The National Stock Exchange (NSE) building ensconced in Mumbai’s Bandra Kurla Complex feels pretty much like a fortress as you make your way through a narrow iron-gated entrance and are subjected to multiple security checks. It’s not without reason. Since its inception a quarter of a century ago, NSE has emerged as a premier market institution and the de facto stock exchange of the country given that it commands 85% of the cash market and 94% of the derivatives market turnover (see: Ruling the roost). Not surprising then that an enviable moat, lip-smacking margins and a meaty cash pile have made the for-profit unlisted enterprise the cynosure of marquee private investors (see: Centre of attraction). Of late though, despite its engineering and IT prowess, the exchange has encountered technical and governance glitches that have cast a shadow on its halo.
On July 10, when the Nifty crossed 9,700 for the first time, traders experienced something that they had never before in the history of the exchange: there was no trading in the cash market for the first three hours. For Mustafa Nadeem, CEO, Epic Research, an Indore-based advisor with 1,500 clients, the whole episode was bizarre. “It was the first time that I came across a situation where spreads were more than 3% in some stocks and traders couldn’t close positions. My trading clients took a hit but there is no mechanism where the exchange compensates them for such glitches,” laments Nadeem. Without revealing much details, the exchange said that few investor and member complaints relating to notional losses are “being handled.”
What’s interesting about the whole episode, according to media reports, is that the exchange allowed the equity derivative segment to trade for close to 45 minutes despite a shutdown in the cash segment. As a result, trades worth 80,000 crore were clocked before it shut the segment. The clarificatory statement that the exchange eventually came out with left a lot to be desired. NSE’s press release on July 10 mentioned that “The matter is being examined by the internal technical team and external vendors, to analyse and identify the cause which led to the issue and to suggest solutions to prevent recurrence. The matter has been referred to the Standing Committee on Technology, comprising of public interest directors and technology experts for review of the problem and to approve measures to prevent recurrence of such glitches.”
Ideally, in such a situation the exchange’s contingency plans should have been activated. Instead, the exchange mentioned that the business continuity plan mechanism is normally invoked during any disaster, hardware failure and connectivity related issues. “Preliminary assessment indicated a software problem. Secondly, the system was expected to be rectified quickly and shifting BCP site would have taken longer time,” the release went on to state. This clearly shows that the exchange’s much talked about IT prowess was not put to the test. “Ideally, the back-up system should have kicked in immediately but that was not the case,” points out Nadeem.
For an exchange that has seen its average daily turnover leap from 7,700 crore to over 400,000 crore over the past two decades, the response from market regulator Sebi, too, was muted. There was just a one-line release from the regulator stating: “Sebi is in touch with NSE and is closely monitoring the situation.” The NSE said in an emailed response: “We have submitted our report to Sebi in which we have outlined remedial steps. These incorporate views of our vendors and brokers.”
For an exchange that is the hallmark of India’s robust financial architecture, such a failure raised the question of whether it was reliant enough to handle increasing volume and about its eventual preparedness to address a trading shutdown. Jayanth Varma, professor of finance and accounting at IIM-Ahmedabad and former whole-time member of Sebi, believes there is something fundamentally deficient in the disclosure standards prevalent in the capital market. “However trivial it is, exchanges have to disclose what exactly went wrong and I am talking not only about NSE but exchanges world over have this habit of saying that there is a technical glitch, it has been fixed and now the market is fine. To my mind, it is unacceptable.”
In yet another instance of regulatory forbearance, in 2012, a punching error led to a huge sell-order that sent the Nifty into a free fall of 15%. The incident showed that the exchange had fallen foul of a 2001 circular issued by the regulator that had introduced an index-based market-wide circuit breaker system at three stages of an index movement at 10%, 15% and 20%, aimed to bring about a coordinated trading halt in all equity and equity derivative markets nationwide. It took Sebi two years, November 10, 2014 to be precise, to issue an order which stated that the NSE “is directed to be careful and cautious in its dealings in the securities market and comply with all the legal requirements that govern its functions as a stock exchange” and it “is directed to carry out a comprehensive review of the processes followed, checks in place, systems employed by NSE, by an independent expert and submit a report to Sebi along with its ‘Plan of Action.” Neither did the NSE in its annual report for FY15 and FY16 mention what follow-up action has been taken and nor has the regulator chosen to given an explanation on what was the follow-up from the exchange.
