AJPA Vol 10 Issue 2 2018

Volume 10 | Issue 2 | 2018

ISSN 1793-5342

Asian Journal of

Public Affairs CONTENTS Editor’s Note Kidjie Ian Cordova Saguin Research Articles When Health Prevails Trade? Regime Complexes and Shifting Strategies in Thailand’s Medicine Compulsory Licenses Benjamas Nillsuwan Progress Tracking of Health-Related SDGs: Challenges and Opportunities for India Shalini Rudra and Oommen C. Kurian Commentaries Anxiety Politics in Singapore: The ’Koro Crisis’ of 1967 Max Everest-Phillips Innovation for Human Well-Being and Security: Perspectives from the Next Generation of Global Health Leaders Gianna Gayle Herrera Amul, Fiona Leh Hoon Chuah and the Raffles Fellows

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On the Ways of Knowing and Understanding Informality 71 Deepanshu Mohan, Richa Sekhani and Arun Kumar Kaushik Climate Change - A Way Forward Venu Gopal Mothkoor

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Asian Journal of

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GLOBAL PUBLIC POLICY NETWORK

Asian Journal of Public Affairs

The Global Public Policy Network (GPPN) is a partnership between Columbia University (USA), Fundacao Getulio Vargas-EAESP (Brazil), University of Tokyo (Japan), Hertie School of Governance (Germany), Lee Kuan Yew School of Public Policy (Singapore), Institute of Public Affairs at LSE (UK) and Sciences Po, Paris (France). The GPPN is global in two ways: the global spread of its members and its subject focus on emerging global trends in public policy.

Vision The Asian Journal of Public Affairs (AJPA) seeks to be the choice journal for scholars and practitioners interested in public affairs in the Asia-Pacific region. The journal endeavours to become the leading intellectual voice on Asia.

Mission The Asian Journal of Public Affairs (AJPA) publishes policy-relevant research written by and for scholars and practitioners around the world who are interested in the Asia-Pacific region. The journal encourages both young and senior scholars and practitioners to reflect on and study the Asian public sphere from an interdisciplinary lens.

The mission of GPPN is to address the most pressing public policy challenges of the 21st century and, as a result, to have policy impact, to be influential in public policy education and training, and to be innovative in teaching and research. For further information please visit www.gppn.net.

CALL FOR PAPERS The Asian Journal of Public Affairs accepts manuscripts of original research articles (6,000-7,000 words excluding abstract and bibliography), book reviews (multiple or single), and commentaries (1,500 words maximum). Contributions are accepted on a rolling basis. Please email your manuscripts to our email address (ajpa@nus.edu.sg). Citations must follow the Chicago Manual of Style. Please refer to “Author Guidelines� on our website for more details.

Should you need more information, please feel free to contact the Editorial Board or visit our website. Please also subscribe to Asian Journal of Public Affairs on our website to receive newsletters.

Aims and Scope of Journal The Asian Journal of Public Affairs (AJPA) is the flagship student journal of the Lee Kuan Yew School of Public Policy (LKYSPP). It is a peer-reviewed publication featuring articles by scholars and practitioners on public affairs issues in the Greater Asia including the Middle East, Central and South Asia, and the Asia-Pacific region. Published on a bi-annual basis, AJPA seeks to influence public policy-making in Asia through interdisciplinary policy-relevant research. Print circulation is targeted not only to academic audiences but also to civil society and government organizations.

The scope of Public Affairs includes, but is not limited to, Public Policy (including sectoral policies), Public Administration and Management, International Security, International Political Economy, Social and Political Sciences and Economics. Each issue features scholarly and practitioner-based research articles, field reports, commentaries, and book reviews. Articles may be quantitative and/ or qualitative, national or cross-national. Preference is given to contributions which have accessible and clearly articulated policy implications.

Asian Journal of Public Affairs EDITORIAL TEAM

ACKNOWLEDGMENTS

Editor-in-Chief Kidjie Saguin

School Advisory Board Professor Michael Howlett Associate Professor Eduardo Araral Jr. Professor Mukul Asher Dr. Suzaina Kadir Associate Professor Zeger van der Wal

Deputy Editors-in-Chief Si Ying Tan Nihit Goyal Managing Editor Libby Morgan Beri Issue Editors Nisha Francine Rajoo Maitreyee Mukherjee Anastasia Rogacheva Akanksha Sinha Prasanna Vishwanatha Salian Senior Editors Nisha Francine Rajoo Tham Zhi Khang, Jansen Editors Shruti Singh Isha Dayal Monnaphat Jongdeepaisal Raiya Kishwar Ashraf Carlos C. Sengu Mergen Dyussenov Janani Balasubramaniam Apala Bhattacharya

International Advisory Board Professor Frances Berry Professor Evan Berman Professor Takashi Inoguchi Professor Qingguo Jia Professor Yijia Jing Professor Jun Ki Kim Professor James Perry Professor Alasdair S. Roberts Professor Allan Rosenbaum Professor Diane Stone Professor RenĂŠ Torenvlied Professor Kaifeng Yang Professor Yang Zhong Professor Amitav Acharya Print Markono Print Media Pte Ltd

ASIAN JOURNAL OF PUBLIC AFFAIRS Volume 10

Issue 2

2018

CONTENTS Editor’s Note Kidjie Ian Cordova Saguin

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Research Articles When Health Prevails Trade? Regime Complexes and Shifting Strategies in 03 Thailand’s Medicine Compulsory Licenses Benjamas Nillsuwan Progress Tracking of Health-Related SDGs: Challenges and Opportunities for India Shalini Rudra and Oommen C. Kurian Commentaries Anxiety Politics in Singapore: The ’Koro Crisis’ of 1967 Max Everest-Phillips Innovation for Human Well-Being and Security: Perspectives from the Next Generation of Global Health Leaders Gianna Gayle Herrera Amul, Fiona Leh Hoon Chuah and the Raffles Fellows

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On the Ways of Knowing and Understanding Informality 71 Deepanshu Mohan, Richa Sekhani and Arun Kumar Kaushik Climate Change - A Way Forward Venu Gopal Mothkoor

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Note from the Editor

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NOTE FROM THE EDITOR Kidjie Ian Cordova Saguin Dear Readers, This year, the Asian Journal of Public Affairs is celebrating its tenth-year anniversary as the flagship journal of the Lee Kuan Yew School of Public Policy. Its publications of over 50 intellectual pieces from five continents serve as a testament that Asian public policy is truly of global concern. Drawing from policy successes and failures, past issues have distilled essential lessons the world can learn from Asia. This issue continues the tradition of acting as a conduit between theory and practice, with our contributors examining a wide range of international and domestic issues within the region, from which three broad important themes emerge.

First, Asia continues to be a policy lab for observing how international norms and domestic issues interact. Domestic policy-making affects the design and implementation of these norms. The research article by Benjamas Nillsuwan examines the underlying processes that allow domestic actors involved in compulsory licensing of medicines in Thailand to further their agenda through international regime shifting strategies. Within the framework of the Sustainable Development Goals, Shalini Rudra and Oommen C. Kurian evaluate India’s current data ecosystem relevant to health and nutrition and concede that the Indian government is confronted by inconsistent and incomplete data. The achievement of these international commitments hinges on the ability of the government to use existing data collection methods like household surveys and to tweak existing data for as proxy indicators.

Second, concepts used in the policy-making need a major re-thinking as they are applied in the context of Asia. The commentary by Deepanshu Mohan, Richa Sekhani, and Arun Kumar Kaushik serves as the call-to-action for governments to move away from the dichotomous treatment of formality and informality, an issue prevalent in much of the developing world. The authors point to the importance of acknowledging the interdependence between both segments of the economy as a critical first step in moving towards a more inclusive urban planning. Venu Gopal Mothkoor elaborates on the false claims of climate change denialists to bring to surface the role of environmental capital in sustainable economic growth. Ultimately, Mothkoor argues to adopt consensus building and promoting voluntary action as the core approaches in coming up with solutions to climate change.

Third, an Asian perspective provides insight in how to successfully confront multidimensional policy issues. The Raffles Fellows, led by Gianna Gayle Herrara Amul and

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Fiona Leh Hoon Chuah, suggest that efforts to innovate on the areas of human wellbeing and security should not only address inter-generational policy challenges but should also be engaging, equitable, and transparent. The diversity of experiences in Asia on experimenting with innovative solutions can also offer lessons for the rest of the World. Similarly, Max Everest-Phillips of the UNDP Global Centre for Public Service Excellence also offers insights for governments around the world contending with “anxiety politics” using the case of the “Koro” epidemic in Singapore. Everest-Phillips highlights the importance of political trust and administrative coordination in these uncertain times.

Even as AJPA celebrates its tenth-year anniversary, there is more work to be done in fostering a vibrant intellectualism on Asian public affairs. The Asia-Pacific region is host to a plethora of problems and innovative solutions that are yet to be documented, analysed and evaluated. On-going debates on the “rise of Asia” and the “Asian century” are indicative of an intellectual niche that AJPA is most suited to serve. These developments present challenges and opportunities for the AJPA editorial team and its advisory boards to take on with enthusiasm in the decades to come.

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RESEARCH ARTICLE

When Health Prevails Trade? Regime Complexes and Shifting Strategies in Thailand’s Medicine Compulsory Licenses Benjamas Nillsuwan1 ABSTRACT This paper explores the three concepts of regime complexes, regime-shifting and forum shopping in the literature from the political and international relations domain and examines the extent to which they can Keywords: Regime complexes, regime-shifting, explain interactions among actors in a global governance, IP politics, Thailand complicated set of international rules and Suggested Article Citation: Nillsuwan, obligations. This paper will investigate Benjamas. 2018. “When Health Prevails Trade? the case of Thailand’s handling of the Regime Complexes and Shifting Strategies in expansion of the intellectual property Thailand’s Medicine Compulsory Licenses” rights (IPR) regime into the country’s Asian Journal of Public Affairs 10(2): p. 3-23. policy space, where there were confusions about the legitimacy of issuing http://dx.doi.org/10.18003/ajpa.20183 compulsory licenses (CLs) for patented HIV/AIDS and cancer drugs in 2006-2008.

ISSN 1793-5342 (print); ISSN 2382-6134 The strategy of regime-shifting employed (online), © The Author 2018. Published by by actors in Thailand’s process to issue Lee Kuan Yew School of Public Policy, National CLs for medicine is discussed. The case University of Singapore of Thailand shows that the IPR regime complexes affected public health policy processes in a way that allowed multiple actors advocating access to medicines to use regime-shifting strategies to seek approval and endorsement from both international and domestic supporters for medicine compulsory licenses.

INTRODUCTION The Doha Declaration on the Trade Related-Aspects of Intellectual Property Rights Agreement (TRIPS) and Public Health in 2001 declared that the World Trade Organization (WTO) member states recognized global public health problems and PhD Candidate, Department of International Cooperation Studies, Graduate School of International Development, Nagoya University.

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the effects of intellectual property rights (IPR) protection on medicine prices.2 The Declaration states that the TRIPS Agreement should be interpreted and implemented in a manner that supports WTO members’ right to protect public health and, in particular, promotes access to medicine for all. On CLs, the Declaration makes it clear that each member state is free to determine the standards by which the licenses are granted. However, on closer inspection, political pressure on governments appeared and confusion with regard to CLs under WTO rules is a hot topic in the media several years after the Declaration.

Thailand is among the many countries debating whether medicine CLs should be considered an appropriate policy tool to achieve public health goals. Thailand’s experience in issuing medicine CLs illuminates how the country responded to and interacted with the complicated global IPR rules. Thailand’s case is the focus of this paper for four distinct reasons. First, after the Doha Declaration in 2001, Thailand became the most active user of medicine CLs. Second, Thailand’s decision to override those medical patents from foreign patent holders was controversial in international media. In contrast, the overall national perception of the government’s decision was the opposite. The pro-access effort, mainly led by the Ministry of Public Health, obtained high moral respect from the public, while some major drug multinational companies faced public scrutiny and their products were boycotted from local medicine. Third, after the CLs, the Thai government was not brought to the WTO dispute settlement mechanism and lawsuits were not brought against the government. However, despite reference to the Doha Declaration, international political constraints led to the exceptional effort of the government and supporters to promote better access to medicines. This paradox provides a warning about how policy makers should decide to use CLs in the future. And fourth, despite an unclear view of Thailand’s level of IPR protection, Thailand’s IPR system is well established and endorsed for general trade and investment. The country has been increasingly equipped with IPR protection laws and measures, but in the case of life-saving medicines, it turned out that arguments for trade and innovation protection were unconvincing. These contradictions and conditions in Thailand brought about a puzzle that this paper attempts to answer: how did the actors respond to the contested and complicated IPR regime in Thailand’s medicine CLs case?

Part II of this article reviews the literature on three concepts: regime complexes, regime-shifting, and forum shopping in political science and international relations (IR). It explores the emerging debates about these concepts relating to global governance and the competing implications of these ideas. Following this is Part III, which discusses the battle over medicine patents in the context of the global IPR and health regime. Part IV then examines the regime-shifting behavior of actors in global IPR governance through the conflicts about the patents for severe diseases and CLs in Thailand. The article concludes by offering two points regarding these concepts and policy implications from the Thai case study.

Paragraph 1 and 3 of the Doha Declaration on TRIPS and Public Health, adopted at the Fourth Ministerial Conference in Doha, Qatar, on 14 November 2001. Available at https://www.wto.org/english/thewto_e/ minist_e/min01_e/mindecl_trips_e.htm.

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Global governance studies and IR have paid increasing attention to the concept of ‘multilevel governance,’ which involves regime-shifting and forum shopping, or venue shopping, tactics. Scholars have started to examine how state and non-state actors respond to the international regime when they encounter extreme difficulties or impasse on highly contested issues that involve multilateral cooperation. Scholars have studied international cooperation by considering international regimes (Keohane and Nye 1977; Bull 1977; Krasner 1982; Young 1982). International regimes and institutions can be stronger or weaker according to the coherence of principles, norms, rules and decision-making procedures with actual practice (Krasner 1982).

Several international regimes or conventions for a specific issue are the venues where states interact. What scholars seek to understand about international regimes is the following: given that it becomes complicated when actors encounter highly contested points of cooperation, in what ways do state and non-state actors respond to the international regime governing controversial issues? In essence, it is the question of how to live with the global rules that dissenting state and non-state actors may find they cannot alter or revoke.

Cooperation in global trade governance, in particular, the IPR regime in regard to medicine patents, has been challenging for policy-makers in developing countries.

This is due to the highly combative character of the IP protection regime itself, and the need for better access to life-saving medicines for severe diseases such as HIV/ AIDS and cancer. For this reason, regime complexes and regime/forum shopping are the focus of this research article. The consequences of complexity may be beneficial or harmful to successful cooperation in any international regime. Therefore, this paper will test whether IPR regime complexes yield favorable outcomes for national public health interests and whether and how the key stakeholders have adopted the practice of regime-shifting or forum shopping in such events.

METHODOLOGY

This paper uses analysis tools offered by international regime studies to understand the behavior and participation of actors involved in medicine CLs disputes in Thailand. The theoretical frameworks are provided in the literature review and analyze to what extent the behavior of actors, both state and non-state, can be explained.

Official documents issued by the Thai government and various online sources were analyzed to capture the complexity of the case study. The empirical data in this research are derived from observations of national discussions, of professional seminars, and meetings held by IP experts, public health bureaucrats and non-governmental organizations in the Thai language. In addition, in-depth interviews with national pharmaceutical-related officer and legal officers in IP-related units were conducted in Thailand during January-March 2017. The interviews were conducted on a one-byone basis to ensure privacy, were semi-informal and conducted in a conversational manner, and were anonymous and confidential. Before the interviews, respondents were informed about the objectives of the research and were encouraged to respond freely. The responses were written down as notes and transcribed by the author. It Asian Journal of Public Affairs | 2018

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should be noted that the weakness of the research might be that the researcher could not interview the already retired public health officers of the highest ranking who were involved in the final decision of CLs issuance.

THEORETICAL FRAMEWORKS Regime complexes

Cooperation studies in IR in the 1980s started to pay attention to the complex nature of international regimes, which have since become increasingly complicated or highly technical sets or clusters of international rules. When faced with new problems, states may expand the scope of existing regimes, create a new one, or adjust any working institutions to better serve their changing purposes (Stein 2008). Scholars have recognized that in many areas, plural institutions are nested or overlap, and are increasingly complex (Aggarwal 1998, Raustiala and Victor 2004; Alter and Meunier 2009). Such phenomenon refers to several connected, intersected and parallel international regimes existing without clear hierarchy among them.

Morin and Orsini (2013) note that regimes tend to become more crowded over time because there are several negotiations or means of implementation to cope with tensions that occur within the regime. For example, the international regime complex for biodiversity protection includes regimes on endangered species, migratory species, wetlands, and whaling. Regime complexes are driven by internal tension among different principles, norms, rules, and procedures across multiple elemental regimes (Morin and Orsini 2013). Scholars have studied various regimes such as the WTO and preferential trade agreements (Davis 2009); the European international trade regime (HalfnerBurton 2009); international security (Hofmann 2009); the refugee regime (Betts 2009); election monitoring regime (Kelly 2009); plant genetic resources (Raustiala and Victor 2004); global labor standards; IP; and international chemical regulations regime (Murphy and Kellow 2013). Different indicators of complexity are identified (such as overlapping mandates, multiple institutions, and overlapping rules). The studies reveal that there can be potential positive and negative consequences of such regime complexity, which implies both opportunities and weaknesses of global governance.

For the intellectual property rights system, scholars observed that it is built up with congested links and connections among treaties, international organizations, as well as multilateral, regional and bilateral negotiating venues. The TRIPS Agreement of the WTO is one of the most renowned for its deep connection to many multilateral treaties.

Intellectual property rules also appear in other international institutions, such as the Conference of the Parties to the Convention on Biological Diversity (CBD), the World Health Organization (WHO), the World Intellectual Property Organization (WIPO), and the Food and Agriculture Organization (FAO) (Helfer 2009). Helfer examined the effects of the denser policy space and relocation of rulemaking in the IPR system and noted it as favorable for developing countries in the WTO. In particular, several institutions relating to the rules of IP protection may allow developing counties that are members of the WTO to have better chances to advance their policy aims or agenda. Whether the complexes of the IPR regime offer positive opportunities to actors to move to other regimes, will be examined in the case of Thailand later in this paper.

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Regime-shifting

Scholars have illuminated the strategies that state and non-state actors use to obtain some opportunities from the complexity of the international regime and that thus enables them to utilize ‘regime-shifting’ and ‘forum shopping’ strategies. Helfer explains ‘regime-shifting’ as actors’ behavior of turning to other regimes with different priorities in an effort to restructure or change the global rules or set of standards in the first regime. Regime-shifting helps broaden policy spaces for states and non-state actors to make decisions and adopt rules that can expand their interests and agendas.

It also offers opportunities for powerful and weaker countries and their supporters to transfer their policy goals or rulemaking institutions to the international working forum for any other issues. Examples include: public health, biodiversity, environment, foreign investment, and human rights (Helfer 2004; 2009).

The forum-shifting concept implies the unceasing continuity of negotiations on complicated issues. Strong states may also shift forums to enhance their power and gains, or to reduce opposition (Drahos 2007). In the process of regime-shifting, some scholars differentiated that actors can attempt both horizontal shifting and vertical shifting (Drahos 2007; Sell 2010). Shifting horizontally occurs when state actors decide to move from a former core organization to another newly established organization for negotiation. Shifting vertically describes when state actors seek official agreements on other levels, such as from the multilateral level to the bilateral or regional agreements, with higher or stricter rules or standards on an issue. With the newer sets of rules and standards on another level, powerful actors can avoid deadlocks or obstacles in the old level of negotiations and more easily influence agreements from weaker state partners to adopt such new rules they desire on the issue (Sell 2010).

Alter and Meunier also spoke of ‘strategic inconsistency.’ Like ‘regime-shifting,’ both are what they call ‘cross-institutional political strategies.’ This is when actors generate incoherent or irrelevant rules in another existing regime with the aim of challenging a rule in the initial agreement. Thus, they can broaden the possibility to select which rules or interpretations to follow (Alter and Meunier 2009). Oran Young, a distinguished regime theorist, also noted that when actors want to change any fundamental rules, they may form a new regime with hopes to initiate and diffuse the trends from one issue area to another (Young 1996; Murphy and Kellow 2013) Much of the literature has identified certain incentives for actors to execute regime-shifting, horizontal and vertical shifting, and the creation of strategic inconsistencies. This paper will adopt these concepts to examine regime-shifting by actors in the empirical case of Thailand’s CLs dispute in Part IV. Forum/venue shopping

The importance of a practice called ‘forum shopping’ has been highlighted by legal scholars, who posit that it is vital to any litigation strategy, including litigations in IR (Busch 2007). Furthermore, a study on international trade policy-making on the multilateral (such as WTO) and regional level (preferential trade agreements) suggested that moving around to those forums are forms of forum shopping or the forum choices which non-state actors select (Pérez-Esteve 2010).

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Also known as venue shopping, forum shopping refers to the selection of strategies and scenes for discussion by actors to achieve favorable policy objectives.

There are several policy areas at the international level where states can participate to seek or block support to certain policy actions from other member countries. Some other venues can be more beneficial for actors, state or non-state, to generate strategic inconsistencies in policy that subsequently influence the primary venue of discussion to take action on an issue (Murphy and Kellow 2013).

In international trade policy, actors may advance their business interests through the multilateral forum at the WTO, and through regional or bilateral free trade Agreements. Other economic platforms such as the North American Free Trade Agreement (NAFTA), the Organization for Economic Cooperation and Development (OECD) and the Group of 8 (G-8) also offer venues for states and non-state actors where they can revive and move on negotiations that are stuck, such as the Doha Round of the WTO (Busch 2007; Murphy and Kellow 2013). These studies seem to suggest that there are abundant opportunities for actors to shift to other regimes whenever they need. However, some scholars view that forum shopping is rather a strategy that occur on a one-time or ad hoc basis and is less permanent and can be rather experimental (Pralle 2003; Helfer 2004).

GLOBAL INTELLECTUAL PROPERTY RIGHTS REGIME AND THE HEALTH REGIME: CONTESTATION AND DIVISIVENESS

The global IPR regime has been observed as having brought about an extensive array of contentious issues, such as the economic and moral legitimacy of the TRIPS to the politics of negotiations in the WTO and the problem of compliance, interpretation, and perception of IP laws at the national level among developing member states. The normative and instrumental claims by IP proponents are increasingly questioned (Helfer 2004). The debate on the interpretation of the TRIPS in regard to the issue of access to medicines in developing countries is also one of the most famous international debates.

The contradiction between economic policy and health policy is a long-standing dilemma, but a prominent one was recognized to be the TRIPS Agreement in 1994 (Lybecker and Fowler 2009). The TRIPS has raised concerns about the centralization of regulations on various forms of intellectual property, which most of them usually refer to the issue of knowledge and its products belonging to multinational corporations.

Notably, the pharmaceutical industry plays a significant role in the agreement (Peet 2003).

Regime-shifting ostensibly occurs in the IPR regime. Proponents of the IP maximalist or protectionist approach have shifted forums in various directions since the early 1980s. The battles between the pro-IP and pro-access side continuously occur in several venues. IP protectionists shift to another ‘more hospitable’ venue when the former venue appears to become a ‘less responsive’ deal for an active protectionist approach (Sell 2010).

