra Pratap Gupta

www.rajendragupta.wordpress.com

Create wealth , increase employment – Shape up Dr.Manmohan Singh


14th February 2010

Dr. Manmohan Singh

Prime Minister of India

7, Race Course road,

New Delhi.110011

 

Sub : Some important issues that needs to be attended on priority

Dear Dr.Singh,

This note needs your esteem , kind and personal attention

I have written to you in the past on healthcare reforms agenda with a detailed note on what needs to be done. Through this note, I wish to draw your attention to broader topics that have a deeper impact on our all inclusive growth agenda and if attended properly, can result in more than 10 % GDP growth.

I have been watching the economy across sectors, government initiatives and speaking to people from all walks of life. I feel that it is the time to do an introspection , look carefully at the realities and take immediate corrective action. This letter might be a bit long for you to read, but it might be worth spending a few minutes .

We all know that India has been passing through a trying time . Last two years, we had a recession and it played havoc on our growth and also rural India. This year we are passing through one of the worst inflation & in not the very best of times. We had not fully recovered from recession when inflation hit us. Today, because of inflation, where the prices of essential food items is beyond the reach of 2/3rd of India’s population for its recommended daily calorific  intake , we are slowly pushing people towards ‘Partial Starvation’.  Exceptional circumstances require exceptional decisions .We need immediate intervention. I recently read that you formed a committee for price control. I had presumed that we must be already having a department for price monitoring & regulating supplies in the ministry of agriculture .  It is high time that the current Minister for Agriculture is replaced and the right person is chosen for a very important job. A job that determines the lives of farmers (2/3rd of the population ) cannot be handling cricket and agriculture and also a political party (NCP is headed by Sharad ). He is dedicating just 1/3rd of his time to his ministry. Also, I see that firstly a wrong person was appointed and now he is wrongly blamed for food price hike ! It is an irony that as a Prime Minister , you are equally responsible for the situation that is created and the congress is just playing a blame game when millions of people are being pushed below the poverty line and death. If you see,  Agriculture , forestry and fishing recorded negative growth in 2009 but I still don’t see proactive approach of the government . I know price rise is an urgent issue , but there is a more important issue ; Supply versus demand of agricultural products. You must take note of the statement issued by Dr.Murli Manohar Joshi , M.P. on 17th January about the sugar prices going up due to bulk allocation of the sugar produce to soft drink companies and chocolate manufacturers. I must state that these MNC’s take cheap raw material from Indian system and sell expensive drinks & chocolates to our people !! High time that they import their raw materials or produce them . Government must not let the common man pay a price for their products in such a manner . Also, let each state have a state farmers pricing authority that fixes the prices of common products till the next season based on regional produce , buffer stock and demand . No one should be allowed to trade in agricultural commodities , hoarding and speculative pricing

Fund utilization : I understand that CAG has stated in his latest report that most of the programs that were announced have not used the funds allocated to them . So, in all, the government’s commitment and efficiency is put to a serious question.

Recently , i also learned that the plan is to discontinue the NUHM ( National Urban Health Mission ). This shows clearly that either the projects are not thoroughly planned or not properly executed. Infact, it is a truth that major projects do not cross the announcements stage and do not go beyond the paper work

Some of the action points I feel are important are mentioned herewith & I would like you to act on them or let me know your views :

Employment generation : It is high time that the government thinks about increasing employment and earnings to raise the GDP numbers of the nation. All I see from the statements of  your finance minister is that the tax collections have gone up or missed their targets .  So , are we confusing the portfolio of finance minister with Union Minister for tax collections ? There is no wealth generation happening in the country . Whatever we have we are depleting our resources . You can privatise our PSU’s , Banks etc and reduce our deficit for the next 2-3 years . What will you sell after that ? We will go back to the World Bank & IMF for loans ? We need to create wealth for rural masses and for India . This is the precursor for an All inclusive growth. NAREGA is a bottomless pit and there are suspicions that this scheme is used to rehabilitate political workers for the ruling party. Please understand the seriousness of the situation and act . We need wealth creation strategies .