It’s not just the NSE that has faced such issues. The Bombay Stock Exchange (BSE) too had episodes of similar glitches. In fact, in 2014, there were two instances in April when a technical snag saw brokers unable to connect to the exchange’s servers for 30 minutes. In July 2014, owing to connectivity issues, trading was halted for around three hours. But given that the bulk of F&O and cash volume happens on the NSE, the hue and cry was relatively muted.
However, following NSE’s recent July 10 shutdown, it was reported that a maiden meeting of Sebi’s newly-constituted panel on cybersecurity aimed at safeguarding the capital market against technical glitches and cyber-attacks was held on July 28 with stock exchanges officials. But neither the regulator nor the exchanges have given details of the steps they are planning to handle unforeseen shutdowns. Varma says there has to be much more that needs to be discussed in public. “We need to know what the vulnerability was; whether the systems are adequate and what are the exchanges doing about it. There has to be a lot more transparency.” The NSE, which spends close to 180 crore on maintenance of IT infrastructure management, software expenses and so forth, in an emailed response said “its systems have performed well over the years with minimal disruption.”
Fortunately, all of the glitches have happened in a bullish market. What if the same had happened when the market was in a downtrend? That would only magnify the panic and stampeding of traders and investors wanting to exit. Imagine the frenzy when you punch in a sell trade in a falling market but there is no trade confirmation and all you see is further price breakdown. In fact, post the Emkay episode, there was a rush among broking firms to hike their insurance cover. As it turns out, according to reports, Emkay Global received only 95 lakh as insurance against the loss of 51 crore owing to the fat finger trade as the brokerage had an insurance cover of only 1 crore to cover trading errors. Here again the safeguards are woefully out of sync given that Sebi’s regulations make it mandatory for every stockbroker to have a minimum professional indemnity insurance of just 5 lakh.
No rules game
The lack of transparency around NSE’s operations had earlier come to the fore when a whistleblower alleged rules and processes were ignored by the exchange when it offered unfair co-location (co-lo) access to some brokers, including OPG Securities and AlphaGrep. The absence of a multicast facility for price feeds in the initial days of co-lo gave some brokers unfair access until the NSE changed the system in 2014. After three complaints, Sebi began its probe and eventually non-executive chairman Ravi Narain, CEO Chitra Ramkrishna and other senior personnel had to step down. However, after three different investigations — one by NSE’s own internal team, second, by a Sebi-appointed expert team and third, a forensic audit by Deloitte Touche Tohmatsu — the issue remains unresolved. Ravi Narain, despite the period under review coming under his tenure, was part of the team that supervised the Deloitte audit. He did not recuse himself from the board discussion despite a clear conflict of interest. Deloitte, too, had completed a business continuity project for the exchange earlier.
The fact that Narain was in complete control of whatever was happening with the forensic audit comes across quite evidently. A digital copy of the Deloitte report, of which Outlook Business has a copy mentions that (sic), “In our discussions with Abhishek Soni [who was then with the product support and management (PSM) team] did not give his statement in writing. On 23 November 2016, he mentioned that oral instructions for server allocations and other changes were often given to the team by seniors. He declined to provide this in writing and name any person in particular and hence we would like to term this information as hearsay.”
Incidentally, an internal email sent by VR Narasimhan, chief regulations, on November 23, 2016, NSE states that (sic), “Delloitte is ok to relive Abhishek since they had three days of discussion with him and that they have taken statement from him.” The fact that Narain was in the loop is amply clear with the mail going on to further state, “I have kept Mr Dinesh and Mr Ravi Narain informed that we will relive Abhishek today.” According to a former NSE employee, while Soni had put in his papers and had to serve his three months of notice, the exchange was keen on relieving him much earlier. “It seems as if the exchange did not want Soni revealing too many details,” says the employee. Ravi Narain and Chitra Ramakrishna chose not to comment on the story.
To begin with, Sebi’s decision to put the onus on NSE to appoint a consultant to look into the whole issue itself seems erroneous. This was not a post-glitch affair that NSE could have undertaken on its own, it was a whistleblower alleging governance issues. Anil Singhvi, chairman, Ican Investment Advisors, believes the regulator should have been more judicious in its approach. “I think Sebi erred in its own judgement. You cannot ask a person who has committed an error to conduct an audit and submit a report.” Little wonder then that Narain chose to do what he did by overseeing the audit rather than excusing himself from the whole process. Email request sent to Sebi chairman Ajay Tyagi’s office went unanswered. Sebi wholetime director Madhabi Puri Buch, too, declined to meet for the story.
