February 07, 2010

Amit Sengupta

WHILE the controversy on genetically modified foods rages in India, very similar issues are being debated in many parts of the world. In India the contention is around the permission sought to be given for introduction of a modified form of Brinjal, called Bt Brinjal. A very similar debate is now raging in Europe, where a genetically modified form of rice is being sought to be introduced by Bayer. At the heart of the debate surrounding genetically modified food, lie several contentious issues. These relate to concerns about safety when GM foods are consumed by humans, the impact on naturally occurring species when GM crops are cultivated on a large scale, and the control of such technologies by giant multinational corporations.


CHANGING NATURE IS NOT A RECENT PHENOMENON
In order to understand the different dimensions of all these issues, we need to understand the technology that goes into the production of genetically modified plants and other living organisms. Humans are unique on this planet in that they are the only species that have developed the capability to actively change the way in which nature works to produce and nurture a large variety of living organisms. Other species also cause changes in nature -- for example grazing animals can change patterns of plant cover, insect populations can predate upon and destroy specific plant species, etc. But only humans are capable of directing changes in nature, with the conscious intent to bring about changes in existing living organisms.

This endeavour by human beings is by no means recent. All the food that we consume is derived from plants and animals that have been changed in particular ways through the method of selective breeding. The early varieties of “wild” maize, wheat and rice that the early humans cultivated, have been transformed by selective breeding into varieties that have desired characteristics. Such characteristics may have to do with better survival of a plant variety in a specific agro-climatic region, better yields, better perceived qualities such as aroma, taste, etc.

Let us for example examine the history of rice cultivation – arguably the most important food grain in the world.  It is believed that rice was first domesticated in the Yangtze river valley about 12,000-11,000 years ago. Domestication followed the earlier practice of collection of the grains of wild rice that grew in the wild. Within a few thousand years, two distinct varieties (known as indica and japonica today) were being cultivated in Central China. From there it is believed to have traveled to South East Asia, and South Asia about 5,000 years ago. Farmers have continued to breed for desired qualities, giving rise to the large variety of rice today, ranging from the sticky rice consumed in Japan to Basmati rice cultivated in India and Pakistan. All of these had their origins in the wild grass that grew more than ten thousand years ago in Central China. Selective breeding has been utilised in the case of a large variety of domesticated animals as well. That is the reason we see such a variety of cattle, horses, dogs, etc. around us. Over a period humans added to their repertoire the process of hybridisation, to produce desired plant varieties. It differed from selective breeding in that new varieties were developed by breeding between two different varieties.

HOW GM TECHNOLOGIES ARE DIFFERENT
The technology of selective breeding and hybridisation is possible because of the way in which living beings are constructed. All living organisms have within their cells, genes, that determine its diverse characteristics. Even within the same species, no two individuals are exactly similar. This is easy to understand if we look around and see how different two human beings can be, even though they are members of the same species. This is also the case with plants and animals. The reason for the differences lie in the genes – while the genes of two individuals in a species are very similar, they are never exact copies. If we remember that a living organism has hundreds of thousands of genes, it is easy to understand that a difference in even a few hundred of them can result in two very different individuals. This is the underlying explanation regarding how selective breeding or hybridisation works. Thus, in a large field of rice, a few plants would grow taller than the others – which means that these plants have genes that make them grow tall. If the farmer were to save the seeds of only these plants and grew them the next season, he would get a larger number of plants that were taller. Over several generations he would have produced a variety that would be taller than the variety he started with. In the case of hybridisation, the farmer would cross two different varieties with characteristics he wants to preserve. He could , for example, cross a variety that is drought resistant with one that provides high yields. The resulting species would have both the desired qualities.

How then are genetically modified varieties different from what has been produced by humans for thousands of years? The perceived need for genetic modification arose from the fact that the techniques discussed above still depend on nature to do most of the work. A farmer can try to select for, say a tall variety of grain, but he is never sure that he will always get a new variety that is better. He may also end up with a taller variety, but that which has other undesirable qualities that he does not want. This uncertainty is related to the thousands and thousands of genes in any variety and the extremely complex way in which they interact and produce the characteristics of an individual. Moreover, the process takes many years, and generations of breeding before a satisfactory new variety is produced. Genetic modification arose as a method of “short circuiting” this process. It also arose in a situation when we now understood much better how genes work, as well as with the development of techniques that can actually change one or a few genes inside a living organism. Techniques for genetic modification, thus, substitute the “mixing of genes” that nature does with actual manipulation of the genes inside a laboratory.

