Health Financing in India

Institute for Financial Management and Research Centre for Insurance and Risk Management Delivering Micro Health Insurance Through the National Rural Health Mission A Strategy Paper Rupalee Ruchismita, Imtiaz Ahmed and Suyash Rai August 2007 Rupalee Ruchismita (rupalee. [email  protected] ac. in) and Imtiaz Ahmed ([email  protected] ac. in) are with the Centre for Insurance and Risk Management at IFMR, Chennai (http://ifmr. ac. in/cirm). Suyash Rai is with the ICICI Centre for Child Health and Nutrition, Pune. The views expressed in this note are entirely those of the authors and do not in any way re? ct the views of the Institutions with which they are associated. . Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Contents 1 Introduction 2 Health Financing in India 3 Key issues in Health Financing 4 Exploring Risk Transfer and Pooling Strategies 5 Proposal for a National Apex Body 6 Conclusion 7 Annexures 7. 1 ANNEXURE I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 2 ANNEXURE II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 3 Objectives, Activities, and Services . . . . . . . . . . . . . . . . . . . . . . . 1 1 3 4 8 13 14 14 19 22 0 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission 1 Introduction The Indian health scenario is fairly complex and challenging with successful reductions in fertility and mortality offset by a signi? cant and growing communicable as well noncommunicable disease burden1 , persistently high levels of child undernutrition2 , increasing polarisation in the health status of the rich and the poor3 and inadequate primary health care coexisting with burgeoning medical tourism! This situation is further complicated by the presence and practice of multiple systems of medicine and medical practitioners (several of whom are not formally certi? ed and recognised) and very limited regulation. In such a context, this paper highlights the challenges in ? nancing health in India and examines the role of health insurance in addressing these. It proposes an operational framework for developing sustainable health insurance models under the National Rural Health Mission, responding to the contextual needs of different states. 2 Health Financing in India The total spending on the health sector in India is not low. According to the National Health Accounts 2001-02, the total health expenditure in India for the year was Rs. 1,057,341 million, which accounted for 4. 6 percent of the Gross Domestic Product (GDP). The concern lies in the fact that households are the major ? nancing sources, accounting for 72 percent of the total health expenditure incurred in India. State Governments contribute 12. 6 percent of the total health expenditure, Central Government 6. 4 percent and the public and private ? rms 5. 3 percent. External support from bilateral and multilateral agencies accounts for 2. percent of health expenditure in India, a majority coming in as grant to the Central Government. So, only about 20% of the overall funding comes from India accounts for only 16. 5% of the global population, it contributes to approximately a ? fth of the world’s share of diseases: a third of the diarrheal diseases, tuberculosis, respiratory and other infections, parasitic infestations and perinatal conditi ons; a quarter of maternal conditions; a ? fth of nutritional de? ciencies, diabetes, cardiovascular diseases, and the second largest number of HIV/AIDS cases in the world. Report of the National Commission on Macreconomics and Health. 2005. New Delhi: Ministry of Health and family Welfare. ) 2 National Family Health Survey III, 2005-06. Mumbai: International Institute of Population Sciences. 3 The poorest 20 percent of Indians have more than twice the rates of mortality, malnutrition, and fertility of the richest 20 percent. (Peters DH et al. Better Health Systems for India’s Poor. 2002. New Delhi: World Bank. 1 Although 1 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission he government, which is one of the lowest in the world. This is a signi? cant problem in a country where the government has mandated itself to provide comprehensive quality health care to all. The problem of household expenditure for health care is compounde d by the fact that 98 percent of this is â€Å"out-of-pocket†, which is fundamentally regressive and burdens the poor more. Also, the absence of proper pooling and collective purchasing mechanisms for the households’ money further worsens the situation because of the resulting inef? ciencies. Most of the household expenditure on health goes to the fee-levying and largely unregulated private providers. The share of household consumption expenditure devoted to health care has also been increasing over time, especially in rural areas where it now accounts for nearly 7 per cent of the household budget4 . This situation is not surprising since public and private expenditure on health are closely linked. Given that government spending on health stands at less than 1 per cent of the GDP, which is very low by international standards, the need for private out-ofpocket expenditure increases. Seventy percent of the total ? nancial resources ? ow to health care providers in the for pro? t private sector. Only 23 percent are spent on public providers. In an environment of minimal regulation, this provides signi? cant opportunity for the exploitation of health care seekers. In addition, there are signi? cant inter-state differences in health ? nancing. Among the major states, Himachal Pradesh ranks highest in terms of per capita public spending on health (Rs. 493 per year) and also has the highest public expenditure as percentage of total expenditure (37. 8%). On both these parameters, Uttar Pradesh is the lowest ranking state, with a per capita public spending on health of Rs. 84 per year, and only 7. 5% of the total health expenditure is public expenditure. All India per capita expenditure on health is Rs. 997 (207 from public and 790 from private)5 . There are also indications of declining state government spending in crucial areas. Overall health spending declined over the decade 1993-94 to 2002-03 in 3 states, and declined between 1998-99 and 2002-03 in 6 4 Government Health Expenditure in India: A Benchmark Study. 2006. New Delhi: Economic Research Foundation. All India public expenditure including expenditure by the Ministry of Health and Family Welfare, Central Ministries and local bodies, while private expenditure includes health expenditure by NGOs, ? rms and households. 2 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission states6 . There are also sharp and generally growing rural- urban disparities in spending in most states. 3 Key issues in Health Financing Drawing from the above analysis and other related literature, the following emerge as the key issues in reforming health ? ancing in India. Increasing government spending on public and more speci? cally, primary health care As discussed earlier, the government spending on public health in India, constituting about 4% of its total expenditure and less than 1% of the GDP, is very low. In per capita terms, the government spends only USD 4 annually on public health. According to the World Health Report (2000), only twelve other countries spend less than India on public health, most of them in Africa. For most other nations, government spending on health is more than 10 percent of the total government expenditure. The Commission on Macroeconomics and Health has estimated that public spending in low income countries should be within the range of $30-$45 per capita to ensure achievement of public health goals. In India, most of the government spending is on medical colleges, into tertiary centres, and very little trickles down to the primary and secondary levels. There is therefore a strong case for increasing government spending across the board, with a much higher focus on primary care services. This will reduce the need for spending by the poor and also improve the overall health status. The options for increasing public ? ancing of health include reallocation of the government budget (possibly by re-routing other direct and indirect subsidies) and earmarked taxes (such as the taxes levied for ? nancing the Sarva Shiksha Abhiyan). Addressing the supply and demand-side factors that prevent the poor from bene? ting from the health sector In general the poor bene? t much less from the health sec tor than the rich do largely because of their inability to seek timely and adequate health care. The poorest quintile of Indians are 2. 6 times more likely than the richest to forgo medical treatment when ill7 . Government Health Expenditure in India: A Benchmark Study. 2006. New Delhi: Economic Research Foundation. 7 Peters, D. et al. Better Health Systems for IndiaSs Poor: Findings, Analysis, and Options. 2002. Washington 3 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission However, whatever care they do access, the poor are found to rely signi? cantly on the public system for preventive and inpatient care including 93 percent of immunizations, 74 percent of antenatal care, 66 percent of inpatient bed days, and 63 percent of delivery related inpatient bed days. Improvements in the public system through increased and more effective spending would therefore bene? t the poor signi? cantly. Increasing the effectiveness of public health spending would require attention to supply side factors such as facility location, availability of staff, medicines, equipment and quality of care as well as demand-side factors such as indirect costs (travel, wage loss), non formal charges, awareness levels, perception of quality and uncertainty about payment. Mitigating risks due to out-of-pocket expenditure, particularly catastrophic expenditure for the oor At least 24 per cent of all Indians fall below the poverty line because they are hospitalised8 . It is estimated that out-of-pocket spending on hospital care might have raised the proportion of the population in poverty by 2 per cent. Risk-pooling and collective purchasing mechanisms could increase the ef? ciency and equity with which the households’ money is collected, managed and used, so that the households’ burden is reduced. 4 Exploring Risk Transfer and Pooling Strategies Exploring Risk Transfer and Pooling Strategies in the context of the NRHM In attempting to understand the potential of risk pooling or risk transfer mechanisms such as insurance (which immediately addresses the cost which a household spends on hospitalization) in achieving public health goals within the overall NRHM mandate, the following issues become relevant: 1. The potential value addition that insurance could provide 2. The various models of health insurance for the poor 3. Implementation of the insurance programme in the context of the NRHM D. C. : The World Bank. 8 Ibid 4 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission 1. Health Insurance leads to: †¢ Risk pooling for in patient care (hospitalization): As discussed, one of the major causes of poor households slipping into the poverty cycle is out of pocket expenditure incurred for hospitalization. In such a scenario, insurance, which allows for risk pooling, helps in making available additional source of ? nancing for the household thereby reducing overall vulnerability and smoothening expenditure shocks for larger unpredictable catastrophic health events. Increased utilisation of health services: It is expected that the introduction of health insurance will lead to greater utilisation of health care services. Across the world it has been found that the overall use of curative services for adults and children was up to ? ve times higher for members of health insurance programmes than non-members9,10 . †¢ Standardization and cost effective q uality health care: Insurance as a mechanism attempts to standardize protocols, procedures and bring down cost through rate negotiations. This ensures the availability of cheaper healthcare, controlling fraud and possibility of rent seeking behaviour which is high in the case of the poor who have comparatively lesser knowledge about their health status or possible treatment required. Further due to Health Insurance, the out of pocket expenditures per episode of illness are signi? cantly lower for members as compared with those for non-members11 . Under the NRHM it is hoped that a national level expert committee will play a pivotal role in standardizing treatment protocol and rates. Presently such an activity has been undertaken by World Health Organisation (WHO), India-Of? e, in collaboration with Armed Forces Medical College (AFMC). †¢ Cover for access barriers (loss of wage, transportation cost) and new and emerging diseases: It has been seen that since most of the micro insurance models evolved from community institutions and NGOs, they packaged critical P. , and F. Diop. Synopsis of Results on the Community â €“ Based Health Insurance (CBHI) on Financial Accessibility to Healthcare in Rwanda. HNP Discussion Paper. 