However, Ajay Shah, senior fellow at the National Institute of Public Finance and Policy, believes the whole co-lo issue has been blown out of proportion. “Algo trading was something new at the time…the rules and procedures were still in motion in the early stages of the market. You don’t want to write down everything. You want to let people develop the business side and gradually, as you start understanding that there are problems, you start writing down rules more carefully. When there were no rules where is the question of a violation?” asks Shah.
On the allegation that some brokers had an unfair advantage in terms of faster access to quotes, Shah believes the gains have been hyper-exaggerated. “The turnaround time for sending an order from inside the co-lo to the NSE and getting a confirmation is 1 millisecond, that is one thousand microsecond. So, the edge that you get is perhaps 1 in thousand, Frankly, it’s not much and it does not make any great difference to the material outcome. If it was so valuable, many people would have been doing it,” says Shah. However, Manish Jalan of Samssara Capital Technologies, a quant analytics firm, feels some brokers did have an edge. “1 millisecond is like 1,000 microseconds. I know players who are able to play on 10 microseconds and 20 microseconds. These traders see spreads that nobody else can,” points out Jalan.
But what’s perturbing about the whole co-lo affair is that even after allowing direct market access in 2008 Sebi is still to lay down precise regulations around algo trading. In 2012 and 2013, “broad guidelines” for algorithmic trading in the securities market were issued by Sebi and, in 2015, guidelines were issued to ensure fair and equitable access to co-lo facilities. In 2016, Sebi put out a discussion paper, titled “Strengthening of the Regulatory Framework for Algorithmic Trading & Co-location.” Even as the regulator is sizing up the animal, algo trading is fast gaining ground. According to estimates by uTrade Solutions, a software developer for multi-asset and algo trading, HFT’s share in the equity segment has risen from 25% in 2012 to 42% in 2016. In equity derivatives, it surged from 22% to 56% during the same period.
In the US, in wake of the “Flash Crash” of May 6, 2010, in November the same year, the SEC adopted a new rule that mandated brokers and dealers to have risk controls in connection with their market access. According to the SEC, ‘Rule 15c3-5 is intended to address risks that can arise as a result of the automated, rapid electronic trading strategies that exist today, and bolster the confidence of investors in the integrity of our markets.’ Further, in 2015, the CFTC unanimously approved a set of proposed rules, referred to as “Regulation Automated Trading”, which covers risk controls, transparency measures and other safeguards.
Shah is not perturbed though. His contention is that nobody expected algo trading would explode the way it has today. “In time, as we go along we have to fix this…there are hundreds of such issues in market design. For decades some people were coming into NSE by satellite and some were coming in through leased lines from Bombay. The satellite roundtrip time was 33 milliseconds and the intra-Bombay roundtrip time was 5 milliseconds. It was not a crime. People accepted it as a part of life. Exchanges have to deal with commercial and engineering trade-offs and they do this all the time.”
Show me the money
Along with a jump in overall trading volume and a surge in algo trades, NSE had to also deal with disgruntled marquee private investors waiting to cash in via a listing. In 2007, the NYSE Group, General Atlantic, SAIF Partners and Goldman Sachs acquired 5% stake each — the maximum permitted — followed by Morgan Stanley, Citigroup and Actis, which picked up 3%, 2% and 1% stake, respectively. Then, in October 2008, Azim Premji’s family office picked up 3% for $100 million and Goldman Sachs and Norwest Venture Partners picked up 2.11% stake in 2009 for 250 crore. Sohil Chand, who led the investment at Norwest and had earlier sealed the deal for Goldman Sachs, his previous employer, recalls, “The key risk was always around listing but indications were given that it will be resolved. The official line always was “we are not averse to listing, that’s the international trend, and it’s just that we need to sort out some aspects of listing.”
