BOOK EXCERPT

Book excerpt: ‘A toolkit of options, short of war, that can inflict costs and damages on Pakistan’

Former Foreign Secretary Shyam Saran says these options have to be combined with a liberal policy for trade, economic and cultural exchanges.

India has not been able to craft an effective strategy to deal with Pakistan’s use of cross-border terrorism as an instrument of state policy. Each time there is a major terrorist strike by elements aided and abetted by the Pakistani state, the choice confronting our political leadership is whether to engage in a retaliatory military strike and risk possible escalation to a nuclear exchange, or do nothing more than suspend bilateral engagement and, in some cases, as after the attack on the Indian Parliament, interrupt trade and transport links.

Indian troops were mobilised and massed on the India–Pakistan border after this attack but no operations were undertaken. It is debatable whether this changed Pakistani calculations in any way. The troops were demobilised after a very costly standoff lasting several months.

India’s basic weakness is that its political leaders have no credible response options between the extreme choices of military retaliation and appeasement when it comes to Pakistan-sponsored terrorism. What we need is a toolkit of options, short of war, that can inflict costs and damages on Pakistan.

We need to have a series of pressure points on Pakistan to contain its hostile activities against India. These would need to be built up gradually.

One pressure point, for example, could be Gilgit and Baltistan; we could pursue our claim on them more aggressively, highlighting the disaffection within the largely tribal population there. After all, technically speaking, they should be treated as our own citizens and their welfare should be a matter of concern to us. I had begun to receive delegations from these areas, even though many of them are now resident in other countries.

Human rights violations continue in Balochistan, and yet we have been hesitant to draw attention to them. On 27 December 2005 I had authorised this press statement to be issued:

“The Government of India has been watching with concern the spiralling violence in Balochistan and the heavy military action, including the use of helicopter gunships and jet fighters by the Government of Pakistan to quell it. We hope that the Government of Pakistan will exercise restraint and take recourse to peaceful discussions to address the grievances of the people of Balochistan.”

The idea was to build up countervailing pressure on Pakistan whenever it raised Kashmir or any other matter to criticise India. But I was advised not to issue such statements any more because this could adversely affect the improvement of bilateral relations. My point was that despite the improvement, Pakistan was not shying away from regularly finding fault with India on Kashmir and a range of other issues.


We have so far discussed only the negative levers of influence for dealing with Pakistan. These must be combined with the positive levers.

Precisely because India has a difficult and complex relationship with Pakistan, it must remain engaged continuously with it at all possible levels, both official and non-official. The lines of communication must never be interrupted. Halting talks whenever there is a serious terrorist incident that is traced back to Pakistan is not the answer; in any event, that has never stopped Pakistan’s policy of cross-border terrorism.

Any rupture in bilateral dialogue only creates a space for external involvement and activism, where the agenda may not be aligned to our interests. During previous India–Pakistan crises, there have been interventions by the US, inevitably hyphenating the two countries. This is welcome to Pakistan but not India.

It is in India’s interests to promote trade and economic relations with Pakistan, even if this means some non-reciprocal measures from our side. There is significant complementarity between the two economies, and it is estimated that as much trade takes place between them through third countries like the UAE, Kuwait and Singapore as through direct channels. Converting this indirect trade into direct trade will benefit both countries.

During my time as foreign secretary, it had been agreed that India and Pakistan would allow direct banking relations. Each side would designate two banks to open branches in the other country on a reciprocal basis. This has still not been implemented. Off and on there have been proposals for India to supply power to Pakistan, and technical discussions on linking transmission lines have also taken place. On a request from Pakistan, India had agreed to supply it diesel using the land route. None of these agreements were followed up, mainly because of opposition from the Pakistani military.

An important instrument in India’s diplomatic toolkit for managing its relations with Pakistan is the promotion of people-to-people relations, cultural relations and civil society dialogue.

This would, over time, create interest groups in Pakistan that have a stake in peaceful and friendly relations with India. The greater the exposure of ordinary Pakistani citizens to the Indian reality, the less effective that country’s official policy of cultivating hostile and negative attitudes towards India.

A more liberal visa policy, implemented unilaterally if necessary, would allow Pakistani citizens to visit any part of India. Currently their visas are limited to only three cities. The burden – and often humiliation – of police reporting for Pakistanis travelling to India must be done away with.