Here are suggestions of some of the means to create employment opportunities in India in the existing government set up.

Post offices : India has 155,000 post offices( Check http://www.indiapost.gov.in/New_Code.pdf ) . Whereas , it might be worthwhile to implement PAL code instead of PIN code but it more important to create 1 million employment opportunities out of this network. Just think, Post offices remain open from morning to evening on weekdays, they are closed after 5 PM ( Except the 24 hour post offices ), and on weekends and holidays . If we gave an opportunity to college going students and unemployed youth to provide some basic services of post offices which do not have a time bound delivery like selling stamps etc  from their residence, and they can work on some commission or may be , take a surcharge for the convenience offered say @ 10 %. We can create a minimum of one million jobs  @ home

Passport : Let us look at appointing government authorised agents for each pin code at least in urban and semi urban India , and let people use their services . This gives the citizens the convenience to get things done locally and they will be willing to pay a little more for their comfort , and this will also create additional jobs . People can work from their home .

Bill payment : Bill payment agents can be appointed by the government and these can be the people who can operate from their residence and get a commission on bill payments

RTO : Learning license should not be issued by RTO because people actually don’t know driving when they apply for the new  or driving license . Like I mentioned in the above 3 options , people can get their temporary driving license or their learners license from these approved agents and then go to the nearest RTO  and give a test to get the permanent license . This will free up a lot of people at RTO from the job of learners license and the proceed of issuing the permanent driving license can be speeded up as well.

Train tickets : Why should only railway stations issue tickets ( Only reservation is available online , normal tickets are still procured from the local station booking counter ). Say even for local trains in Mumbai. There are around 79 sub-urban stations and people should have the comfort to buy a local train ticket at their comfort in their locality , and step in to board the train at the station . This will ease the queue at the stations and people will not hurry up and get tense reaching the station and buying the tickets and then boarding the train

Forms for different office work should be sold by such agents @home .

India is the global capital in Information Technology. We can have MPRSO’s ( Multi-Purpose Resident Service Officers ), who operate from their homes and provide services 24 X 7. It is do-able . We need political will , rest is possible

Indian Restaurants abroad : The world is turning towards vegetarian food and we have an opportunity to open restaurants abroad , create the India brand abroad and win the hearts of people and feed them healthy Indian food. Indian dishes are relished in U.K. / U.S etc . Same is possible for Indian herbs & Ayurveda , Yoga schools , mediation etc . These opportunities create employment , wealth , and do brand building for India

Tourism : India has tremendous potential and the irony is that , it remains to be ‘Potential’.  Giving advertisements in newspapers does not help. Major tourism destinations have terrible infrastructure and poor connectivity

Organic food presents a great opportunity for farmers , industry and India . We are missing a multi –billion dollar opportunity . If we work on this , I see that some farmers in every state can earn enough to have their own helicopters to spray insecticides etc and drive BMW’s .  Today , even after 62 years of Independence , when we think of farmers , the image that we get is that of an ill clad , dark skinned , white bearded old age person looking at the sky . We must live up to the fact that ‘ Farmers of the nation are the fathers of the nation’ and give top most priority to the sector. Government must allot land to the tillers. When government can acquire land for SEZ for big business houses why not for landless farmers !!

SEZ should not be allowed. No more development should be allowed in already crowded towns . New towns should be built in remotest part of the country .

Courier Service : Government must start courier service as a PPP with existing players or with unemployed youth . This can create lacs of jobs across India .

There is a lesson to learn from Dubai. The vision of one man could convert a desert into  a business and tourism hub ( Though they overdid it !! ). People from all over the world go to Dubai . India has a desert ( We too can have a desert safari ) and our products are cheapest . So we can have a shopping festival and our Duty free can be the cheapest in the world . But unfortunately , our politicians are ‘Duty Free’ !