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Regime-shifting in the IPR regime was explained as multiple rounds of action and counter-action between pro-IP and pro-access, and IP maximalists and IP minimalists. For example, the pro-access side, which includes the allies of access to medicines (India, Brazil, etc.) and non-governmental organizations (NGOs), first started the movement within the WTO. At the beginning of the WTO’s 2001 Doha Ministerial Meeting, member states disagreed on how developing countries use the TRIPS safeguard in their efforts to sustain access to affordable generic versions of essential medicines for communicable diseases such as malaria, HIV/AIDS, and tuberculosis. The issue actively involved non-governmental activists such as Médecins Sans Frontières (MSF), the Quaker United Nations Office, the generic pharmaceutical producers, and concerned groups of people gathered as the ‘access to medicines’ network (Murphy and Kellow 2013). In 2001, they successfully pushed for the WTO’s Doha Declaration on the TRIPS Agreement and Public Health.

Then, the pro-IP or the IP maximalists turned to WIPO to restart a Substantive Patent Law Treaty (SPLT) that aimed to assure stronger IP protection than that of the TRIPS. The pro-access side countered this move with a Development Agenda for WIPO, which led to the impasse of the SPLT at WIPO. In another example, the pro-IP nonstate actors such as corporations also pushed forward the Anti-Counterfeiting Trade Agreement (ACTA) supported by their governments so that all countries signed on to the WIPO Copyright Treaty (WCT) and the WIPO Performances and Phonograms Treaty (WPPT). These actors seek IP protection stronger than that of the WTO framework.

In the ACTA, for other advanced economies who support the pro-access approach, such as Canada, pro-IP non-state actors aimed to push them to adopt the same level of protection as in the U.S. Digital Millennium Copyright Act (DMCA), despite their differences across jurisdictions (Sell 2010).

The concept of ‘regime’ in the context of the IPR system has been studied since the early period of IP politics study. Studies on the international regime and IPR policy implications started to focus on the ‘Doha Declaration’ and considered whether it made a meaningful change within the IPR regime, particularly with regard to developing countries’ concern about the impacts of TRIPS on their ability to procure medicines to tackle HIV/AIDS and other diseases. The essence of the Doha Declaration is that it emphasized member countries’ rights to implement the international IP obligations in a way that supports public healthcare.

Therefore, the Doha Declaration assists and ensures the flexibility of TRIPS, by specifically addressing the difficulties that countries with insufficient medicine production capabilities are facing, and the permissible conditions for medicine exports from countries where they are patented to any particular countries. Various scholars observe that the IPR regime under TRIPS was not changed because of the Doha Declaration, as the Declaration itself merely restates the original text stated in TRIPS in a short document and only clarifies ambiguity in the TRIPS rules (Chorev and Shadlen 2015). Drahos noted that while developing country negotiators, social activists, and supporters of the Access to Knowledge movement might win only small battles (e.g. the Doha Declaration), they might lose in a greater war of access to affordable medicines Asian Journal of Public Affairs | 2018

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(Drahos 2007; Sell 2010). Though it seems modern governments have formulated increasingly clearer and more sophisticated views of social and political implications of even the most technical rules than before (Lowe 2007), indeed, the study of regime complexes illustrates the dynamic and divisive nature of the global IPR regime.

REGIME-SHIFTING STRATEGY IN THAILAND’S EXPERIENCE OF CLS

The empirical findings of this research add the following points to literature on regime complexes and regime-shifting concepts. For regime complexes, most of the literature has recognized the feature of international regime complexes in modern days, the increasing phenomenon of such complexity, and the potentiality for both positive and negative consequences of the regime complexity differently in several various regimes. This paper confirms that the IPR regime is complex because several international organizations and groups involved in this issue supported wider access to medicines, and such complexity opens the possibility for countries seeking to exercise the autonomy to issue the medicine CLs in their public health policy to achieve their policy goals.

With regard to the concept of regime-shifting and venue shopping, this research confirms the concepts but also offers more critical implications about policymaking in three ways. First, to understand the context that leads to incentives or the rationales for actors in public health policy to choose regime-shifting strategies, this paper presents the elements that shaped the rationale for actors to move to other regimes or forums: the economic relationship with major power states; in this case the United States, the conduct of economic actors, the compliance with the international IPR regime, and the existing national policy on HIV/AIDS and medicine prices. The case of Thailand demonstrates that the finalized rationale of the actors on the pro-access side to undergo the regime-shifting was from the expected negative post-rulemaking consequences that actors face in the aftermath of a policy decision.

Second, this paper suggests differentiating the process of regime-shifting into the international level and national level. On the international level, the process includes reaching out to the authority in other powerful states and international organizations in the developed world. At the national level, the leadership of the key bureaucrats was effective in pushing the decision. The findings demonstrate that reaching out to authorized personnel or influential public figures abroad, based mainly on the careful calculation for approval, is vital for the outcome of the regime-shifting strategy in this case.

Third, multiple actors collectively and simultaneously participate in regimeshifting strategies. Drawing from the case study of Thailand, several actors joined forces to make access to HIV/AIDS medicines a matter of public health and human rights. Meanwhile, the IP-proponents also moved their strong IP agenda to other negotiation venues.

As this paper attempts to understand the complicated picture of the IPR regime through the case of Thailand, the background of the problem is retrospectively 10

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examined. The context of Thailand’s trade policy making and the external and internal factors affecting Thailand’s following actions regarding medicine CLs should be examined first.

Four elements in the context of Thailand’s trade policy-making

First, crucial to understanding the context relating to Thailand’s trade policy making is the trading relationship with the United States. It is well known that the U.S. has been the most active and unequivocal state with the policy agenda of trade liberalization and IPR protection, both at the multilateral and bilateral level. The U.S. is distinctive from other trading partner states as there are the United States Trade Representatives (USTR) who are specifically in charge of promoting strong IP laws and effective enforcement worldwide. According to the USTR’s Office of Intellectual Property and Innovation, pharmaceutical and medical technology industries are the main U.S. concerns. Apart from the TRIPS, the annual Special 301 Report and Generalized System of Preferences (GSP) are major trade tools with adequate pressure against the violation of IP protection for Thailand. Interestingly, the U.S. has not brought Thailand to the dispute settlement mechanism in the WTO regarding the medicine CLs and trade sanctions have never been imposed on Thailand. Meanwhile, the Thai authority also recognized the importance of stronger IP protection and that American economic interests have been highlighted as the priorities for the U.S. in trade relations.

Second, multinational drug corporations coherently stand for high IP protection, at least with the TRIPS standards. However, the business approach of American drug businesses in Thailand has been outstandingly perceived among locals as challenging to address, especially when original medicines are sold at much higher prices than those of generic drugs. A sharp contrast between perceptions about American or foreign corporate conduct in medicine trades and the Thais’ general expectation about the role of doctors, hospitals, and care providers in saving lives and taking care of patients has been observed. From the local perspective, American drug corporations are somehow perceived as profiteering enterprises coming together with capitalism and globalization.

Third, Thailand’s adoption of the IPR regime is markedly linked to its interest in attracting foreign investment and compliance with global trade governance. Thailand has formerly adopted systems of IP protection through international treaties, such as the Berne Convention in 1931 and the WIPO Convention in 1989. Then, TRIPS concluded in 1994 and required that developing member countries apply the TRIPS provisions to their IP laws by the year 2000. Indeed, Thailand had previously changed the patent protection period from fifteen years to twenty years in 1992, eight years before what the TRIPS later required. Contrary to what has been understood as TRIPS’s pervasive impact on domestic IP laws after 1995 among developing countries, IP laws in Thailand had been made stronger since before the TRIPS. Thailand has taken several measures to comply with the TRIPS. The country subsequently enacted in total nineteen of the IP protection laws (WIPO 2017). The Central Intellectual Property and International Trade court was also established in 1997, and a variety of measures to promote IP protections were set (IPITC 2017).

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Fourth, national medicine pricing policies and regulations do not exist in Thailand. Thus, different prices for the same medicine have been observed. Additionally, high prices of the innovator brand (brand name) drugs are widely recognized (Sooksriwong et al. 2009). Several campaigns by citizen groups and activists proposed a medicine price control law, with requirements that drug producers must declare drug price structure and the patent status, but the proposal was vehemently opposed by the pharmaceutical industry (Thai Drug Watch 2015). Meanwhile, Thailand implemented the universal coverage scheme (Gold Card program), which later covered 49.8 million Thai citizens. In October 2003, the Thai government successfully implemented a policy that provides universal access to antiretroviral drugs for AIDS patients. The continuation of public health policy was consistent with the World Health Assembly resolution 54/10 of 21 May 2001 entitled “Scaling up the response to HIV/AIDS,” and the “Handbook for Legislators on HIV/AIDS, Law and Human Rights,” published in autumn 1999 (IPU 2001; NSO 2015).

To achieve universal access to medicines for AIDS patients, Thailand continuously pursued the policy of drug price reduction without success. Since 1997, Thailand’s Department of Disease Control (DDC) was in charge of negotiations to lower the price of Fluconazole, an anti-fungal drug for patients who have AIDS, a patented product of an American company but was unsuccessful. Throughout 2004-2005, the DDC officially requested the reduction of prices for antiretroviral drugs through official contact and many informal meetings with drug patent holders but also failed. In April 2005, the Thai authority set up a special Working Group, which was composed of members of Thailand’s Ministry of Public health, Ministry of Commerce, and the Secretary General of the Thai Food and Drug Administration, to negotiate price reductions on patented drugs, but by 2006, the Working Group reported its failure to negotiate lower patented medicine prices due to the lack of cooperation of the patent holders (PIJIP 2009).

Rationally, the issue of price is a government priority because the quantity of the public procurement for AIDS medicines would be massive, and the purchase volume is the largest source of the bargaining power over the drug multinational corporations (MNCs). Unfortunately, price negotiations failed. According to the Government Pharmaceutical Organization (GPO) of Thailand, there were three steps for these price negotiations with drug MNCs. First was the bargaining for lower prices. Second was demanding licenses. Additionally, the CLs would be considered as a last resort when other measures failed. The drug MNCs refused to decrease the price and declined to give the licenses for selected medicines for GPO production. Since the first two steps were unsuccessful, CLs were then considered. Though the government prepared the royalty fees according to the law, the patent holders never contacted them to receive such payment from the GPO.3

Only a month after the military coup in September 2006, the DDC and the Ministry of Public Health concluded that the interim government would issue a CL for an AIDS drug (Efavirenz) to the GPO as the producer. The terms also included that the GPO will pay the royalty fees to the patent holders 0.5 percent of the generic’s 3

Interview with a GPO executive officer, Bangkok, 20 March 2017.

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total sale value (PIJIP 2009). In 2007, the Ministry announced another CL for Lopinavir/ Ritonavir. The next drug granted the CL was a heart disease and stroke drug, Clopidogrel.

In addition, the last group composed of four anti-cancer drugs (Imatinib, Letrozole, Erlotinib, and Docetaxel) was given CLs on 4 January 2008.

Strategic inconsistencies against the CLs

This paper contends that strategic inconsistencies were created after the CLs issuance, although it had been clear that CL is a measure allowed by TRIPS Article 31.

The USTR placed pressure on the Thai government by expressing its dissatisfaction and issuing threats to trade retaliations. The drug MNCs in Thailand initiated such strategic inconsistencies through the international media by stating that the Thai government and the GPO issued unlawful CLs. American pharmaceutical companies appeared to believe that CLs were illegitimate and that the CLs could not be granted without consultation with the patent holders first. This confusion was in contrast with the Doha Declaration clarification. In March 2007, an American drug corporation, one of patent holders, retaliated by withdrawing other medicines registered with Thailand’s Food and Drug Administration (Head 2007; Fuller 2007), which meant that importation and supply of those drugs into Thailand would be suspended. Such reactions from foreign businesses led to adverse perceptions towards drug MNCs in Thailand among medical professionals as they observed corporations to be socially irresponsible, anticompetition, and a hindrance to the Thai people’s access to medicines. A subsequent online campaign to boycott the corporation’s products at the local market was raised, and it was observed that some of their products were banned from general pharmacy shop shelves.4 Shifting from trade to health and human rights

Thailand’s actions on CLs brought about not only controversy but also ‘much momentum’ (Kuek et. al. 2010). As expected, once the Thai government faced unfavorable political consequences after issuing CLs, it took subsequent actions in horizontally shifting to other international regimes and venues to seek external supports and endorsements for its decision. This paper argues that the shifting for justification and approval of the CLs occurred at many levels of authority and governance: international organizations, political arena in foreign countries, national agencies in charge of international obligations, international non-governmental organizations and domestic civil society advocates.

Despite acting lawfully according to the Thai Patent Act Section 46 (Guennif 2016) and the TRIPS Article 31, it seems that having only legal legitimacy was inadequate for the government’s decision. The Thai government thus turned away from the WTO realm of IP protection and turned to assistance from other healthrelated and development international organizations. Officers from the WHO, United Nations Development Program (UNDP) and United Nations Conference on Trade and Development (UNCTAD) gave their technical support to ensure that Thailand knew how to implement the CLs in compliance with both Thai and international legislation.

Online sources and fieldwork observation (during December 2016-March 2017)(in-Thai) See also: http:// www.thaiplus.net/?q=node/53, http://www.consumerthai.org/news-consumerthai/consumers-news/ food-and-drug/3564-2009-11-27-05-43-02.html, http://www.ftawatch.org/node/11290 4

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The Thai Public Health Ministry sought special support from the then Director General of WHO, Dr. Margaret Chan, who provided firm support in a letter to the Thai Public Health Minister, that the announcement of the Government Use of the Patents is entirely consistent with the TRIPS Agreement and that governments are not required to pursue negotiation with drug corporations before the CLs issuance. (Third World Network 2007) The Thai government also sought support from authorities abroad.

Through extra efforts by public health bureaucrats, Thailand received support from a number of American politicians in the CLs decision for Efavirenz. The Thai government received support from U.S. Democratic representatives5 and the former President of the United States Bill Clinton for its decision to announce the CLs. A letter signed by twenty-two American Congressmen to the USTR regarding the Efavirenz CL issuance case, on 10 January 2007, stated that Thailand’s decision was entirely in line with international trade rules, the WTO’s TRIPS and the Doha Declaration. The Congressmen expressed concern about the USTR’s intervention in Thailand’s decision to issue the CLs on Efavirenz and thus demanded that Thailand’s autonomously pursued public health measures be respected by the USTR (Institute for Population 2009). Such a move was unusual, but it was a source of the concrete supports that the Thai government could use to eventually secure the legitimacy of these CLs issuances.

The National Human Rights Commission (NHRC) also provided the shifting venue for the supporters of medicine CLs. In May 2007, the Commission issued a ‘Statement of the National Human Rights Commission on Compulsory Licensing in Thailand and Pressure from the United States.’ The document condemned the attitude and operation of the U.S. government in using the Special 301 report as a tool to put pressure on Thailand, although the action was coherent with the Doha Declaration on TRIPS and Public Health, and it is a widely accepted international humanitarian principle that access to medicines is a fundamental human right (NHRC Thailand 2007).

The government could receive support for the CLs from the NHRC in this issue for two reasons. The first reason is that the number of HIV/AIDS patients in Thailand who were among poor and low-educated populations at the time was high (approximately one million infected people and five hundred thousand people were living with HIV), while only twenty-five percent of patients could access to the antiviral drugs. This issue would be regarded as a truly moral problem in Thai society if the government did not intervene in the access to medicine problem. Second, the NHRC possesses authority and duty as an independent organization under the Constitution. The Commission has an obligation to investigate any violations of human rights if anyone files a complaint.

Since AIDS activists in Thailand, such as AIDS Access Foundation and Thai Plus Network, are very active and raised their voices to the NHRC, the access to medicine complaints were effectively realized by the Commission. Notably, the NHRC in South Korea and India also took this kind of approach in calling for priority of access to essential drugs over patent rights (NHRCK 2009; NHRC India 2016), though the impact could be different among countries.

5

Tom Allen (of Maine) and a Democrat Senator, Sherrod Brown (of Ohio).

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The issue attracted international organizations and non-state actors such as UNAIDS, Consumer Project on Technology, Médecins Sans Frontières (MSF/ Doctors Without Borders), The Global Fund, Health GAP and the Transatlantic Consumer Dialogue Working Group on Intellectual Property. UNAIDS supported the sovereign rights of member states regarding fighting and ending HIV/AIDS. These actors took part in calling on the U.S. and the European Community to respect the 2001 Doha Declaration and asserted that the Declaration must not make CLs a “last resort.”

They supported the financing, Thailand’s sovereignty right, and the CL legality for the country’s public health programs, without a requirement for prior consultations or negotiations supervised by the U.S. and the European governments (PIJIP 2009; Institute for Population 2009).

Domestically, the Health System Research Institute (NSRI) funded a research project on ‘Evergreening medicine patents in Thailand.’ As a part of the project, the researchers published a ‘Manual for Examination of Pharmaceutical Patents’ that was given to the Department of Intellectual Property of Thailand to use as a guide for preventing the inappropriate granting of patents. This project was based on and largely referred to the reference guide of WHO Southeast Asia (WHO 2009) and the guidelines developed by the International Center for Trade and Sustainable Development (ICTSD), UNCTAD and WHO (Correa 2007).

The effects of regime-shifting finally turned back to the primary governing institution of the global IP in trade rules. Pascal Lamy, the then Director-General of WTO, finally addressed the 11th Annual International Generic Pharmaceutical Alliance Conference in Geneva in 2008. The director-general recognized the ‘need to find a balance within the intellectual property system, as well as the use of some of the TRIPS flexibilities by certain WTO member states (WTO 2008).

This paper considers two levels of actions for regime-shifting. One level is the international level: to handle the confusion about the legitimacy of the CLs, it was crucial for the Thai government to be active in seeking supports for these CLs decision officially. The mission was mainly led by the incumbent high-ranking officers in the Ministry of Public Health who sought support from key individuals in the United States.

Meanwhile, civil society groups and activists brought the issue to other areas for discussion, such as the human rights, public health, and customer rights forum. The intention was to challenge the existing controversy in the global IPR regime, especially with regard to medicines, so that WTO member states can widen the space for selecting how to interpret IPR rules.

International and domestic non-state actors proved to play important roles in global IPR policy making. Their movements and strategies in informal venues or channels could be influential, as they provide normative justifications, the rationale for social or moral purposes of an action and bring the issues to public attention to influence other actors to consent with them.

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Another level is the national level. However, as a state actor, it should be noted that the Thai government did not create strategic inconsistency in IPR rules because the government actually gives high priority to compliance with international obligations, so it strictly followed what the TRIPS allows. As the TRIPS permits flexibilities in Article 31 for member countries to grant CLs if necessary, the government firmly insisted its policy decision was justified in the face of accusations and criticisms by transnational drug companies and the USTR that the CL is unlawful and illegitimate. It should also be recognized that regarding the problem of evergreening patents, there are conflicting views among IP experts. Some IP lawyers may deny the existence of ‘evergreening’.

Rather, they would argue it is called an ‘IP management strategy’ by patent holders, while some IP experts accept the existence of such a practice but see it as a practical claim-drafting approach for maximum possible protection.6 Such diverse viewpoints may reflect the weakness of current IP governance and the difficulty of implementing IPR protection rules.

On the other hand, movements by non-state actors also built another strategic inconsistency at the domestic level to generate negative public attention against the strong IP enforcement and multinational pharmaceutical companies, specifically in regard to the availability and affordability of medicine. It turned out that activists’ arguments were sufficiently powerful and won general public supports. Another IP legal expert in Thailand, however, commented about such disputes that ‘IPR is understood as trade protectionism; thus, the key concerns of improvement of IPR system in Thailand is the precise and correct understanding about the scope and legal procedures of IP protection. Arguments by civil society groups might not be based on the exact legal argument; rather, they tend to focus on social, political or moral reasons.’7

In the health regime, the WHO documented that Thailand achieved effective reduction of the number of annual new HIV infections from 143,000 people in 1991 to 10,853 people in 2010 (National AIDS 2010). The estimated number of new infection is 6,900 people in 2015 (UNAIDS 2016). The WHO proclaimed it would continue to help Thailand with technical support and provide health forums for Thailand in responding to HIV and AIDS so that ‘disparate health stakeholders’ are prioritized in healthcare provision. With the focus on promoting national activeness in enhancing the highquality treatment and care, counseling, HIV testing and access to essential medicines, Thailand is supported through the International Trade and Health Programme, which is assisted by several health agencies, including WHO Thailand (WHO 2017).

Shifting to more stringent IP protection

Actors on the pro-IP side could employ the regime-shifting strategy of searching for other venues outside the multilateral forum, such as regional and bilateral trade and investment treaties that propose the so-called ‘TRIPS-Plus provisions’. Multinational pharmaceutical producers have also been moving their IP agenda by avoiding opposition from developing countries and activists to other unclear venues for talks with pro-IP proponents (Murphy and Kellow 2013).

6 7

Interview with an IP legal expert, Chiang Mai, 16 March 2017.

Interview with an IP legal expert, Chiang Mai, 23 January 2017.

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This case study considers the Thailand-U.S. trade relationship as central to the strengthening of the IPR regime in Thailand. The Thailand-U.S. Free Trade Agreement negotiation was first launched in 2003. Since the Doha Declaration in 2001 with the uncertainty in the Doha Round negotiation, the United States has incentives to generate alternative venues for trade negotiations, where it can sharply focus on the IP agendas and policy with important trading partners. However, as reported on the USTR website, the bilateral trade rounds between the two countries were suspended as the result of the military-led coup in Thailand in 2006.

The draft of the Thailand-U.S. FTA (TUSFTA), proposed higher protections of IP by the USTR than what TRIPS required. For example, in the case of medicinal products, ‘data exclusivity’ is required, so national drug regulatory authorities cannot use the clinical test data conducted by the drug originators for five years. The agreement also requires Thailand to allow patents for any new uses or methods of using a known product. It means that under this deal, old medicines with slightly changed ways to using or taking can be accepted as patents. The pre-grant opposition and revocation of patents are also prohibited by the text, despite the fact that they are tools to handle patent abuses or unqualified patents, which are a general cause of high medicine prices. In the TUSFTA text, CLs are restricted to narrowly limited circumstances to private companies only, with full compensation to patent holders. More importantly, the draft would demand the extension of the term of patents from twenty years to twenty-five years, to cover the extended period of patent applications in Thailand.

TUSFTA is criticized as having wider and deeper impacts on the public of Thailand, compared to those of other free trade deals with other major trading partners because the framework for negotiation is more wide-ranging, especially in regard to the intellectual property and investment protection issues. The details are more specific and narrow. Moreover, the bargaining processes are more secretive. The trend of bilateral free trade areas spread in Southeast Asia started from Singapore, Thailand, Malaysia, the Philippines and Indonesia. In Thailand, the major drivers off free trade area deals came from Thaksin, the agro-industry Charoen Pokphand Group, and the Thai-Summit auto parts manufacturers (Pongsudhirak 2010). The FTA negotiation was a trend resulting from the stalled Doha Round, and non-participation would have an immense cost for Thailand (Thanaphonphan 2005). However, after the coup in 2006, the energetic force for numerous free trade area deals somehow faded away, especially the one with the United States. The TUSFTA had been intensely opposed by coalitions of NGOs who stand against pervasive economic globalization and the issues of stricter IP protection relating to access to affordable medicines tend to continue as a difficult national debate between the pro-IP side and pro-access sides.

