Context

Former Indian High Commissioner to Pakistan TCA Raghavan discussed the implications of the Shehbaz Sharif-led government in Pakistan, the possibility of India re-engaging with it and the future of Imran Khan.

Key Takeaways from Politics in Pakistan

• Evolving Dynamics of Pakistan’s Military Influence: Although the Pakistan military maintains a significant presence in the nation’s politics, recent events indicate a shift away from its historical dominance. 
• Unexpected Shift in Perception: The second noteworthy observation is equally astonishing; few anticipated that Imran Khan, initially seen as the face of a hybrid administration orchestrated by the military, would swiftly fall out of favor and become widely vilified.
• Shifting Alliances: The traditional adversaries, the Pakistan People’s Party (PPP) and the Pakistan Muslim League led by Nawaz Sharif (PML-N), have unexpectedly aligned with the military, forming an informal coalition to govern the nation.
• Political Autonomy: Despite military influence, politics retains a degree of autonomy within the country.

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Fragility of the PPP-PML Coalition

• History of PPP and PML-N Collaboration: The PPP and the PML-N have previously collaborated, notably in 2007-08 to undermine the Musharraf regime and in 2014 to resist military intervention against Nawaz Sharif’s civilian government.
• Unexpected Coalition with Military: The coalition with the military is unexpected considering both parties‘ fundamental narratives, which are anti-military and anti-establishment.
• Challenges Ahead for Pakistan: Pakistan faces challenging times, as whoever assumes government is bound to suffer a loss in public popularity due to the ongoing economic downturn.
• Temporary Alliance for Economic Stability: In the short term, both parties are likely to maintain unity, recognizing the necessity of presenting a united front to stabilize the economy. 
  • Challenges in negotiating with the IMF and public criticism for mismanagement are anticipated otherwise.
• Army’s Efforts to Sustain Coalition: The military will strive to maintain their unity. Nevertheless, the prevailing sentiment in Pakistan suggests that this coalition is unlikely to endure beyond two years, giving rise to new conflicts.

Sharif Family’s Plan

• Nawaz Sharif’s Strategic Role within the Family: Nawaz Sharif is positioned as a senior advisor within the family circle. The PML-N’s underperformance in the elections deeply concerns him on a personal level. 
• Maryam’s Role in Punjab Politics:As a component of the broader family strategy, Maryam is appointed as the Chief Minister of Punjab temporarily, likely due to her lack of administrative experience. Appointing her as Prime Minister directly would have invited considerable criticism.
• Shehbaz Sharif’s Operational Efficiency and Loyalty: Shehbaz Sharif is adept at executing ground-level initiatives, particularly infrastructure projects.
• Shehbaz Sharif’s Pragmatism and Party Cohesion: Shehbaz is perceived as less inherently opposed to the military compared to Nawaz’s historical stance. Despite enduring pressures over the past two decades, the PML-N has remained united without fracturing.

Challenge to the Authority of Pakistan’s Army Chief General Asim Munir

• Impact of Imran Khan’s Popularity: Despite the military’s endeavors, Imran Khan’s substantial public and political support have significantly challenged the military’s authority to control Pakistan. 
• Military’s Pragmatic Approach: Within the military, there may be voices advocating against escalating tensions with Khan. Maintaining functional ties with all political factions ensures the military’s continued dominance.
• Uncertainty in Pakistani Politics: One intriguing aspect of Pakistani politics is the perpetual uncertainty surrounding the future of civilian leaders.

Economic Crisis in Pakistan

• Structural Challenges of Pakistan’s Economy: Every four or five years, there is an economic crisis of this kind, essentially because Pakistan spends more money than it generates. It has a narrow taxation base.
  • It imports more than it exports.   There is not enough investment or production because of its poor internal security. Structurally, it is a crisis-prone economy.
• Shifts in Pakistan’s Geopolitical Position:This crisis stood out due to Pakistan’s recent geopolitical significance, especially regarding Afghanistan for the US. However, in 2022-23, Pakistan realized its geopolitical leverage had diminished. Global attention shifted due to events like the Ukraine situation and the pandemic.
• Challenges Ahead in IMF Negotiations: Pakistan is currently faced with arduous IMF negotiations and the implementation of significant structural reforms, tasks that are particularly challenging for the current coalition government. 
  • Many Pakistanis are resistant to these changes, as the country’s economic model relies heavily on patronage, favors, and government control.