2001. Washington, D. C: World Bank. 10 Preker, A. S, Carrin, G. SHealth Financing for Poor People – Resource Mobilisation and Risk Sharing. T 2004. ? ? Washington D. C. : World Bank. 11 Preker, A. S and G Carrin. Health Financing for Poor People – Resource Mobilisation and Risk Sharing. 2004. Washington D. C. : World Bank. 9 Schneider 5 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission access barriers as part of their insurance cover. Also, insurance as a concept works on the principle of risk pooling and cross subsidization for low frequency events. The cost of healthcare for life style diseases like diabetes or critical illnesses and HIV/AIDS, is very high. Community Insurance models delivered at a large aggregation can cover for these rare events and ensure that the poor do not fall back into poverty in the process for paying for this high cost event. This has been tried in some schemes like the Arogya Raksha Yojna (ARY)12 . †¢ Development of stronger referral linkages: Insurance as a mechanism to be sustainable requires developing strong upward as well as downward referral mechanisms. Strong referrals ensure non escalation of cases, thus ensuring ‘right care at the right time’, reducing possibilities of collusion and fraud. †¢ Ef? ciency in the health system in terms of: – Allocative ef? iency in addressing the most risky event a household faces i. e. hospitalisation and by diverting the surplus premium to strengthen the health infrastructure and incentivise manpower. – Value for money: Presently the expenditure on health by the poor includes leakages such as transport costs, spurious drugs, unlice nsed medical practitioners who offer health care of sub optimal quality. 2. Various Models of Health Insurance for the Poor Models of micro health insurance may be categorized into the following: †¢ Social Health insurance: Such insurance models are found in about 8 countries across the world. The overall model works with a differential premium payment mechanism where the economically secure pays a relatively higher premium than what their risk pro? le dictates and the poor pay a comparatively lower premium commensurate with their income. This leads to cross subsidization across the rich and poor category. In India it is mostly seen in the formal sector in the form of ESIS and the CGHS scheme. 12 With Narayana Hrudayalaya, Biocon and ICICI Lombard in Anekal Taluka of Bangalore district of Karnataka. 6 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Community Based Health Insurance (CBHI): There are three basic designs of CBHI, depending on who the insurer is. In Type I (or HMO design), the hospital plays the dual role of providing health care and running the insurance programme. In Type II (or Insurer design), the voluntary organisation is the insurer, while purchasing care from independent providers and ? nally in Type I II (or Intermediate design), the voluntary organisation (NGO/CBO) plays the role of an agent, purchasing care from providers and insurance from insurance companies. This seems to be a popular design, especially among the recent CBHIs13 . The merit14 of the last model is the aggregating role and the context speci? city that the NGO/CBO assumes. Since the NGO has systematically addressed information asymmetry, and also shares the community’s trust, these initiatives show better results (as seen in case of Dhramasthala insurance programme). In the case of a national roll out this can be the best model as it will capture the diverse nature of health requirements in the different NRHM states. The provider model or insurer model may not work out as customisation to local condition becomes the main crux of success or failure of the scheme. Further an NGO along with an insurer will be in a better position to retain the large risk of the community as compared to an individual entity like a provider or an NGO alone. It is crucial to ? nd NGOs that have a long term stake and therefore would act as ‘conscientious players’ who will ensure that the insurance programme, generates long term positive impact on the health system of the speci? c geography. 3. Some suggestions for the proposed Health Insurance Programme As discussed earlier, the health system in India is characterised by grave inequities leading to a political economy that makes health care access income and classdependent. This creates the need to explore various types of innovations and changes that could improve this unacceptable situation. Insurance is potentially one such et al. Community-based Health Insurance in India: An Overview. July 10, 2004. Economic and Political Weekly. New Delhi. 14 The Yeshaswani insurance programme (the large health insurance programme in the country) follows this model through the various cooperatives facilitated by the department of cooperatives. Other example is the Dharamasthala insurance programme where the NGO (Dharmastahala trust) is the aggregator and has about 1 million insured under its scheme. 3 Devadasan 7 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission innovation. However, for health insurance to effectively improve the ef? ciency of health spending and ultimately improve health status, it would need to be conceptualised as a part of a larger effort to improve the accessibility and quality of health care s ervices, especially for the poor. In the Indian context, any health insurance programme will have to take into account the plural nature of the health system, especially the presence of a large fee-levying, unregulated and ill understood private sector. It will have to explore synergies and integration with the widespread public health system and its current ? nancing mechanisms. Questions such as who should pay the premiums for the poor and how should incentives be aligned will have to be carefully thought through to ensure the management of problems such as adverse selection, inadequate monitoring and moral hazard, exacerbated because of extreme information asymmetries inherent in health services and goods. Internationally and within India, there is a signi? ant body of literature regarding the impact of different health insurance programmes on the health system. For the Indian context, it would be important to learn from these various experiences, develop a theory about the mechanisms through which insurance can contribute to public health goals, run pilots in different contexts within India to understand feasibility and impact, and determine the ? nal programme based on these learnings. 5 Proposal for a National Apex Body Proposal for a National Apex Body Working as a Coordinating Centre for Micro Health Insurance: It is proposed that a National Apex Body, ideally placed within the Insurance Regulatory and Development Authority (IRDA), be established to monitor and coordinate the implementation of the micro health insurance operations in the country (see ANNEXURE 2). The Apex body should have capacity in the areas of public health and insurance, host national and state-level dialogues on the idea of insurance in the context of health systems, implement pilots in speci? geographies and take forward the learning, and ensure knowledge sharing so that progressively larger regions can be covered under the micro 8 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission insurance scheme. ANNEXURE 2 provides details of potential roles this apex body (tentatively named Micro-insurance Coordinating Centre) could play in taking forward the agenda of usefully employing the strategy of insurance to get closer to the public health goals of the country, focusing on the vulnerable. It is envisaged that this body should play a knowledge-building, technical advisory, policy advisory, facilitative coordination role with a long-term aim of achieving universal health insurance coverage by an optimal combination of social and micro health insurance mechanisms, in a manner that it integrates seamlessly with the overall health system. The proposed apex body should host a process that ‘arrives’ at a framework of implementing health insurance under NRHM. Based on our understanding, the following emerge as important aspects of any national level health insurance programme developed under the NRHM. The health insurance model under the NRHM should explore the Partner-Agent approach which includes both the insurance partner (risk partner) and the agent (NGO). Based on experiences from the pilots, the insurance cover could be a compulsory, cash less health insurance product with a family ? oater with minimum initial deductibles. Depending on the availability and quality of providers, the insured should have the choice to access the nearest (private or public) health care facility and should be allowed to choose between any provider within a given geographical parameter. The client could be issued a biometric ID card which is updated with diagnostic information and refers her/ him to the desired care provider to control overcrowding at the tertiary facility. 1. Product Cover: To begin with, the product should cover basic hospitalisation at the secondary care level (either at the cluster of village, block or district level). It should include the cost of: †¢ Hospitalisation †¢ Diagnostic services †¢ Medicine and consumables †¢ Consultation and nursing charges †¢ Operative charges 9 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission The product should also try to cover for access barriers like transportation cost (with a initial deductible to control frauds and limited to only the cheapest mode of transport available, customized according to the district), loss of wage (in case of the male or female member of the household as de? ned by the state according to the minimum wage guaranteed by the state government. This could be done in tandem with the National Rural Employment Guarantee Scheme (NREGS). In geographies where investment in directed preventive and promotive services can bring down the need for seeking in-patient care, directed primary care primary level care can be provided by the insurance programme. For example, Directed preventive promotive community health education could lead to reduction in the frequency of inpatient care due to vector borne diseases in several geographies15 . Thus based on the speci? location package of additional community health intervention will be developed, which can be paid from the insurance model The insurance programme can work with District Health Societies to offer rehabilitative care and ? nancial help to patients who have recovered but are disabled due to diseases like leprosy or polio. It can also help the People Living with HIV/AIDS (PLHIV) by providing additional services like providing nutritional supplement and other additional services wh ich will supplement the current care being provided by the national programme for control of HIV/AIDS. 2. Health providers: Both private and public facilities at the secondary care level could be empanelled as providers. Private care hospitals could include nursing homes or 20 bedded medical facilities as seen in the Missionary hospitals as well as entrepreneur led inpatient care. For the government hospitals such as the district hospital, the difference in rates could be used for improving infrastructure and incentivising staff. 