CONCLUSION

This article has attempted to examine the three concepts of regime complexes, regime-shifting and forum shopping, as political strategies of actors in global governance and to study to what extent they help to explain how actors in patented medicine disputes responded to the complicated global IPR rules. Two remarks are drawn from the case study of Thailand in exercising medicine CLs during 2006-2008.

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First, the findings of this paper confirm the need to be aware of international regime complexes and the use of the political strategy of regime-shifting in contemporary trade politics. Studies of regime complexes help to magnify the importance of the multiplicity of organizations and the discussion of venues and choices of the forum for any international issue. The problem of medicine patents and their high prices for people in developing countries, is an open arena for several actors taking part in policy-making to participate with competition for priority of trade and innovation, public health or human rights. Strategic inconsistencies created for confusion should be something policymakers are aware of. Though the effect of complexity might need to be examined on a case-by-case basis, conceptualization helps capture more about constraints and flexibility of international cooperation in difficult issues. Additionally, it may reflect the trend towards increasing legal fragmentation and weaknesses of global governance, which should be further deliberated in order to figure out how to cope with and to avoid recurrent disputes or litigations among every stakeholder.

Studies of regime-shifting and venue shopping also challenge earlier regime studies in IR by demonstrating that it may not be sufficient to consider each international issue area separately anymore. The case study of Thailand also confirms that implementation of global trade rules, such as TRIPS, can get support or face challenges by several actors working under regimes other than trade.

The second remark is, the conceptualization of regime-shifting and forum shopping helps to reveal some implications for developing countries. This paper has added to the existing literature in three ways. First, the incentive or the rationale for actors to choose the regime-shifting strategy and the finalized rationale of the actors for public health goals to do the regime-shifting was driven by the expected negative post-rulemaking consequences that actors face in the aftermath of a policy decision.

To understand the rationale or the necessity of using regime-shifting, the context of international trade policy-making needs to be considered.

Second, the process of regime-shifting also includes, on the international level, reaching out to the authorities in other powerful states and international organizations in the developed world. This research indicates that reaching out to authorized personnel or influential public figures abroad needs careful anticipation for approval and supports. At the national level, regime-shifting by only domestic health advocates would have not been effective without the leadership and strong determination of key bureaucrats in pushing for the CLs decision and standing firmly against any confusions and misinformation in the public media. It also gives rises to the questions of whether this kind of strategy is mostly on ad hoc or experimental basis or if it can be useful in dealing with frequent conflicts in any highly contentious debate on international regimes.

And third, multiple actors collectively participate in regime-shifting strategies.

Drawn from the case study of Thailand, public bodies such as the National Human Rights Commission, key bureaucrats in public health, NGOs, international and domestic activists joined together in making access to HIV/AIDS medicine a matter of public health interest and human rights. Meanwhile, multinational companies and the U.S. 18

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also moved the strong IP agenda to another negotiation venue, that is, a proposal of bilateral trade agreement with the more stringent IP protection requirements.

For the pro-access side of patented medicine problems, public health bureaucrats and civil society actors could bring their agenda away from trade and innovation promotion (with IP protection as a mean) to the protection of public health at various levels of public health and human right governance such as the WHO, National Human Rights Commission, and politically influential figures in other key states. In sum, the complexes of the global IPR regime provide ways for developing states and social activists that support more access to expensive antiretroviral drugs to make their voice heard in other policy venues that are more favorable to the public health agenda. It should also be noted, however, that the outcome of campaigns through various agencies and organizations can be different among countries. The experience of Thailand showed that proactive effort of the government in seeking support from authorities and people in charge of health and human rights regime, the necessity of the medicines, the affected number of patients, and the firm cooperation among government, bureaucrats, and civil society actors were crucial for the proaccess side strength.

For the supporters of strong IP protection, after the Doha Declaration in 2001, pharmaceutical corporations have been facing huge moral constraints in claiming IPR violations of medicine patents through the WTO dispute settlement bodies and private lawsuits. Policymakers need to aware that strategic inconsistencies might be created about what the IPR laws allow or prohibit, through public media and direct interactions.

From this medicine CLs dispute in Thailand, the multiplicity of actors at the international and national level in public health policy process is observed. These actors formed coalitions into pro-access and pro-IP sides, but the former had successfully gained justification at both the international and domestic level. In contrast, the latter still faces limitations in making arguments based on economic benefits. More concrete evidence of IPR rules in promoting innovation and benefits for the public, including patients with severe diseases, not only for large multinational corporations, should be further exhibited to the public to improve the overall future IP protection system.

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Global Governance,2(1):1–24.

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RESEARCH ARTICLE

Progress Tracking of Health-Related SDGs: Challenges and Opportunities for India Shalini Rudra and Oommen C. Kurian1 ABSTRACT Given its size and the low baseline, India has a crucial role in global progress and achievement of the Sustainable Development Goals (SDGs), particularly in health. As a result, there is a great need for effective monitoring Keywords: Sustainable Development Goals, of the country’s progress toward India, Health, Nutrition, indicator framework. health-related SGDs, through timely and disaggregated data, which would Suggested Article Citation: Rudra and Kurian. allow for systematic assessment and 2018. “Progress Tracking of Health-Related SDGs: Challenges and Opportunities for India” Asian course correction. This paper aims to classify the health and nutrition-related Journal of Public Affairs 10(2): p. 24-52. indicators from the existing health and healthcare surveys that India relies on for http://dx.doi.org/10.18003/ajpa.20186 tracking progress and recommends that ISSN 1793-5342 (print); ISSN 2382-6134 two of the largest household surveys be (online), © The Authors 2018. Published by streamlined to strengthen the National Lee Kuan Yew School of Public Policy, National Indicator Framework (NIF) for goal University of Singapore tracking purposes. The paper also reviews the draft NIF and proposes certain revisions from a data perspective in a revised draft framework for the government’s consideration. Finally, it highlights various gaps and constraints in data availability, and develops specific recommendations to achieve a data sphere consistent with the envisaged NIF.

INTRODUCTION With the adoption of the Sustainable Development Agenda on 25 September 2015, the United Nations (UN) member-nations have affirmed their commitments toward an “all-inclusive, far-reaching and people-centered” set of universal and transformative development goals, known as the Sustainable Development Goals (SDGs). Governed by the principles of national sovereignty and subsidiarity, the countries were to draft action plans based on national priorities and commitments.

Observer Research Foundation, 20, Rouse Avenue Institutional Area, New Delhi - 110002, INDIA. Corresponding Author: Shalini Rudra (Email: shalini.rudra@orfonline.org) 1

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The signatory countries are at various stages of implementation of the agenda through actionable strategies and metrics enclosed within their national visions. To this end, the Ministry of Statistics and Programme Implementation (MoSPI), Government of India prepared a draft National Indicator Framework (NIF) that will lay the foundation for India’s SDG tracking. This paper was part of an exercise of providing feedback on the draft NIF for a thorough revision, effectively negotiating data availability. The draft NIF is currently undergoing revision after receiving feedback, and according to latest available information, five regional workshops in this regard held at Ahmadabad, Lucknow, Chennai, Guwahati and Bhubaneswar (Unknown Author, Sneak Peak: Ministry of Statistics and Programme Implementation).

The SDGs are comprised of 17 universal goals steered through 232 targets. One major challenge towards achievement of the SGDs is the availability of data for monitoring progress and evaluation of policies. To overcome this concern, a comprehensive monitoring framework based on a robust data ecosystem is a key strategy for regular and systematic assessment of progress toward the SDGs. India admittedly has limited capacity to produce data for all the indicators and will soon have to either devise an exhaustive system of data generation to track progress or adapt indicators based on existing data sources. Building on the experience with the Millennium Development Goals (MDGs), where the lack of data on policy shifts contributed to difficulties in attributing success to the enabling conditions, the SDGs have built-in monitoring at all the levels that specifically rely on each country’s data ecosystem.

With this background, the paper examines the available information base and outlines issues related to the feasibility of monitoring indicators. The paper presents specific recommendations for streamlining existing surveys either by altering data construct or by revising instruments for data collection. The paper also suggests strategies for strengthening and modifying the monitoring framework itself. With a focus on analysing the scope, availability and appropriateness of indicators adopted in the draft NIF for a sub-group of indicators on health and nutrition, the paper is organized as follows. Section II describes the methodology adopted for systematic classification of the draft NIF indicators into categories to identify gaps in the available data. Section III discusses the existing national surveys to populate the draft NIF and its various categories. Section IV presents a set of recommendations for streamlining existing surveys as well as for revising the draft NIF, acknowledging the limitations of the indicators and negotiating data constraints. Section V concludes.

METHODOLOGY Health-related data in India: Relevance for low and middle-income countries For most low- and middle-income countries (LMICs), a Vital Registrations Systems (VRS) either does not exist or lacks robustness in data coverage and capture.

In the absence of a VRS, health systems data such as hospital records fill the gap— but with two fundamental concerns. One major challenge is the absence of electronic data management systems. Another is that with a varied and fragmented private sector that is involved in provisioning of healthcare services, it is difficult to enforce norms for record-maintenance that are compatible with the public sector. VRS can Asian Journal of Public Affairs | 2018

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be complemented with data from alternative data generation systems like large-scale household surveys, population surveys, disease notification programs and demographic surveillance. An exhaustive review of indicators by Helleringer (2015) recommended that, if data for target tracking are unavailable, countries should resort to a tiered monitoring framework. For non-existent data, information could be obtained from alternative options like decennial censuses, surveillance data, administrative data on program records, annual surveys of frequent events (viz. illnesses, use of ambulatory care, verbal autopsy, anthropometric indicators, etc.), and periodic large surveys of rare health events. Moreover, the frequency of occurrence of an event covered by the SDG indicator should govern the method of collection in order to furnish unbiased estimates. Indicators related to periodic outbreak of diseases, for example, would require special data collection efforts.

Given India’s fragmented data infrastructure, one major policy challenge is finding a reliable metrics to track India’s SDG progress. The central focus of the SDGs on inclusiveness and equality poses further calls for disaggregated data across geographies, gender, age, social groups, and economic class. In this regard, the two largest sources of population-level data for health and nutrition in India are the National Family Health Surveys (NFHS), an offshoot of the Demographic Health Survey (DHS), and the National Sample Surveys (NSS). The DHS is a key source of information for SDG targets on health, hunger, poverty, education, gender equality, drinking water and birth registration. The DHS program has a built-in reappraisal mechanism that works on compatibility of inter-country comparability across indicators or attributes on which it gathers data. Reshaping the DHS indicators and coverage to correspond with the national indicator framework provides an opportunity to streamline existing data sources for a comprehensive set of indicators. Revising DHS is relevant also as it can be a potential source of disaggregated information for triangulating health system data.

These are some features that are presently beyond the scope of collection through the nation-wide household surveys. This paper furnishes a prototype with modifications to the existing DHS modules that are feasible for collection to enable SDG tracking.

Assessment of health-related SDG indicators

Under the UN General Assembly’s Resolution 70/1, an Inter-Agency and Expert Group (IAEG) was mandated to develop a Global Indicator Framework (GIF) for monitoring the SDG targets with a focus on equity and sustainability. The final GIF was adopted by the UN Statistical Commission in July 2017 through resolution 71/313. The framework comprises a comprehensive set of indicators that are simple yet robust with a wide spectrum to reflect differing national capacities and levels of development.

In this context, the member-nations recognized the importance of adequate data for the follow-up and review of progress, and agreed to intensify efforts to strengthen capacity-building, especially for developing countries.

Based on the level of methodological development and overall data availability, the GIF groups the SDG indicators into three different tiers. Tier one indicators are conceptually clear, have an internationally established methodology and available standards, and data are regularly produced by at least 50 per cent of countries and for at least 50 per cent of the population in every region where the indicator is relevant. Tier 26

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two indicators are conceptually clear, have an internationally established methodology and available standards, but data are not regularly produced by countries. Tier three indicators have no internationally established methodology or standards yet available, but a methodology/standard is being (or will be) developed or tested. The GIF currently contains 82 tier I indicators, 61 tier II indicators and 84 tier III indicators. However, the situation in India in the context of availability of data differs from the global picture that emerges from such tier classification. The following section gives a detailed analysis of the indicators, based on India’s draft NIF. Global framework worked as a guideline for drafting respective nation’s priority through vision documents like NIF. SYSTEMATIC CLASSIFICATION OF THE NIF INDICATORS We use the GIF indicators for goal two (“end hunger, achieve food security and improved nutrition and promote sustainable agriculture”), goal three (“ensure healthy lives and promote well-being for all at all ages”) and goal six (“ensure availability and sustainable management of water and sanitation”). There are 53 indicators related to these three goals between the GIF (33 indicators) and the draft NIF (52 indicators) (Table A1). There are 24 indicators that are common to both, whereas 28 indicators in the draft NIF aim to replace certain broad GIF indicators.

Building on the global schema, we divide indicators from India’s NIF into three categories according to the availability of data through established sources in the country. Following Saikia and Kulkarni (2017), the classification is undertaken through a mapping exercise of current and potential data sources. The data for indicators is mapped concurrently with the level of disaggregation. We then highlight the data challenges that need to be overcome in order to strengthen the draft NIF in the immediate future. As such, a national focus helps govern the selection of the indicators, but it must also reflect the most relevant aspects of the SDG targets. In its current form, the NIF has mostly “population-based” indicators that require information on the size and composition of populations to estimate at-risk populations for any morbidity and mortality statistics. However, the availability of such information needs to be established before enabling target-tracking. To address these concerns, we develop a framework for classification of indicators based on three basic criteria: a) the alignment of the NIF indicator with the specific SDG targets; b) the availability of data representing all population sub-groups and c) the possibility of capturing the data through alternative sources. See Table A2 in the appendix for indicator categories.

Category one indicators have clear and direct yielding questions/biomarkers and data are available through surveys or other government sources that can offer disaggregated information at administrative levels like states and districts. Minor revisions are suggested for certain indicators in this category, where data are unavailable at a further lower level, say district.

Category two indicators do not have an ease of operationalisation through a methodology and cannot furnish data for all population sub-groups at all disaggregated levels. Thus, some modification can be undertaken in either the available datageneration methods through rephrasing questions, adding a focused module within Asian Journal of Public Affairs | 2018

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the survey instrument, re-categorising the response codes or replacing them with information available through existing surveys. The proximate replacement indicator was chosen based on availability and informed by reflection on the normative interpretation of the goal and respective targets.

Category three indicators currently have no data source, or data and hence, need to be revised completely. The reason being either no scope of including these indicators in the current data-generation processes or they require a different mode of data generation, for example special surveys or rapid assessments. We suggest alternative indicators that could be included in the NIF instead.

Figure 1. Framework for classifying the indicators into the three categories

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The paper categorised 44 indicators according to the classification scheme which excludes repeat indicators. Although NIF has 52 indicators, five indicators are repeated twice in the draft framework. We also sought to fit the recommendations into the future ‘data revolution’ that will not only impact the current progress of the SDGs but will upgrade the country’s data ecosystem to have backward and forward linkages with policymaking (Atun, 2014). Figure 1 presents the framework for classifying these indicators and suggests greater focus on strengthening statistical systems to improve tracking progress of indicators listed under Category two and three. Based on this a revised NIF is proposed for stakeholder consultations before incorporating them in the NIF.

NATIONAL SURVEYS AS A MAJOR SOURCE OF DATA FOR THE NIF The availability of data at the smallest disaggregated level, which in the Indian context is the district, is key in the analysis of the draft NIF. However, availability of some indicators is perceptibly poor at the state level and disaggregated data at the district level is highly limited. Therefore, those indicators that are available at the state level for all states and Union Territories (UTs), with some scope for sub-state estimates, were added in the first category. Currently, 12 out of the 44 indicators studied are in category one, with reliable data available at the state level. Out of these, only a few have data available at the district level. In the following section, most of the indicators are discussed under the respective category.

Category One Indicators SDG indicators 2.2.1 and 2.2.2 pertain to prevalence of stunting and malnutrition among children aged five and below. With a fivefold increase in the sample size, the latest NFHS survey (NFHS-IV) can give robust estimates at the district level. Data for coverage indicators, such as indicator 3.1.2 on skilled birth attendance, is available at the district level from the NFHS. In addition, there is a group of indicators on age-related fertility and health-service utilisation for maternal, child health and family planning services, for which disaggregated data are available from the NFHS. These indicators are 3.7.1 on proportion of women whose family planning needs are satisfied with modern methods, 3.7.4 on proportion on institutional deliveries, 3.8.2 on percentage of women with childbirth in a given time period receiving antenatal care four times and 3.8.4 on children suffering from Acute Respiratory Infection (ARI) pneumonia. For the indicator 3.8.4, does not exist in any national-level source in India. A proxy for pneumonia, with data available at the district level, comes from all the rounds of NFHS, which track the “percentage of children with acute respiratory infection (ARI) in the last two weeks preceding the survey who sought care”.

For indicators that are available through both the NFHS and NSS surveys, a feasible alternative is to triangulate data figures to track progress. Data for indicator 6.1.2 (proportion of population using an improved drinking water by source) as well as indicator 6.2.2 (percentage of population using basic sanitation services) are available in the NSS and NFHS surveys. Description wise, “basic sanitation” connotes improved sanitation, and district-level numbers are readily available from NFHS-4. However, before proceeding with an attempt of triangulation, there is a need to carefully evaluate the varying definitions used in the NFHS and NSS. For example, there is a variation in Asian Journal of Public Affairs | 2018

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the definition of what is labelled as “improved drinking water sources” across NFHS-IV and NSS survey on sanitation.

Data for indicator 3.8.14 (human resources for health (HRH)), is available from the census as well as NSS employment surveys based on occupational classification.

NSS might give more timely data on employment surveys than the census, which is available after considerable delay (Anand and Fan 2016). While it is possible to arrive at a composite number, separate estimates for nurses and midwives are not available as these categories are merged together at the point of data collection. NSS samples are sometimes considered too small to obtain robust state-level estimates (Rao, Shahrawat and Bhatnagar, 2016). However, assigning population weights using the census can help in arriving at robust employment estimates. The pooled data of state and central samples of the NSS should enable the generation of estimates at the sub-state level. Given the prominent role that community health workers play in the healthcare delivery system, a separate code for community health workers in the NSS would allow for more policy-relevant estimates. Currently, the National Classification of Occupations, which the NSS and census follow, does not have a separate code for community health workers (Rao, Shahrawat and Bhatnagar, 2016).

Lastly, for indicator 3.8.12 on tobacco use among individuals, NFHS provides information on the “use of any kind of tobacco” from men and women, aged 15–49, at the district level. The last indicators in this category is 3.8.15 should be easy to track as it is health systems data on supply stocks of drugs and consumables. These stocks are centrally procured through issuing contracts from the state governments and dispersed on request.

Category Two Indicators Out of the 44 indicators analysed, 15 belong to category two—where data sources have some scope for improvement or where possible alternatives offering better geographical coverage are available. The indicator 2.1.1 on “prevalence of undernourishment” refers to lack of calorie intake, in terms of minimum dietary energy requirement norms. Since calorie consumption is collected by the NSS only at the household level and not at the individual level, the scope of analysis is limited.

District-level figures can be calculated by pooling the NSS data from state as well as central samples. For this reason, while using “prevalence of undernourishment” for global reporting, it may be prudent to use “percentage underweight” (children) or “percentage low BMI” (adults) for sub-national tracking. As undernutrition is a widely prevalent problem, with pockets of the country showing highly worrying numbers, it will be important to track these indicators disaggregated for socioeconomic categories at the district level. NFHS provides data that can give disaggregated estimates for children, women and men, although only for sub-groups of the population belonging to reproductive age groups.

Data related to indicators 3.2.1, on under-five mortality rate, and 3.2.2, on neonatal mortality rate, are available through the NFHS, given that the survey has an explicit focus on reproductive, maternal, newborn and child health (RMNCH). The

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mortality rates can be estimated using (indirect) demographic techniques based on birth history and survival information obtained in the survey. None of these mortality rates can, however, be estimated beyond the state level, given the sample size constraints. Strengthening of the Civil Registration System (CRS) can be instrumental to provide regular sub-state mortality numbers.

The data for indicator 3.3.1 on new cases of HIV infections per 1,000 unaffected population is generated by the National AIDS Control Organisation (NACO) on a regular basis through estimation based on Integrated Biological and Behavioural Surveys (IBBS) and HIV sentinel surveys (HSS). The IBBS surveys and the sentinel survey are regarded as the best source for generating statistics for HIV/AIDS by the World Health Organization (WHO). NFHS IV also provides information on HIV prevalence for adult women and men at the national level and for 11 states/groups of states/UTs, including high HIV prevalence states. These estimates are used to triangulate the HIV estimates that are based on NACO’s surveillance data (IIPS, 2014).

Data for indicator 3.3.2, on Tuberculosis (TB) incidence, can be sourced from the Revised National Tuberculosis Control Programme (RNTCP) aimed to identify and treat people with TB. As TB is a notifiable disease, the programme generates statistics based on numbers from the public and private sectors. However, the quality of data is questionable: TB prevalence is seriously underestimated due to limited success with the private sector notifying TB cases (Krishnan, 2016). Indirect estimation, using the NSS morbidity survey and self-reported TB from the NFHS, is perhaps a potential alternative for state-level estimates of self-reported TB. However, data quality and representativeness need to be ascertained to determine the robustness of estimates at the national and state level.

Indicator 3.7.2 on adolescent births is kept in the second category, due to the possibility of high relative sampling errors in general and specifically for those states where the proportion of child marriages is low. Despite the estimation challenges, the NFHS is expected to offer district-level estimates, where marriage before the legal age is a problem. As the age of marriage is increasing across the country, the error margins for estimation of rates will increase too. For this reason, indirect estimates can offer a robustness check for the directly obtained estimates.

Regarding the data on proportion of children aged 12-23 months who received pentavalent vaccines (3.8.3), the previous rounds of NFHS contains information on four of the five diseases covered under pentavalent vaccine (Haemophilus influenzae type b (Hib) is not covered). Subsequent waves of NFHS can include this indicator in immunization schedule to supply data that can be directly attributable. For now, the percentage of fully immunised children—percentage of children (aged 12–23 months) fully immunised for BCG, measles, and three doses each of polio and DPT—is a viable alternative, as these data are available at the district level. Full immunisation coverage should be part of target 3.8, especially if it is not part of the final NIF as an indicator on immunization under the goal 4 on “Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all”.

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Data pertaining to indicator 3.8.6 of the draft NIF (the percentage of People Living with HIV (PLHIV) currently receiving Antiretroviral Therapy (ART) among diagnosed adults and children living with HIV) are available only through HSS. This data might be available even at the district level from the programme data, as ART medication is strongly monitored via diagnostics, and all the hospitals providing free drugs maintain records at the state headquarters (NACO, 2016). However, coverage of private sector hospitals will still be an issue since private hospitals generally do not notify HIV patients under treatment.

Use of Insecticide Treated Nets (ITN) in malaria-endemic regions is incorporated as indicator 3.8.7 under the draft NIF. The NFHS gives the use of bed-nets (for the previous night) by members of a family. However, the use of bed-nets the previous night may not be a good indicator for the disease burden, primarily because of bias in reporting due to seasonal changes, and this indicator needs revision. The key question here is whether this indicator is in consensus with the concern reflected in the respective goal and target. The goal aims to capture the availability of a country’s antimalaria measures. A useful related question would seek to measure “the proportion of households that have an insecticide treated net/bed net,” based on NFHS data.