Youth : We have reduced the age for voting and increased the age for retirement but no one thinks about lowering the age for employment . India is yet to ratify the minimum age convention ( No.138 ) of the International Labour Organization (ILO ). Rahul must rethink about the call to youth to join politics at young age and change the politics .Rahul has been running around the country to do that- I find this call quite ridiculous ! While Congress party is in power why are your people asking the poor Indians to join politics ? You run the government, and can change the things the way you want ! I would say let the youth do their jobs and let you do your job rightly. Please do not drag people for doing what you have already been voted for doing . Only message that you, or for that sake any politician must give is to ‘vote’ during elections and keep a watch on the tax payers money.

Remember it is not the defence, technology , Industry, SME , agriculture that will take the nation to the next level of growth, but it is the power of the youth that will push the nation ahead on 10 + % growth per year and we can do it only by empowering the youth with employment and wealth creation opportunities .

Today , every youth is disturbed by competitiveness and lack of options after doing hard work at school and college . Students are committing suicides . Please control the same . Those who are not committing suicides live worse lives .

Agriculture supports more than 65 % of the population but government still has a casual approach towards agriculture . In 2009, agriculture , forestry and fisheries grew negatively . If this sector can grow 4 % , the overall economy will grow more than 10 % . Which will be an all inclusive growth . Government spending in agriculture is neither planned and neither committed .  Occasional waver of loans does partially solve the problems of the past but does not open opportunities for the future .

Foreign policy : We do not have a single friendly neighbour . All our neighbours are hostile.

Our relations with the three big world powers are on a shaky ground . Recent statements made by Barack has created a lot of unrest in the IT & BPO industry. We are failing in our foreign policy

Internal security : Blasts in Pune and continuous increase in infiltration are not a good omen . Some areas of the country are not under the control of the government . Go and see in Darjeeling & Maoists areas which is approximately 1/6th of the nation . They run their rule of law  . Police and politicians fear treading into their territory .

Healthcare : I will not mention much about what needs to be done as i have already written to you about the same in November 2009. (Link https://rajendragupta.wordpress.com/2009/12/04/india-needs-massive-healthcare-reforms-rajendra-pratap-gupta/ .I read that the Ministry of Health & Ministry of Railways are working on setting up hospitals on railway land near stations . I believe that this is not the best option, as some of the medical equipments need pin drop silence ( For Electron Microscope , the doctors even have to stop their breath for a second to avoid any noise for the sake of accurate results ). Please drop this plan . Else , there could be more harm than general good . Remember bad decisions taken with good intentions are still bad decisions !!

You are building six AIIMS like institutes ,but you are not even able to control the exits from AIIMS ? AIIMS  has become a center of excellence due to its intellectual wealth and not due its buildings or medical equipments . You must realise this point . There is no fun spending thousands of Crores from our money ( taxes that we pay ) for things that you will not be able to manage .  Work out alternatives, or  go back to the drawing board .

I don’t see that the government has concrete plans for healthcare . Ideally , along with six AIIMS , government should have set up National Research & Resource Center for Diabetes, Similar centres for Epidemiology , CVD , Arthritis , mental health , Telehealth etc. Healthcare is becoming expensive due to the high cost of equipments. MRI costs a few thousand due to our lack of technical R&D . Our health minister must push more funds & incentives for research for technical & clinical R&D. This one factor will drive down the cost of diagnostics . Retail margins must be increased from 20 to 25 % for pharmacies so that the storage conditions can improve and the public can take medicines that are efficacious . Still you can drive down the cost of medications by asking doctors to write just generic medications. Please refer my earlier note on healthcare reforms sent to your office in November 2009.