3. Building information systems: There is a need for a reliable transparent MIS sys15 For Insurance covering hospitalization due to events that can be impacted by Sspeci? S preventive promo? tive health education, it makes economic sense to proactively invest in Community Health Education, which will reduce the probability of hospitalization due to the event. Vector borne diseases show a high degree of sensitivity to such Community Health Education programmes. 10 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission tem to improve the overall ef? ciency of the system. This would reduce paper work, streamline referral linkages and aggregate data helpful for product customization. The community health insurance model could generate a much needed Electronic Health Records (EHR) system. This would imply that as per commonly agreed terms all health related information of an individual (parameters like diagnostic test results (blood pressure, body temperature, pulse rate, ECG), diseases to which he/she is prone; past illnesses etc) is stored onto a system or a database. This database can be accessed by all ensuring anonymity and therefore all insurers, health workers and policy makers can access and interpret the health data to be able to conduct community risk assessment. This will encourage insurers to compete for risk pricing of the community in the said geography and lead to cheaper insurance premiums. The focus of the EHR system would be to ensure – Universality, Consistency, Open Standards, Non-Proprietary, and Acceptability. To institutionalize a reliable EHR system it should be made compulsory that any treatment/diagnosis/medical intervention be updated into the individual’s EHR, such that the EHR is the most authentic source of health information about an individual. The other challenge that needs to be addressed for development of better health insurance products as well as better health care delivery is the challenge of targeting and uniquely identifying the individual. Such identi? cation could be achieved through a biometric identi? cation smart card. The smart card can be used to not only help in identi? cation, but also for storing of? ine health information With an EHR and smart card system, the insured can freely access b oth the public and private health care facilities available in the geography. This helps the insured as well as the medical practitioners and improves diagnosis and response time. The Smart Card can also be used to store health insurance related information of the client. The health provider can thus check the eligibility of the individual in terms of insurance before delivering treatment. The same card can also be used as a payment instrument to capture the payments that need to be made to the health providers. The card can be used to pass 11 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission n incentives to clients as well as the hospital to keep using the card. The biometric card will have terminals (which can upload data of? ine) in the various network hospitals to upgrade data whenever the insured avail care. 4. Formative Research: a Community Needs Assessment (CNA) will need to be done to list down the health needs and the willingness to pay, a mapping of the healthcare facilities in the geography, an unde rstanding about the type of premium and payout that the community are expecting from the insurance scheme and the broad range of social protection measures that they want the insurance to take up. Based on the information provided above the product and the EHR can be developed. Initially, it is advisable to undertake health insurance pilots in different contexts to develop and ? nalise the health insurance programme. 5. Implementation and monitoring: The proposed National Apex body, should monitor and coordinate the implementation of the micro health insurance operations in the country (see Annexure- 2). The following ideas can potentially strengthen the monitoring and implementation of the programme: †¢ The District Health Accounting System and the proposed ombudsman (to be created under NRHM to monitor the District Health Fund Management) will work closely with the NGO and the insurer to ensure the smooth running and monitoring of the programme. †¢ At the backend, the insurance programme with the EHR system will develop a rich data source and act as a Fraud control mechanism. This data will help in identifying disease patterns for the community and could be a critical tool for the NRHM team to de? e ? nancial allocations, target services and make evidence based policy recommendations. (While developing this EHR we should ensure that we are following international standards to be able to be coded properly and stored in a card). In the long run, this apex body should aim at achieving universal health insurance coverage by combination of social and community based health ins urance mechanisms. There is a case for building facilitative institutional arrangements of the ‘right’ stakehold12 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission rs who will pursue this goal. The learning from the challenges and processes involved in implementing Universal Health Insurance Scheme (UHIS) will be very valuable. 6 Conclusion Promoting health and confronting disease requires action across a range of challenges in the health system. These include improvements in the policy making and stewardship role of the government; better access to human resources, drugs, medical equipment, and consumables; and a greater engagement of both public and private provider of services. Insurance has a limited but important role to play in solving some of the health ? nancing challenges. Innovative pilots of partner agent model led micro health insurance could giver useful insights for designing a national level programme, led by an apex body. Such a programme could systematically impact the health system in the country. 13 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission 7 Annexures 7. 1 ANNEXURE I Beyond the pilot, the initial cover will be modi? ed to cover primary and tertiary tier of the health systems in the country. . Primary level: The Insurance will cover: †¢ Diagnostic charges incurred on low and high end diagnostic16 †¢ Medications including expensive medication (like life saving drugs, higher antibiotics etc), injectibles and other consumables not usually available in the primary health centre †¢ Based on the recommendation given in the NRHM document, practitioners of AYUSH and other speci alties can be roped in to act as the Primary Physician †¢ Based on the scale and/or the insurance experience in 1st year, further social security bene? s can be added as follows: †¢ Reimbursement of transportation charges, wage loss, ? nancial compensation for attendant, compensation for disability and subsequent rehabilitation. 2. Impacting infrastructure and Manpower: †¢ Depending on the claims experience and the volume, some monies can be utilized to purchase new or replace old goods/equipment at the Primary Health Centre (PHC) and such activity monitored by District Health Mission through district health accounting system and the proposed ombudsman under NRHM. Besides there is a need for 5-10 bedded hospitals to come up at the taluka or clusters of village level in severely resource constrained area for which emerging entrepreneurs like the Vatsalaya hospitals who have already set up such hospitals elsewhere in the country (especially in Karnataka in this case). L ocal doctors looking at running hospitals can set up such hospital and run it on a franchise model. in this realm may lead to cost effective and customised diagnostic solution. in this regard ICICI Knowledge Park is involved in coming out with such customised solution for the rural poor 16 Innovation 14 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission †¢ There is also a need for high end diagnostic chain to come in to the rural space with similar franchise model of commercial diagnostic companies17 . Standardization of all the services will be done by a committee of experts in each state. These services will include outpatient, in-patient, laboratory and surgical interventions. †¢ Manpower: The ANMs/CHWs/ASHA/MPWs can be incentivised to provide their services more ef? ciently and quickly from such fund given to the Panchayat either from the government or from the insurance fund. It is assumed that with the introduction of ICT component (EHR and biometric cards) like smart card, the 40% of time wasted by ANM on documentation will be saved18 . – To incentivise the doctors to work in the PHC: – Posting of quali? ed graduate doctors in PHCs can be made mandatory and also made necessary pre-requisite for eligibility to sit for Post Graduate Medical Entrance Examination. – Top 10 or 20 high performing PHC doctors in the entire state might be allowed to join specialty of their choice in P. G courses directly or some higher percentage of quotas may be assigned to them which will facilitate them to get admission. Transparency and accountability in the whole service delivery can be brought about by making the health manpower within the PHCs and other levels accountable to the PRIs and the Village Health Committee through a rigorous and scienti? c accountability system19 . †¢ Additional Services: De? ned amounts of fund can be made available to the local Panchayat or a certain percentage of premium collected be allowed to remain with them and be spent for these purposes according to their discretion 17 This entity can set up satellite diagnostic centre at the taluka or district level. They can have sample collection unit which collects the pathological samples from the villages and brings it to the satellite centre where it is examined. The report is either passed on to the patient the next day when the sampling collection team goes to the villages or can be sent directly to the referred doctor under the health insurance scheme. 18 This will give her more time to cover more villages, services and bring about ef? ciency in the overall healthcare delivery. It will also reduce paper work and make information easily accessible at each level. 9 Smart card technology will be used to increase transparency and accountability of the health staff bringing about good people governance. In this the gram Panchayat and the Village Health Committee will completely evaluate the work of ANM and other staffs (including the doctor). Their performance will be graded in a scale devised in consultation with the representatives of the PRIs and the District Health Mission and accordingly incentive/disincentive can be given based on the score. This information can be made available online for access to the general public. 5 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission and mutual decision (It can also cover other expenses like loss of wage and destitute supports). †¢ Health Database management system: ICT component in the form of smart card technology (in the form of a biometric card) be introduced which will ensure the capturing of health and insurance data of the population and minimize fraud. †¢ It requires a decoder cum uploading device which will be portable and hand held. This can be used by ANM/Health staff/PRI/Hospitals to upload or read information starting from the primary to tertiary level †¢ Will be able to transmit images and radiographic reports (X-ray and ultrasound, CT scan) apart from other routine test results. This can be done of? ine (Because in villages, the power supply is erratic or absent and the internet connectivity is lacking) and can be the precursor of telemedicine20 . 