Indicator 3.8.9 in the NIF reads “Proportion of population (aged 18 years and above) who are currently taking antihypertensive medication among number of adults (18 years and older) who are taking medication for hypertension with systolic blood pressure ≥ 140 mmHg, or with diastolic blood pressure ≥ 90mmHg.” The information on blood pressure is collected in NFHS-IV in the biomarker survey separately for men and women (aged 15–54) along with self-reporting on the use of prescription drugs.

The survey covers only the eligible population of reproductive age, thus limiting the usefulness in estimating the real burden of hypertension, a disease that mostly impacts older people. A combination of the NFHS and the Longitudinal Aging Study in India (LASI) survey on aged can generate a trend analysis on the mutually exclusive age categories. The first wave of LASI is currently underway and will only cover people aged 45 years and above.

The data for indicator 3.8.10 on proportion of the adults receiving the diabetes medication out of the total adults can be obtained from the latest NFHS. However, in the NFHS it’s available as random glucose levels through the biomarker survey.

However, the information on medication is not available.

Information on target 3.8.11 (the proportion of women (aged 30–49) ever being examined for cervical cancer) is available in NFHS. We suggest re-classifying eligible women (from 15–49) to broaden the population base that answer this question of ever undergoing a cervix examination. However, India has very low cancer awareness and therefore including others will make the indicator more inclusive (Gupta, Shridhar and Dhillon, 2015). If the indicator in the draft NIF aims to assess the coverage of cancerspecific screening, the essence of the question can be captured by the percentage of women who have ever undergone a breast examination, since breast cancer is a common type of cancer among women and the information is available with NFHS.

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Indicator 3.8.13 (number of Outpatient Department (OPD) visits per person per year and the Inpatient Department (IPD) admission rate per 100 population per year) is available in NSS. However, robust district-level numbers may not be feasible; small area estimation can give information for lower levels.

Data for indicators 3.8.17 and 3.8.18 (poverty headcount due to out-of-pocket (OOP) expenditure on healthcare and OOP expenditure on health) can be obtained from the NSS Health Surveys. However, there are limitations to the conventional measures of catastrophic financing, which systematically exclude people who are unable to seek necessary care due to lack of purchasing power (Moreno-Serra, Millett and Smith, 2011). To mitigate such deficiencies, it would be preferable to include a complementary “health need-based” analysis with an indicator on the proportion of people not accessing medical care for financial reasons. Moreover, given the focus on insurance-based interventions, it is important to harmonise the data on health insurance collected by all the sources. While NFHS collects data on employee insurance schemes and social health security schemes for people living below poverty line as separate categories, NSS treats all “government-funded insurance schemes” as a single entity, reducing the scope of analysis. However, the sampling adequacy for each of these separate categories will need to be kept in mind before modifying survey instruments.

Category three Indicators Predictably, 17 out of 44 indicators analysed in the draft NIF fall into category three, indicating significant scope for improvement. Indicator 2.1.2, pertaining to the prevalence of moderate or severe food insecurity based on the recommended Food Insecurity Experience Scale (FIES), does not have any existing data source in India.

However, FIES is being canvassed as part of an ongoing survey called “Comprehensive National Nutrition Survey” (CNNS) conducted by UNICEF and MoHFW and statistics on this will soon be available (Sethi et al., 2017).

Indicator 3.1.1 (“maternal mortality ratio” (MMR)) is extremely important, given the scale of the problem in the Indian context. Data on maternal deaths in the two years preceding the survey have been collected in NFHS rounds I, II and IV, which can give comparable estimates (Dandona, Pandey and Dandona, 2016). While the earlier sample design was inadequate for a robust state-level estimate of MMR, the enhanced sample of the latest round NFHS survey is expected to provide robust MMR estimates.

However, the relative sampling errors may be huge at the state level, and therefore, the indicator is categorized in category three. The Sample Registration System (SRS) also gives estimates of MMR from pooled data for states, but covers only larger states (Kurian, 2016).

The incidence of malaria (indicator 3.3.3) is not available through any source except district-wise malaria incidence and blood examination reports provided by the National Vector Borne Disease Control Programme (NVBDCP). NVBDCP data reports are deemed incomplete as they do not cover the private sector (Kumar and Furtado, 2015). The previous NSS morbidity survey (2004) used a separate code for malaria was given, and it is not clear why it has been removed in the latest round. The estimates Asian Journal of Public Affairs | 2018

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may also suffer from seasonality bias, as malaria is mostly reported during the monsoon and post-monsoon period. Ideally, data for this indicator should be provided by routine surveillance. Data for indicator 3.3.4, on the incidence of viral hepatitis (including A, B, C, D, E), is not available through any surveys. Although the disease codes in NSS do not include hepatitis, the report clarifies that the working definition for jaundice includes hepatitis as well (NSSO, 2014). In the NSS health data, all self-reported illness with their causes may not be ideal for assessing the true diseases incidence, as in the case of hepatitis. As with malaria, ideally, routine surveillance can capture the necessary data for this indicator, although only hepatitis A and B (not C, D and E) are notifiable under the government’s regulatory framework. Since data are not currently available, immunisation coverage can be used as a proxy for risk, even though only hepatitis B is part of universal immunisation.

Indicator 3.3.5, on the proportion of population requiring interventions for the treatment of Neglected Tropical Diseases (NTDs), does not have data sources except through the corresponding Health Management Information System (HMIS), which does not cover the private sector adequately. However, some diseases such as dengue, chikungunya and viral Leishmaniasis are endemic in particular seasons in certain spots. Therefore, data can be obtained by conducting a rapid assessment of the burden during outbreaks through household surveys of the endemic areas or through sentinel surveys. In addition, the NSS morbidity survey should include dengue with a separate code in the “nature of ailment” variable as a representative indicator of an emerging NTD causing considerable morbidity/mortality burden. Given that previous exposure to dengue is known to increase the potency of Zika infections, more data on dengue is necessary for pandemic preparedness against such outbreaks. Since the SDGs mandate monitoring of the disease burden for NTDs, international collaborations can leverage resources through health diplomacy for tracking infectious diseases that can threaten global health security.

Data pertaining to indicator 3.4.1 (mortality estimates attributable to cardiovascular diseases, cancer, diabetes or chronic respiratory diseases) are not collected in any regular surveys, although some morbidity estimation is available.

Only the Medical Certification on Causes of Death (MCCD) surveys conducted by the Registrar General of India (RGI) collects data on causes of death through household surveys. However, if the goal is to reduce the burden of non-communicable diseases (NCDs), a feasible alternative is to take the second-best available statistics on “morbidity due to NCDs” instead of mortality. Data on causes of death may become redundant if seven years’ worth of data are pooled to get state estimates, as is being done currently.

Rates for diabetes and hypertension provided by NFHS can be used as a proxy for risk.

Additionally, self-reported cancer, asthma and heart disease numbers for men and women can be used from the NFHS. For indicator 3.4.2 on the suicide mortality rate, data sources within surveys remain absent. The National Crime Records Bureau (NCRB) is the only source of data on suicide mortality, but the NCRB are is incomplete, given the substantial definitional issues on suicide as well as under-reporting (Mishra, 2006). Another source of data on suicide mortality comes from the verbal autopsy-based survey. The estimates for 34

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2007–13 give data for larger states and UTs, which come with considerable delay (RGI, 2017). Alternatively, the NFHS includes the question: “was the death in the family due to an accident, violence, poisoning, homicide or suicide?”—which can be used to estimate this indicator, if the data can be collected for these categories using separate codes rather than a composite one. Alternatively, NSSO morbidity surveys can be used to obtain information on disease burden under “mental illnesses” at the state level.

Reliable data for indicators 3.5.1 and 3.5.2 (coverage of treatment for substance abuse and harmful use of alcohol among people aged 15 years and above) remain absent in India. The only available data is from a one-time survey conducted in 2004 by the Ministry of Social Justice and Empowerment (GoI) and the UN Office of Drugs and Crime, the “National Survey on Extent, Pattern and Trends of Drug Abuse in India”.

There is routine data available from 122 centres offering interventions on the Drug DeAddiction Programme (DDAP), MoHFW, but again, the coverage of the private sector is a major challenge. In the long run, India should strengthen collection of routine data from the DDAP to enable target tracking.

The indicator on harmful use of alcohol (3.5.2) was left to countries to design.

In the absence of a common benchmark and consistency in construction, the indicator might lose inter-country comparability. In India, however, there is a need to streamline the construction of data collected by the surveys that regularly collect information (NFHS and NSS). NFHS asks a question on alcohol consumption to men and women eligible for a survey that focuses on maternal and child health, while NSS records alcohol consumption in the consumer-expenditure surveys that provides a time series of household consumer expenditure data. NFHS records the frequency and type of alcohol but not quantity. NSS cannot give information on non-individual consumption and is likely to underestimate because of underreporting as well as poor recording of consumption outside the home. The gap can be bridged by adding a question on quantity along with frequency and type of alcohol consumption. Asking questions on individual consumption of alcohol and tobacco products would be the best approach to follow. In the short run, the NIF indicator can be the proportion of people usually drinking “hard liquor” and drinking “almost every day,” given the availability of NFHS data for the district level.

Data for the indicator related to mortality due to traffic injuries (3.6.1) have issues similar to suicide mortality data. NCRB data remain unreliable, and no household survey data are available on death rates other than SRS. In “causes of death,” SRS has a category on “unintentional injuries: motor vehicle accidents,” but its policy relevance is limited if we pool seven years’ data, with considerable delay, to get state estimates.

The NSS morbidity survey question on the “nature of ailment” across ambulatory care and hospitalization can serve as a proxy. However, currently, “accidental injury, road traffic accidents and falls” are grouped together as a single variable. Separate data on road traffic accidents will have to be collected by NSS in the “nature of ailment” question. Alternatively, the NFHS question, “Was the death in the family due to an accident, violence, poisoning, homicide or suicide?” can be tweaked to have a separate answer on traffic accidents.

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NIF’s indicator 3.8.5, the percentage of TB cases successfully treated (plus treatment completed) is available from Revised National Tuberculosis Control Program (RNTCP) programme data at the state and district levels. However, coverage of the private sector remains a major gap and the programme data cannot give reliable estimates of cure rate; therefore, an alternative indicator needs to be explored. NFHS4 gives information on morbidity as well as treatment, although the exact information on cure rates may not be available. NFHS-IV can give the “proportion of people selfreporting TB who are ever treated.” In the long run, the coverage and engagement of the private sector should be scaled up to get reliable estimates of the burden and to ensure treatment adherence, thus reducing chances of developing resistance.

Indicator 3.8.8, on population using safely managed drinking water and sanitation services, is a combination of two other NIF indicators (6.1.1 and 6.2.1). While NSS and NFHS collect data on the nature of the source of water as well as sanitation facilities, the phrase “safely managed” is difficult to operationalise, and currently, there are no data available in the Indian statistical system on this aspect, other than on some elements such as handwashing. We suggest dropping these three indicators, as the NIF already has other indicators on “proportion of population using an improved drinking water by source” as well as on “percentage of population using basic sanitation services,” which have been discussed earlier.

Indicator 3.8.10 in the NIF reads “proportion of population (aged 18 years and above) who are currently taking medication for diabetes (insulin or glycaemic control pills) among the number of adults (18 years and older) who are taking medication for diabetes or with fasting plasma glucose ≥ 7.0 mmol/L,” which, in all probability, was meant to be the proportion of people aged 18 and above on medication for diabetes out of the total people with a fasting plasma glucose reading of more than or equal to 7.0 mmol/L (126mg/dL). However, NFHS only has data on random (and not fasting) diabetes test, and information on medication is not available. The usefulness of the information is further limited given that NFHS is limited to the reproductive age group.

A modified indicator covering treatment of diabetes, customised to align with available data with NFHS, would be a very valuable addition to the NIF, as it allows for trend analysis every three years.

Indicator 3.8.15 in the NIF, “percentage of health facilities with essential medicines and lifesaving commodities”, has no possible data sources in its current form.

Centralised drug procurement and disbursal records of essential medicines by each state can give some information but cannot help estimate the shortfall of medicines.

Arriving at an operational definition of “lifesaving commodity” may add an extra layer to the problem at hand. In this context, health-seeking behaviour by the local population can be a good proxy of the dependability and quality of the public sector. NSS collects data on the percentage of people reporting ailments who didn’t choose government hospitals, because “required specific services [were] not available” or were “available but quality not satisfactory,” which can be used in the revised NIF. Indicators pertaining to mortality due to household/ambient air pollution (3.9.1), unsafe sanitation, lack of hygiene (3.9.2) and unintentional poisoning (3.9.3) 36

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are difficult to obtain from the household survey due to problems with establishing causality. In many cases, instead of death, poisoning/lack of hygiene/air pollution might result into illnesses requiring intervention. Self-reported asthma from NFHS is a good proxy for 3.9.1, and self-reported diarrhoea from NFHS is a good proxy for 3.9.2. Data for indicator 3.9.3, mortality rate attributed to unintentional poisoning, can potentially be collected by NFHS, which has the question: “Was the death in the family due to an accident, violence, poisoning, homicide or suicide?” However, as discussed earlier, data for these categories will have to be coded and collected separately to develop this indicator. Alternatively, NSS data on households reporting morbidity due to poisoning can be used to develop a new indicator.

CONCLUSION AND RECOMMENDATIONS The main purpose of the paper is to evaluate the capacity and constraints to monitor the progress of SDG indicators shortlisted in a draft National Indicator Framework in India, which sets up the nation’s priorities for the coming decade and a half. Given the inconsistent and incomplete data on vital events together with the lack of a holistic data approach within the health system, the household surveys are going to be a panacea for monitoring progress. Modifications to the existing collection tools would better align surveys with the NIF and provide a regular source of data. If specific data are unavailable, realistic modifications to the health and nutrition indicators in the draft NIF can be tweaked to the available proximate indicator. Indicators must reflect the aims of the respective SDG goal and target that they represent. Several limitations persist when it comes to India’s data ecosystem. Until a strong data ecosystem exists, India must revamp existing national surveys and fill the gap with estimates generated through census figures on fertility and mortality.

Indicator-wise scrutiny of the surveys in this paper yielded a comprehensive understanding of sources of data vis-à-vis the NIF. Respective health surveys need to furnish indicator data that are comparable across rounds and between surveys. Survey periodicity needs to be based on need, purpose, and opportunity cost as well as by the potential for driving programmatic decisions on the ground. To obtain detailed analysis of the disease burden at sub-national levels, year-long surveys capturing seasonal variability with standard recall periods, and the use of internationally prescribed disease codes with sub-modules on focused diseases, will be required. The sufficiency of sample for estimation of statistics at the tenable administrative levels will not only enable target tracking at disaggregated levels but will also facilitate programme monitoring. It will also be useful to add fresh questions on themes with limited availability of information through surveys.

The current data-generation process should be revisited to incorporate critical information on insurance enrolments, coverage and usage along with wideranging information on consumption expenditure in general, and health expenditure in particular. In a nutshell, the way forward will be to combine the strengths of various surveys and encompass a holistic design that caters to programmatic needs. The availability of data related to indicators will improve tremendously if the different agencies responsible for undertaking surveys engage in a dialogue aimed at harmonising Asian Journal of Public Affairs | 2018

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surveys. Some surveys that cover different thematic areas run the risk of duplicating information sought from different purposively selected sub-populations. In addition, internal consistency within each questionnaire can be improved by linking questions based on cause of hospitalisation/outpatient visits with the household-level health information where questions on specific illness are asked.

India is currently producing statistics on cause-specific mortality and morbidity through population surveys. However, questions in the instruments require some honing to furnish the exact details required for arriving at an ‘at-risk population’ estimation. Another concern is the alignment of the proposed indicators with the goals and targets broadly representing categories of risk indicators, impact indicators or coverage indictors. Some of the indicators do not necessarily reflect the success of national programs/policies as they are impacted by confounders. For instance, the indicator on deaths due to road traffic not only connotes to the implementation traffic safety program but also to the patterns of risks. Now, sudden increase in accidental deaths can be caused by worsening of road safety or increased at-risk population by virtue of increasing vehicular ownership. To get rid of these confounders, the indicators must be as clear and standardized as possible and should reflect the goal precisely.

Of all the category one indicators for which relatively better data are available, barring the three that deal with human resources for health and health spending, data are sourced directly from NFHS. Apart from mortality and fertility indicators, NFHS gives district-level estimates for all indicators within this group. To accurately track India’s health and nutrition performance, it is imperative that the NFHS survey is conducted every three years, and that delays similar to the one between NFHS-III and IV do not happen again. To estimate fertility and mortality rates, decennial census data should be made available without delays, supplemented with periodic surveys like NFHS to determine fertility through proximate determinants.

Even for many category one indicators, current surveys can only furnish reliable estimates at the state level, and sub-state estimates suffer from large sampling errors. If the Ministry of Health and Family Welfare (MoHFW) plans the NFHS every three years, the sample size can also be enhanced to enable the production of robust district-level estimates for essential indicators under this category. In a similar vein, an initiative driven by the Ministry of Statistics and Programme Implementation (MoSPI) is needed to pool independent samples for state and central level governments to furnish figures.

In fact, NITI Aayog’s Three-Year Action Agenda also suggests a central agency to collate and disseminate district-level data that is comparable across states. The suggestions for category two indicators mostly relate to streamlining existing surveys; there are various ways in which the current surveys can address the data needs triggered by the draft NIF. Category three indicators need to be redefined based on the purpose for which they are required. If the purpose of an indicator is to serve as evaluation of the policy or program, indicators that reflect impact and outcome must be used. But if indicators are used to assess the ground-level situation, proximate determinants will help ascertain the confounders.

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To improve India’s data ecosystem for tracking health-related SDGs, the following steps should be taken: • Disease categorisation needs to be revised in the national surveys to incorporate diseases focused on the SDG indicator framework. In addition, having NSS morbidity rounds on the ground for a year rather than six months as done now, will curtail the seasonality bias. In the NSS, the addition of a separate question on the common NTDs that can then be linked to healthcare utilisation would allow for easier estimation of morbidity as well as economic burden. An NSS module on health covering specific morbidities can be canvassed with yearly rounds.

• Non-sampling errors that creep into large-scale surveys due to lengthy schedules, large sample sizes to ensure geographic coverage, and non-response also are a concern. These need to be addressed along with sampling errors. To improve quality of data, questions on tobacco use and alcohol consumption need to be asked directly to respective individuals rather than the head of the household in the household questionnaire.

• Information from the morbidity modules cannot be used to estimate incidence rates, as it is based on lay reporting. Similarly, many respondents might not know the names of the disease for which symptoms were presented and treatment was sought. Due to problems associated with the self-reported morbidity, verifying hospital/ambulatory care records will make the information more robust. However, supplementing self-reported illness with information on diagnosis/medication does not reflect actual prevalence as diagnosis/medication is largely conditioned by access and programme coverage. A better view of the disease situation would be provided by cautious combination of such complementary information. Additionally, to make the statistics on outpatient and inpatient visits representative at the district levels, it is worthwhile to consider pooling of central and state samples. If it is not viable to pool the central and state samples due to structural issues in the data design, another option is to generate sub-state estimates from the matching sample of the state, provided synchronicity can be established. Further, indicators can be developed by judiciously combining statistics from NSS state samples and census-based indirect estimates, especially for indicators that are not amenable to direct estimations.

• Regarding NFHS, while working with the district-level survey design, experts must be engaged to explore options, within ethical limits, to allow codes and weights to districts, blocks and households for merging them to enable some level of parliamentary constituency-level analysis. Having constituency-level health and nutrition indicators is an important step towards a re-prioritisation of public policy.

• Given that the SDG indicators are meant to monitor inequity, the known axes of inequity such as gender, class and socioeconomic status need to be monitored. For that reason, the obtained estimates must be robust for time series comparisons, especially concerning indicators that are declining, resulting in events getting rarer (which might result in the existing sample yielding estimates with wide confidence intervals). In such cases, timely revision of the the sample frame for routine sample surveys at an adequate frequency is necessary to enable reliable comparisons.

• Importantly, within the scheme of the SDGs, a lack of data, absence of benchmarking, ill-suited construction or selection of indicators that digress from goals will delay Asian Journal of Public Affairs | 2018

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the pursuits of agenda 2030. Keeping this in mind, the following table gives some recommendations to modify the draft NIF, based on the above discussion. Column three in table A3 presents the authors’ suggestion for the modified NIF. In the past, there have been various suggestions to integrate existing sample surveys in India, including by the former chairperson of the National Statistical Commission. It is important to make sure that survey data are available for analysis. If necessary, the government can leverage the Collection of Statistics Act of 2008 (Sen, 2015). With universalisation of birth and death registration and better surveillance, many fundamental challenges based on the dependence on sample surveys will disappear. However, in the interim, India’s capacity to track its health and nutrition targets will depend on whether and how national surveys, which have the potential to provide robust estimates of population health and nutrition at the district level, are streamlined. The recommendations from this paper are meant to help India harness that potential and enable regular tracking of district-level health and nutrition indicators.

REFERENCES Anand, Sudhir, and Victoria Fan. “The health workforce in India.” Human Resources for Health Observer Series (Geneva, Switzerland: World Health Organization, 2016), http://www.who.int/hrh/resources/16058health_workforce_India.

Atun, Rifat. 2014. “Time for a revolution in reporting of global health data.” Lancet 384, no. 9947: 937-8.

Dandona, Rakhi, Anamika Pandey, and Lalit Dandona. 2016. “A review of national health surveys in India.” Bulletin of the World Health Organization 94, no. 4: 286.

Gupta, Addya. Krithiga Shridhar, and Preet K. Dhillon. 2015. “A review of breast cancer awareness among women in India: Cancer literate or awareness deficit?.”

European Journal of Cancer. 51, no 14: 2058-66.

Helleringer, Stephane. 2015. Monitoring demographic indicators for the post 2015 Sustainable Development Goals (SDGs): a review of proposed approaches and opportunities. Maryland: International Union for Scientific Study of Population (IUSSP). http://www.iussp.org/sites/default/files/SDG_Indicator_ Review_IUSSP_2015.pdf.

International Institute of Population Sciences. National Family Health and Welfare (NFHS-4) India Report of Pretest. Deonar, Mumbai: 2014. http://rchiips.org/ NFHS/NFHS4/pdf/Final%20Pretest%20Report.pdf.

Krishnan, Vidya. 2016. “India under-reported TB for 15 years: WHO.” The Hindu, December 1, 2016, Sci-Tech. http://www.thehindu.com/sci-tech/health/ India-under-reported-TB-for-15-years-WHO/article16070274.ece.

Kumar, Alok and Kheya Melo Furtado. 2015. Disease Surveillance: Engaging the Private Sector. NITI Aayog, Government of India. http://niti.gov.in/writereaddata/ files/document_publication/Disease_surveillance_pvtsector.pdf.

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Kurian, Oommen C.. 2016. “Health Data Should Leave No Indian Behind,” Public Media, The Wire, 8 July 2016. https://thewire.in/49973/health-data-shouldleave-no-indian-behind.

Moreno-Serra, Rodrigo, Christopher Millett, and Peter C. Smith. 2011. “Towards improved measurement of financial protection in health.” PLoS Medicine 8, no. 9: e1001087.

NACO. 2016. “National AIDS Control Organization (NACO) Annual Report 2015–16,” Annual Report. New Delhi: NACO, Government of India, 27 July 2016. http:// naco.gov.in/sites/default/files/Annual%20Report%202015-16.pdf.