Legal System or Judiciary ? : I will quote CJI , Justice K.G Balakrishanan , who apprehends public revolt because of delayed justice with an every –increasing back log . He once said ; For many , real life is different from reel life . Our judicial system has become an adjournment based judicial system  . Parties take stay order in initial date , and then never care to allow the case to proceed by seeking adjournments on one excuse or the other

My personal view is that , we do not have a judicial system at all. What we have is a legal system that works for the benefit of lawyers ,criminals & politicians in power. We can safely say that the current CJI will be sitting on some assignment after retirement. Similarly , we can say the same about our Chief Election Commissioner or the Chief of Armed forces or the Chief of CBI etc. The possible rehabilitation after retirement in return for their political obedience and return gifts.

Judicial system is one that not only acquits or convicts but delivers justice . Our judicial system delivers only incomplete judgements about either conviction or about acquittal ; mostly about acquittal. I will quote two cases for your better understanding

Jessica lall murder case : The judgement that came can be safely concluded as that ‘No one killed Jessica ‘ . This is what it meant when it acquitted the so called ‘Suspects’. Ideally a judicial system should have stated that Jessica was killed by ———– and he is found guilty and convicted . Stating that the suspect was not guilty and freed, the judiciary did not state who killed Jessica ? Why at all we call ‘Black coats’ as ‘Judges’ or ‘Justice’ ? . You cannot call it a judicial system !! It is a legal system where all can argue but outcome is one ‘Justice delayed if not denied or both in most of the cases’.

Second case – Babri Masjid :  It took few hours to demolish the mosque with all video clippings and it took 17 years to figure out who did it ? It took seventeen years for Justice Liberhan to deliver his ‘TRASH Report’ on the demolition of Babri Masjid. While a lot of finger pointing is being done at Raji Gandhi who did the Shilanyas in 1989 and opened the doors to the problem , then it comes to the turn of P.V.Narasmiha Rao, during whose ‘Rule’ the Masjid was demolished and lastly, comes the names of politicians like Atal Behari Vajpayee , Dr.Murli Manohar Joshi and Shri L.K.Advani et al. From different political perspectives , you can blame all of them or either of them !! History is always written by who wins the war !! This time the history was written by ——————-( Anyone’s Guess ) !!

Over the last few weeks i have followed the Liberhan Commission report , the discussions and the writings in the media about the blame game on this Babri Demolition . If i were Justice M.S.Liberhan , i would have concluded my report in just three lines .

When love fails , people resort to justice ,

When justice fails people resort to power,

When power fails , people resort to violence

My understanding is that ,the  Babri Masjid case has been running for decades. What the hell was judiciary doing for all these years ? Had they decided the case , the people would not have taken the law in their hands . History has proven that whenever law fails to deliver justice on time , people lose patience and take the law in their hands . So I would say that , neither Congress nor BJP nor Kar sevaks nor the politics of this nation was responsible for the demolition of the Babri Masjid . It was the failure of the Indian Judicial system that led to the demolition.  I have been reading that our CJI has been asking for reimbursements for his wife’s bill who travelled with him abroad. Shame on him ! India is running a huge budgetary deficit and the government is following an austerity drive .  CJI must understand that his legal system is a sham when it comes to efficiency but he has the temerity to demand allowances from a government in deficit . On the contrary , he should not have taken his spouse with him under the current circumstances and given up the cabinet status enjoyed by him as CJI .

RTI : We must move RTI online and provide information by email as well. Why should I have to go to a post office to give my form . Get an online payment gateway so that the people can use online application and get an online form . The process saves hassles of travel ( Fuel cost ), Paper ( Eco friendly ) and time .

Role of ministers : We have approximately 100 people who work as union ministers and it is their responsibility under your leadership to run this nation as per the mandate of the people.

Delay of the 3G auction has cost our tax payers a loss of approximately Rs. 7000.00 crore. Read this : https://rajendragupta.wordpress.com/2009/10/18/vulgar-salaries-indian-corporate-world/I would say that the basic responsibility of each and every minster should be measured on few Key parameters every six months against targets set for each . Incase people fail thrice, remove them. They cannot be wasting our money.