Genetic modification involves the insertion or deletion of genes inside the cell of a living organism. The genes, thus transferred could be derived from the cells of an organism of the same variety – this process is called cisgenesis. Alternatively, the transferred genes could be derived from an entirely different species – this process is called transgenesis. To do this, there are procedures which involve attaching the genes to a virus or physically inserting the extra gene into the cell of the intended host with a very small syringe, or with very small particles fired from a gene gun. Other methods exploit natural forms of gene transfer, such as the ability of Agrobacterium (a naturally occurring bacteria) to transfer genetic material to plants, or that of lentiviruses to transfer genes to animal cells. As we can now see, genetic modification can do what nature can never (or very rarely) do – i.e. transfer the genes of one species into another.

We can understand better how the technology is utilised if we take the case of Bt Brinjal. Bt Brinjal is a modified variety of Brinjal created by the insertion of a gene [Cry 1Ac] from the soil bacterium Bacillus thuringiensis (hence the name Bt) into Brinjal. The gene is inserted into the Brinjal cell using Agrobacterium. The Bt gene makes the Brinjal plant produce a toxin that is harmful to common pests that afflict Brinjal crops, such as the Brinjal Fruit and Shoot Borer (Leucinodes orbonalis) and Fruit Borer (Helicoverpa armigera). The underlying theory is that if the Brinjal plant is protected from common pests in this manner crop yields will be better and the need for insecticides would be reduced. The technology has been developed by the giant agri-biotech multinational corporation – Monsanto. In India the trials on Bt Brinjal have been conducted by Mahyco -- Maharashtra Hybrid Seeds Company. Mahyco is part of a joint venture with Monsanto, through Mahyco-Monsanto Biotech.


SEVERAL CRITICAL CONCERNS
The concern that has been raised regarding introduction of genetically modified varieties in nature relates to the possible impact on natural varieties. Experience now shows that there is no fool proof method of avoiding contamination of naturally occurring varieties with genetic material from genetically modified ones. Once the GM varied is allowed to be cultivated on a large scale, it would eventually, transfer some of its genetic material to natural varieties growing in other fields. This means that, over time, as more and more GM plants are introduced into nature, existing varieties would incorporate their genetic material. This could be a concern if we are not completely sure about the long term harmful effects of an artificially introduced gene, in terms of its long term survival and other characteristics. So, theoretically, an artificially inserted gene may cause the destruction of the entire crop, or may have other harmful ecological effects, for example on insects that help in pollination. As other natural varieties are also likely to be contaminated, there would then be no turning back. One the crop is out in the open and widely cultivated, there is no way of recalling it. This is why very stringent tests, at the stage of development of a GM variety, are necessary, to allay fears that the inserted gene that is set loose on nature will not fundamentally damage nature itself.

Moreover, GM technologies lend themselves to monoculture and erosion of biodiversity. With widespread use of GM plant varieties, huge swathes of land may be taken up for plantations of GM crops. The danger of severe dislocations in food supply, if the variety were to fail, is something that needs to be factored in. Such a danger is a powerful reason to institute steps to protect the diversity of plant varieties that still exist in the planet.

The second concern particularly relates to those GM varieties that are intended for human consumption. For obvious reasons, we need to be cautious that GM plants that are used for food, do not cause harm when ingested by humans. Over thousands of years, humans have leant through experience, which plants are fit for human consumption. Here we seek to compress the process into a short span of a few years. Thus, transparent and clear evidence needs to be produced to show that the new GM variety being introduced does not cause harm to humans when they are introduced. Further, different countries have different ways of dealing with regulations related to GM foods, once they are allowed to be marketed. The United States and Canada do not require labeling of genetically modified foods. However the European Union, Japan, Malaysia and Australia require such labeling so consumers can exercise choice between foods that have genetically modified, conventional or organic origins. This requires a labeling system as well as the reliable separation of GM and non-GM organisms at production level and throughout the whole processing chain.