National Sample Survey Organisation (NSSO). 2006. “Morbidity, Health Care and the Condition of the Aged.” Survey Data Report. New Delhi: MoSPI. National Sample Survey Organisation (NSSO). “Chapter Three, Schedule 25.0: Social Consumption: Health,” Instructions to investigators. New Delhi: NSSO, n.d.. http://mospiold.nic.in/Mospi_New/upload/nsso/ins71chap3.pdf.

Pronab Sen. 2015. “Towards Integrating Sample Surveys in India,” Perspectives, Ideas for India for More Evidence-Based Policy (19 January 2015), http://www. ideasforindia.in/article.aspx?article_id=401.

RGI. 2017. “Causes of Death Statistics 2007–2013.” Registrar General of India; New Delhi.

Saikia, Nandita, and Purushattam M. Kulkarni. 2017. “An Assessment of India’s Readiness for Tracking SDG Targets on Health and Nutrition.” Observer Research Foundation. Occasional Paper 108.

Sethi, Vani, Chandana Mitra, Rasmi Avula, Sayeed Unisa, and Surbhi Bhalla. 2017.

“Usage, Internal Validity and Reliability of Experience-Based Household Food Insecurity Scales in Indian Settings.” Agriculture, Food and Security 6, no.1: 1-21.

Srijit, Mishra. 2006. “Suicide Mortality Rates across States of India, 1975-2001,” Economic and Political Weekly 41, no. 16: 1566–69.

Unkonw Author. “Sneak Peak: Ministry of Statistics and Programme Implementation (MoSPI)”. Blog. myGOV, 7 Feb 2018. https://blog.mygov.in/sneak-peakministry-of-statistics-and-programme-implementation-mospi/.

World Health Organization. 2015. “Health in 2015: from MDGs, millennium development goals to SDGs, sustainable development goals.”.

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APPENDIX Table A1: Health and nutrition related indicators in the Draft NIF and GIF S.No. NIF Indicators

S.No. GIF Indicators

1

2.1.1: Prevalence of undernourishment

1

2.1.1: Prevalence of undernourishment

2

2.1.2: Prevalence of moderate or severe food insecurity based on FIES 2.2.1: Prevalence of stunting (children under five years of age) 2.2.2: Prevalence of wasting (children under five years of age)

2

5

3.1.1: Maternal mortality ratio

5

2.1.2: Prevalence of moderate or severe food insecurity 2.2.1: Prevalence of stunting (children under five years of age) 2.2.2: Prevalence of malnutrition among children under five years of age, by type (wasting and overweight) 3.1.1: Maternal mortality ratio

6

6

7

3.1.2: Proportion of births attended by skilled health personnel 3.2.1: Under-five mortality rate

7

3.1.2: Proportion of births attended by skilled personnel 3.2.1: Under-five mortality rate

8

3.2.2: Neonatal mortality rate

8

3.2.2: Neonatal mortality rate

9

3.3.1: Number of new HIV infections per 1,000 uninfected population

9

10

3.3.2: Tuberculosis incidence per 100,000 population 3.3.3: Malaria incidence per 1,000 population 3.3.4: Viral Hepatitis (including A, B, C, D, E) B incidence per 100,000 population 3.3.5: Number of people requiring interventions against neglected tropical diseases (Dengue, Chikungunya, Kalaazar, Leprosy, Lymphatic Filariasis, Soil Transmitted Helminths, V. Lieshmaniasis) 3.4.1: Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease 3.4.2: Suicide mortality rate

10

3.3.1: Number of new HIV infections per 1,000 uninfected population, by sex, age and key populations 3.3.2: Tuberculosis incidence per 100,000 population 3.3.3: Malaria incidence per 1,000 population 3.3.4: Hepatitis B incidence per 100,000 population 3.3.5: Number of people requiring interventions against neglected tropical diseases

3.5.1: Coverage of treatment interventions (pharmacological, psychosocial & rehabilitation & aftercare services) for substance use disorders 3.5.2: Harmful use of alcohol (aged 15 years and older) within a calendar year in litres of pure alcohol 3.6.1: Death rate due to road traffic injuries

16

3.7.1: Proportion of women (aged 15-49 years) who have their need for family planning satisfied with modern methods 3.7.2: Adolescent birth rate (aged 15-19 years) 3.7.3: Proportion of deliveries attended by skilled health personnel

19

3 4

11 12 13

14 15 16

17 18 19 20 21

42

3 4

11 12 13

14 15

17 18

20

3.4.1: Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease 3.4.2: Suicide mortality rate 3.5.1: Coverage of treatment interventions (pharmacological, psychosocial & rehabilitation & aftercare services) for substance use disorders 3.5.2: Harmful use of alcohol (aged 15 years and older) within a calendar year in litres of pure alcohol 3.6.1: Death rate due to road traffic injuries 3.7.1: Proportion of women (aged 15-49 years) who have their need for family planning satisfied with modern methods 3.7.2: Adolescent birth rate (aged 10-14 years; 15-19 years) Not Listed

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S.No. NIF Indicators 22

3.7.4: Proportion of institutional deliveries

23

3.8.1: Proportion of women (aged 15-49 years) who have their need for family planning satisfied with modern methods 3.8.2: Percentage of women aged 15-49 with a live birth in a give reference period who received ANC four times or more

24

25 26

27

28 29

30 31

32

33

34 35

3.8.3: Percent children aged 12-23 months received three doses of pentavalent vaccine before their first birthday 3.8.4: Percentage of children with suspected Pneumonia (cough and difficult breathing not due to problem in chest or blocked nose) in two weeks preceding the survey who sought care from appropriate health facility or provider 3.8.5: Percent TB cases treated (cured plus treatment completed) among those notified to the health authorities during a specified period 3.8.6: Percent PLHIV currently receiving ART among detected number of children and adults living with HIV 3.8.7: Percent population in Malariaendemic areas who slept under an ITN the previous night and/or percentage population at risk protected by IRS during a specified time period 3.8.8: Percent population using safely managed drinking water and safely managed sanitation services 3.8.9 Proportion of population 18 & older who are currently taking antihypertensive medication among number of adults 18 years & older who are taking medication for hypertension with systolic blood pressure >= 140 mmHg, or with distolic blood pressure >=90mmHg 3.8.10 Proportion of population 18 & older who are currently taking medication for diabetes (insulin & glycemic control pills) among numbers of adults 18 years & older who are taking medication for diabetes or with fasting plasma glucose >=7.0 mmol/L 3.8.11: Proportion of women aged 30-49 who reported ever screened for cervical cancer to the total women aged 30-49 screened for cervical cancer in the last five years 3.8.12: Age standardized prevalence of tobacco use among persons aged 15+ 3.8.13: Number of OPD visits per person per year and IPD admission rate per 100 population per year

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S.No. GIF Indicators Not Listed 21

3.8.1: Coverage of essential health services

22

3.8.2: Proportion of population with large household expenditures on health as a share of total household expenditure or income Not Listed Not Listed

Not Listed

Not Listed Not Listed

Not Listed Not Listed

Not Listed

Not Listed

Not Listed Not Listed

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S.No. NIF Indicators 36 37 38 39 40 41 42 43 44 45 46

47 48

49 50 51 52

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S.No. GIF Indicators

3.8.14: Total physician, nurses and midwives per 1000 population 3.8.15: Percent health facilities with essential medicines and life saving commodities 3.8.16: Percentage of attributes of 13 core capacities 3.8.17: Poverty head count due to OOP expenditure on health 3.8.18: OOPs on health

Not Listed Not Listed Not Listed Not Listed Not Listed

3.9.1: Mortality rate due to household/ambient air pollution 3.9.2: Mortality rate attributed to unsafe water, unsafe sanitation and lack of hygiene 3.9.3: Mortality rate attributed to unintentional poisoning 3.a.1: Age-standardized prevalence of current tobacco use among persons aged 15 years and older 3.b.1: Out - of - Pocket expenditure on health

23

3.b.2: Total net official development assistance to medical research and basic health sectors NO INDICATOR IN THE NATIONAL FRAMEWORK

28

3.c.1: Total physicians, nurses and midwives per 10000 population 3.d.1: Percentage of attributes of 13 core capacities [1. National legislation, policy and financing 2. Coordination and national Focal Point Communications 3.

Surveillance 4. response 5. Preparedness 6.

Risk Communication 7. Human Resources 8. Laboratory 9. Point of entry 10. Zoonotic events 11. Food safety 12. Chemical events 13. Radio nuclear emergencies] that have been attained at a specific point in time 6.1.1: Proportion of population using safely managed drinking water services 6.1.2: Proportion of population using an improved drinking water by source 6.2.1: Proportion of population using safely managed sanitation services, including a hand-washing facility with soap and water 6.2.2: Percentage of population using basic sanitation services

30

24 25 26 27

29

31

3.9.1: Mortality rate due to household/ambient air pollution 3.9.2: Mortality rate attributed to unsafe water, unsafe sanitation and lack of hygiene 3.9.3: Mortality rate attributed to unintentional poisoning 3.a.1: Age-standardized prevalence of current tobacco use among persons aged 15 years and older 3.b.1: Proportion of the population covered by all vaccines included in their national programme 3.b.2: Total net official development assistance to medical research and basic health sectors 3.b.3: Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis 3.c.1: Health worker density and distribution 3.d.1 International Health Regulations (IHR) capacity and health emergency preparedness

32

6.1.1: Proportion of population using safely managed drinking water services Not Listed

33

6.2.1: Proportion of population using safely managed sanitation services, including hand-washing facility with soap and water Not Listed

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Table A2: Categorization of Indicators in the Draft NIF S. No.

Indicators in the Draft NIF

Categories

2.1.1

Prevalence of undernourishment

Second

2.1.2

Prevalence of moderate or severe food insecurity

Third

2.2.1

Prevalence of stunting (children under five years of age)

First

2.2.2

Prevalence of malnutrition among children under five years of age, by First type (wasting and overweight)

3.1.1

Maternal mortality ratio

Third

3.1.2

Proportion of births attended by skilled personnel

First

3.2.1

Under-five mortality rate

Second

3.2.2

Neonatal mortality rate

Second

3.3.1

Number of new HIV infections per 1,000 uninfected population, by sex, Second age and key populations

3.3.2

Tuberculosis incidence per 100,000 population

Second

3.3.3

Malaria incidence per 1,000 population

Third

3.3.4

Viral Hepatitis (incld. A, B, C, D, E) incidence per 1,00,000 population

Third

3.3.5

Number of people requiring interventions against neglected tropical dis- Third eases (Dengue, Chikungunya, Kala-azar, Leprosy, Lymphatic Filariasis, Soil Transmitted Helminths, V. Lieshmaniasis)

3.4.1

Mortality rate attributed to cardiovascular disease, cancer, diabetes or Third chronic respiratory disease

3.4.2

Suicide mortality rate

3.5.1

Coverage of treatment interventions (pharmacological, psychosocial & Third rehabilitation & aftercare services) for substance use disorders

3.5.2

Harmful use of alcohol (aged 15 years and older) within a calendar year Second in litres of pure alcohol

3.6.1

Death rate due to road traffic injuries

3.7.1

Proportion of women (aged 15-49 years) who have their need for family First planning satisfied with modern methods

3.7.2

Adolescent birth rate (aged 15-19 years)

Second

3.7.3

Proportion of deliveries attended by skilled health personnel

Repeat of 3.1.2

3.7.4

Proportion of institutional deliveries

First

3.8.1

Proportion of women (aged 15-49 years) who have their need for family Repeat of 3.7.1 planning satisfied with modern methods

3.8.2

Percentage of women aged 15-49 with a live birth in a give reference First period who received ANC four times or more

3.8.3

Percent children aged 12-23 months received three doses of pentavalent Second vaccine before their first birthday

3.8.4

Percentage of children suffering from Pneumonia in two weeks preced- First ing the survey who sought care from appropriate health facility or provider

3.8.5

Percent TB cases treated (cured plus treatment completed) among those First notified to the health authorities during a specified period

3.8.6

Percent PLHIV receiving ART among detected children and adults living Second with HIV

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Third

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S. No.

Indicators in the Draft NIF

3.8.7

Percent population in Malaria-endemic areas who slept under an ITN Second the previous night and/or percentage population at risk protected by IRS during a specified time period

3.8.8

Percent population using safely managed drinking water and safely man- Second aged sanitation services

3.8.9

Proportion of population 18 & older who are currently taking antihyper- Second tensive medication among number of adults 18 years & older who are taking medication for hypertension with systolic blood pressure >= 140 mmHg, or with distolic blood pressure >=90mmHg

3.8.10

Proportion of population 18 & older who are currently taking medication Second for diabetes (insulin & glycemic control pills) among numbers of adults 18 years & older who are taking medication for diabetes or with fasting plasma glucose >=7.0 mmol/L

3.8.11

Proportion of women aged 30-49 who reported ever screened for cer- Second vical cancer to the total women aged 30-49 screened for cervical cancer in the last five years

3.8.12

Age standardized prevalence of tobacco use among persons aged 15+

3.8.13

Number of OPD visits per person per year and IPD admission rate per Second 100 population per year

3.8.14

Total physician, nurses and midwives per 1000 population

3.8.15

Percent health facilities with essential medicines and lifesaving com- First modities

3.8.16

Percentage of attributes of 13 core capacities

Not categorized

3.8.17

Poverty head count due to OOP expenditure on health

Second

3.8.18

OOPs on health

Second

3.9.1

Mortality rate due to household/ambient air pollution

Third

3.9.2

Mortality rate attributed to unsafe water, unsafe sanitation and lack of Third hygiene

3.9.3

Mortality rate attributed to unintentional poisoning

3.a.1

Age-standardized prevalence of current tobacco use among persons Repeat of 3.8.12 aged 15 years and older

3.b.1

Out - of - Pocket expenditure on health

3.b.2

Total net official development assistance to medical research and basic Not categorized health sectors

3.c.1

Total physicians, nurses and midwives per 10000 population

3.d.1

Percentage of attributes of 13 core capacities [1. National legislation, Not categorized policy and financing 2. Coordination and national Focal Point Communications 3. Surveillance 4. response 5. Preparedness 6. Risk Communication 7. Human Resources 8. Laboratory 9. Point of entry 10. Zoonotic events 11. Food safety 12. Chemical events 13. Radio nuclear emergencies] that have been attained at a specific point in time

6.1.1

Proportion of population using safely managed drinking water services

Second

6.1.2

Proportion of population using an improved drinking water by source

First

6.2.1

Proportion of population using safely managed sanitation services, in- Second cluding a hand-washing facility with soap and water

6.2.2

Percentage of population using basic sanitation services

46

Categories

Repeat of 3.a.1

First

Third

Repeat of 3.8.18

Repeat of 3.8.14

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Table A3: List of Targets and Indicators in the Draft NIF with proposed NIF based on our recommendations Targets

Draft National Indicator Framework (NIF)

Proposed NIF

2.1: By 2030, end hunger and ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round.

Indicator 2.1.1: Prevalence of undernourishment

Low BMI for adults Underweight for children below five

Indicator 2.1.2: Prevalence of moderate or severe food insecurity based on FIES

Indicator 2.1.2: Prevalence of moderate or severe food insecurity based on FIES

2.2: By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.

Indicator 2.2.1: Prevalence of stunting (children under five years of age)

Indicator 2.2.1: Prevalence of stunting (children under five years of age)

Indicator 2.2.2: Prevalence of wasting (children under five years of age)

Indicator 2.2.2: Prevalence of wasting (children under five years of age)

3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.

Indicator 3.1.1: Maternal mortality ratio

Indicator 3.1.1: Maternal mortality ratio

Indicator 3.1.2: Proportion of births attended by skilled health personnel

Indicator 3.1.2: Proportion of births attended by skilled health personnel

3.2: By 2030, end preventable deaths of newborns and children under five years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and underfive mortality to at least as low as 25 per 1,000 live births.

Indicator 3.2.1: Underfive mortality rate

Indicator 3.2.1: Underfive mortality rate

Indicator 3.2.2: Neonatal mortality rate

Indicator 3.2.2: Neonatal mortality rate

3.3: By 2030, end the epidemics of AIDS, TB, malaria and neglected tropical diseases, as well as combat hepatitis, water-borne diseases and other communicable diseases.

Indicator 3.3.1: Number of new HIV infections per 1,000 uninfected population

Indicator 3.3.1: Number of new HIV infections per 1,000 uninfected population

Indicator 3.3.2: TB incidence per 100,000 population

Indicator 3.3.2: TB incidence per 100,000 population

Indicator 3.3.3: Malaria incidence per 1,000 population

Indicator 3.3.3: Malaria incidence per 1,000 population

Indicator 3.3.4: Viral hepatitis Children age 12–23 months (including A, B, C, D, E) incidence who have received three doses per 100,000 population of hepatitis B vaccine (%) Indic ator 3.3.5: Number of people requiring interventions against neglected tropical diseases (dengue, chikungunya, kala-azar, leprosy, lymphatic filariasis, soil transmitted helminths, v. leishmaniasis) Asian Journal of Public Affairs | 2018

Indicator 3.3.5: Number of people who sought IPD/ OPD care in the last one year/15 days for dengue

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Targets 3.4: By 2030, reduce by onethird premature mortality from NCDs through prevention and treatment, and promote mental health and well-being.

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Draft National Indicator Framework (NIF)

Proposed NIF

Indicator 3.4.1: Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease

Indicator 3.4.1: Morbidity rates for:

Indicator 3.4.2: Suicide mortality rate

Indicator 3.4.2: Morbidity attributable to mental disorders

Indicator 3.5.1: Coverage of treatment interventions (pharmacological, psychosocial, and rehabilitation and aftercare services) for substance use disorders

Indicator 3.5.1: Proportion of households reporting ganja and “other drugs” (NSS)

Indicator 3.5.2: Harmful use of alcohol (aged 15 years and above) within a calendar year in litres of pure alcohol

Indicator 3.5.2: Proportion of people usually drinking hard liquor and drinking almost every day (NFHS)

3.6: By 2020, halve the number of global deaths and injuries from road traffic accidents.

Indicator 3.6.1: Death rate due to road traffic injuries

Indicator 3.6.1: Morbidity attributable to road traffic accidents.

3.7: By 2030, ensure universal access to sexual and reproductive healthcare services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.

Indicator 3.7.1: Proportion of women (aged 15–49 years) who have their need for family planning satisfied with modern methods

Indicator 3.7.1: Proportion of women (aged 15–49 years) who have their need for family planning satisfied with modern methods

Indicator 3.7.2: Adolescent birth rate (aged 15–19 years)

Indicator 3.7.2: Women (aged 15–19 years) who were already mothers or pregnant at the time of the survey (%)

Indicator 3.7.3: Proportion of deliveries attended by skilled health personnel

Repeat Indicator. Dropped.

Indicator 3.7.4: Proportion of institutional deliveries

Indicator 3.7.4: Proportion of institutional deliveries

3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.

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a) Blood sugar level: high (>140 mg/dl) (%) b) Hypertension Slightly above normal (Systolic 140–159 mm of Hg and/or Diastolic 90–99 mm of Hg) (%) c) Self-Reported Cancer d) Self-Reported heart disease

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Targets 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

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Draft National Indicator Framework (NIF)

Proposed NIF

Indicator 3.8.1: Proportion of women (aged 15–49 years) who have their need for family planning satisfied with modern methods

Repeat Indicator. Dropped.

Indicator 3.8.2: Percentage of women (aged 15–49) with a live birth in a given reference period who received ANCs four times or more

Indicator 3.8.2: Mothers who had full antenatal care (at least four antenatal visits, at least one tetanus toxoid injection, and took iron folic acid tablets or syrup for 100 or more days)

Indicator 3.8.3: Percentage of children (aged 12–23 months) who received three doses of pentavalent vaccine before their first birthday

Indicator 3.8.3: Children (aged 12–23 months) fully immunised (BCG, measles and three doses each of polio and DPT) (%)

Indicator 3.8.4: Percentage of children with suspected Pneumonia (cough and difficulty breathing, not due to problem in chest or blocked nose) in the two weeks preceding the survey who sought care from appropriate health facility or provider

Indicator 3.8.4: Percentage of children with ARI in the last two weeks preceding the survey (%) who sought care

Indicator 3.8.5: Percent TB cases Indicator 3.8.5: Proportion treated (cured plus treatment of people suffering from completed) among those TB, medically treated. notified to the health authorities during a specified period Indicator 3.8.6: Percentage of PLHIV currently receiving ART among detected number of children and adults living with HIV

Indicator 3.8.6: Percentage of PLHIV currently receiving ART among detected number of children and adults living with HIV

Indicator 3.8.7: Percentage of population in malaria-endemic areas who slept under an ITN the previous night and/ or percentage of population at risk protected by indoor residual spraying during a specified time period

Indicator 3.8.7: the proportion of households that have an insecticide treated net

Indicator 3.8.8: Percentage of Dropped. population using safely managed drinking water and safely managed sanitation services

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Targets

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Draft National Indicator Framework (NIF)

Proposed NIF

Indicator 3.8.9: Proportion of population (18 years and older) who are currently taking antihypertensive medication among the number of adults (18 years and older) who are taking medication for hypertension with systolic blood pressure >= 140 mmHg, or with diastolic blood pressure >=90mmHg

Indicator 3.8.9: Proportion aged 18 years and above) taking antihypertensive medication among total population (aged 18 years and above) with systolic BP >= 140 mmHg or with diastolic BP >=90mmHg

Indicator 3.8.10: Proportion of population (18 years and older) who are currently taking medication for diabetes (insulin and glycaemic control pills) among numbers of adults (18 years and older) who are taking medication for diabetes or with fasting plasma glucose >=7.0 mmol/L

Indicator 3.8.10: Of those reporting diabetes, the proportion who seek treatment

Indicator 3.8.11: Proportion of women (aged 30–49) who reported ever screened for cervical cancer to the total women (aged 30–49) screened for cervical cancer in the last five years

Indicator 3.8.11: Women (aged 30–49 years) who have ever undergone examinations of breast

Indicator 3.8.12: Agestandardised prevalence of tobacco use among persons aged 15 and above

Repeat Indicator. Dropped.

Indicator 3.8.13: Number of OPD visits per person per year and IPD admission rate per 100 population per year

Indicator 3.8.13: Number of OPD visits per person per year and IPD admission rate per 100 population per year

Indicator 3.8.14: Total physician, nurses and midwives per 1,000 population

Indicator 3.8.14: Total physician, nurses and midwives per 1,000 population

Indicator 3.8.15: Percentage of health facilities with essential medicines and lifesaving commodities

Indicator 3.8.15: Percentage of people reporting ailments who didn’t choose government hospitals, because “required specific services not available” or “available but quality not satisfactory”

Indicator 3.8.17: Poverty headcount due to OOP expenditure on health

Indicator 3.8.17: Poverty headcount due to OOP expenditure on health

Indicator 3.8.18: OOPs on healthcare

Indicator 3.8.18: OOPs on healthcare Asian Journal of Public Affairs | 2018

Progress Tracking of Health-Related SDGs

Targets 3.9: By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination.

3.a: Strengthen the implementation of the WHO Framework Convention on Tobacco Control in all countries, as appropriate.