3. Tertiary level: It will cover all high cost, sophisticated care which may not be available at the secondary level. The diseases that can be covered are as follows: †¢ Cancer †¢ Myocardial infarction †¢ Major organ transplant †¢ Paralysis †¢ Multiple sclerosis †¢ Bypass surgery †¢ Kidney failure †¢ Stroke †¢ Heart valve replacement 20 With internet connectivity through satellite (which are now provided free of cost by ISRO to interested NGOs and CBOs) which will mean that the patient will not have to travel to district level or tertiary level care and can walk in to such tele-consulting centre within the village where his diagnostic reports are accessed by punching in the unique I. D number of the patient on the smart card. The specialist sitting at the district level can then assess the prognosis of the case and decide whether the patient needs to travel or else advices the local doctor on what is the line of treatment for the patient which then can be carried out locally. This will save a lot of money (on traveling and loss of wages), time and resources which the patient would have spent otherwise. 16 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission 4. Impacting infrastructure, Manpower and Services: †¢ It is envisaged that the government medical college hospitals, other government health institutions, central or regional health institution operating in the state can act as the tertiary care provider. †¢ Insurance can start paying for upgrading these infrastructures and incentivising the medical work force in a similar way as was explained under primary level care. Besides private healthcare who will start the franchise model or other wise interested (and agreeable to the negotiated rate for the insured) will act as the tertiary care providers21 . The government should play a central and leading role in developing a strong referral linkage in the state. †¢ As most high level tertiary care hospital are charitable trust hospital and get substantial subsidies and exemption from the government in return for providing subsidized services for the poor (but in reality a very few actually provide such services) it should be made mandatory and compulsory for these hospitals to treat the insured poor. 5. Health Database Management: †¢ There will be a Central Data Warehouse which will develop from the EHR integrate all the information collected from the primary level upwards, making it accessible to each level and hence acting as a central store house of information. †¢ Additionally it will have personnel(s) who will analyse such data. Such analysis will be invaluable for monitoring, evaluation and mid-course correction. This will help in achieving the following: – Help revise insurance premium – Incentivise and monitor providers 21 The bene? will be two fold – it will provide quality care to the poor (through a TPA and the District Health Mission and Rogi Kalyan Samiti which will empanel hospital) which will ensure compliance to a particular standard of care) and will also help reduce crowding in the government hospital. At the tertiary level, a working arrangement should be made with national level government hospital (like AIIMS,CMC etc), regional ins titutes, post graduate medical institutes (JIPMER) and large private/corporate hospital (Apollo, Wockhardt, Fortis etc) so that patient requiring advanced critical care can be referred to them. 7 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission – Control fraud The developing of referral linkages is very much possible with insurance playing a central role and ICT in the form of smart card technology will ensure equity, ef? ciency and quality in healthcare delivery at each level. The coupling of the whole machinery with tele-medicine will bring about synergy and help the poor in terms of saving money on traveling and also loss of wages. It has to be always borne in mind by all the stakeholders that all component of health care i. . preventive, promotive, curative and rehabilitative care as emphasized under National Rural Health Mission as well as the coming of all stakeholders to work together will ensure harmonious and ef? cie nt delivery of quality healthcare with insurance playing a vital role. None of the components or stakeholders can be undermined as each will ensure that we will be able to see demonstrable impact in the health indicators of the community in days to come. 18 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission 7. 2 ANNEXURE II Setting up of a national coordinating and development entity: One of the key issues recognised by many is that increased coordination as well as sharing of knowledge and resources among the various actors in the sector would greatly stimulate success of NRHM as well as micro insurance development. This is especially true of health micro insurance for which few (if any) truly successful and sustainable programs have been observed to date. Hence it is felt that there has to be an apex body in the form of a coordinating centre which will initiate, regulate and monitor these activities. Following is a matrix which delineates the various stakeholder who will be represented in such a supra structure. 19 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Stakeholders Stakeholder Needs Coordinating Centre’s Criteria for Success 1. Bene? ciaries * Simpli? ed claims procedures with minimal bureaucracy * Solutions that result in fast claims payment 1. 1 BPL families * Timely payments of * Service satisfaction from bene? ciaries * Solutions leading to affordable insurance products with quality servicing promised bene? s * Systematic increase in product coverage to ensure reduction of access barriers * Access to health services and health risk protection services 2 Microinsurers, Insurers, reinsurers * Access to technical assistance, actuarial studies, EHR records and the Centralized Data Warehouse reports, exposure to international innovations * Long term sustainability of microinsurance programs servicing the poor * E ffective, broad-based microinsurance delivery channels * Microinsurance pro? ts commensurate to investment risk * Competent pool of microhealth experts insurance technical Service packages developed and patronized * Service satisfaction from micro-insurers * Insurers aggressively competing to offer superior products and services to MICC client governments * Investment and ? nancial support from insurers 20 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Stakeholders Stakeholder Needs Coordinating Centre’s Criteria for Success 3 NGOs, MFIs, trade unions, employer grassroots organizations, organizations, * Strong partnerships with hospitals, diagnostic players, NRHM team, AYUSH, ASHA workers and insurers Satisfaction with the coordinating agency’s ability represents all stakeholders’ interest and re? ected by strong involvement and support and investment through time in the centres work corporate sector, co-opera tive sector, etc. * Successful delivery of risk protection services to their memberships and clientele 4 Insurance Regulatory Development Authority * Robust, vibrant health microinsurance industry * Insurance regulations followed * Robust and vibrant network of micro-insurer clientele * Mandate and support from the IRDA * Achievements towards supportive and enabling policy 5 Health Providers * Timely payment from insurers * Reliable stream of BPL clients utilizing their services * Reasonable pro? tability * Positive ratings from health providers * Service satisfaction of BPL clients * Minimal problems with * Fast claims turnaround Solutions that result in: fraud and overcharging, etc. 6 TPAs Innovative and effective collection, distribution, and servicing channel 21 Sharing best practices Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Stakeholders Stakeholder Needs Coordinating Centre’s Criteria for Success 7 State Governments * BPL population covered Support and mandates from governments * Ef? cient utilisation of resources and resources leveraged through a resource center * Moving closer to the goals stated under NRHM 8 Government of India * Access to comprehensive and quality health care for all * Improvement in national statistics on accessibility of health care services 8. 1 Ministry of Health and Family Welfare 8. Department of Insurance, Ministry of Finance * In synergy with existing programmes and structures * Proper utilization of departmental funds * National statistics on health insurance penetration * Increase in the number of legalized community health insurance programmes * Moving towards universal coverage * Regularising illegal community health insurance programmes Other major stakeholders that will have to be consulted are the likes of Indian Medical Association (IMA), Institute of Public H ealth (IPH), Federation of Obstetric and Gynecological Societies of India (FOGSI) and Institute of Health Management Research (IHMR). . 3 Objectives, Activities, and Services The stakeholders and clients of the Microinsurance Coordinating Centre envision a network of professionally-managed micro-insurers and accredited service providers offering 22 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission affordable, comprehensive, quality risk protection to the majority of poor people in India. Similarly, the Mission Statement may read as follows: The Microinsurance Coordinating Centre aspires to facilitate delivery of innovative health ? ancing and health insurance solutions in the country and improve the health indicators. It also aims to improve the capacity of insurance providers to provide risk protection services on a sustainable basis. The Centre is committed to building a vibrant health ? nancing and risk pooling sector through coll ective advocacy and through concentration, leveraging, and focusing on resources and knowledge towards developing innovative technologies. More speci? cally, activities and services of the MCC may include the following: †¢ To diagnose the feasibility and requirements of proposed micro-insurance projects in speci? districts of the identi? ed NRHM states; †¢ To develop and offer comprehensive, feasible, customized technical solutions complete with onsite guidance and implementation assistance; †¢ To facilitate strengthening the technical and cost effective management capacities of the NRHM team at the district level; †¢ To analyze and document the leading and best practices in the health microinsurance industry; †¢ To provide a forum for regular exchange and dissemination of ideas, innovations, lessons learned, achievements, and international best ractices; †¢ To develop and support EHR central data warehousing and tools; †¢ To develop health microin surance performance standards and prudential indicators, and the supporting technologies and tools that will enable micro-insurers to meet these standards; †¢ To provide a rating service of NRHM districts with micro health insurance pilots micro-insurers with respect to the standards and indicators; 23 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission To facilitate and strengthen collaboration and partnerships among the various microinsurance providers and Health Ecosystem partners †¢ To establish linkages between insurers and resource institutions such as funding agencies, ? nancial institutions, and research institutions; †¢ To accredit a network of providers delivering affordable, quality health care through use of clinical protocols and negotiated tariff schedules; †¢ To provide and manage a data repository and also a national helpline for query redressal. To conduct industry experience studies and share resul ts for use in pricing and management purposes; †¢ To represent the health microinsurance sector to the Government of India and lobby for favorable and enabling policy; †¢ To identify and facilitate networking and business opportunities among the various stakeholders; and †¢ To elevate the insurance consciousness through awareness campaigns and education. Some of the activities such as product design are already being carried out by insurance companies. However, since microinsurance differs greatly from commercial insurance it requires unique design, marketing, and distribution strategies and skills. The MICC, with its personnel focused and specializing in micro insurance and health (health economists), with access to current data, and with concentration of knowledge about the industry would be positioned to facilitate superior solutions in these areas. 24