That assurance unravelled when the Jalan Committee was set up to look into the workings of stock exchanges. In 2010, a seven-member panel headed by former Reserve Bank governor Bimal Jalan, was constituted to review the ownership and governance structure of market infrastructure institutions (MIIs). The shocker came for investors when the panel recommended that the exchanges stay unlisted. The rationale was that MIIs “being public institutions, any downward movement in their share prices would lead to a loss of credibility and prove detrimental to the market as a whole. Hence, such institutions should not become a vehicle for attracting speculative investments.” That set the alarm bell ringing for investors, who later learnt that while the NSE management had all along given them the impression that the exchange was all for listing, in a presentation to the committee, it had, instead, made a case for staying unlisted. “The report was a big disappointment as the management had all along assured us that they were engaging with the Committee and that they were pro-listing. That is why investors didn’t directly represent to the Committee,” reveals Chand.
More than the investors, it seemed that the management was worried about rising competition as Jignesh Shah of Financial Technologies, once a supplier of IT systems to the exchange, had started dreaming big. With the Multi Commodity Exchange stealing a march over the NSE-promoted NCDEX and its currency exchange, MCX-SX, fast gaining ground, Shah had evinced interest in entering equities trading. In fact to counter MCX, NSE was looking at hiking its stake in NCDEX by buying out stake of other strategic investors. Shantanu Guha Ray, journalist and author of the book, Target, which chronicles the rise and fall of Jignesh Shah’s empire, points out that the NSE had the complete backing of the-then finance minister P Chidambaram and his favourite bureaucrat in the ministry, KP Krishnan. “What was astonishing in this whole matter is the fact that Chidambaram and Krishnan had asked two financial institutions to off-load their stake in NCDEX in favour of NSE. Though commodity exchanges come under the jurisdiction of Ministry of Consumer Affairs and Agriculture, no one asked why the FM and a bureaucrat of the level of joint secretary interfered in the affairs of another ministry, and that too in favour of a private entity?” says Ray.
The rift became public when NSE disallowed its trading members from using a software developed by MCX’s parent, Financial Technologies, for currency futures trading, citing security issues. MCX went to court attributing the rejection to the fact that it was a rival in currency futures trading. The face-off continued when MCX filed a complaint with the Competition Commission of India, accusing NSE of anti-competitive practices in currency futures segment by not charging its members any fee. The Commission levied 55 crore penalty on the NSE, accusing it of predatory pricing, but the exchange has appealed the ruling which continues to be pending. Ironically, CCI’s former chief Ashok Chawla now chairs the NSE board. The fact that NSE was turning vitriolic in its campaign against Shah was evident when it issued a newspaper notice publicly denouncing its compliance officer A Sebastin, who had taken up a job at MCX-SX. The ad went on to mention that anyone dealing with Sebastin would be doing so at their own risk. The ex-employee dragged the exchange to the court which castigated the NSE for taking such a deplorable step. According to sources, the case was mutually settled after former Finance Commission chairman Vijay Kelkar intervened in the matter. When contacted, Kelkar refused to comment on the story.
Due to the nature of its recommendations, the Jalan Committee report was being viewed as an attempt by the NSE to stifle competition. “The panel’s suggestion for a cap on profits to discourage new entrants, and the need for ‘optimal number’ of exchanges, as ‘large number of stock exchanges will fragment liquidity’ was clearly aimed at safeguarding NSE’s monopoly,” reveals Ray. Coincidentally, CB Bhave, who was the chief of NSDL, a subsidiary of the NSE, and was under a cloud over the fictitious demat accounts scam, ended up heading the regulator between 2008 and 2011. It was during this tenure that despite MCX-SX’s licence for currency derivatives being renewed, the regulator strangely passed an order on September 23, 2010, terming Shah and his entities “dishonest” and, therefore, not “fit and proper to start equity trading.” It seemed odd that the regulator found the group worthy of currency trading but dishonest and unfit for equity trading. Though in 2013 MCX-SX finally launched its equity trading platform, Jignesh Shah’s dreams went bust after the NSEL crisis came to the fore.
The regulatory favouritism was evident in several such instances. In March 2010, NSE allowed some of its members to exploit the client code modification facility to help clients evade tax. Client codes for trades worth 55,000 crore were modified post trading hours. The modification is permitted by Sebi and exchanges to rectify errors that occur when client codes are punched in while placing orders. Two years later, Sebi whole-time member Prashant Saran, let off the exchange with a warning stating in an order that: “Suspending/interrupting the working of stock exchanges is also not an appropriate penalty as it involves negative externalities and could be considered only in extreme cases.”