Indian Government’s view on Political Situation In Pakistan

• Current State of Diplomatic Relations with Pakistan: India’s  primary emphasis has been on counter-terrorism efforts and stabilizing the line of control. 
  • However, there exists a notable absence of political dialogue with Pakistan. High commissioners are absent, and diplomatic relations have been downgraded.
• Geopolitical Challenges Facing India: India currently faces a fragile stability with Pakistan, characterized by minimal engagement. Additionally, tensions persist with China along the Line of Actual Control (LAC), accompanied by suboptimal political and diplomatic ties. 
  • Moreover, a concerning situation is unfolding along the northeastern border with Myanmar due to internal instability within the Myanmar state.
• Advocating for Bilateral Stabilization: Hence, it’s often argued that stabilizing the relationship is in the national interest. India has consistently taken the initiative to engage, recognizing Pakistan’s limited maneuvering space. Waiting for Pakistan to initiate may lead to indefinite delays.
• Divergent Views on Kashmir: Pakistan asserts a strong sense of entitlement regarding Kashmir, a prevailing narrative within its political landscape. Conversely, for India, Jammu and Kashmir (J&K) is an inseparable part of the nation. 
  • Reconciling these opposing viewpoints seems unfeasible. However, diplomacy may facilitate the pursuit of interim solutions.

US-China-Pakistan Relations

• Persistent Mistrust in US-Pakistan Relations: For the past 15 years, US-Pakistan relations have been characterized by an enduring undercurrent of mistrust. Beyond its engagements in Afghanistan, the United States is concurrently grappling with pressing matters in West Asia and Europe.
• Strategic Significance of China-Pakistan Relations: The bond between China and Pakistan holds immense strategic importance for both nations and is expected to endure.
  • Despite encountering challenges in business operations within Pakistan, the Chinese acknowledge the complexities involved. Nonetheless, the political and military ties between the two countries remain robust.”

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Conclusion

Pakistan’s elections and evolving geopolitical landscape underscore the complexities and challenges facing the nation and its neighbors. Navigating these dynamics requires astute diplomacy, pragmatic leadership, and a commitment to addressing economic and security concerns.

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Context

Recently, concerns arise regarding Pradhan Mantri Jan Arogya Yojana (PMJAY’s) sustainability, especially as some hospitals in certain states report significant outstanding dues and reduced acceptance of PMJAY patients.

About Pradhan Mantri Jan Arogya Yojana (PMJAY)

• Components of Ayushman Bharat: Ayushman Bharat, initiated in 2018, comprises two main components: health and wellness centres and the Pradhan Mantri Jan Arogya Yojana (PMJAY). 
• Aim of the Scheme: PMJAY aims to provide a health cover of ₹5 lakh per family per year for secondary and tertiary care hospitalization to over 12 crore families that form the bottom 40% of the population.
• Target Achieved: As of now, PMJAY has issued 34.27 crore cards, facilitated treatment for about 6.5 crore individuals, and enlisted over 30,000 hospitals.

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Supply Side Perspective

• Private Sector Role in Healthcare Access: There’s acknowledgment of the importance of allowing patients to access the private sector due to perceived deficiencies in the public sector’s ability to provide universal healthcare.
• Challenges for Comprehensive Coverage: Current expenditure on PMJAY remains minimal, constituting less than 2.5% of total health expenditure, raising doubts about its capacity to achieve comprehensive coverage.
• Challenges Public Healthcare System:  The reason we see high out-of-pocket expenditure in Kerala, for example, is that the public sector, despite being well funded, is unable to deliver universal healthcare.
  •  Its primary care is underutilized and there is enormous waste and inefficiency.
• Healthcare Access Concerns: Concerns are raised about the potential misallocation of government resources and the emergence of barriers, even within the public sector, which may hinder access to healthcare for low-income families. 
  • A high-income family can handle a claim rejection or delay, a low-income family cannot.