Andy Warhol Essay

Andy Warhol is one of the significant famous personalities of the twentieth century. He is an artist, a film maker, a celebrity and even a businessman. Warhol advanced the Popular art movement in America. He made compelling and controversial art works that yielded praises and even criticisms. Warhol had once said, â€Å"I’d prefer to remain a mystery. I never like to give my background and, anyway, I make it all up different every time I’m asked. It’s not just that it’s part of my image not to tell everything, it’s just that I forget what I said the day before, and I have to make it all up over again† (Wrenn Andy Warhol: in his own words).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Andy Warhol was born in 1928 in Pittsburgh, Pennsylvania as the son of Slovakian immigrants. His father was Andrej who was a construction worker who died when he was 13 and his mother was Julia. According to his mother, Warhol suffered three nervous breakdowns in his childhood (Andy Warhol). By 1945, he entered the Carnegie Institute of Technology (now Carnegie Mellon University) where he majored in pictorial design . After college, Warhol went to New York and started his career in illustration and advertising for several magazines including Vogue, Harper’s Bazaar and The New Yorker (Cribbs Andy Warhol: Biography). It was film director Emile de Antonio who encouraged Warhol to start as an independent   artist because he considered commercial art as a real form of   real art. His fondness for art and commerce gained him several recognitions from established organizations (Andy Warhol).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   During the 1960’s, many of Andy Warhol’s most famous and iconic images were generated. By adapting various images from popular culture, Warhol created many paintings that remained icons of 20th-century art, such as the Campbell’s Soup Cans, Disasters and Marilyns. In addition to painting, Warhol made several 16mm films which have become underground classics such as Chelsea Girls, Empire and Blow Job (Cribbs Andy Warhol: Biography). Most of Warhol’s films were deemed plotless,   complex and somewhat pornographic. Though there were scripts, most of the dialogues in his films were improvised by the actors who were usually transvestites, homosexuals and his acquaintances. According to Warhol, he never particularly wanted to make simply sex movies, but attempted to show how people can meet other people and what they can do and what they can say each other. Warhol’s gradual withdrawal from films production coincided with his near fatal shooting in 1968 by a female ‘factory’ reject connected with an anti-male hate group (Andy Warhol). More so, in this period, Warhol moved to the â€Å"Factory.† It was his place at Union Square in New York City where he and his team of hired workers massly produced screen prints of popular culture. This immediately became the hangout venue for   artist, musicians, and actors where they expressed their individuality. The Factory also served as a working place where he produced most his masterpieces in art and film (Andy Warhol Biography).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   In the 70’s amd 80’s, Warhol had expanded his empire beyond mere art making. He was in the center of a corporation that produced films, books, plays, and was involved with television (Andy Warhol). He founded inter/VIEW magazine. He also created two cable television shows, â€Å"Andy Warhol’s TV† and â€Å"Andy Warhol’s Fifteen Minutes† for MTV . More so, Warhol had several collaborations with younger artists such as Jean-Michel Basquiat, Francesco Clemente and Keith Haring (Cribbs Andy Warhol: Biography). In his book The Philosophy of Andy Warhol he wrote: â€Å"Business art is the step that comes after Art. I started as a commercial artist, and I want to finish as a business artist. After I did the thing called ‘art’ or whatever it’s called, I went into business art. I wanted to be an Art Businessman or a Business Artist. Being good in business in the most fascinating kind of art† (Andy Warhol).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Andy Warhol died after a gall bladder surgery on February 22, 1987. His funeral was attended by his friends, colleagues and more than   2, 000 fans at St. Patrick’s Cathedral in New York (Cribbs Andy Warhol: Biography) .   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Warhol made a huge contribution in art history. His eccentric personality brought him to beyond levels of stardom. He constantly shook the art industry with his controversial art works that were considered avant-garde during that era. Warhol’s personality have been subjected to several suspicions. His concepts and interpretations gave an impression that he was a homosexual. According to Wayne Koestenbaum’s psychoanalytical interpretation, everything was sexual for Warhol, who was †as gay as you can get† and he also said that â€Å"Warhol’s major artistic contribution was reinterpreting the worth of cultural waste products† (Andy Warhol). Many would think that Warhol is not a true blooded artist because mainly for the fact that he was driven by monetary ambition and even came to the point where he became obsessed in being rich and famous. But he proved that business can be mixed with art making. He utilized the best of both worlds, which are the corporate world and the art world. In a but shell, he merged art, wealth and fame producing the Pop Artist Andy Warhol (Andy Warhol Biography). Works Cited â€Å" Andy Warhol Biography.† ArtQuotes.net. 28 February 2008   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   . â€Å"Andy Warhol.† 2000. Books and Writers. 28 February 2008   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   . Cribss, Martin. â€Å" Andy Warhol: Biography.† 2002. The Andy Warhol Foundation for the   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Visual Arts.   28 February 2008 . Wrenn, Mike. Andy Warhol: In His Own Words. Omnibus Press, 1992.

Compare and Contrast the Ideas about What Happens after Death in Research Paper

Compare and Contrast the Ideas about What Happens after Death in Buddhism and Christianity - Research Paper Example Death is one entity which causes the cessation of these duties. There are many definitions of death in different scriptures and religions. The scientific world describes death as a mode when there is a permanent termination of all biological functions needed to sustain a living body. The journey does not end here as there is a mention of a life after death or the beginning of the afterlife across various religions of the world. According to the second law of thermodynamics, all energetic states in nature strive to attain the most probable state thus the more disordered and the highly undifferentiated state (Koslowski 4). As such, resurrection or gaining eternal life or Nirvana would not be possible in a world that is subject to the laws of thermodynamics. It would be possible only in a world that is free from such physical laws. The theories on bodily resurrection or eternal life are based on the assumptions of ontological transformation of the dead or the matter. Eternal life â€⠀œ its depiction across religions There are many ways by which the theories regarding after life or life after death is explained. No single belief or faith can provide an accurate concise explanation to the same. Christianity and Islam speak about the existence of the heaven and the hell as places where the dead transcend after death. Sikhism and Hinduism also believe in the concept of reincarnation and heaven and hell. According to these religions, one’s life after death or his journey in the afterlife depend on the deeds he performs in his biological life. Good deeds lead to heaven while wrong deeds lead to hell (Ellis and White, 83). Christianity, Judaism and Islam acknowledge the apocalyptic transformation of matter and thus a realization of the afterlife (Koslowski, 4). Buddhism advocated the presence of life after death. But it does not mention the existence of heaven or hell in its religion. According to the Buddhist doctrines, human life is a cycle that consists of b irth, death and rebirth. The process is a continuous one and is known as the Dharma chakra or the Samsara (Prasad, 4). According to it, living life forms a continuum of life after death that begins immediately after a person is dead. Buddhism lays great emphasis on the karma of a person. According to it, a person leaves behind his karma and his character. The force generated out of his karma brings in an entity that would be influenced by it and bear the same disposition as the dead (Prasad, 4). Afterlife as in Buddhism and Christianity Buddhism began with the teachings of Gautama Buddha to address the suffering that exists in the world. Buddhism accepts the religious philosophies of Hindu doctrines which believed in reincarnation and karma. It believes that the ultimate goal of any religious life is to attain liberation from the cycle of life, death and rebirth. Buddha said that desire and cravings for materialistic things keeps one bound to the cycle of life, death and after death . When one liberates himself completely from such material pleasures he liberates himself from the cycle and enters the state of Nirvana. Buddhism however was not focused on ultimate salvation or attaining Nirvana as the sole motive in the life of an individual. Little is said about Nirvana in the Buddhist scriptures as Buddha felt the importance of attachment, pain and sufferings. The people were encouraged to give alms to the needy, donation of goods and services, to chant or copy sutras and engage in activities to gain merit. This would lead them to think