The difference in approach is evident from the fact that GM crops account for only 0.05 per cent of total area under cultivation in the EU while it constitutes 18 per cent of US agriculture. The US produces 96 per cent of the world’s edible GMOs and is the principal driver of GM foods across the world. The European approach, in a nutshell, is that because we don’t know enough about the technology, long-term assessments of the environmental and health impact are necessary. Clearly, there is no single consensus today on how GM foods are to be used or regulated and many countries leave the choice to individual consumers. In India too, we need to develop our own guidelines based on a public debate.

The third, and perhaps most important concern, relates to the control of GM technologies. Today biotechnology has become the preserve of giant transnational corporations, and they control much of the technology. This holds true for technologies related to genetic modification of plants as well. GM technologies have the potential to transform the vary nature of agriculture, especially in developing countries such as India. Traditionally farmers save seeds from their fields, to be used in the next season. Farmers also share seeds among themselves, using a variety of arrangements. The technology of hybridisation changed many of these practices, as farmers now have to buy hybrid seeds from seed companies or depend on government supplies. GM technologies are poised to add another layer of dependency, where farmers would have to depend on global monopolies such as Monsanto. The scenario of a few giant corporations controlling agriculture across the globe, and deciding who can eat and who shall starve, is to say the least, frightening. The concern is also linked with the manner in which the public funded research system in India is being increasingly made subservient to the needs of private corporations, many of them foreign owned. If India really wishes to take advantage of advances in science and technology they have to be based on local needs and need to be backed up by indigenous efforts at developing our own technologies. A short cut, that is predicated on dependence on transnational corporations, especially in an area such as food, is fraught with obvious dangers.


ON WHOSE SIDE IS THE GOVERNMENT?
The present debate on Bt Brinjal in the country straddles all the major concerns we list above. At the heart of the issue is the fact that there are serious apprehensions that Monsanto and its partner in India have not been transparent in disclosing the findings of their trials related to safety and economic benefits of Bt Brinjal. For good reasons, many are also suspicious of the complicity of the present government in such a non-transparent process, given its public acknowledgment of a pro business mindset. When  Jairam Ramesh laments that the debate on Bt Brinjal has become one between pro and anti technology groups, he is missing the mark completely, perhaps deliberately. The debate is on who controls the technology and on whose side the government is – on the side of the people or on the side of corporations such as Monsanto. 

Amit Sengupta

10th January 2010

FOR over two years the government has made known its intention to introduce a bill in parliament, titled: “Public Funded Research and Development (Protection, Utilisation and Regulation of Intellectual Property) Bill”. The standing committee on science and technology is presently engaged in deliberating over the contents of the bill, and the bill is likely to be introduced in the next session of parliament. As the bill, if enacted, shall have far reaching consequences for scientific research in India, provisions of the bill need to be examined closely.

The genesis of the bill is shrouded in mystery, though there are indications that one major stimulant was a letter written to the government by Sam Pitroda, chairperson of the Knowledge Commission. A perusal of the bill suggests that it has been modeled on the Bayh Dole amendment of 1980 in US Patent law. Let us start with looking at the rationale and objectives of the bill.

In short the bill makes it mandatory, that all forms of IP generated through public funds, be “disclosed”, subsequent to which the recipient of government funding would have the choice to retain ownership of the IP or transfer such ownership to the government. The major impact of the bill would fall on research conducted in government institutions and universities, which are the largest recipients of public funds for research. Those entities who would choose to retain ownership of the IP have the freedom to transfer the IP to private enterprises and they also have the freedom to choose the terms under which such IP would be transferred. Thus a government institute can transfer all rights over an invention to a private enterprise through an exclusive licensing agreement (though it may also enter into an arrangement where the rights conferred are non-exclusive, i.e. it can reserve the right to transfer the IP to other enterprises as well).

RED HERRING OF THE US’S BAYH DOLE AMENDMENT: However, it is important to note, that at present there is no bar on recipients of public funds to obtain protection for IP generated through such funds. This is a significant difference from the situation that existed in the US when the Bayh Dole amendment was enacted in 1980. In the US, at that time, exclusive licenses could not be granted to enterprises, in the case of public funded research. Thus the US enactment was an attempt to circumscribe a legal block to licensing of public funded research to commercial enterprises. No such block exists in India. So much of the rhetoric of the bill being modeled on the Bayh Dole amendment in the US is an absolute red herring!