Similarly, a proposal from the BSE, then headed by Madhu Kannan, to buy a majority stake in share registry firm CAMS was nixed by Sebi in 2010 on the ground that exchanges should not get into unrelated business. Three years later NSE struck a deal with two of CAMS’ shareholders to buy a 45% stake. Section 41 (3) of the Securities Contracts (regulation) (stock exchanges and clearing corporations) Regulations, 2012, states, “The recognised stock exchange and recognised clearing corporation shall not engage in activities that are unrelated or not incidental to its activity as a stock exchange or clearing corporation, as the case may be, except through a separate legal entity and as permitted by the Board.” Currently, the NSE holds the stake as a step-down associate investment through its 100% subsidiary, NSE Strategic Investment Corporation. In a communication to Sebi, a copy of which is available with Outlook Business, the exchange merely mentions that the “Purchase of stake in CAMS was done with due approvals at the NSE board level after due discussions.”
After the Jalan Committee’s report became public, aggrieved investors hit the emergency button by knocking on the doors of North Block and the regulator. In August 2015, the majority of investors congregated at SBI’s headquarters in Mumbai and it was decided that SBI chairperson Arundhati Bhattacharya would take the lead in demanding a meeting with the NSE management and initiate the IPO process. When contacted, Bhattacharya refused to comment on the story. In February 2016, the NSE sent minutes from a meeting to its shareholders, saying “all shareholders welcomed developments such as the creation of a listing committee”. Chand of Norwest was then quoted as saying: “They (NSE management) set up a stakeholders’ committee, but only called select shareholders — whoever they felt like. In a letter dated March 7, 2016, some shareholders said the minutes “misrepresent the true proceedings and discussions”. SAIF Partners managing partner Ravi Adusumalli said his fund was ready to call for a replacement of management as well as the board. “We have been extremely reasonable for years now and have tried to work with management. But we have run out of patience,” mentioned Adusumalli in the letter. Adusumalli did not respond to an email sent by Outlook Business.
Sandeep Parekh of Finsec Law Advisors believes that by capping individual non-strategic shareholding at 5% in exchanges, shareholders have been left toothless. “The cap has, in fact, caused this perversion in governance norms. Shareholders have no voice. If there is mis-governance, they cannot throw the management out.” The other option of course is to sell their stake to other investors but that is too lucrative an option to give up. As a result, investors began questioning the board’s role in safeguarding shareholders interest. YH Malegam, the former public interest director (PID) on the board, when contacted by Outlook Business refused to comment on the affairs of the exchange during his tenure. “If I am not on the board, I cannot discuss anything while I was on the board.” On whether the PID did not have powers to question the management, Malegam, without getting into specifics, replied: “A public interest director is like any other director on the board…he has no special powers.”
Even as a fresh forensic audit is underway to determine whether stockbrokers and their clients, software providers or any other entity benefited from the preferential access, Sebi has issued showcause notices to 14 NSE officials. Besides Narain, Ramakrishna and Subramanian, the notices have been issued to Ravi Varanasi, present chief of business development, Suprabhat Lala, chief of regulation, Ravi Apte and Umesh Jain, both former chief technology officers. Though the notices are not in the public domain, NSE has said the notices have been issued under Section 12 A of SERA read with Section 11(1), 11(2) and 11(B) of Sebi Act. The nature of violation is failure to provide fair access to all members. Incidentally, of the 14, seven are still on the rolls. The principles of fair practice and corporate governance would demand that the showcaused personnel either step aside from their duties or be given a non-critical role till completion of the enquiry. “While the Sebi Act has no specific provision dealing with notices and investigations, where senior employees are concerned and charges are serious, it’s a best practice to take a paid leave for the duration of investigation. However this requires investigation to be fast, so that the person is not punished without finding of guilt,” points out Parekh. Vikram Limaye, the new MD & CEO of NSE, says, “NSE has submitted a letter to Sebi to resolve the matter through the consent process. We are awaiting feedback from Sebi. NSE will support employees unless there is evidence of wrongdoing.” The exchange has stated that it will support legal costs of employees, provided there is no evidence of wrongdoing. Proving unlawful gains by either the employees or by OPG and AlphaGrep would be quite a task for the regulator. As per RoC filings, from FY11 to FY14, OPG clocked total revenues of 161 crore. How much of this would have come through algo trades; how much of the trade was generated through prop accounts and how many in client accounts; were there any unaccounted trades? Looking into the deal book and trade log, poring over client ledgers and OPG’s own books would be a long drawn affair.