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Draft National Indicator Framework (NIF) Indicator 3.9.1: Mortality rate due to household/ ambient air pollution Indicator 3.9.2: Mortality rate attributed to unsafe water, unsafe sanitation and lack of hygiene

Proposed NIF Indicator 3.9.1: Proportion of respondents reporting Asthma

Indicator 3.9.2: Prevalence of diarrhoea (reported) in the last two weeks preceding the survey (%)

Indicator 3.9.3: Mortality rate attributed to unintentional poisoning

Indicator 3.9.3: Percentage of households reporting morbidity due to poisoning (NSS)

Indicator 3.a.1: Agestandardised prevalence of current tobacco use among persons aged 15 years and above

Indicator 3.a.1: Agestandardised prevalence of current tobacco use among persons aged 15 years and above

3.b: Support the research and Indicator 3.b.1: OOP development of vaccines and expenditure on health medicines for the communicable No indicator in the NIF and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all.

Repeat Indicator. Dropped.

3.c: Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing states.

Indicator 3.c.1: Total physicians, nurses and midwives per 10,000 population

Repeat Indicator. Dropped.

6.1: By 2030, achieve universal and equitable access to safe and affordable drinking water for all.

Indicator 6.1.1: Proportion of Dropped. population using safely managed drinking water services Indicator 6.1.2: Proportion of population using an improved drinking water by source

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Indicator 3.b.2: Percent of households incurring large expenditure on drugs

Indicator 6.1.2: Households with an improved drinking-water source 51

Progress Tracking of Health-Related SDGs

Targets 6.2: By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations

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Draft National Indicator Framework (NIF)

Proposed NIF

Indicator 6.2.1: Proportion of population using safely managed sanitation services, including a handwashing facility with soap and water

Dropped.

Indicator 6.2.2: Percentage of population using basic sanitation services

Indicator 6.2.2: Households using improved sanitation facility (%)

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Anxiety Politics in Singapore: the ‘Koro Crisis’ of 1967

Everest-Phillips

COMMENTARY

Anxiety Politics in Singapore: The ‘Koro Crisis’ of 1967 Max Everest-Phillips1 SUMMARY

Suggested Article Citation: Everest-Phillips, Max. 2018. “Anxiety Politics in Singapore: The ‘Koro Crisis’ of 1967.” Asian Journal of Public Affairs 10(2): p. 53-66.

In 1967, many Singaporeans became convinced that their sexual organs were withering away. This mass anxiety - known as Koro – presented, perhaps, the oddest challenge for public administration in the early years of Singapore’s independence. Linked to the country’s declining pig industry and Lee Kuan Yew’s personal efforts to attract foreign investment, the episode illustrates important principles for the role of public service in state-building.

http://dx.doi.org/10.18003/ajpa.20181

INTRODUCTION – SHRINKING POLITICS

Keywords: Koro, vaccination, pork, public administration, public trust, anxiety politics.

ISSN 1793-5342 (print); ISSN 2382-6134 In 2015, Singapore commemorated (online), © The Author 2018. Published by a half century of independence. It was Lee Kuan Yew School of Public Policy, National something worth celebrating. Since University of Singapore

splitting away from Malaysia in 1965, the small island city-state has enjoyed sustained economic growth, achieved long-term political stability and maintained honest government. The country’s success can, however, be all too easily taken for granted. The early days of the newly independent city-state were challenging. In 1967, Singapore’s political and administrative leadership unexpectedly confronted a ‘premodern’ public health scare that threatened their still fragile aspirations for national development. The newly independent city-state briefly suffered a mass psychogenic illness, or collective anxiety neurosis.

Hundreds of people suddenly became overwhelmed by intense alarm.

A cultural epidemic of public anxiety was triggered across Singapore by a deeply private neurosis (Tseng & McDermott 1981; Atalay 2007). Sufferers (mostly men, but sometimes women; almost entirely ethnically Chinese) suddenly believed that their genitals were disappearing. This medical condition, known as Koro, was sparked by 1 Max Everest-Phillips has been the Director of the United Nations Development Programme’s (UNDP) Global Centre for Public Service Excellence (GCPSE) in Singapore since 2013. The author contributed his article in his personal capacity. The views expressed herein are his own, and do not necessarily represent the views of UNDP. Asian Journal of Public Affairs | 2018

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a false rumour among residents of Singapore that eating pork from pigs vaccinated against swine fever caused genital shrinkage. This ailment was widely believed not only to threaten their sexuality, but also to put their lives at risk (Mun 1968; Ngui 1969).

Half a century on, in modern Singapore, this strange episode has two wellestablished interpretations. The medical literature suggests that it was an acute hysterical panic syndrome (eg. Ng 1997). Ethnographic accounts describe a cultural, non-psychopathological phenomenon of social psychology (eg. Adeniran & Jones 1994; Bartholomew 1994). Both explanations accept that excessive, disproportionate anxiety not only expresses an individual’s acute personal worries but also, as an epidemic, reflects collective neurosis. Such mass hysteria transmits shared culturallyspecific delusions through rumours and fear. It often causes people to believe that they are suffering from the same disease and manifest similar symptoms. Although the phenomenology and nosology remain unclear, these occurrences all appear to articulate deep anxiety when people feel vulnerable during a time of rapid social and economic change. That suggests a third explanatory factor: politics.

This account of the ‘Koro Crisis’ of 1967 offers the first from a political perspective. The episode is examined for its political significance, reflected in the handling by its public administration of the government’s response to socio-economic transformation in Singapore. The incident presented the then Prime Minister Lee Kuan Yew (LKY) with undoubtedly the oddest, yet potentially serious, problem to arise concerning public health during the early years of Singapore’s independence.

The event provides a bizarre, yet revealing, vignette of the challenges faced by the country’s officials in seeking to modernise national institutions. It highlights the importance of political trust for effective public administration, and of co-ordination between the different arms of a government. Furthermore, fifty years later some of the political issues remain salient. Since the comparatively poor election results in 2011, the authorities have again sought to allay the anxieties of citizens troubled by the rapid pace of change.

ANXIOUS TIMES The Koro mass hysteria began in Singapore around the middle of 1967. The immediate trigger for the delusion was alarm generated over rumours concerning unspecified health risks of eating pork from pigs inoculated with anti-swine fever vaccine. Why this worry arose at that time is unclear. Popular anxiety over the transmission of the swine fever virus from pigs to humans was first reported in medical literature in 1958. The first case of swine fever in Singapore had been detected on 8 July 1967. Within seven weeks, 57 cases involving 680 pigs were confirmed. The government responded with a mass vaccination campaign, covering about 113,000 pigs at 1,485 farms. Publicity in the press and over the radio and television advised farmers to have their pigs vaccinated as early as possible. The scientific evidence was, however, clear. Meat from vaccinated pigs posed no health hazard, so pork from such animals remained on sale.

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In 1967, there were still about 10,000 pig farms (with more than 715,000 pigs) dotted around the island. The $120 million industry was sufficient to meet the domestic demand for pork. But the Primary Production Department (now the Agri-Food and Veterinary Authority) of the Ministry for National Development (MND) was concerned that pig farming required too much intensive use of land and water – increasingly scarce resources as Singapore sought to industrialise. This policy position may explain why, in the ensuing weeks and months, the ‘urban legend’ (believed to have started, however, in rural areas) took hold that the government was hiding another threat to the existing way of life.

Before the swine fever epidemic, up to 3,000 pigs a day were being slaughtered in the state-run abattoirs. After the epidemic began, rumours about the supposed danger of eating pork from vaccinated pigs took hold. Bland assurances from the government that ‘pork is safe’ failed to convince the public. By early September, the number of pigs slaughtered daily had dropped to barely 100. Butchers could not sell the meat. Farmers did not want to sell their pigs, only to receive heavily discounted prices for the carcasses. Some pig producers, clearly hoping to save on vaccination costs, ignored government advice and accepted the risk that any pig that died as a result of the disease could not be sold.

When the impact of the swine fever outbreak was raised in Parliament on 7 September 1967, the government revealed that compulsory pig vaccination was being considered but during October, sales of pork still remained unusually depressed. These events came together and resulted in an open public health crisis on 29 October.

That morning, local newspapers broke the news that many Singaporean men had become convinced that their genitals were at risk of withering away, due to eating pork from pigs vaccinated against swine fever—and that this would eventually lead to its permanent disappearance. Sufferers from the ‘genital retraction syndrome’ often sought to prevent further shrinkage by securing their private parts with red string or wooden clamps until medical assistance could be sought.

With the fear publicly surfacing, victims of the condition rushed in growing numbers to seek medical advice. An unrecorded number of patients consulted traditional healers in Chinese medicinal dispensaries or private doctors. In addition, over 500 sufferers sought treatment at public hospitals. The records from Accident and Emergency (A&E) departments show that patients suffering from a disappearing manhood panic attack usually recovered within hours or at most a few days, either after being sedated or persuaded that the ‘illness’ was over or had never existed. The only lasting medical damage occurred in those few cases where the wooden clamps, rubber bands, chopsticks or red string that patients had tied around the membrum virile to prevent shrinkage had unduly restricted normal blood circulation (Gwee et al. 1969).

This physical risk was not the only threat. The country’s rapid urbanisation and economic transformation was also imperilled. Pig waste caused considerable pollution and was expensive to treat. By the 1980s, improved technology for safely importing live pigs and frozen pork would allow pig farming to be phased out, but in 1967 a core component of the staple Chinese diet was under threat without a policy solution. In Asian Journal of Public Affairs | 2018

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addition, swine fever, believed by then to have been eradicated in the UK, could still only be controlled in Singapore by rapid diagnosis, temporary bans on the import of pigs, and slaughter.

The MND imposed strict controls and required any pigs who died as a result of swine fever to be buried on the spot. As a result, consumers had no legitimate reason to fear that the pork that they were consuming was infected by swine fever and were also informed that meat from vaccinated pigs was safe to eat. On 3 November 1967, the MND declared that “no one in Singapore need worry over the safety of pork from pigs slaughtered at the government abattoir where every carcass is carefully examined and stamped as fit for human consumption before they are released to the market.”

The general public was, however, evidently not convinced. Far from alleviating the problem of public concern over the safety of meat from vaccinated pigs, the initial intervention by the authorities seemed to intensify public panic. Newspapers added to the scepticism, under such headlines as in the Eastern Sun on 1 November 1967: “Contaminated pork rumours strongly denied.” The minister for the MND handling the crisis then was Edmund Barker, a Cambridge-educated lawyer. He was a close personal friend of LKY and had worked for the Lee & Lee law firm before becoming the People’s Action Party (PAP) Member of Parliament for Tanglin. Criticism of the MND was therefore particularly unwelcome to LKY. He arrived back in Singapore on 2 November to find the next day that the Koro crisis was vying for attention on the front page of the Straits Times with coverage of his five-week mission abroad.

The reported Koro caseload peaked in the first week of November. On 2 November, Thomson Road General Hospital recorded eleven cases, and the following day at the Singapore General Hospital ninety-seven patients turned up. Worried parents brought their sons, and anxious mothers carried in their baby boys (Chong 1968). In one incident, a driver stopped for speeding by the police was supposedly given an escort to a hospital A&E department when the officers discovered the cause of his hurry. Female cases now also appeared, albeit in much smaller numbers.

The doctors on duty had been counselling their patients and, if unable to allay their fears, administered mild Valium tranquilisers and sedatives such as chlordiazepoxide. The spike in the number of cases and the rapidity of its spread across the island, however, now alarmed the medical profession and the Ministry of Health (MOH). The concentration of cases pointed to epidemic proportions. On 3 November 1967, newspapers ran on their front pages the MND instruction, Pork: ‘Ignore rumours’.

This uninformative order did nothing to alleviate public concern.

On 4 November, the Singapore Medical Association (SMA) announced that its experts had reviewed all the scientific evidence. The panel it had set up a few days earlier was spearheaded by Dr Ah Leng Gwee, then Senior Physician at Singapore General Hospital and Honorary Editor of the Singapore Medical Journal, who had already published a study on the cultural characteristics of the Koro phenomenon.

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The SMA’s statement was simple and its message was clear: the physicians had reviewed all the evidence and had unanimously concluded that there was no threat to humans from the current strain of swine fever, the vaccine against it, or from consuming the pork produced from inoculated pigs (Gwee 1963; Gwee 1968). Despite this re-assurance, some alarmist newspaper reporting continued. Under the headline ‘Koro hits Tampoi,’ the Eastern Sun on 5 November 1967 stated that the condition had spread across the border to Johor Bahru in Malaysia.

Over the next few days, the MOH repeated the message, which was widely covered in the national newspapers and on television. Public respect for the medical profession seemed to have been the decisive factor in calming anxiety and quelling rumours. From then on, A&E visitor numbers rapidly declined. The Singapore General Hospital caseload fell from 38 Koro patients on 5 November, the day after the first SMA announcement, to 17 by 7 November. That day, the Straits Times prominently declared that Koro was a delusion due to psychological worries and reported on another MOH press conference in which a panel of experts headed by MOH permanent secretary, Dr Ho Guan Lim, repeated the message that Koro was purely a psychological ailment caused by mass hysteria. The next day, however, the story appeared in the foreign press. The Canberra Times, under the headline KORO ‘NOT THREAT TO MANHOOD’ reported that the Singapore government was seeking to calm thousands of men who feared that their manhood was being threatened by a mysterious ailment sweeping the city.

The epidemic scare faded away as rapidly as it had appeared. The price of pork had returned to normal by mid-November and had completely disappeared by the end of the month, though occasional individual cases were reported over the following years (Ng 1997).

CULTURAL POLITICS? In China, the condition of genital retraction (suo-yang) has a long history (Tseng 1973; Tseng et al. 1988). Traditional Chinese medicine sees the cause as sexual anxiety arising from a dangerous disturbance of the Taoist yin-yang equilibrium between the heart and the kidneys. This is often due to mischievous female fox spirits, and it is treated it by acupuncture (Prince 1992). Koro was almost unknown among other races in the Malay Peninsula. Ethnic-Chinese sufferers treated by public hospitals were distributed between Chinese language (133) and English language-educated (82) roughly in proportion to the overall population, further suggesting that at that stage in development, at least, culture trumped schooling (Gwee et al. 1969). So, in 1967, Chinese-speaking doctors in Singapore declared it to be a “culture-bound” ailment (Gwee 1963; Simons and Hughes 1985; Tseng et al. 1988; Ng and Kua 1996; Chowdhury 1998; Garlipp 2008; Wing 2013). The medical profession risked being aligned with language politics.

However, the Koro phenomenon has been observed in other places and in other eras. The condition was already known in the Middle Ages in Europe, where it was widely believed that a man could lose his membrum virile through magic spells Asian Journal of Public Affairs | 2018

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cast by witches. The late medieval study on witchcraft, the Malleus Maleficarum by Heinrich Kramer and Jacob Sprenger, warned of sorceresses who “take away male members” and keep them in birds’ nests. The end of such superstition, according to Oxford historian Sir Keith Thomas in Religion and the Decline of Magic: Studies in Popular Beliefs in Sixteenth and Seventeenth Century England (1971), was the product of the intellectual spirit of scientific enquiry that came to characterise education in Europe through the Enlightenment, and which spurred the Industrial Revolution.

Many non-European states, however, achieved industrialisation without the scientific and philosophical transformation that preceded ‘modernisation’ in Europe. This left their populations still superstitious and, perhaps, less politically able to exercise critical judgment on collective anxieties (Gabrielpillai 1997).

Sir Philip Manson-Bahr, in his medical textbook Tropical Diseases: A Manual of The Diseases of Warm Climates (1960 edition), suggested that the condition, known as ‘Koro’ in Malay, had first been recorded in the region at the end of the 19th century (see also Blonk 1895). The Dutch ethnographers Nicolaüs Adriani and Albert Kruyt encountered the phenomenon in the Dutch East Indies and in 1912, proposed that the name derived from a tribe in Sulawesi bearing the name Koro (Adrian & Kruyt 1912).

The Dutch professor of psychiatry and neurology, Pieter van Wulfften Palthe, believed that the term derived from the Malayan kura (head of the tortoise) because both the Chinese and the Malays used the expression “head of a turtle” for the glans penis (Wulfften Palthe 1934; Wulfften Palthe 1936). Dr Gwee thought that the etymology of the term came from the word keruk (“to shrink” in the Malay language).

Incidents of individual cases have been recorded in contexts as varied as Britain, Ireland, Jamaica, Ethiopia, Haiti, and Israel (Durst & Rosca-Rebaudengo 1991; Garg 1968; Modai, Munitz & Aizenberg 1986). Anthropologists have interpreted the phenomenon to be an important example of the influence of culture on medical conditions (Ahmed & Bhugra 2007). The psychological disappearance of genitalia may be a universal syndrome of an obsessive-compulsive disorder and treated with psychoanalysis (Davis et al. 2012). As a result, the Koro phenomenon has been reported elsewhere since the 1967 Singapore incident in other societies experiencing sudden political shocks or undergoing rapid change (eg. Dan et al. 2016; Al-Sinawi, AlAdawi & Al-Guenedi 2008). In Thailand, for instance, Koro epidemics during the 1970s supposedly caused by pollution appear to have reflected anxiety over industrialisation (Suwanlert & Coates 1979); in Assam and West Bengal in India during the 1980s, the malady affected the middle classes, worried by rapid social upheaval and its influence on their political power (Dan et al. 2016).

Nowadays, the most frequent occurrences happen on the African continent. In recent decades, claims of genital theft accredited to sorcery have become a widespread phenomenon (Ilechukwu 1992). Among diverse ethnic and religious groups, popular delusions still command widespread respect. A study published in 2005 in the journal Culture, Medicine and Psychiatry noted that at least 56 separate cases of genital shrinking, disappearance, and snatching had been reported in the media in the past seven years across West Africa (Dzokoto & Adams 2005). In places as diverse as Nigeria (in 1990), Ghana (in 1997), Benin (in 2001), Sudan and the Gambia (in 2003), the Congo 58

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(in 2008) and the Central African Republic (in 2013), for instance, periodic episodes of collective ‘Koro panic’ have occurred in the aftermath of political turmoil. The delusion is facilitated by the underlying common belief in witchcraft. A 2010 Gallup poll found that faith in black magic is widespread throughout sub-Saharan Africa: on average, 55 percent of the people polled believed in witchcraft, and people from minorities and other politically powerless groups are regularly accused of causing penises, breasts, and vaginas to shrink or disappear (Geschiere 1997; Meyer 1998).

In Africa, the fear can be ascribed to the collective anxieties caused by rapid urbanization. In vast and growing cities like Lagos in Nigeria, often illiterate erstwhile village inhabitants suddenly found themselves rootless, living among unfamiliar cultures, and suffering economic insecurity (Ndjio 2016). Koro-type beliefs thrive where political systems fail to articulate the concerns of rapidly changing societies and address their needs. This can have deadly consequences, when the supposed perpetrators of genital thefts are lynched on the spot by “street justice.”

THE POLITICS OF MODERNITY Managing modernisation effectively, therefore, is a profoundly political process (Piot 1999). While the Koro phenomenon itself was not unknown in 1967, the Singapore episode was significant as the first reported epidemic of the disease.

An article in the Singapore Medical Journal published in December 1969 by local doctors reviewing the epidemiology of the outbreak two years earlier described it as a disease characterised by psycho-dynamics. Subsequent research has demonstrated that outbreaks highlight the complex interplay between the psychic and the cultural aspects of symptomatology (eg. Crozier 2011). The ailment seems to occur at times of political tension, accompanied by socio-cultural, psychological-psychiatric and organicneurological triggers, such as improving gender equality (Tan 2010; Bures 2016). Some even argue that LKY’s paternalistic politics deliberately fostered crises. The alleged aim was to generate a widespread psychosis that strengthened the PAP ideology of ‘survivalism’ (eg. Ortmann 2009).

This incident, however, potentially posed a threat to LKY’s ambitious plans for modernising the country – he had been overseas seeking to attract foreign investment when the Koro crisis erupted. Singapore in 1967 was at a significant stage of development. Partly ‘modern,’ especially in the widespread use of English as the language of Western education, many in the country nevertheless also remained ‘premodern,’ reflected in the use of colloquial Chinese and vernacular Malay, as well as the prevalence of popular folk beliefs and traditional cultural attitudes. The potential impact of the Koro episode on the country’s long-term development strategy was serious. A bizarre ‘pre-modern’ culture-bound ethno-psychiatric syndrome could imperil Singapore’s political ambition to attract foreign investment and tourism. The idea that the Singaporean labour force was subject to such beliefs would contradict the image of modernisation which depended on government efforts to attract American and European multinational companies. Foreign investments were then needed to create the jobs required to tackle unemployment and foster political stability. Mass hysteria in factories, within a few years, did indeed affect Singapore. In January 1973, Asian Journal of Public Affairs | 2018

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the General Electric factory in the Kallang Industrial Estate suffered a disruption to its TV assembly lines from mass hysteria among Malay female employees troubled by ghosts.

Today, the traditional local community ‘kampong’ life of the 1960s is often described in nostalgic terms. The reality was less benign. Rigid conformity, entrenched social hierarchy and the comparative isolation of village life often fostered divisive politics. While some three-quarters of Singapore’s population were of Chinese descent, the rest of Malaysia had a majority of Malays, with ethnic Chinese comprising about 37 percent of the population and ethnic Indians another 10 percent (according to the 1971 Census). In such a context, rumours spread rapidly in Singapore about Malay atrocities planned against the ethnic Chinese population in Malaysia, and in Malaysia of imminent Chinese rioting that required Malays to strike first (Conceicao 2007).

Such rumours are most liable to spread and appear credible at a time of international or domestic tension, and their political dynamics deserve more attention (Kapferer 2013; Coast & Fox 2015). In August 1964 for example, LKY presciently warned against rumours of ethnic threats as a significant cause of ‘pre-emptive’ or revenge violence in the fraught racial politics of Singapore. Just a few weeks later, when a Malay trishaw rider was stabbed to death at Geylang in September 1964, rumours that the murder was the racially motivated work of the Chinese secret societies triggered five days of communal rioting that left 12 dead and over 100 people seriously injured.

The Malay minority in Singapore had been urged by the United Malays National Organisation (UMNO) to demand special political rights in Singapore, in opposition to the ideology of a Malaysian Malaysia or that of racial equality as espoused by LKY’s government. An inflammatory ‘urban legend’ developed, fostered by the Chineselanguage press speculation that Malay butchers in Singapore were covertly killing off Chinese males. As a result, racial attacks and apparently at least one murder occurred.

That the delusion of emasculation in Singapore in 1967 was ascribed to eating pork, and that 98.2 percent of patients recorded were ethnic Chinese (95 percent males and 3.2 percent females), further suggested a politically contentious connection to religious divides and racial tensions. Only three years earlier, serious race riots had broken out in Singapore. 36 people were killed and over 500 seriously injured. The government clamped down hard: thousands were arrested, including many members of Chinese secret societies, and curfews were imposed. The fear of further racially motivated violence remained a deep concern in 1967. Barely eighteen months after the Koro crisis, a race riot in Malaysia against ethnic Chinese triggered a reaction in Singapore against Malays. Four people were killed and eighty wounded. LKY believed the violence to have been politically motivated and blamed the UMNO Secretary-General, Syed Jaafar Albar, and the Malay language nationalist newspaper, Utusan Melayu.