There is another way in which the present bill differs from the US Bayh Dole amendment. The latter pertains only to invention, which means it seeks IP protection through patenting. The Indian bill seeks protection of all forms of IP, including copyrights and designs! Curiously, the provisions of the bill make no sense when applied to copyrights. There are indications that the decision to go beyond patents, unlike in the US, was influenced by pressure from Microsoft!

PUBLIC DOMAIN SCIENCE TO PRIVATE MONOPOLY OVER KNOWLEDGE: The most important departure that the bill seeks from present practice, is to make it mandatory to disclose and subsequently register all advances in research as “Intellectual Property”. The bill is thus an encouragement to universities and government research institutions to patent all forms of research and subsequently to pass on the patents to private enterprises. The introduction of onerous mandatory provisions in the bill, shifts the balance as regards disclosure of research findings, from largely being in the public domain to largely being under IP protection.

This is not a minor departure because it incorporates not just an administrative step, but also a deeply ideological understanding of how innovation is to be promoted and how such innovation can be used for public interest. The first important premise of the bill is the argument that unless research is protected through protection of Intellectual Property, it cannot be used for “public good”.

Such an understanding is reflected in the preamble, where the bill is described as: “A Bill to organise, promote, and regulate the public availability of Intellectual Property originating from government funded research and development.” The preamble further states that the proposed legislation, “promotes collaboration between government, private enterprises and non-government organisations; promotes commercialisation of IP generated out of government funded R&D and promotes the culture of innovation in the country”. Thus, the bill is premised on an understanding that “public availability” of the fruits government funded R&D is best ensured through “protection of Intellectual Property”, by “commercialisation of IP” and through “collaboration with private enterprises”. These are the major operative elements of the proposed bill.

FLAWED UNDERSTANDING OF THE RESEARCH CYCLE: Unfortunately the premise is deeply flawed as it is located in an erroneous understanding of how research is done, how research is utilised and how research results in public goods. When scientists conduct research, they are not concerned with the IP that is generated at every step. This is so because the claim of Intellectual Property is a claim to an exclusive right and has to be based on proof that the research is entirely innovative, that it is not the product of already existing facts. The dividing line between true innovation, that produces something entirely new, and research that builds on known facts is often blurred, especially in situations where emerging disciplines of scientific research involve collaboration between different streams in the sciences.

Moreover, such constant urgency to identify what can be patented actually constrains rather than promote research. Most research that produces important results starts as a branching tree, with each twig giving rise to new ideas, and finally one or more of the branches bear fruit! Patenting at every step prevents others from building on ideas generated, and thus one can end up with a long stem with one patent, rather than a full grown tree of ideas with several novel products. Thus for example when attempting to find a new drug that treats Tuberculosis, different research teams can approach the problem from different ends. One team may try to locate a weakness in the cell of the bacteria while another tries to identify compounds that exploit the weakness and kill the bacteria. If each team were to patent, we may end up with two very good patents, but no final product as the two would not have collaborated. This problem is most prominent in the case of “upstream” research, that results in development of tools for further research of different kinds or “platforms” on which future research can build on. Rather than promote commercialisation, patents on basic research platforms constitute a veritable tax on commercialization.

Compulsive patents also lead to the generation of what are known as “patent thickets”, that is registration of a large number of patents that restricts others from approaching a problem by surrounding the core of the problem with patents.

These are some of the real pitfalls of a research system that is designed to patent at every step – a system that the bill seeks to promote aggressively. The bill, thus, clearly falls into the trap of believing that patenting aggressively will lead to better utilisation of research.

Further, by making it mandatory to patent, the bill places onerous responsibilities on both researchers and research institutions. Researchers could well be bogged down constantly by the need to file and then maintain patents. Filing a patent is really the first small step in IP management. The much larger, cumbersome and expensive part is to face off challenges to the patents, especially if the patents are to be filed in foreign locations as well. The bill also talks about making it mandatory for all institutions and universities who receive public funds for research to set up IP management cells. The sum of this entire exercise could well be that scientists and scientific institutions spend a major share of their time in filing and managing patents, rather than in doing actual research!