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ANALYSIS heart of atlanta motel v. united states - Case Study Example In the case under consideration, Heart of Atlanta Motel questioned and challenged the constitutionality of the Civil Rights Act of 1964 and attempted to justify and assert its policy of discrimination against African Americans. The Heart of Atlanta Hotel was located in Atlanta, Georgia. This facility denied the rights of admission to Black Americans, in direct violation of the Civil Rights Act of 1964. The suit filed by the owner of this motel questioned the powers extended to Congress by the Civil Rights Act in the domain of interstate commerce. In addition, he validated his stance of discrimination against Black Americans on the grounds of the rights extended to him by the Fifth and Thirteenth Amendment. The United States justified its authority under the Commerce Clause and denied any violation of the Fifth and Thirteenth Amendment Rights of the appellant. On December 14, 1964, a nine-judge bench led by Justice Tom C. Clark unanimously voted in favor of the United States of America. The court validated the authority of Congress in the sphere of Interstate Commerce, as far as the passing of the Civil Rights Act of 1964 was concerned. It denied any violation of the Thirteenth Amendment rights of the appellant. The decision accepted the authority of the United States Government in interfering in the acts of discrimination in public accommodation and noted that the jurisdiction of the Title II was, â€Å"carefully limited to the enterprises having a direct and substantial relation to the interstate flow of goods and services†¦ (U.S. Supreme Court Media). Title II of the Civil Rights Act of 1964 prohibited the practice of racial discrimination in public accommodations whose operations had an impact on the interstate commerce. The Heart of Atlanta motel located in Atlanta, Georgia denied admission to African Americans, in direct contradiction and violation of the Title II of the Civil Rights Act of 1964. The owner of this motel stated that the interference of the

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Creative Writing Assignment - Essay Example Just with any other marriage, his was approved by the committee and certified by the Party. He knew very little about his wife Susan when they got married after Edmond has just turned 25 and she was 22. They seem fit to be wed and that was enough reason to do so. The committee seemed to agree by affirming their union. But what ensued after the marriage was something they did not expect. All their conception about marriage and the relationship between two people does not seem adequate to describe what they have. They have nurtured a trusting acceptance of each other and where sex is deplorable at first, they have grown to enjoy it as much as the company of each other. It was beyond companionship. Susan’s first pregnancy proved difficult which led them to decide to stay at her mother’s house before her due up until the first month after giving birth. Lucy and Edmond knew nothing about childcare. Lucy, Susan’s mother, lives in an old beaten-up yet warm house with a spacious yard. The house is right next to a shop owned by a certain Mr. Charrington. She is a typical matriarch up and about in her house incessantly cooking, washing and sweeping. She takes care of two other grandchildren. She had been a complete delight except for a few stories that she tells about life before the Revolution that even she can’t reconcile. Lucy at times mentions the change in Mr. Charrington since his wife’s death and how his entire business has turned shady. She even told him how she has seen a man peering outside one of the windows. Edmond dismissed all of these with a smile and a few neutral comments he figured could not hurt an old lady. Hi figured his sporadic conversations which at times tend to be subversive is enough trouble for both of them. Lucy constantly cared for them and could not be more pleased to a new addition to the household squeals. He knew he was capable of doublethink and has proved to be a difficult albeit useful

A selected annotated bibliography on Edgar Dega's Singer in Green Research Paper

A selected annotated bibliography on Edgar Dega's Singer in Green - Research Paper Example Degas illuminates his subjects from below. Shckenkel also argues that Degas has depicted his artistic knowledge using coarse hatchings that suggests the existing backdrop behind the singer herself. According to this author, Degas had a deep meaning behind this style of art. He says that the subject matter of the Artist mainly represented the modern approach. He also states that Degas had a great interest in the portrayal of romance as a major theme of his work of art. His intended message of this image is also facilitated or backed up by his claim that Degas had absorbed her artistic tradition outside people’s influences and later reinterpreted them in various innovative and inventive ways. He created and came up with a lot of information from a single work of art. From the art, it is evident, according to the author that Degas did an experiment with various techniques, thus breaking up the existing surface textures with hatching. He also contrasted the dry pastel with a wet o ne. Degas used watercolors and gouache in the softening of the contours of the figure. Degas, in this concept, is seen as an experienced artist in the use of colors to decorate hi artworks. He uses vivid yellow, orange, and turquoise, which area all features of saturated hues and complementary colors with which other several artists in his circle began to experience during the mid-1880s. The posture of the picture shows that Degas used the modern artistic styles. It is actually the same as the current postures taken by most live performing artists. Reff, Theodore. The Pictures within Degas’s Pictures. Columbia: Columbia University Press, 2004. Print. Theodore affirms that Degas applied Venatian art in the creation of the picture. His painting styles with the use of several colors are an indication of the use or application of the mentioned art that was popular during the mid-1860s. He says that the appearance of the picture was because of various works of other artists such a s Tintoretto, Giorgione, and Veronose. Like other works of Degas such as Finding of Moses, Theodore asserts that most of the art styles used in the picture, were that of Tissot who wrote to him, â€Å"L’Assomtion du Titien m’a laisse froid-le Tintoret de Saint- Marc piquant une tete m’a bien†¦Ã¢â‚¬  Theodore goes ahead to explain the history of Degas artistic knowledge that he used in the making or compilation of the picture. He says that the knowledge on the use of colors in the decoration of the picture came from Venatian first, before it; Tissot got it and later shared it with Tissot. He says that, through this, Degas managed to create the picture that was remarkably varied in styles and subjects. The skills he gained through these early artists also helped him come up with juxtaposition in photos. He asserts his beliefs in the existing relevance of modern art. To verify the issue of modernity, Theodore talks of the realism of European paintings and th e artificiality of the Japanese prints. The curving of the hand in the picture, the paintings, the textures and the posture, are all original works of other artists during the renaissance era that was adopted by Degas during the creation of the artworks. Reff, Theodore. Degas: A master among Masters. Columbia: Columbia University Press, 2001. Print. In this article, Theodore still discusses the styles that Degas used in the picture. He talks of many aspects of the pictures, in terms of its composition and making styles. She refers to one of the known and popular statements that Degas made

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US-Iran Conflict Essay Example | Topics and Well Written Essays - 750 words

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Assessment and Tests Evaluation Research Paper Example | Topics and Well Written Essays - 500 words

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Cisco Case Study Essay Example for Free

Cisco Case Study Essay Cisco Systems is an industry leader in network technology. Their primary business is technology that is used to enable communication with people all over the world with multiple functions. Whether it be email, voice video or general applications these service are transported over Cisco Networks. The current CEO is John Chambers who has held the position since 1995. This case study focuses on his vision and strategy over the past 17 years. Cisco is a market leader in networking technology. Financial Information: www. Bloomberg.com (1) Sales 2012 Sales/Revenue/Turnover: Total Operating Revenues. $46,681,000,000 Gross Profit $28,558,000,00 Net income $ 8,356,000,000 Key Milestones in Cisco’s History (2) 1997 All in One: Data/Voice/Video 2000 Network of Networks 2006 Network as Platform 2008-Current Collaboration/ Web 2.0 SWOT ANALYSIS Cisco’s’ internal strengths are its people. 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See Juniper.com(7) ANALYSIS VIA PORTER’S FIVE FORCES MODEL Analyze the competitive environment by listing the threat of new entrants, the bargaining power of buyers, the bargaining power of suppliers, the threat of substitute products and services, and the intensity of rivalry among competitors in the industry (Chapter 2). Summarize your key points in a Figure. (25 points) Cisco’s’ threat of new entrants is limited due to Cisco’s market cap on network Switching: Modular/Fixed (2) . They currently hold a 69% market cap sue to their design and build of these devices. Their competitors have copied and duplicated these products and there are only handful that compete. The bargaining power as a buyer based on thre volume allows them to keep manufacturing costs low. There suppliers in turn have strong bargaining power with their silicon and chip manufactures. New Chipsets are developed rapidly and suppliers can gain a competitive advantage over the manufacturers. The threat of substitute products is a common theme with Cisco. An example was a Chinese company stole Cisco’s design and started producing replica hardware. Years of litigation was later settled however the cost to do so was a major impact. (3)This caused an intense rivalry with its competitor 3Com who partnered with the Chinese company (4). The other issue with its competitors is its talent pool. Many of Cisco’s engineers leave for competitor with hopes of creating the next generation of technology. STRATEGY USED Cisco’s competitive advantage in the switching market has led them into being market leaders in other sectors. Having the market share of the core network as the base layer of Infrastructure allows them to see the need of its customers. These sectors have all been supplicants that utilize the Cisco core networking products that today has brought them an industry market share in the following area. The core strategy used is there overall cost leadership to create this competitive advantage Performance Market share per sector Security 31% Digital Video: IPTV-64% Switching: Modular/Fixed- 69% Voice-37% Wireless: LAN-54% Storage: Area Networks-44% Routing: Edge/Core/Access-53% Networked Home-23% Web Conferencing-38% (2) One core strategy they used in the area of differentiation was the introduction of Voice over the network. Voice is a legacy technology created over 100 years ago and up until recently was run with the same original design concepts. Cisco changed that system buy running voice over the IP network. Today VOIP phone systems are a standard and the original POTS (plain old pots lines) are now considered legacy. They used acquisitions to buy phone providers and break down there core fundamental and produce them on IP networks., allowing today the use of voice over your PC Email Text. They were very successful in this space however not all companies can use this strategy for this particular technology. There install base is so strong the market is saturated and would not be cost effective. This strategy however is now in the maturity stage of the industry life cycle. They contain 69% of the voice market and they are continued to grow. The core installations will eventually decline however the service to maintain the phones systems will continue to remain in the maturity stage. Cisco’s strategy is based on catching market transitions—the market transitions that affect our customers. With the proliferation of video and collaborative Web 2.0 technologies, the network continues to evolve from the plumbing of the Internet—providing connectivity—to the platform that will change the way we work, live, play and learn.â€â€" John Chambers, Chairman and CEO, Cisco THE ISSUES AND CHALLENGES FACING THIS COMPANY Cisco’s’ competitive advantage in some sectors can be maintained. The overall progress should continue however weaker sectors where they have lost focus on have declined. In the example of the home Networked sector they maintain a low 23% market share. This has not been inline what the projections were when they entered these markets. Recently they have announced they are moving away from the home based market with a sale of their Linksys lien to Belkin (5) I believe the companies’ competitive advantage can be maintained if they focus on areas where they have control on market share. Shedding unprofitable business such as Linksys is a step in the right direction. This product is clearly on the decline side and Cisco should focus on growth areas such as storage area networks. The companies’ culture is changing from when they were a smaller enterprise they were able to maneuver with market needs more quickly. The fierce competition in the home market was one of the company problems. I believe that they are an enterprises corporation provider of services and do not understand the needs of home based users. COURSE OF ACTION RECOMMENDED I would advise Cisco to focus on server storage sectors. They are not a market leader in servers such as HP but have new products that are changing the way we companies utilize servers. This is a differentiation strategy that will change the industry if done correctly. They created a virtual server solution called UCS that if markets correctly could achieve future growth in the server storage sector. (6) I would use my market power and customer to base to provide these solutions at a low cost and this will expose a broad customer base to the product OPINION What do you think of this case study? Describe what you believe are the lessons learned from this case. (10 points) I think this case study showed me new concepts in strategic management. By studying Cisco’s market dominance based on 46 billion in revenues I now understand that having a competitive advantage must be maintained. Seeing Cisco now leaving markets is a new direction for them and these concepts have brought me to understand that. REFERENCES When you have completed the paper using the above sections, insert a page break and have a separate references page. The references should be listed in accordance with the APA guidelines as shown in the tutorial. (5 points) http://www.bloomberg.com/quote/CSCO:AR (1) http://newsroom.cisco.com/documents/10157/0/Corporate+Overview+-+Q2FY12.pdf (2) http://www.theregister.co.uk/2004/07/29/cisco_huawei_case_ends/ (3) http://www.theregister.co.uk/2003/07/09/3com_welcome_to_join_ciscohuawei/(4) http://www.dailytech.com/Belkin+Plans+to+Purchase+Ciscos+Linksys+Home+Networking+Business+Unit/article29747.htm(5) http://www.cisco.com/assets/global/europe/powerofu/ucs_vs_hp_deployment.pdf(6) http://en.wikipedia.org/wiki/Juniper_Networks(7)