Demand Side Perspective

• Lack of Trust in Public Healthcare: The preference for private hospitals over public ones reflects a perception of better quality care, potentially indicating a need to enhance trust in the public health system.
  • Empanelled hospitals are 43%  private,  and the rest are government.
• High Patient-to-Provider Ratios: In many States, the number of people per empanelled healthcare provider (EHCP) is really high. 
  • In Bihar, it was over 10,000 families per EHCP. There is a shortage of  adequate number of beds and facilities to be able to cater to that demand.
• Private Sector Challenges: Challenges faced by the private sector, such as capacity limitations, delays in claim payments, claim rejections, and capped treatment charges, hinder effective implementation of PMJAY.
• Impact on Private Facilities: Lack of faith in the public health system drives patients towards overburdened private facilities, exacerbating costs and quality concerns.

Performance Disparity Among States

• Inactive Hospitals: Disparities exist among states in terms of hospital activity levels, with some hospitals remaining inactive since empanelment. 
  • In Uttar Pradesh, for instance, 39% have been inactive since empanelment, and only 50% have been active in the last six months. 
• Variations in Coverage and Hospital Distribution; Differences are observed in coverage rates, hospital dispersion, and claim payment delays, necessitating further research to understand underlying factors contributing to performance variations.
  • In terms of claim payments, some States saw a delay of more than 45 days, while others paid the claims faster. 
  • There is a concentration of claims in Andhra Pradesh, Arunachal Pradesh, Rajasthan, Karnataka, Maharashtra, and Tamil Nadu. 
• Drivers of Disparities: While technological platforms enable claim processing, deficiencies in hospital capacity, particularly in Northern and North-Eastern states, contribute significantly to performance discrepancies. 
• • Lack of network adequacy requirements for insurers exacerbates challenges, as cards are issued without ensuring accessible healthcare facilities.

Addressing Out-of-Pocket Expenditure

• Pradhan Mantri Jan Arogya Yojana (PMJAY) Coverage Gaps:While PMJAY aims to mitigate healthcare cost shocks, its current design may not comprehensively cover outpatient care, diagnostics, and drugs.
• Towards Universal Health Care: Alternative state schemes like those in Tamil Nadu and Rajasthan offer insights into providing some form of universal healthcare, indicating the need for a broader perspective.
• Global Ranking: India is ranked 67th out of 189 countries in terms of out-of-pocket expenditure.
• PMJAY Funding Allocation Gap: The Union government is meant to allocate 60% of PMJAY funds, but the amount it is actually spending is less than this.

Insurance Model and Universal Health Coverage (UHC)

• Evaluating the Insurance Model: While the insurance model has been instrumental in delivering universal health coverage in several countries, its effectiveness in the Indian context warrants scrutiny. 
• Lessons from Global Context: Countries like Thailand, Turkey, Vietnam, and Uruguay have leveraged insurance models to achieve UHC, but India’s approach requires careful consideration due to its unique healthcare landscape.
• Enhancing Public Sector Performance in Insurance:Restrictions on insurance to the public sector could potentially enhance performance, especially in poorer states, but broader reforms focusing on payment structures and non-price mechanisms are crucial. 
• Revamping PMJAY for Comprehensive UHC: Rethinking PMJAY’s design is crucial to align with broader UHC objectives, emphasizing integrated financing mechanisms and strengthened primary healthcare infrastructure to reduce out-of-pocket expenditure and improve health outcomes for all citizens.

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Conclusion

Enhancing trust in the public health system, reevaluating the insurance model, and adopting a holistic approach to healthcare delivery are essential for achieving sustainable and comprehensive universal health coverage in India.

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Context

Recent droughts in Colombia and Ecuador have severely hampered energy supplied by hydropower generation.

Vulnerability of Hydropower Generation

• Climate Vulnerability of Hydropower: The resulting power shortages have highlighted the vulnerability of hydropower in the face of climate change.
• Impact of Drought: A drought fueled by the El Nino weather phenomenon has reduced reservoir water levels in hydropower plants, which both countries rely on for most of their electricity.  
  • This has led Ecuador to declare a state of emergency and institute power cuts. 