KNOWLEDGE TRANSFER NEED NOT BE MONOPOLY CONTROL: A second premise of the bill is that in order for research products to be commercialised, enterprises need to be given exclusive monopoly right over that product. If this were not so, rather than the cumbersome process of patenting, placing in public domain research findings should suffice in promoting uptake of research by commercial enterprises. In fact, the conventional wisdom as regards public funded science has been that the fruits of such research should be placed in the public domain, so as to promote public goods. Public institutions were seen as repositories of knowledge, and technology transfer arrangements with enterprises led to the dissemination of that knowledge. The IP based system of knowledge transfer seeks to change this model into one where the balance shifts to private monopolies, who not only commercialise the products of research but also have monopoly control over the products. The impact this has had on medicine prices, and the consequence for millions of people who desperately need life saving medicines, is too well documented to repeat here. Importantly, there is no evidence that the IP based system actually leads to more innovation and better and larger number of useful products. The TRIPS agreement in 1995 was an attempt to create a global system that would make it easier for drug companies to patent, and thus hold monopoly rights. Fifteen years since the TRIPS agreement, the evidence suggests that this has not led to any increase in innovation or the uptake of research. In fact the number of really innovative medicines introduced in the market have declined over the past decade and a half.

INCENTIVISE RESEARCH THROUGH ADEQUATE GUIDELINES: The third premise behind the bill is that it shall provide incentives to researchers to innovate. Thus the bill has provisions that specify the percent of income that accrues to a university or institution through licensing research products to enterprises that would be transferred to researchers. It should be understood that most public institutions have rules which specify just this. If the intent is to incentivise innovation, there is no need to legislate regarding this. Instead the government can frame appropriate guidelines to be followed by all public institutions.

MIRAGE OF EXTRA RESOURCES: A fourth premise is that licensing of research products to commercial enterprises would be a lucrative additional source of revenue for public funded institutions. Evidence in this regard from the US after the enactment of the Bayh Dole amendment in 1980, similar to the proposed bill, actually suggests something which is surprisingly different. In 2006, US universities, hospitals, and research institutions derived US$1.85 billion from technology licensing compared to US$43.58 billion from federal, state, and industry funders that same year, which accounts for less than five per cent of total academic research dollars. Moreover, revenues were highly concentrated at a few successful universities that patented “blockbuster” inventions. In the case of an overwhelming majority of institutions, the cost of IP management was marginally less than the revenues generated, i.e. they barely broke even (Anthony D So et al, Is Bayh-Dole Good for Developing Countries? Lessons from the US Experience, Plos Biology.)

SCANDALOUS MOVE: The manner in which the bill is being pushed by the government is nothing short of a scandal. For a piece of legislation that could have such far reaching repercussions on the way scientific research is done in the country, there has not been any attempt to build a consensus. The scientific community is, largely, blissfully ignorant of how the bill can transform them from scientists to IP managers! Parliament must reject the enactment of this legislation. Moreover it is the task of all democratic forces in research institutions and universities to conduct a campaign to explain about the dangers that loom ahead in the shape of this Tughlak like attempt to restructure Indian science.

Amit Sengupta
3rd January 2010

A PUBLIC document of the National Rural Health Mission (NRHM) of Rajasthan, still available on its website, pays glowing tributes to a gentleman by the name of Ramalinga Raju. It says: “Ramalinga Raju is founder & chairman of Satyam Computer Services Ltd. Satyam is one of India’s premier IT companies with a global presence, providing solutions to over 300 multinationals of which over 100 are Fortune 500 companies. An MBA from Ohio University and a participant in the Owner/President program at Harvard. EMRI, Satyam Foundation and the Byrraju Foundation are a manifestation of his strong sense of commitment to society. Mr. Ramalinga Raju strongly believes emergency management in India can achieve global standards only through the judicious application of Knowledge and Technology and a strong leadership”.

Not surprising, given that the former CEO’s most prominent “charity”, known as the Emergency Management Research Institute (EMRI), was the much flaunted poster boy for the National Rural Health Mission (NRHM). From the mandarins in the corridors of Nirman Bhawan to state NRHM officials, everybody was eager to hold up EMRI as an example of the Brave New Path that the health sector in India was being primed to travel on. A path that was paved with “Public Private Partnership” (PPPs) – the new clothes that the government had  ordered to cover the frail and decaying body of the public health infrastructure in India.

EMRI: ALL THAT IS WRONG WITH PPPs: EMRI is a classic example of all that is wrong with PPPs in the health sector. Given that it was projected as one of the principal success stories by the health ministry, a closer look at its modus operandi is clearly indicated.