  1. Wealth creation – ironically no ministry works for it . Please don’t take divestment as wealth creation !
  2. Job creation
  3. Managing expenditure
  4. Regulation , controls & reputation ( Brand building for India )
  5. Protecting the citizens
  6. Enhancing the international foot print of their respective ministries as applicable .
  7. All the above should be self-sustaining  and the ministers must spend half of their work time amidst the public and not in the comforts of their AC cabins and cars.

Charitable public work cannot be a long term plan. It can at best work as a short time gimmick which costs exorbitant to the exchequer and loss to the citizens ; in a sense it is like a bottomless pit . One must remember that , any investment that does not build assets or results in outcomes that positively impact the future become ‘case studies of fraud, faulty implementation and finally, failure ‘

Dr.Singh, you are known for knowledge ,integrity and obedience to 10 Janpath . But that is no measure of your performance. I tried to rate you on the following parameters as a Prime Minister of India on a 10 marks report card for each of the following key performance Indicators:

  1. Performance on national integrity & Secularism: 00/10 ( India is fast becoming regional – A dangerous sign that can split India )
  2. Performance on Preparedness for war – defence capability – 2/10
  3. Performance on population control : 00/10
  4. Performance on forecasting , identifying key priorities : 00/10 .
  5. Performance on preparation and pro-activeness of the government for unforeseen contingencies : 00/10
  6. Performance on action time from the time of identification of problem : 3/10.
  7. Performance on Team work  :  5 /10 .
  8. Performance on foreign policy : 0.5 /10 ( 0.5 marks for signing the nuclear deal )
  9. Performance on law and order at home : 2 /10
  10. Performance on planning , fund allocation and utilization : 2/10
  11. Performance on enhancing the competitiveness of Indian industry & exports :  2/10
  12. Performance on making India’s voice heard in the global affairs : 3/10
  13. Performance on rural upliftment  – farmers , rural infrastructure : 3/10
  14. Performance on healthcare : 2/10
  15. Performance on delivery of justice : 00 /10
  16. Performance on Raising funds from divestment, issue of Telecom licenses : 1/10
  17. Performance on wealth creation in India : 00 /10
  18. Performance on brand building for India : 1/10
  19. Performance on climate change : 00 /10
  20. Performance on empowerment of youth : 1/10
  21. Performance on women welfare : 1/10
  22. Performance on long term planning : 00 /10 ( Infact, there is no plan )
  23. Performance on budget / deficit : 2 /10
  24. Performance on approvals / industry : 3/10
  25. Performance on SME : 2/10
  26. Performance on Education reforms and capacity building including vocational courses : 2/10
  27. Performance on infrastructure creation & new towns : 1/ 10
  28. Performance on curbing corruption : 00 /10
  29. Performance evaluation of the team / reports : 00 /10
  30. Performance on transparency & accountability of public servants and representatives  : 00/10
  31. Performance on public perception : 2 /10 ( This was much higher before elections in 2009 )
  32. Overall performance versus commitment & mandate : 1.5 /10

Dr.Singh , i believe that leadership is performance and you are failing badly. Time to shape up  !! Good image is not performance !I am not surprised as your team of advisors lack ‘common man’ and internal critiques . You have advisors who are out of touch with reality . Correct this immediately .

As a honest tax payer , it is my duty to seek answers from the people who use our money and run the ministries and as bureaucrats . Every minute you people spend in your office or every inch that you move is funded by money collected as tax from people like us . I need your response

Please respond at your convenience . Should you require any details , feel free to connect . This is an environmental friendly mail and so not sending a hard copy

Best wishes & with warm regards

Rajendra Pratap Gupta

Email : office@rajendragupta.org

Office.rajendra@gmail.com

Cell : +91 9 22 33 44 542