The Rational Decision Making Essay

The Rational Decision Making Essay Rational decision making, along with the thinking process that it involves, is a subject that has been vastly researched, both theoretically and empirically, and many different opinions have been, therefore, stated, since decision making is perhaps the most crucial part of human behaviour. As a result, a variety of social scientists have, at some point of their activity, occupied themselves with it and especially with its assumptions and their consequences. This essay will attempt to answer the question of what is a rational decision, by contrasting the classical to the behavioural approach of rational decision making, along with the perfect and the bounded rationality assumptions that accompany them, as well as the conditions under which they hold true. It will also, through this process, try to show that the classical approach lacks realism that would promote its widespread applicability and will further elaborate on the more realistic concept of bounded rationality. Moreover, a key part of the behavioural decision making, the heuristics process, will be presented and will serve as a bridge to the second part of the essay, which will analyse biases, the, perhaps, most important category of barriers to rational choice in organisations. Lastly, ways of overcoming those biases debiasing techniques will be demonstrated. But first, in order to decompose the essay question, two definitions will be given regarding the rational thinking and the decision making procedure. According to Baron, rational thinking is the desirable kind of thinking that each of us would want to do, if we knew our best interests, in order for our goals to be achieved in the best possible way, the ultimate of which is utility maximisation (2000, p.5). Furthermore, we are involved in a decision making process, when we choose an action of what to do or not so as to achieve a goal, after having judged a particular situation and evaluated the different possible outcomes (Baron, 2000, pp.6-8). This judgement can be spontaneous or thorough, it can be perfect or satisfactory, depending on the different theories and their elements that will be described in the main body of this essay that follows. Rational reasoning and decision-making: The two theories A rational decision is one taken under the conditions of either perfect or bounded rationality, depending on which of the two completely opposed theories is taken into consideration in order to explain our behaviour. Although these two theories are totally contradictory, a general model of rational behaviour which fits both of them was described by Simon. More specifically, he wrote that every rational behaviour incorporates some common elements such as that the decision maker will analyse only a subset of numerous decision alternatives, out of which process, possible choice outcomes will occur. Then, according to an exact pay-off function, in the classical theory, or approximate, in the behavioural one, value or utility is allocated by the decision maker to each of the possible outcomes, and the one with the higher value is finally chosen (1955, p.102). However, the two theories assume very different things and entail alterative consequences in their effort to account for a rational decision. The classical, also referred to as normative, the one that assumes perfect rationality and utility maximisation in all decisions, derives from the traditional economic theory and portrays an economic man, who, while allocating scarce resources, is also rational. He is aware of all the relevant aspects of his complex and immense environment, his system of preferences is stable and well-organised and he is so skillful in computation, that he can calculate by himself the produced utility of all the possible actions that can occur as a result of his decision and eventually, choose the one with the highest (Simon, 1955, p.99; Simon, 1979, p.493). In addition, it is possible for us to, correctly or not, predict human behaviour without actually observing it. We are able to do that, because of the way that the environment, in which this whole process t akes place, is shaped (Simon, 1979, p.496). On the other hand, the behavioural theory of rational decision-making, that originates from the theory of institutionalism the transformation of the economic theory in order to include the tied to market transactions, legal structures and is based on the concept of bounded rationality, is not as simple and brief and does not make as strong and absolute assumptions about the human cognitive system as the classical theory does. The knowledge and computational skills that the human agents possess are realistic and much weaker than the same that are taken for granted in the previous outlined theory of utility maximisation. People, in this theory, are not expected to equate costs and return at the margin, as Simon puts it. Instead, the idea of satisficing is introcuded, where humans, far from optimising, try to achieve, through their rational, but less competent than in the classical theory, reasoning, an acceptable, in terms of the gained utility, threshold. To put it plainly, lacking knowledge of relevant outcomes probabilities and of external environments state, non accurate evaluation of all possible outcomes and weak human memory are key factors for the bounded rationality theme (1979, pp.495-496, 499). Elaborating a bit further on the concept of deciding under the bounded rationality context, two are the main mechanisms that are needed in order for a decision to be made: the idea of search and that of satisficing. The decision maker must search for the alternatives for choice, if they are not given to him initially, so a theory of search needs to be included in the bounded rationality model. Moreover, because the computational skills that people possess are limited and utility of all different possible choices can not be measured precisely, they have developed a minimum satisfaction level that they want to achieve with their outcomes value, terminating their search and choosing that particular decision. Another feature of this approach is that the predictions it makes, can be easily tested through observation and empirical phenomena (Simon, 1979, pp. 495, 502-503). In an attempt to show that the behavioural theory of rational decision making is superior to the classical one, two important flaws of the latter will be briefly presented and a general, relevant to both approaches, conclusion will be drawn. A major flaw, that originates from the unrealistic notion of the classical theory, is that agents decisions are made in a context in which all relevant, present details, future expectations and risks are incorporated, according to Kahneman, an assumption which rarely holds true (2003, p.706). Secondly, the, perhaps, most important pylon for the classical theory, utility maximisation, is severely challenged, since there is no existence of evidence that this is actually happening (Simon, 1979, pp.496-497). Connected to the previous fact is the economic model that indicates negative sloping demand curves which, according to Becker, do not necessarily portray rational behaviour that aims to utility maximisation, because there is evidence that people who use other irrational decision rules, find themselves in the exact same position (1962, pp.4-5). Conclusively, regarding the two presented theories, although in relatively simple and stable decision situations where uncertainty is not present, people seek and achieve maximisation of their personal expected utility function, there are serious deviations from this procedure, when, even slightly, complicated features are introduced in the decision process. The decision attempts in the latter context are explained by the behavioural theoretic model, in which the issue of bouned rationality plays a central role. This theory explains the wide variety of empirical observations that do not abide by the classical models assumptions (Simon, 1955, pp.103-104; Simon, 1979, pp. 497, 505-506). Heuristics and their twofold connection to decision-making A subject of major importance that is closely linked to the behavioural or descriptive theory of decision-making, is the heuristic technique. Heuristics have been adopted by people as responses to complex and uncertain decision-making situations and are mental shortcuts, sometimes unconscious, that help them reason in a continuous way (Hammond et al., 1998, p.47; Tversky and Kahneman, 1974, p.1124). They are generally part of humans problem-solving process and include very selective search through problem spaces that are often immense, as Simon explains. As soon as a satisfactory enough outcome is produced, the search ends and this decision is taken, as explained in the analysis of the behavioural theory above (1979, p.507). Heuristics are widely used for the reason that they regularly accomplish the goal(s) they were summoned for, making them the, probably, most reliable and with strong properties medium towards a rational decision (Simon, 1965, p.183). One of the most common heuris tic methods is representativeness, through which, probabilities of events are calculated in respect to how resemblant of an event is another. If the resemblance is high, then the probability that one of the events derives from the other is also high. Another way to attribute probabilities and frequencies to events, is through the availability or accessibility heuristic, which indicates that elements of large categories are more easily retrieved from our memory and therefore higher probabilities are assigned to them. Lastly, the anchoring and adjustment heuristic indicates that people begin their syllogism from a familiar starting point and, usually, their final decision lies not so far from it, being only mildly adjusted (Tversky and Kahneman, 1974, pp. 1124, 1127-1128; Hammond et al., 1998, p. 48). However, the second dimension that connects heuristics to decision-making is that, through them, barriers to rational choice, may be created. The, perhaps, most important category of suc h barriers, namely biases, will be presented in the following second part of the essay and potential ways of overcoming them will be demonstrated. Biases and ways to overcome them Because of the essays length limit, the sole barriers to rational decision-making that will be analysed are biases and will be featured along with some techniques that can soften their impact. Generally, the range of biases is really wide but there are some common causes that are responsible for most of them. Stimuli in judgement and evaluation are not translated in a linear mode, creating distortion in the reasoning process, is one of the causes. A second one, is the unconscious automatisation of humans cognitive action when they are trying to recall information from their memories and their choice between a narrow information base and finally the use of inferior strategies, due to lack in superior ones, is a third (Larrick, 2004, pp.319-320). The anchoring heuristic that was mentioned in the previous section of the essay can lead to biases that influence rational decisions. This happens because our thoughts and judgements are anchored by the first impression that we have on a situation and we rarely consider new perspectives to the situation, a fact that might lead to incorrect conclusions. Nevertheless, there are ways of overcoming this bias, such as being open-minded and viewing and adopting the cognitive strategy of considering the opposite, which alters the starting point of our reasoning (Hammond et al., 1998, p. 48; Larrick, 2004, p.323). In addition, a very common bias which severely influences rational choice in organisations is when decision makers tend to choose alternatives that do not affect much the status quo. This happens often because people rarely want to hold responsibility for an action that can lead to criticism from colleagues and prefer the safer course of doing nothing, that poses a less psychological risk to them. It is also the case, that when there are many alternatives to a decision, because more effort is required in order to analyse all of them, people usually stick to the status quo. A way of overcoming this particular bias, which can have general applicability as well, is through the adoption of the motivational strategy of accountability. This technique indicates that people should, at all times, be held responsible for their actions, or in the case of the status quo bias, the non-actions, and they will have to explain the logic behind their decision. As a result, they begin to consider alter native possible decisions and, what is important, they take into account that the attractiveness of the status quo can change over time, thereby learning to evaluate decisions not only in terms of the present but of the future as well (Hammond et al., 1998, pp. 48-50; Larrick, 2004, pp. 322-323). Lastly, a bias that strongly influences the rationale of our decisions, is the sunk-cost one. According to this, employees, involved in a decision-making process, the majority of whom are managers, continue to support past choices, even if they do not seem valid any more and not surpassing them involves more losses than gains. Although most people know that these sunk-cost decisions are not relevant to the present one, they influence their minds and often lead them to making improper decisions. The reason why people seem to not let aside those decisions, is because they are unwilling, consciously or not, to admit to a mistake, as Hammond et al. underline, since that would hurt their self-esteem. People in business environments where the penalties for bad decisions outcomes are high, do not have the motive to terminate any such decision-relevant results, because they are hoping that they will be able in the future to somehow generate gains from them. The most efficacious way to tackle the sunk-cost bias is to consult the views of people who did not take any part in the decision-making process and will likely not have a biased perspective concerning it (1998, pp. 50-52). In order to avoid the possibility of getting tangled into a sunk-cost bias situation, people can engage into the technological strategy of group decision-making, in which the effective sample size of experience used to make a decision is widened, and the particular bias is statistically less likely to occur, if the groups experience and training is diverse, according to Larrick (2004, pp.326-327). Conclusion To sum up the key points of the essay, concerning the first part about rational decision-making, the classical theory, although attractive and relatively simple to comprehend, lacks a great degree of realism and applicability, since it presupposes perfect rationality and flawless computational ability of possible decisions outcomes for all human agents, a fact that leads to utility maximisation. On the other hand, the behavioural decision-making theory has been developed in order to provide an explanation to many empirical findings and data, which illustrate humans as boundedly rational, meaning that instead of optimising, they are looking for a decision alternative that meets some minimal criteria that are set by them. One of the extensions of a behavioural theory are heuristics, which are standardised judgemental operations that deal with situations that demand reasoning and assessment of probabilities. However, traps that lead to systematic syllogisms distortion, a multitudinous c ategory of which, are biases, do exist and are sometimes caused by heuristic processes. They, nonetheless, can be confronted in several ways, the most important of which is awareness of their existence. Because human behaviour and decision-making are interlinked, more chapters in the theorisation of the latter, especially in more specific areas of it, are expected.