Emergency Management Response Institute (EMRI), is one of the four 'non-profit' organisations run by the Rajus. When the storm broke, EMRI thought it could weather the crisis by cleaning up its website and deleting nearly all references to the former chairman of Satyam Computer Services. It hasn't been enough to insulate EMRI from allegations of a Rs 7,000-crore scam.

The emergency ambulance service, is modeled on the 911 service provided in the US during medical emergencies. EMRI's story began on August 15, 2005, with 30 ambulances deployed to cover 50 towns in Andhra Pradesh. Today EMRI owns 1500 ambulances and employs 12,000 people. The AP government chipped in with 95 per cent of the cost of running the service, or a whopping Rs 1,12,000 an ambulance per month, while EMRI bore only 5 per cent, funded mostly by the Rajus.

Also, as EMRI grew, it began to cost the public exchequer a lot more than earlier services. In AP, the cost per ambulance per month rose from Rs 14,000 to Rs  1,12,000 in less than two years. TN already had an ambulance service at Rs 10,000 an ambulance per month using World Bank funds under the national rural health scheme. This was scrapped by a government order and EMRI's lakh plus per month services ushered in. EMRI claims that it operates in eight states — Assam, Gujarat, Karnataka, Andhra Pradesh, Tamilnadu, Goa, Maharashtra and Orissa; though the Maharashtra government is believed to have put its contract on hold after the filing of a Public Interest Litigation on the way EMRI contracts were awarded.

PIL AGAINST CONTRACTS TO EMRI: The PIL was filed by two NGOs – Ambulance Access Foundation India (AAFI) and Transparency in Contracts (TIC) – in 2008, a few months before the Satyam scam came to light. The PIL argues that contracts were awarded by state governments to EMRI without proper tendering, while in some cases the tender documents were tailored to favour EMRI.

The PIL claims that EMRI, which was registered in 2005, became the nodal agency for the Andhra Pradesh government for ambulance services, without having had any prior experience of running an ambulance service. The Rajasthan government, it is claimed in the PIL, issued a tender which set the eligibility criteria for potential bidders as follows: a turnover of Rs 5 crore, a fleet of 200 ambulances, and a contract from one Indian state. It meant that only EMRI was eligible to bid. After EMRI was awarded the contract in Rajasthan, Tamilnadu followed with tender specifications that asked for: a turnover Rs 25 crore, a minimum of 400 ambulances and two contracts from Indian states. Again, only EMRI was eligible to bid!

Counsel for the petitioners, Rajeev Dhavan, has also alleged that “EMRI is all set to withdraw an estimated amount of Rs 3,800 crore from public funds and get control and possession of approximately 500 acres of prime government land in state capitals and leading cities valued at Rs 1,800 crore”.

The Supreme Court, in a recent order has said that it will give its final opinion on the PIL in February, 2010. A bench headed by Chief Justice of India, K G Balakrishnan, on Monday had earlier sought replies from the Centre, 12 states and EMRI.

While the matter regarding the existence of mala fide procedures in awarding contracts to EMRI will be opined on by the Supreme Court, some very serious issues need to be taken note of. The EMRI “model” has been one of the most discussed examples of “success” stories of Public Private Partnerships. In fact, the first common review mission of the National Rural Health Mission had noted this as one of the two successful public private partnerships worth replicating.

PUBLIC MONEY TO CREATE PRIVATE INFRASTRUCTURE: Let us first examine what is “public” and what is “private” in the EMRI “model”. From all accounts, 95 per cent of funds for the EMRI scheme are being provided by the state government, with EMRI bearing just five per cent of the cost. Thus while EMRI functions with the help of massive budgetary support from state governments, the top management of this "non-profit" organisation, it is understood, draw huge remuneration packages, with some individuals drawing annual pay and perks worth a crore! It is understood that Satyam created the software that is bundled with EMRI’s services, as part of its Corporate Social Responsibility. At the same time this is “sold” to states at a reported cost of Rs 10 crore.

Thus, clearly, public money is spent to create a privately managed infrastructure. This is the new model of “public private partnerships” that are being promoted. The argument in favour is seductive. It is argued that since the state does not have money to build new infrastructure, it is a “win-win” situation for everybody if through such partnerships, private infrastructure is utilised to provide public services. Such an argument, by an ingenious sleight of hand, inverts the real debate.