Even the limited visa liberalisation of the past few years has helped Indians and Pakistanis connect with each other. Pakistani authors come to India to launch books, their artistes perform at concerts here and Pakistani actors appear in Bollywood films. These should be encouraged. Instead we resort to jingoism.


India’s Pakistan policy must be based on the recognition that India–Pakistan relations are deeply adversarial and likely to remain so for the foreseeable future. The policy objective should be the management of this adversarial relationship rather than any quest for a grand reconciliation. We can prevent tensions from escalating and avert violence.

As we have seen, the adversarial nature of the relationship is rooted in the widely different and deeply entrenched historical and national narratives of the two countries. For example, even so-called liberal Pakistanis believe that cross-border terrorism, even if not justifiable, is not without good reason because of the power asymmetry between the two countries.

Competing and deeply held narratives change slowly and can only be reconciled over a long period of time with patient engagement.

There must be a willingness to separate historical fact from politically inspired distortions. That not being the reality, only modest and incremental measures to improve relations are possible. Any suggestion of a path-breaking initiative to transform relations has inevitably led to a backlash from those who are deeply invested in the perpetuation of hostility and are pro ting from it.

A recent example of this is the 2016 terrorist attack on the Pathankot air base days after the unexpected but highly publicised visit of Prime Minister Modi to Lahore at the invitation of his Pakistani counterpart Nawaz Sharif.

Another factor that has influenced Indian policy towards Pakistan is the implicit but unarticulated anxiety that the latter’s disintegration or descent into chaos will present India with an existential crisis. This fear inhibits Indian actions that may be seen as contributing to that denouement.

The reality is that India is only marginally relevant to the domestic political dynamic in Pakistan. Whether it survives as a stable entity or disintegrates will depend upon what its people want. To refrain from rapping Pakistan’s rulers for fear of destabilising that country is a flawed proposition.

One should also take note of the fact that while Pakistan’s fragility is advertised as a mitigating circumstance by one set of analysts, its resilience is lauded by another set. Pakistan is often described as being suicidal. But its record shows that its ruling elite has displayed a remarkable ability to cut deals to ensure its survival and maintain its privileges. We are, in fact, dealing with a state that is coldly calculating in pursuing its declared interests, and it must be confronted as such.

Pakistan also uses our shared language and culture to arouse sentimentality.

This mawkishness camouflages its mostly unsentimental aims as a state with hostile intent. Indian civil society and political leaders fall prey to this tactic, having no clue about the ulterior intent. Our bonds of language and culture are very real and should be used to advance links but they must not influence the calculus of interstate relations.

Managing Pakistan will always be a challenge. But we must think of it as a state amenable to influence – economic, military and cultural. Once we see this, we must then throw off our self-imposed inhibitions and be open to all options, creating and using both positive and negative levers to yield the results we want. This is what we do in dealing with other states. And this is what we need to do with Pakistan.

As the back-channel talks progressed, it became clear that the Jammu and Kashmir problem could not be resolved, not for a very long time to come. But the discussion took for a starting point Prime Minister Manmohan Singh’s declaration that while he did not have the mandate to change India’s borders he did have the mandate to make those borders progressively irrelevant. Of course, his comment applied not just to Pakistan but to all our subcontinental neighbours. But this points us back to what I referred to earlier in this book – the need to restore the geopolitical integrity of the region.

The practical application of Dr Singh’s statement to India– Pakistan relations did yield results. What was agreed in the back-channel talks has still not been revealed in reliable detail but enough is known to conclude that the two sides committed to an essentially open border between the parts of Jammu and Kashmir under their respective de facto jurisdictions. But the agreement could not be taken forward precisely because it was not part of the larger peace process between the two countries.

It has been argued that converting the LoC into an international boundary is the only realistic solution to the issue of Jammu and Kashmir. Even if that were the case, it can only be the end point of negotiations and not the beginning. For the present there is no reason to abandon our formal position that the whole of the erstwhile state of Jammu and Kashmir is the sovereign territory of India.

We must chip away at Pakistan’s hostility because our current adversarial relations with it and its use of asymmetrical strategies do impose significant constraints on India. We may have to adopt counter-constraint policies to attempt to change the strategic calculus in Islamabad. This may include the option of inflicting pain on Pakistan if India’s security is threatened. India must also include in its policies an uninterrupted, longer-term project to enhance people-to-people links, trade and commercial relations and cultural interactions at every opportunity.

Excerpted with permission from How India Sees The World: Kautilya to the 21st Century, Shyam Saran, Juggernaut Books.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.