Cell and Voice Over Internet Protocol Research :: essays research papers

Cell and Voice Over Internet Protocol Research Our contract is coming up for renewal from Nextel our current provider of cellular service, and SBC our local and long distance landline service. I will research three cellular service and Voice over the Internet Protocol providers (VoIP). By looking at three of each will give a good idea of what is out there and what trends of services to expect. For cellular, I will choose a phone to increase our work force productivity that cannot be done with our current type of phone, and find a plan that can meet our changing needs. For VoIP, pricing plans and equipment included. Finally I will give my conclusion on which companies to go with and why. Cellphone Providers Cingular phone   Ã‚  Ã‚  Ã‚  Ã‚  BlackBerry 7100g Features: Built-in Speakerphone, Bluetooth capable, Polyphonic speaker and downloadable ring tones, Downloadable games and graphics, Blackberry handheld software, and Quad-band world phone operates on 850/1900 and 900/1800 MHz GSM/GPRS networks (http://onlinestorez.cingular.com/cell-phone-service/cell-phones/cell-phones.jsp?source=INC230056&_requestid=50674). Clingular plans Nation 1000 FamilyTalk w/Rollover – 79.99 first two lines, 14.99 per additional line this package comes with 1000 anytime minutes, nights and weekend is unlimited, mobile to mobile is unlimited. Nation 1500 FamilyTalk w/Rollover – 99.99 first two lines, 14.99 per additional line this package comes with 1500 anytime minutes, nights and weekend is unlimited, mobile to mobile is unlimited (http://onlinestorez.cingular.com/cell-phone-service/wireless-phone-plans/cell-phone-plans.jsp). Nextel phone BlackBerry 7520 features: Walkie-Talkie Services, Speakerphone, Color display (65K colors), Group Connect Walkie-Talkie, Multimedia Messaging Service, Direct Talk - The Off-Network Walkie-Talkie, Web and Email Capable, Ring Tones, Applications & Games, Adheres to Military 810F Spec (http://nextelonline.nextel.com/NASApp/onlinestore/en/Action/DisplayPhones). Nextel Phone Plan Nextel National 1000 has 1000 monthly minutes for 55.99, the night and weekend minutes are unlimited direct connect is included. (http://nextelonline.nextel.com/NASApp/onlinestore/en/Action/DisplayPlans) TMobile phone The BlackBerry 7100t is the first of its kind--a full-featured mobile phone that delivers the power of BlackBerry e-mail. This is one sweet little phone, loaded with all of the cool features you want, like integrated Bluetooth ® connectivity, speakerphone, and downloadable ringtones. Moreover, surf the Web the way it was meant to be with an ultra-large, high-resolution color screen (http://www.tmobile.com/products/overview.asp?phoneid=246167&class=pda). T- Mobile phone plans The FamilyTime plan is 69.99 a month with 1000 whenever minutes, and the weeknight and weekends are unlimited (http://www.t-mobile.com/plans/FamilyTimeRatePlanDetails.asp). Voice over the Internet Protocol What is VoIP/Internet Voice?   Ã‚  Ã‚  Ã‚  Ã‚  VoIP allows you to make telephone calls using a computer network, over a data network like the Internet. VoIP converts the voice signal from your telephone into a digital signal that travels over the internet then converts it back at the other end so you can speak to anyone with a regular phone number.