The real debate is two-fold. First, is there any long term saving of public money when such partnerships are promoted. Second, is it a given fact that the state cannot find resources to build infrastructure that is publicly owned and managed.

As we have seen earlier, an overwhelming portion of EMRI’s finances come from public coffers. What, then, prevents the government from creating infrastructure that it not only finances but also owns. The way we examine schemes such as the EMRI is inherently flawed. After decades of neglect, health care infrastructure lies in shambles in most parts of the country. We then turn around and say that the EMRI scheme is actually able to deliver services, unlike the situation that existed earlier. It is true that the EMRI, in many places, is an improvement over existing facilities for emergency medical care and ambulance services. But the right question to ask is: if the same amount of public money was spent in strengthening the public system, would there have been larger long term benefits. Such a question will not even be posed today because those at the helm have lost all faith in the ability of public systems to deliver (not just in the case of health care -- we see this happening in all fields of public utilities such as water, electricity, and even in the education sector).

INFRASTRUCTURE BY THE STATE: Let us now turn to the issue of the State’s ability to fund infrastructure creation in the health sector. This goes beyond ambulance services, and extends to in-patient and out-patient care, including hospital services. The argument used is that a bulk of infrastructure in the health sector is today privately managed and a majority of people access health services from the private sector. Thus, make a virtue out of necessity by not spending money to create public infrastructure, and by utilising privately owned and managed infrastructure for provision of public services. This is the model that is being promoted through the recently announced Rajiv Gandhi Swasthya Bima Yojana (RSBY) and in several state level schemes. To buttress the arguments in favour of such models, examples are used of other countries such as UK, Brazil, Germany, etc. where the government reimburses for care provided through private providers. So the role of provisioning is sought to be separated from that of financing.

The argument is flawed at two levels. Brazil, UK, Germany, etc. are examples of countries with clustering of population in urban centres -- thus creating a situation where private facilities exist in large numbers in areas where the bulk of the population resides. What are the private facilities we are talking about in India in large parts of rural India except for what are euphemistically known as RMPs (Registered Medical Practioners), and which are really untrained quacks. Public Private Partnerships in health service delivery in India, thus would translate into strengthening of the private sector by the utilisation of public funds. We have already seen this happening with the liberalisation of norms for reimbursement for the Central Government Health Scheme (CGHS). On one hand the public infrastructure of hospitals and dispensaries have been dismantled, and on the other, CGHS beneficiaries are encouraged to seek treatment in private institutions, for which the latter are reimbursed with public funds. This is the logic of neo-liberal economics – public subsidy to strengthen the private sector.

The argument is also flawed if we look at examples of many countries around us – and not just at some selected examples, as the votaries of neo-liberal reforms would want us to. In Sri Lanka, for example, even while neo-liberal policies are diluting the public thrust of Sri Lanka's health system, 90 per cent of in-patient care is provided by public facilities (and 50 per cent of out-patient care). Sri Lanka spends about 2.0 per cent of GDP on public health -- similar to the 2 per cent  which even this government accepts is to be aspired for (including in the Eleventh Five Year Plan). Malaysia is again a similar example. Their system is under even more severe strain from neo-liberal votaries, but public provisioning is still the norm and not the exception (with 2.2 per cent of GDP spent on Public Health). Thailand has received accolades for extending coverage to almost its entire population in a relatively short span of less than a decade. In Thailand approximately 75 per cent of hospital beds are in the public sector. There are several other examples of predominantly public provisioning – Cuba, Iran, Chile, Costa Rica, etc. Unfortunately, these examples are never talked of when health administrators in India talk about the merits of the private sector provisioning of health care.

SHORT TERM SOLUTIONS NOT A PANACEA: In the short term, it may be necessary to create arrangements where private facilities are utilised to provide public health services. This, however, can never be a long term solution or a panacea. In the long term, there is no alternative to creating public infrastructure in a country like India. But for that to happen, it is necessary that health administrators are not completely seduced by the perceived virtues of public private partnerships. It needs to be understood that a for-profit private sector – increasingly corporate managed and controlled as in India – cannot be relied upon as the solution to provisioning of public goods such as health care.