Sucheta Dalal, editor, Moneylife, is puzzled about the grounds on which NSE has filed the consent application? “The issue of front-running by those who benefitted has not been tackled seriously, so how can those who are accused of having permitted it file consent and close the matter without admitting or denying the charges? How does this impact action that must be taken against the brokers identified by Sebi-ordered investigations?” Dalal, earlier, had to battle a 100 crore defamation case from the NSE. Though the HC verdict went against the institution, it has gone in for an appeal. Chand of Norwest says, “They didn’t inform shareholders when the whistleblower allegations came to light. It would have been good if they had treated this matter with the seriousness it deserved rather than issuing a defamation claim against Sucheta Dalal.”
Singhvi of Ican feels the move by Limaye to opt for consent does not bode well. “Sebi would fail if it agrees to NSE’s bargain plea. Bargain plea is admissible in case of petty lapses. But in the Indian context, the exchanges are not only just a trading platform, but almost a frontline regulator. If they can ask so many questions to other listed companies, what happens to their own accountability when there is a slippage?” That is a point that Varma, too, is piqued about and is critical of how the whole affair is being dealt with. “How is it that an unlisted exchange has no disclosure obligation which an ordinary listed company has? The disclosure obligations on a company are quite stiff; Clause 49, Companies Act 2013 and so forth. That disclosure is much less material from public interest point of view. On the other hand, there is an exchange which is hugely systemically important and just because it is unlisted, it need not disclose all of it.” All the disclosure obligations placed on a listed company should automatically be placed on critical institutions feels Varma. “It strikes to me as extremely odd that you have to disclose all of this only because you are doing an IPO. To me that you are an exchange with 90% market share is far more important than whether you are listed or not listed,” he adds.
This turn of events has come at a time when the exchange has filed its DRHP with the regulator to go public, so it is in NSE’s interest to put things behind it. Chand, too, believes that the worst is behind for NSE on the governance front. “Anyone who is going to invest in the business is going to have a remarkable 10 years. If indeed there was a trust issue why would brokers still be trading on the exchange? They would have switched en masse to the BSE.”
In any case, even if they want to switch it is not easy says Alok Churiwala, a third-generation stockbroker and vice-chairman of the BSE Brokers Forum, He believes that despite its cutting edge technology, BSE hasn’t gained market share because of the absence of interoperability among the clearing houses of the NSE and BSE. “If the depositories NSDL [owned by NSE] and CDSL [owned by BSE] have interoperability among each other, why do clearing corporations not have the same? Today, if 85% of the business is happening on the NSE, I am always going to allocate 85% of my capital to that exchange and this capital is not fungible. At the click of a switch I can’t transfer the capital to BSE,” laments Churiwala.
The existence of interoperability among clearing corporations would have meant that in the event of technical glitch, positions could have been easily moved or created on the BSE. It does seem like prudent risk management but Limaye says it is not a straightforward exercise, “There are several issues surrounding risk management, technology, legal and operational matters to operationalise interoperability of clearing corporations. Sebi has had conversations with stakeholders on these matters,” he says.
Though a Sebi panel in 2015 suggested introducing a single clearing corporation (CC) or interoperability, it kept the option open-ended. The report stated, “Preserving the current market structure and maintaining separate clearing corporations for each exchange would be prudent at this stage. However, Sebi may keep the interoperability option open and consider the proposal for implementation when ground conditions are met, which, inter alia, include clear intent of the participants coming together and having a suitable framework in place to the satisfaction of Sebi.” Churiwala believes the regulator should take the lead in ensuring that the issue is resolved at the earliest. “There is no harm in having one exchange. But don’t make a farce of keeping the other exchange and not having meaningful business there. Today, we have to do twice the amount of compliance, incur twice the cost to earn the same revenue. We are not getting any extra revenue out of running business on two exchanges. We will be the happiest. But the point is that the regulator does not have a roadmap on where they want to take the Indian market.” Limaye is cognisant of the task at hand, “NSE’s relationships with all stakeholders need improvement and this will require sustained effort and cultural change,” he says matter-of-fact.