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Hydropower Generation

Hydropower, or hydroelectric power, is a renewable source of energy that generates power by using a dam or diversion structure to alter the natural flow of a river or other body of water.   

• • Hydropower relies on the constantly recharging system of the water cycle to produce electricity, using a fuel—water—that is not reduced or eliminated in the process. 
• Mechanism: Hydropower functions by harnessing the movement of water flowing through a turbine, which generates electricity as it spins.
• Current Dominance in the Clean Energy Sector: Hydropower has evolved into a crucial clean energy source due to its reliability, affordability.
• Classification of Hydro Projects based on Installed Capacity: Hydro power projects are generally categorized in two segments i.e. small and large hydro. 
• In India, hydro projects up to 25 MW station capacities have been categorized as Small Hydro Power (SHP) projects.
  • Micro: upto 100 KW
  • Mini: 101KW to 2 MW
  • Small: 2 MW to 25 MW
  • Mega: Hydro projects with installed capacity >= 500 MW

Advantages of Hydropower

• Reliable: Hydropower is needed to stabilize electricity generation, providing power when wind and solar can’t.
• Renewable Source: It is a renewable source of energy with no consumables involved; 
• Little Recurring Cost: There is very little recurring cost and hence no high long term expenditure. It is cheaper as compared to electricity generated from coal and gas fired plants.
• Ideal for Peak Load Management: Hydropower stations are a preferred solution for meeting peak loads in grids due to its unique capabilities of quick starting and closing.

Challenges to Hydropower Sector

• Capital Intensive: The hydropower generation is a highly capital-intensive mode of electricity generation.
• Environmental Impact: Submergence of land, thereby loss of flora and fauna and large scale displacement, due to the hydropower projects.
• Dependency on Water: Hydropower is dependent on water and its shortage disrupts energy production and stressing energy systems.
• Climate change: Droughts and sudden floods which can damage dams have been made more frequent and severe by climate change. Thus, it is an “increasing concern” for hydropower.
• Over-reliance increases climate vulnerability:  Countries with a high dependence on hydropower are particularly vulnerable to climate impacts.

Global Scenario Hydropower Generation

• 2023 saw a Historic drop in Hydropower: According to Ember, a UK based energy think tank, in the first half of 2023 the global output of hydropower saw a historic drop in 2023.
  • Drought conditions, potentially exacerbated by climate change, resulted in an 8.5% decline in global hydroelectricity production during this period.
• Impact of Drought on China’s Hydroelectricity Generation: China, the world’s largest hydroelectricity generator, accounted for three quarters of the global decline.
  • During 2022 and 2023, droughts resulted in Chinese rivers and reservoirs drying up, leading to power shortages and necessitating electricity rationing in the country.

Way Forward: Diversified and Resilient Renewable Energy

• Diversification of Energy Mix: The climate vulnerable countries need to diversify their power sources by incorporating other renewable technologies such as wind and solar into their energy mix.
  • Ghana and Kenya are successfully moving from high reliance on hydropower towards a more “robust portfolio of technologies”.
• Exploring the Potential of Floating Solar Panels in Hydropower Plants: Placing floating solar panels on the water’s surface in hydropower plants have significant potential. Ex- China and Brazil are exploring them.
• Focusing on Medium scale Plants: Despite the climate-risks associated with the technology, it is still considered significant in decarbonizing the global economy because it can provide cheap power at large scale.
• Building more medium scale plants, rather than the mega dams, would help mitigate the climate-risks associated with overdependence on one big dam.
• Enhancing Hydropower Resilience: Improved water management within basins and strategic integration of hydropower plants with other renewable sources can enhance resilience to drought.
• Pumped-storage hydropower systems: These pump water uphill during periods of low electricity demand and release it downhill during peak demand. 
  • These systems have minimal water consumption as they recycle water. While not entirely immune to drought, they are more resilient compared to conventional hydropower schemes.

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Conclusion

While climate change is going to increase the risks for hydropower, better management of water within a basin and how plants are integrated with other renewables can improve resilience to drought.

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