LESSONS FOR PUBLIC ADMINISTRATION What insights, then, can be derived from the events of 1967 for public administration and development? The first lesson from the Koro episode is the importance of ‘whole of government’ co-ordination. The vaccination campaign against swine fever was implemented by the Primary Production Department of the 60

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MND. The director of the department, Cheng Tong Fatt, despite (or on account of) being a trained veterinarian, evidently struggled to win the trust of pig farmers. He had brought swine fever under control but was clearly frustrated that its complete eradication was thwarted by ignorant farmers adopting a ‘wait-and-see’ attitude to the epidemiology, instead of following the scientific advice and getting their pigs vaccinated as soon as possible. Such pig-breeders were mainly people with either no or limited education who felt their small-scale livelihood was under threat.

The subsequent Koro epidemic and the public’s trust in the SMA and MOH ultimately resolved the resistance to the vaccination campaign. In 1967, the MND’s veterinary experts from the Primary Production Department were regarded with suspicion by some pig farmers, and thus apparently lacked credibility with the citizens.

As a result, official efforts to halt the swine fever vaccination rumours through public education using scientific evidence failed. By contrast, the SMA and MOH doctors had evidently established the trust of their patients, and their factual non-emotive guidance was believed. People evaluated individual and collective risk against the perceived reliability of public institutions, and evidently trusted Western medicine even while the threat was premised on traditional Chinese beliefs that the penis could shrink under certain conditions of ill health. The medical authorities were able to build on the trust that the public had in doctors, in order to bring the epidemic under control. The government learnt the importance of clear messages. One possible source for the crisis may have been inadvertent comments by an official at the MND about the anti-swine fever vaccine.

A second lesson from the episode is that any immunisation campaign an essential ‘public good’ to reduce the collective threat posed by communicable diseases - requires public trust in both the government and science. The early efforts at building trust in public health in Singapore have implications for public administration everywhere. Such trust is strongest within social groups, while distrust often prevails across different social divides. As society becomes more complex, people are increasingly reliant on the quality of public administration. On the basis of trust and common values, societies learn to delegate their collective protection to public authority. Technical solutions can only work in context, even during a public health crisis.

Since 1967, the government of Singapore has improved its approach to public fears about health crises. But the political context has also sheltered public health administration from public criticism. One example was the outbreak of severe acute respiratory syndrome (SARS) in Singapore that occurred in February 2003. 33 people died before the country was removed from the World Health Organization’s list of SARSaffected areas on 31 May 2003. The strategy involved educating the public on the disease while the MOH invoked the Infectious Diseases Act on 24 March 2003 to quarantine and monitor all SARS patients. The use of infra-red scanners and home quarantine surveillance cameras was an important technological breakthrough. Airlines operating flights to Singapore were required to screen passengers. Visitor arrivals and hotel occupancy rates plunged, revenues at shops and restaurants dived, taxi drivers reported fewer passengers, the stock market fell, and some people lost their jobs. At the height of the outbreak in mid-April, the government cut Singapore’s economic growth forecast for Asian Journal of Public Affairs | 2018

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2003 from 2 to5 percent, to 0.5 to2.5 percent. During the April-June quarter, when the full impact was felt, the economy contracted sharply, by 4.2 percent. The government announced a S$230 million relief package on 17 April, specifically to help affected sectors.

The politics of trust influences policy effectiveness. When politics and science get badly intermingled, public trust in the authorities can quickly evaporate in ways that do not help improve public policy. Tan Tock Seng Hospital held its Annual Dinner and Dance as scheduled on 14 March 2003, even though the World Health Organisation had issued a global alert, and the hospital had alerted the MOH to a rare infection not responding to antibiotics. The landmark research papers published in the world’s premier medical journals such as The Lancet came from Hong Kong, not Singapore, even though the outbreaks occurred in both places at about the same time. In other political contexts, there might have been more media criticism of such limitations.

A parallel can be drawn with two other politically sensitive public health scares shaping and shaped by citizens’ trust elsewhere in government, both of which occurred in the UK. First, in the 1980s, was the fact that officials sought to hide the public health implications of the outbreak of Bovine Spongiform Encephalopathy (BSE) (popularly named ‘Mad Cow Disease’). When the dangers became known, public confidence in ministers and public servants plummeted.

Then, in 1998, the influential medical journal The Lancet published research that seemed to suggest that autism in children was linked to the combined measles, mumps and rubella (MMR) vaccine. Although the research was soon discredited, serious damage was again done to public confidence in the government’s stewardship of public health. Skeptical parents thought the Government’s approach to be ‘defensive’ and too heavy-handed. Many parents perceived the MMR debate to be a political issue, and they did not trust politicians. British ministers’ earlier mishandling of the BSE crisis seriously undermined parents’ confidence in ‘political’ pronouncements related to health. As a result, the government’s emphatic support for the MMR vaccine apparently diminished, rather than restored, UK public confidence. Broader politics also shaped citizens’ trust. The widespread perception that the prime minister had lied about the justification for the war in Iraq undermined belief in the integrity of his government (Critcher 2007). Official strategies that were perceived as emotional manipulation into immunising proved damaging to the credibility of the medical authorities.

The third lesson is the role of education. An informed citizenry is essential to an effective polity. With the adult literacy rate having improved from 73 percent in 1965 to almost 100 percent in Singapore today, it seems that kongtow, or the traditional Chinese belief in magic, has waned. This makes it inconceivable that a similar outbreak of mass hysteria could happen today. But education itself is not sufficient to ‘modernise.’

Indeed, in the episode in Singapore, only 5 percent of those patients who agreed to a follow-up interview (some 236 out of the 469 tracked) were uneducated. Today, a better educated population might be more skeptical of the government and the media.

In 1967, television underpinned the credibility of the public health message. Although televisions were still new (service began in 1963), it was widely trusted and seen as

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speaking directly to every viewer, thereby helping forge national identity (Lewis & Martin 2010).

The Koro hysteria reflected potentially explosive racial aggravations and religious sensitivities at a politically difficult moment, both domestically and internationally. In July 1967, Britain had announced the withdrawal of its military presence in Singapore, threatening both the country’s security and its economy, with 20 percent of national income being derived from the military bases. Although Indonesia’s Konfrontasi campaign had started to ease in 1966, the politics in Jakarta remained uncertain. Singapore’s small size, its lack of natural resources, and its location as a predominantly ethnic Chinese enclave surrounded by Malaysia and Indonesia, posed threats from which Singapore’s post-colonial leaders constructed a national identity and so legitimated the ideology of ‘survival’ (Ortmann 2009).

The collective neurosis that the episode revealed reflected dis-empowerment and the lack of adequate political ‘voice’ or influence at a time of political instability.

When the hysteria appeared to be growing, with the authorities uncertain on how to respond, the political credibility of the government was threatened. Even if the PAP intuitively fostered crises to generate a widespread collective psychosis, nevertheless, an effective interface between a country’s political and administrative leadership proved critical to address public concerns at a time of upheaval and transformation.

The challenge was not of medical science but, at a time of deep concern over rapid social change, of public trust in the authority of the state (Gwee et al. 1969).

CONCLUSION: THE POLITICS OF CHANGE AND UNCHANGING POLITICS The early days of independence were politically anxious times. Singapore then was a country plagued by existential doubt. Small and insecure, it had been suddenly expelled from the Malaysian Federation. The Communist threat, the ‘confrontation’ with Indonesia, and the ongoing Vietnam War meant that national survival in the 1960s was not guaranteed.

That climate of existential anxiety triggered the ‘Great Singapore Penis Panic’ of 1967. The fact that this mass hysteria was prompted by a veterinary vaccination policy and focused around public health also suggests a fear of modernity and, at least in the farming community, an evident ambivalence to public authority in the immediate post-colonial era. The root causes were, therefore, at once psychological, socioeconomic and cultural, all of which were well covered in the burgeoning literature on the episode, but above all political. This paper offers the first analysis of the 1967 Koro epidemic as an early test of the newly independent state’s political responsiveness to public concern.

Singapore’s capacity to embrace constant change is nowadays regarded as an essential characteristic if the country is to survive and thrive in the 21st century.

Today’s Singapore, constantly encouraged by the government to embrace innovation, can perhaps laugh at the events of 50 years ago. In retrospect, even LKY might have Asian Journal of Public Affairs | 2018

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been amused. 30 years later, Dr Gwee remembered the episode as the oddest moment in his distinguished medical career. He recalled how a touch of humour about the effect of cold weather on the male organ had helped to dissipate his patients’ anxiety around the shrinking Singaporean penis.2 Indeed, for cheap laughs, the 1967 incident in Singapore has periodically also attracted international prurient curiosity. The episode was the subject of a 2011 book written by US psychiatrist Scott Mendelson with the low-key title, The Great Singapore Penis Panic and the Future of American Mass Hysteria. Perhaps unsurprisingly, this publication was shortlisted for the Diagram Prize for Oddest Book Title of the Year.

The cause of ‘Koro epidemics’ is ultimately political – and serious. The disease reflects the worry that citizens of a country can feel at being powerless in the face of rapid social change and economic transformation. Although clinicians diagnosed sexual and bio-cultural causes arising from interpersonal difficulties and intra-psychic conflicts, the political context of 1967 could hardly have seemed worse. Modernisation was resisted, and urbanisation resented; domestic and international anxieties were profoundly troubling. As a result, the ‘Koro Crisis’ posed a potential challenge not just to the credibility of LKY’s PAP government, but also to the competence of its public administration.

Some two generations later, public disquiet about the speed of the country’s transformation resulted in a comparatively marked decline in electoral support for the ruling PAP government in the 2011 general election. In response, the government launched the ‘Singapore Conversation.’ One significant political worry then was, and remains, the country’s declining birth rate, the subject of an unusually contentious White Paper in 2013. Half a century on from the panic, to the strategic planners in the Prime Minister’s Office, the ‘black swan’ existential threat of another ‘Koro epidemic’ in Singapore is probably no laughing matter.

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COMMENTARY

Innovation for Human Well-being and Security: Perspectives from the Next Generation of Global Health Leaders Gianna Gayle Herrera Amul1*, Fiona Leh Hoon Chuah2*, and the Raffles Fellows Acknowledgements The authors would like to thank the Raffles Fellows for sharing their reflections during the Dialogue. The authors would also like to thank Professor Tikki Pang and Associate Professor Helena Legido-Quigley for their thoughtful Keywords: global health, Raffles Dialogue, suggestions on this commentary. innovation, youth, trust, leadership, Asian

The 2017 Raffles Fellows are Angelina Arulraj, Jane Lim, Claus Kao-Chu Soong, Gianna Gayle Herrera Amul, James Guild, Jinwon Lee, Boon Piang Cher, Saravanan Sugumaran, Parmeet Kajal, Reuben Ng, Francisco Cervero-Liceras, Aastha Srivastava, Joel Jun Kai Koh, Matthew Godfrey Reinert, Kah-Hong Yuen, http://dx.doi.org/10.18003/ajpa.20182 Dymples Leong, Si Ying Tan, Arif Budy ISSN 1793-5342 (print); ISSN 2382-6134 Pratama, Fiona Leh Hoon Chuah, Victoria (online), © The Authors 2018. Published by the Elizabeth Haldane, Shweta R Singh and Lee Kuan Yew School of Public Policy, National Suan Ee Ong. Suggested Article Citation: Amul, Gianna Gayle Herrera, Chuah, Fiona Leh Hoon and the Raffles Fellows. 2018. “Innovation for human well-being and security: Perspectives from the next generation of global health leaders” Asian Journal of Public Affairs 10(2): p. 67-70.

University of Singapore

INTRODUCTION The world has entered a new era of development, guided by a set of aspirational global goals encapsulated in the 2030 Sustainable Development Agenda.

Central to achieving this universal agenda is the imperative for transformative change and innovation in addressing the myriad of challenges facing the global community in achieving sustainable and equitable human development. Such was the topic of the 2nd Raffles Dialogue held from September 4-7, 2017 in Singapore that gathered global opinion leaders to discuss the critical role of innovation for human well-being Lee Kuan Yew School of Public Policy, National University of Singapore.

Saw Swee Hock School of Public Health, National University of Singapore. *Co-first authors.

Corresponding author: Gianna Gayle Herrera Amul (giannagayle@nus.edu.sg).

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and security in 2030, and to elevate policy recommendations for achieving these goals. This year, the Raffles Dialogue provided a unique and novel platform for the younger generation to participate in the overall discourse through its very own Raffles Fellowship. As hopeful and committed leaders in the future of global health, this first cohort of Raffles Fellows contributed a set of key reflections on the Dialogue’s theme summarised in this commentary.

ENGAGING YOUTHS IN INNOVATION A core theme that emerged from the reflections of the Raffles Fellows was on the importance of engaging youths in innovation. The global challenges of today are complex and multidimensional, requiring solutions that are both innovative and sustainable. The need for addressing these challenges across generations is evident, which demands a continuous investment in youths as dynamic and creative sources of innovation and as agents or catalysts of change. Tapping on the creative minds of the younger generation can yield fresh and novel ideas and ensure continuity in innovation for solving the world’s challenges for the future of human well-being and security. Beyond institutional innovations for better governance and human resources in global health and development, it is critical that tangible interventions are devoted to involving youths, giving them a voice and preparing them in their personal and professional development to engage meaningfully in future leadership roles.

Fundamentally, more platforms for youth engagement is needed to allow greater accessibility to opportunities in innovation. As the world strives towards becoming an inclusive society for sustainable development, it is especially important to extend these opportunities to vulnerable groups and those in low and middle-income settings who may not have equal access to participate in policy and academic dialogues. Importantly, these platforms ought to embody an environment where healthy, participatory and relatable communicative exchanges of new ideas can take place among youths and others at the local and global level. In addition, the younger generation may be better placed to take full advantage of advances in information and communication technologies and digital social media to develop such platforms in the future.

BRINGING BACK THE HUMAN FACTOR IN INNOVATION As members of the younger generation who are inherently acquainted with the advancements in digital media and technology, the Raffles Fellows assert that it is vital to take into account the human factor in all innovations. In our world of technological advances, digital solutions such as mHealth, health IT, wearable devices, telehealth and telemedicine have been used extensively as innovative mediums to improve healthcare access, reduce cost, personalise care, prevent disease and improve health.

Similarly, despite the intergenerational and development gaps across the developed and developing world, social media has been used as a productive tool to disseminate information, generate public discourse, regulate public opinion and galvanise global governance on health issues. However, the use of these platforms is constantly evolving alongside fast-moving modernizations in the realm of digital media and technology,

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hence the need to constantly reflect on the utilization and personal experience of our target users in driving forward health innovations.

Importantly, as a youthful intellectual community, we must deliberate on how to ensure more equitable access to the health innovations we pursue. Delivery in health innovations should encompass the consideration of whether our beneficiaries particularly the vulnerable and voiceless such as children, the elderly, the disabled, the marginalised and those living in poverty - have the necessary social, educational, cultural and economic capital to fully benefit from our innovations. Innovation to improve human health and well-being should therefore be centred on the very people who are the intended beneficiaries of such innovation and they too need to be meaningfully included in the conversation. Ultimately, the outlook of effective and impactful innovation hinges on our duty to be cognizant of the human factor in innovation.

BUILDING TRUST TOWARDS INNOVATION Measuring and monitoring the impact of innovation to ensure that we “do the right thing right” was another theme that the Raffles Fellows identified as key in innovation for human well-being and security. This is where the issue of trust in reliable and transparent processes, and accountable leadership - whether in governments, the private sector or civil society - becomes critical in spurring the “right” innovations.

Measurable outcomes and the utility of data-driven and evidence-based innovations are vital, and although the social and psychological impact of innovations on well-being are less quantifiable, it is equally important to account for, and develop, these indices.

In addition to creating incentives to collect data, there is also the need to build trust in sharing data through collaborative information-sharing platforms. The trust that drives political efficacy thus becomes a viable indicator that lends political, economic and social value to the public’s engagement in policy processes and innovations. If innovations are to become global social goods, then trust is the currency.

Innovations that rely on the stability of critical infrastructures and developed health systems that are successful in high-income countries, can fail in low-income settings where health systems are still developing or transitioning, or are in a fragile state. In low-resource settings, the challenges for data-driven innovations range from lack of data and infrastructure to capacity gaps. Therefore, it is not enough or may even be counterproductive to introduce innovations from other settings without appropriate contextualization as there is no one-size-fits-all solution to global health challenges exclusive of the flexibility of adapting to the specific context they would operate.

Innovations that come from the ground-up not only have planted the seeds of trust right from the start but also enables innovations to be tailored to the communities’ needs and capacities.

AN ASIAN PERSPECTIVE ON INNOVATION FOR HUMAN WELL-BEING AND SECURITY Asian experiences also emerged as a point of reflection for the Raffles Fellows.

What makes Asian experiences distinctive, is that the region includes countries at various Asian Journal of Public Affairs | 2018

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stages of health development, from developed to developing to transitioning health systems. The relatively younger or transitioning health systems in most developing Asian countries enable the establishment of testbeds or living laboratories that draw lessons from both the success and failures of more developed Western countries, and the sharing of experiences between these countries. Along with these transitions, the region has also brought to the global stage a proliferation of new actors in global health with new and innovative ways of convening and collaborating across sectors. Evidently, new innovations can flourish from the adaptations of the lessons learnt globally, and in this regard, Asian states too have much to contribute in offering innovative solutions for human well-being and security at the global stage.

However, there is a need for more voices from the region to be heard in this topic area - not merely from “Western” observers or scholars based in the region - but more so from Asian experts and scholars from the region itself, to elevate the discourse to converge on more realistic challenges and pragmatic lessons from their own countries’ successes and failures. This is where the concepts of ownership, community and mutual assistance become more pronounced - where Asians shape and direct their own health development pathways, and where there is cautious optimism in applying the lessons from the Western world - towards engendering the “Asian way” of working based on mutual respect in tackling issues that affect human well-being and security. The Raffles Dialogue can thus engage more opinion leaders from Asia in its biennial convenings to serve as the ideal platform for Asia’s current and future global health leaders.

CONCLUSION The future of human well-being and security is contingent upon our ability to promote transformative change and innovation in overcoming the challenges of achieving global sustainable development. To attain this aspirational goal, we need continuous efforts in engaging and nurturing the innovative minds of our younger generation as leaders of tomorrow. For sustainable and equitable human development, we must ensure that the human factor is central to all our innovations and that trust towards these innovations is built on the basis of inclusive and transparent processes driven by accountable leadership to ensure innovations are transformed into global social goods. From the Asian perspective, it is clear that the region has a lot more to offer in contributing to the dialogue on improving human well-being and security, and in providing innovative solutions that are contextually appropriate for the region.

Overall, we believe that the Raffles Dialogue can promote further academic and policy discourse to achieve a better future for the betterment of human well-being and security.

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COMMENTARY

On the Ways of Knowing and Understanding Informality Deepanshu Mohan1, Richa Sekhani2, and Arun Kumar Kaushik3 SUMMARY In the mainstream international development discourse, one often finds a general dualistic outlook in classifying the concept of (urban) informality, seen to be strikingly different from the formal, regulated economic arrangements.

Keywords: Fintech, regulation, finance, policy, Earlier definitions explaining informality technology in context of market arrangements across Suggested Article Citation: Mohan, Deepanshu, the Global south often failed to present Richa Sekhani, and Arun Kumar Kaushik. 2018. a cohesive, inclusive framework vital “On the Ways of Knowing and Understanding for analysing (urban) informal, socioInformality.” Asian Journal of Public Affairs economic arrangements as an integral 10(2): p. 71-79. part of rapidly urbanizing developing economies. This essay seeks to examine http://dx.doi.org/10.18003/ajpa.20184 the extent of this epistemological conflict while reviewing some of the ISSN 1793-5342 (print); ISSN 2382-6134 classical studies on urban informality. (online), © The Authors 2018. Published by the We argue how an inclusive framework Lee Kuan Yew School of Public Policy, National to urban policy planning is needed to University of Singapore avoid a broader generalization of the subject. Since the developing countries of South and South East Asia constitute a large share of workers being employed in the informal market arrangements; an inclusive perspective in understanding informality is warranted and emphasised upon in this essay.

INTRODUCTION Over the last few decades, the existence of informal market segments across countries of the developing Global South (as well as in some cities of the Developed North) has become an intriguing subject of scholarly exploration. Studies have attempted to understand the nature, form and gradual expansion of unregulated, 1 Centre for New Economic Studies, Jindal School of International Affairs. O.P Jindal Global University, Sonipat Narela Road, Sonipat, Haryana-131001.

2 ICRIER, New Delhi.88C, Press Enclave Marg, Khirki Extension, Khidki Village, Malviya Nagar, New Delhi, Delhi 110017.

3 Jindal School of Liberal Arts and Humanities, O.P Jindal Global University, Sonipat Narela Road, Sonipat, Haryana-131001.

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informal market spaces (as part of the informal economy4) as against the regulated, formal market structures in developing economies.

To study the role and normative reasoning behind urban policy formulations, we view policy as a functional expression of an epistemology or as a way of knowing, to indicate that policy approaches are not only techniques of implementation but also ways of knowing (Roy 2005).

In most countries, the state tends to design urban policies (with respect to market regulations, property ownership etc.) in ways that present a dualist view on formality-informality across socio-economic arrangements,5 i.e. considering them to be mutually exclusive from one other. There are two different emerging views on understanding (urban) informality from the recent academic discourse.

This essay reviews some of the classical studies explaining the concept of urban informality to (re)visit the dualist view and link it with a more inclusive perspective in understanding informality, drawn from empirical research. In the later part of the essay, we briefly discuss the Indian informal economy and emphasize the need for Indian states to take a more inclusive view towards designing urban policies while accommodating for social structures and human agencies (existing in the informal economy) as part of an overall economic structure.

The literature on informality can be broadly classified into two sets of academic discourses. The first discourse tends to highlight the distinctive aspects of both formality and informality (Hart 1973; Giddens 1984; Santos 1979; Jenkins 2001) and operationally views both formality and informality in isolation. We term this the dualist view.

The second discourse, drawing upon empirical findings from different socioeconomic arrangements in developing countries (Portes 1983; Bhowmick 2005; Roy 2005; Daniels 2004), challenges this dualistic view and sees informality in a more inclusive way. We classify this as the inclusive view. Unlike the hostile policies under the dualistic discourse that favours formal arrangement and norms that embraces control and order and puts premium on legality, image building, and efficiency at the expense of economic needs and welfare of the affected populations, the inclusive view on (urban) informality accommodates for a hostile orientation of the labour markets and complexities present in the understanding of structure-agent relationships, within socio-economic arrangements present in different societies.

International Studies identify more than thirty different names for the term “informal economy”, including terms like parallel economy, black economy, shadow economy etc. For a simple understanding, we refer to informal economy as one, that encompasses all synonymous references to a part of the economy which generates income for residents (who are part of it) outside the regulatory principles set by the state (i.e. rule of law) and lies outside the purview of reporting to any tax authorities.

5 The word “socio-economic” often remains loosely used across various social science literature and prevalent public policy discourse. In context of understanding the concept of informal economy, we use the term using a more structural approach, explaining the presence of informality in social structures (example, economic policies) and human actions (example, resistance) and the inter-linked relationship between them.

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The development of an inclusive view on studying urban informality (and its forms) remains evident from a closer reading of few recent studies (Waibel 2016; Recio 2017; Roy 2005; Bhowmick 2005; Chen 2005). Thus, in the intellectual exercise of theorizing informality in developing countries, there is a stronger emphasis on expanding the ways of knowing informality from different endogenous cross-country narratives, to avoid broader generalizations on the subject. This is vital for a robust urban policy making process.

THE DUALIST VIEW The early informality literature in the field of international development studies and economics developed in the early 1970s to explain the differences in the nature of economic systems and socio-economic arrangements present in the developing Global South as against the developed Global North.

While studying the nature and form of informality existing in the socio-economic arrangements within developing economies, scholars like Hart (1973) invoked a dualist view by identifying formal and informal operational arrangements as independent of one another. The categorization of the formal from the informal was done in terms of regulatory principles (i.e. rule of law) and labour standards, distinguishing highincome earning opportunities as part of a formal market set up and low-income waged opportunities as part of an informal market set up.

British anthropologist Keith Hart6 formulated the concept of the informal sector in his study on low-income activities amongst low-skilled migrants from northern Ghana to the capital, Accra, who could not find wage employment According to his study, the informal economy was the outcome of the dualistic tendency of the urban labour market, where despite facing external constraints, internal migrants in Accra were able to engage in “informal activities” (such as farming, gardening, shoemaking, working as street hawkers etc.) for their livelihood and sustenance.

Although the nature of work for most of these migrants existed somewhere between open unemployment and formal sector employment, Hart noted that migration was not the only factor responsible for the growth and persistence of the informal economy in developing societies. In adopting a wide-ranging employment inquiry scale, he described the presence of informal activities from marginal operations to large enterprises which were seen to be categorized as legitimate and illegitimateform of activities. This dual conceptualization of informal (illegitimate) and formal (legitimate) activities saw them as being mutually exclusive in an employment landscape where even “self-employed” work was seen under the domain of informality.

Later, with a study of informal market arrangements in different Latin American and Caribbean economies, Tokman (1978) studied the interrelationship between the regulated, formal sector and the rest of the economy. Tokman accepted some of the 6 The study on Kenya was published by the International Labor Organization (ILO) in 1972 which mentioned the term “informal economy” for the first time.

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apprehensions of Hart and sought to examine whether the reserve army of unemployed and underemployed constitutes itself as a passive, exploited majority of the informal sector. He also explored whether the sector can sustainably create employment for other people in the future. He identified the informal economy to be restricted in its growth potential because of the scope of market competition in formal, regulated sectors of the economy.

However, in current scenario, we see how the growth of informal markets and the informal economy has expanded across developing countries and have even found a way in parts of cities in the Global North (Daniels 2004; Crossa 2009; Recio 2010).

The dualist view of the formal and informal sector was further expanded by Moser (1978), Santos (1979), and Sethuraman (1981), amongst others. These authors observed that firms, in their process of reducing inputs and labour costs, pushed workers out from formal sector employment to the informal sector, which emerged as part of a survival strategy for poor, low-skilled labour. The shift in the labour force signals a disdain for the tight rules and regulations imposed earlier by the state for sustenance needs (i.e. in areas of land acquisition, property ownership, granting of licenses for new enterprises etc.), ultimately leading to the expansion of the informal economy.

This dualist view on formality-informality views the informal sector as an economic reality of low-waged, low-skilled labour (emerging from a lack of formal employment opportunities) that requires “formalization� with policy intervention as it has limited growth potential. The distinction seen in such conceptions of formality and informality in developing economies depends on the degree of adherence to regulatory principles (i.e. state rules or rule of law), evident from policy matters of income generation, property rights, taxation etc.

THE INCLUSIVE VIEW The second discourse on informality takes a more inclusive view to explain the causes, consequences, and form of the informal sector in developing economies (Cooper 1987; Portes 1989; Jenkins 2001; Daniels 2004; Bhowmik 2005; Roy 2005; Anjaria 2006).

As noted in a 2002 study published by the Economic Social and Cultural Rights (Asia) Association (Recio 2017): The perceived difference between the formal and informal economy is, in reality, artificial in nature. There exists only one national economy with formal and informal livelihood approaches. Those that are seen as formal economies are capital-intensive and growth-based, while those that are seen as informal economies are labor-oriented and peoplecentered. However, the truth is that these basically interact with one another under a single economy. The perceived difference lies in the fact that there is a lack of awareness and/or understanding of the mutual dependency of these two aspects of the economy.

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Rezio et al. (2017) compare countries including Bangladesh, India, China, Thailand, Vietnam, Mexico, and Brazil using this inclusive view, emphasizing how a structuralist, inclusive lens can support a better understanding of the different government approaches to urban informal vending. The structuralist lens (explained below) used in their study employs the framework of “structuration theory” associated with the Giddens (1984) and Archer (1995). Rezio et al. note that the interlinked view of structure and agency is vital to informality because it captures how social structures and human actions form the causes, consequences, practices and benefits of informal transactions.

Thailand presents a useful example to understand the importance of informal markets in supporting employment. Warunsiri (2011) argues that as a result of Thailand’s development policy and the limitation of the formal sector in absorbing excess labor supply, the informal sector has played a distinct role in supporting the Thai labor market. The government seems to have taken an inclusive view on informality.

In particular after the economic crisis of 1997, there has been a high degree of labor mobility into the informal sector.

The inclusive view on understanding the informal economy emphasizes the need to adopt a “post-dualist lens” to see informality in conjunction with formality, using methods for policy approaches to accommodate for existing, fragmented labour orientation scenarios across developing societies, where labour markets are still evolving. This is critical in designing robust urban developmental plans and policies in (developing) cities.

THE INDIAN CONTEXT Given the size of developing countries in South and South-East Asia, it remains pertinent to study the governing dynamics of urban informality in these contexts. The informal economy constitutes more than half of the non-agricultural employment base in most developing countries, and as much as 82 per cent in South Asia (WEIGO), capturing a large share of economic units and workers that remain outside the sphere of regulated economic activities and protected employment. India represents a good example to study informality, given its population size and the traditional informal sector. Keeping aside the complexities involved in measuring informal employment statistics in countries like India (and elsewhere), Rustagi (2015), on observing the employment data in the National Sample Survey Office’s (NSSO) 68th Round, notes that: “79% of the informal workers7 do not have a written job contract; 71% are not eligible for paid leave; and 72% are not eligible for any social security benefits…and 80% of the workers are engaged in activities which have no union or association.”

In most urban cities across India, the urban poor and lower-middle income class group find livelihood opportunities within the informal sector; informal activities ‘employ’ a significant portion of the overall labour force and make up a significant portion of the economic structure of India. With rapid urbanization into the metropolises Rustagi (2015) includes data on employment available for workers from both agricultural and non-agricultural sector.

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(Delhi, Bombay, Calcutta, Ahmedabad, Chennai etc.), the scale and size of the informal economy in these cities has proliferated.

The increase in the expansion of the informal economy across Indian cities has resulted from increased rural-urban migration because of a lack of employment opportunities in rural areas. Migrants, typically with lower skill levels and lower education levels, come in search for higher-income opportunities in cities. Hawking or street vending8 is one means of earning a livelihood in the informal economy that requires “minor financial input” and low skills (Bhowmik 2005). Several studies on street vending and informal markets across the metropolises of Delhi, Bombay, and Calcutta (Roy 2003; Bhowmik 2005; Bose & Mishra 2013; Bromley 2000) explain the causal factors responsible for the expansion of informal market segments in these cities, often seen in proliferation of slums and unregulated land use.

There is a perpetual conflict in the relationship of street vendors with local development authorities and the state in matters of land use, access to state-regulated resources (such as power, water etc.) which warrants policy approaches by agencies of the state across the country to study the nature and role of street vending and accommodate for it in the state’s design of urban planning.9 The total volume of commerce out of street vending in cities like Calcutta, Bombay and Delhi is significant and it is critical for the state, in its urban planning process, to accommodate and allocate space for the market of street vending to thrive, as an economic activity.

Roy (2005) studies the contemporary nature of urban informality (a rural/ urban interface) by examining policy responses to informality via slum upgrading and land titling—two pertinent areas of focus for most urban planners today. The study offers comparative cases from Mexico, Bangladesh, Brazil and India and explains the key causal forces responsible for the recent expansion in the development of informal, unregulated spaces within cities. Informality can be seen “not as the object of state regulation but rather as produced by the state itself” through state policies on existing ownership models of land.

As Roy (2005) argues: “Informality also indicates that the question of to whom things belong can have multiple and contested answers”. One can argue that it would be a mistake by the state to study instruments of informality, such as street-vending/ hawking/informal markets in the Global South, in isolation from formal market spaces under a framework that is identified by the “Global North-oriented formal rule of law” (Recio 2017). An inclusive, endogenous view is vital for urban planning in addressing challenges related to urban informality.

Mohan, Sekhani and Medipally (2018), in a forthcoming study, present an empirical study on Cambodia, focusing on the capital Phnom Penh. The authors pose 8 Here we use “street vending” and “hawking” interchangeably.

9 Urban planning includes plans, formulated by the state which help in allotting urban spaces for public use. The spaces include public educational institutions, parks, markets, hospitals etc.

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that the informal economy absorbs the increasing labour force migrating from rural to urban areas as the growth in the formal sector is far behind the increase in the country’s labour force. In addition, the informal sector also offers opportunities to seasonal migrants; many people in the formal economy are also involved in the informal economy to complement their income. Around 80 percent of the city’s 400,000 slum dwellers earn their income from informal sources. Many children are also involved in informal sector activities as shoe cleaners, sellers, rag pickers or even beggars. The structural connection of the formal and informal sectors across developing countries calls for an inclusive view in urban planning.

ON AN INCLUSIVE VIEW ON POLICY APPROACHES TO (URBAN) INFORMALITY Three issues that emerge from the two discourses on understanding urban informality (in India and elsewhere) include: a) a critique of policies on land use and acquisition and its role in distributive justice; b) a need to rethink the object and subjects of development, in praxis; and c) a need to replace the so-called best models of economic development with a realistic critique, in argument for a framework that accommodates hostile socio-economic arrangements within cities.

Most scholars advocating for an inclusive view on informality see the presence of informal sectors and spaces as a natural feature of developing societies and as a complement to the formal, regulated sectors-under a fragmented orientation of (existing) labour markets with segregated skill sets, operating under an accommodative environment. In this way, most developing economies are seen to have informal institutions facilitating mediums of exchange that remain strongly embedded in the socio-economic and socio-political landscape.

In India too, we see an increasing tendency amongst people to view informal institutions and market arrangements as legitimate sources of livelihood (Roy 2005).

The state, however, continues to adopt a more dualistic view and considers formalinformal spaces as being mutually exclusive from each other. Policie10 are designed to “formalize” the informal sector without understanding the nature and the form of existing socio-economic arrangements (Bhowmik 2005).

Across developing economies, there is an urgent need for the state to accommodate an inclusive view in urban planning. This can be accomplished by paying closer attention to the structural roots of the formal-informal divide and going beyond the previously categorized regulatory aspect of the difference between the two sectors Bhowmik (2005) notes that Malaysia, India and Philippines have policies for regulating street vending.

However, Malaysia is the only country which is sincere in effective implementation of the policies, including provision of credit for street vendors. Philippines government refuses to recognize most of the street vendors and it takes harsh measures to clear them off the pavements. The street vendors in India constantly suffer from harassments and the rent seeking is very high. Overall, most of the street vendors are not unionized.

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(via legal standards and rule of law). The mutual interdependence seen in the governing dynamics of economic exchange (for example, in manufacturing-selling commodities and services) and political arrangements (as evident in cases of land use) requires a tolerant atmosphere in the policy approach to accommodate for hostilities in the orientation of dynamically evolving labour markets and socio-economic arrangements.

REFERENCES Anjaria, Jonathan Shapiro. 2006. “Street hawkers and public space in Mumbai.” Economic and Political Weekly, 2140-2146.

Archer, Margaret Scotford. 1995. Realist social theory: The morphogenetic approach.

Cambridge university press.

Bhowmik, Sharit K. 2005. “Street vendors in Asia: a review.” Economic and political weekly, 2256-2264.

Bose, Shreya, and Yashi Mishra. 2013. “Notes on: Street Vendors in Kolkota: A Review.” Labor Law Journal 64, no. 3: 165.

Bromley, Ray. 2000. “Street vending and public policy: a global review.” International Journal of Sociology and Social Policy 20, no. 1/2: 1-28.

Chen, Martha Alter. 2005. Rethinking the informal economy: Linkages with the formal economy and the formal regulatory environment. Vol. 10. United Nations University, World Institute for Development Economics Research.

Crossa, Veronica. 2009. “Resisting the entrepreneurial city: street vendors’ struggle in Mexico City’s historic center.” International journal of urban and regional research 33, no. 1: 43-63 Daniels, Peter W. 2004. “Urban challenges: the formal and informal economies in mega-cities.” Cities 21, no. 6: 501-511.

Giddens, Anthony. 1984. The constitution of society: Outline of the theory of structuration. University of California Press.

Hart, Keith. 1973. “Informal income opportunities and urban employment in Ghana.” The journal of modern African studies 11, no. 1: 61-89.

International Labour Organization. 2002. Decent work and the informal economy.

International Labour Organization.

Jenkins, Paul. 2001. “Regularising ‘informality’: turning the legitimate into legal?”

In N-AERUS Workshop, Centre for Environment & Human Settlements, Edinburgh School of Planning & Housing.

McFarlane, Colin. 2012. “Rethinking informality: Politics, crisis, and the city.” Planning Theory & Practice 13, no. 1: 89-108.

Moser, Caroline ON. 1979. “Informal sector or petty commodity production: dualism or dependence in urban development?.” In The Urban Informal Sector, pp.

1041-1064.

Portes, Alejandro. 1983. “The informal sector: Definition, controversy, and relation to national development.” Review (Fernand Braudel Center) 7, no. 1: 151-174.

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Recio, Redento. “Street use and urban informal vending: Towards a policy framework addressing socio-spatial issues of urban informal vending vis-à-vis the use of streets (The case of Caloocan City).” Unpublished Master’s Thesis. University of the Philippines Diliman, Quezon City.

Recio, Redento, Iderlina Mateo-Babiano, and Sonia Roitman. 2017. “Revisiting policy epistemologies on urban informality: Towards a post-dualist view.” Cities 61: 136-143.

Roy, Ananya. 2003. City requiem, Calcutta: gender and the politics of poverty. Vol. 10.

U of Minnesota Press.

Roy, Ananya. 2005. “Urban informality: toward an epistemology of planning.” Journal of the American Planning Association 71, no. 2: 147-158.

Rustagi, Preet. 2015. “Informal employment statistics.” Economic & Political Weekly 50, no. 6: 67-72.

Santos, Milton. 2018. Shared Space: The Two Circuits of the Urban Economy in Underdeveloped Countries. Routledge.

Sethuraman, Salem. 1981. The urban informal sector in developing countries: employment poverty and environment. Geneva: International Labour Office.

Tokman, Victor. 2016. “An Exploration in the nature of formal-informal sector relationship”, World Development 6, no 9-10:1065-1075.

Waibel, Michael. 2016. Urban informalities: reflections on the formal and informal.

Routledge.

Warunsiri, Sasiwimon. 2011. “The role of informal sector in Thailand.” In International Proceedings of Economics Development and Research (IPEDR), 2011 International Conference on Economics and Finance Research. Singapore.

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Climate Change- A Way Forward

Mothkoor

COMMENTARY

Climate Change – A Way Forward Venu Gopal Mothkoor1 SUMMARY

Keywords: global warming, natural capital, climate change denialists, sustainability Suggested Article Citation: Mothkoor, Venu Gopal. 2018. “Climate Change- A Way Forward” Asian Journal of Public Affairs 10(2): p. 80-84. http://dx.doi.org/10.18003/ajpa.20185 ISSN 1793-5342 (print); ISSN 2382-6134 (online), © The Author 2018. Published by the Lee Kuan Yew School of Public Policy, National University of Singapore

In a recent exchange of statements during the 2016 US Presidential elections, Hillary Clinton told audiences that her opponent believed, “climate change is a hoax invented by the Chinese”, a claim corroborated by a tweet that Donald Trump himself posted months earlier: “The concept of global warming was created by and for the Chinese in order to make U.S. manufacturing noncompetitive.” Obama, on the other hand, explicitly linked global warming to “more extreme droughts, floods, wildfire and hurricane”. Such polar opinions regarding climate change constitute a central theme in American politics today.

Pro-environment advocates and climate change denialists do not disagree that the planet is getting warmer. Rather, they differ on whether the development path undertaken by the US and other developed nations are responsible for the climate change, or if it is an illusion painted by a few nations to dislodge the supremacy of US. They disagree on the impact of global warming. Climate change denialists point out that efforts to combat climate change have come at great cost and there is no real economic or ecological damage due to global warming. On the other hand, pro-climate change advocates point at the enormous losses that have resulted due to climate change. Scott Pruitt goes on to claim that there is tremendous disagreement among the scientific community on the degree of global warming impact, despite overwhelming evidence that 97% of the scientific community agrees that climate change is a global threat. Although, there is no direct evidence to link climate change and the recent Hurricane Harvey, there is definitive agreement that global warming will intensify such storms. Harvey is a warning to the denialists that climate change poses a real and significant threat.

Climate change is admittedly a bewildering issue, with groups approaching the issue from different perspXectives and drawing different interpretations. Pro1 Double degree MPP; Lee Kuan Yew School of Public Policy; London School of Economics.

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environment lobbyists point at the enormous losses to humanity and ecosystems2 caused by a rise in greenhouse gases (GHGs) on account of economic growth led by fossil-fuel burning and land-use changes. Climate change denialists point out that the efforts to combat rising GHGs have come at a huge cost, and often encroach on the division of powers in the federal set-up. Scott Pruitt, who is now the head the Environmental Protection Agency (EPA), states that “The Clean Power Plan represents an extraordinary moment in our constitutional history. Extraordinary in scope, extraordinary in costs, and extraordinary in its intrusion into the sovereignty of the States.” It impinges on the authority of states by mandating emission reduction requirements which states are forced to comply with and additionally, it is in violation of the cooperative federal spirit where states have reasonable discretion to decline the implementation of policies. Another argument made by the denialists is that clean energy programmes have left many Americans jobless. President Donald Trump, during his election campaign, went on to claim that “for too long, the Environmental Protection Agency has spent taxpayer dollars on an out-of-control anti-energy agenda that has destroyed millions of jobs.” Denialists point out that the Paris Treaty and the EPA’s Clean Energy plan actually drove up energy costs, making energy unaffordable for many and thus causing not only energy poverty but also economic stagnation.3 They note that proposed actions to combat rising temperatures are not only ineffective, but also cause economic stagnation. Denialists call for the dismantling of excessive emission regulations and subsidies given to the clean energy sector.

Central to the denialists’ arguments is their reliance on traditional economic models to understand how individuals, firms, governments, and the market interact with each other - a choice that oversimplifies the myriad dynamic interactions between parties and ignores the role of environment capital (KN), despite KN being the source from where inputs are derived. The Circular-flow economic model assumes that economies can grow endlessly at a constant rate provided manufacturing capital (KM) and labour (L) are used efficiently and technology provides newer ways of seeking inputs or drawing new inputs to increase economic output. An oft-neglected view is that it takes time for the discarded material to decay before it returns to the KN-sink as well as for this material to start functioning as viable input again. This poses limitations to growth, contrary to the belief that economies can grow endlessly.

Denialists point out that excessive regulations on the fossil fuel industry created huge job losses and made energy unaffordable for many, besides resulting in economic losses. However, they fail to see that underground fossil fuel is not just a simple extractable resource but also part of a larger ecosystem. The extraction of oil resources creates after-effects (such as earthquakes) elsewhere (USGS Survey, 2015).

The mining of fossil fuels is also associated with damages to local ecology i.e. damage to ground-water and air quality due to mining and emissions from the usage of fossil 2 According to Climate Vulnerability report (2012), climate change has contributed to 400,000 deaths per year and over $699 billion, 0.9 percent annually, in loss to gross domestic product (GDP). Continuing today’s patterns of carbon-intensive energy use…... is estimated to claim 100 million lives between now and the end of the next decade.

3 The purpose of green taxes is to account for negative environmental externalities. But the taxes that the UK already levies on petrol in particular far exceed the costs of the externalities.

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fuels. Productive losses to the economy due to poor environmental quality are often ignored by the denialist lobby. Further, the mitigation and adaption efforts, such as air-masks, water-filters etc., are erroneously perceived to be part of the economic growth. They do not ask whether people need them in the first place if the quality of the environment is preserved. Is the economic growth achieved on the account of fossil fuels real? If the depreciation costs of environmental degradation are accounted for in the economic calculations, then the denialists’ claims of fossil fuels leading to economic growth will no longer hold true.

Contrary to the popular argument put forth by denialists that they are fighting for the poor, the poor often emerge weaker in the fight against climate change.

Poor people are disproportionately affected as they have few resources and receive less social support to cope and adapt to climate-related shocks. In the absence of mitigatory efforts and good governance, a report compiled by the World Bank entitled ‘Shock Waves: Managing the Impacts of Climate Change on Poverty’ predicts that an additional 100 million people will end up in extreme poverty by 2030, undermining the UN goal of poverty eradication. On the contrary, recent innovations have spurred the growth of renewables and decreased the cost of producing energy from renewables.

Denialists also call for lifting the emission regulations and dismantling of green subsidies. This is, however, primarily flawed because willingness-to-pay is often non-existent for the provision of ecological services, such as maintenance of bio-diversity, maintenance of access to clean air etc. Also, the free market will not produce entrepreneurs who will clean the polluted water-ways and polluted air unless suitable incentives exist for them. Firms’ continuous discharge into KN-sink leads to the loss of assimilative ability of KN. This effect is clearly visible when the discharge of air pollutants beyond a point creates a domino effect that worsens the health of the local population. Air-sheds (a form of KN) provide not only clean air, but also act as a sink and receptacle for pollutants that are emitted.

Acknowledging the role of KN therefore lays the foundation for sustainable growth. Denialists ignore the fact that the perpetual extraction of limited finite resources will leave little resources for the future. The question to be asked is: Is future life worth less than present life? Initiatives therefore should be aimed at maintaining that KN be advocated through consensus and voluntary action stemming from the moral considerations, rather than regulatory authorities unilaterally enforcing the standards.

Policy-makers armed with KN knowledge should consider lifestyle changes: wasteful and extravagant consumption should decrease in developed nations while developing and under-developed nations should set modest growth aspirations. As nations make the transition towards low-carbon, resilient economies, traditional industries based on fossil-fuels are bound to suffer; therefore, it is imperative for governments to acknowledge this fact and make the transition as painless as possible by skilling or re-skilling affected employees for the new industry, and providing social support in the form of unemployment allowance, pensions, free education, and healthcare.

Suitable incentives should be given so that energy costs from new, innovative, lowcarbon sources are driven down, and this means there is no escalation of household

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energy budget. This is possible through the adaptation of closed-loop production models (waste is treated as input rather than as undesirable bio-product) and biomimicry (based on the premise that nature has already solved many problems that we are grappling with). Adaptation of these models also counters the argument of denialists that climate change efforts have come at a large cost and have little effect on the environment; these models have capacity to show results.

As best summed by eminent environmental economist Jesuthason Thampapillai, “The sustainability of environmental capital (KN) is an essential pre-requisite for the sustainability of an economy.” Investing in enhancing KN and minimizing damages to KN provides the way forward for tackling the consequences of climate change.

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Rose, D. “And now it’s global COOLING! Record return of Arctic ice cap as it grows by 60% in a year”. Mail on Sunday, 8 September 2013. Available at: http://www. dailymail.co.uk/news/article-2415191/And-global-COOLING-Return-Arcticice-cap-grows-29-year.html (accessed 12/3/2018).

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