09 January 2005

India's poor need a radical package: Interview with Amartya Sen

Date:09/01/2005 http://www.thehindu.com/2005/01/09/stories/2005010900161400.htm

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India's poor need a radical package: Amartya Sen

IF THE Manmohan Singh Government is serious about ending the chronic under-nutrition that so many poor Indians suffer from, it needs to think seriously about the public provision of basic healthcare, nutritional support for children and income sup port for the unemployed poor, says Nobel Prize-winning economist Amartya Sen in an exclusive interview to Siddharth Varadarajan of The Hindu.

Siddharth Varadarajan: If one looks at the social policy commitments of the UPA Government — for example on education and employment — health seems to have something of a low priority. You have been involved in a recent study on the state of healthcare in rural areas. Based on those findings, what do you feel the Government's approach to health services should be?

Amartya Sen: We need a radical change in the way health delivery in the public sector occurs. India spends a lower percentage of GDP on public health than almost any other country, including those of similar income levels. The neglect here is massive, particularly because this has led to both the substandard delivery of public health and the development of an immensely exploitative private enterprise in healthcare that survives on the deficiencies — and sometimes absence — of public health attention.

What we found in the Pratichi Trust survey in West Bengal but also much more sharply in Jharkhand — and based on other information we have, the picture seems fairly widespread — is that when patients go to many of the primary health centres, they find no one there. Sometimes, when they find someone, they will be referred to private doctors. Also, the medical system in the public sector offers no diagnostics, even of basic illnesses like malaria or TB. Patients are usually told to go to private practitioners for testing. Sometimes the testing isn't very good and, in any case, the economic cost could be ruinous.

On top of that, the care that is often provided by the private sector comes from quacks. We found an incredible proportion of quacks in Jharkhand, particularly, but a significant proportion even in West Bengal, who provide almost no serious medical attention and instead give saline injections for malaria, which is not really known anywhere in the world as a cure.

These are modern quacks, not ojhas?

Modern quacks. There are ojhas too, who are at least cheaper. The modern quacks are no more effective than the ojhas and are very expensive. So they have the effect of making the illnesses linger while whatever meagre economic assets the poorer families have may be lost in the process. This is a dreadful situation. There are many areas where more privatisation might make sense — hotels, tourism, a number of industries — but this is not one of them. And the high private share in the provision of healthcare in rural areas is a major deficiency of the Indian system.

Private medical treatment can work quite well when, as in Kerala, the public health sector provides a minimum care for all. On the basis of that, you can then get special care on a private system. But that's quite different from relying primarily on a private health system, especially when the patient has no idea who is a quack ...

Is the poor state of public healthcare the result of systematic low investment over the years, bad monitoring, or "corruption," as the critics of public provision are fond of saying?

There are three different deficiencies here. First, there is an awfully inadequate amount of investment, so that the amount of public resources going in to providing healthcare for all is extraordinarily little.

Secondly, the monitoring of the performance of public health centres is often totally absent or thoroughly defective. Thus, the absenteeism of doctors is quite high and the incidence of doctors trying to recommend that patients go and see them in their capacity as private practitioners is distressingly high. Third, there is no way the Government helps patients diagnose who is a quack and who is not. That requires a monitoring not just of the public health service but of medical services as a whole.

All three things act together to ruin the rural poor who, from their meagre resources, must spend whatever they can to deal with that which is of greatest importance to them — namely their health. And they get hit both by the continuation of illness and economic ruination. Corruption is there in the sense that a doctor in a public health service asks patients to go to himself or a friend in private care, instead of providing treatment.

Accepting a salary and not being at the job is also a type of corruption. But to see the problem primarily as a penalty of corruption would be to lose the precise story in the health sector deficiency in a more general story of corruption.

We ought to clearly point out the defect of under-investment in public health care, the under-monitoring of public health delivery, and the lack of diagnosing of medically trained personnel compared with quacks. These three things together produce the dreadful situation in which we are.

If you look at the priority of political parties nationally, the NDA wanted more super-speciality hospitals like AIIMS and the public health priority seems to be on the building of large, grand hospitals at the cutting edge of medical technology. You seem to be suggesting the priority has to be at the level of basic care.

Given the economic inequalities in the country, you will get a tremendously unequal delivery of medical attention. There is no way of escaping it. There are a lot of rich people in the country and there is no way you can prevent them from having state-of-the-art medical attention within India if they can pay for it. There is no way you can say it's all right to buy a yacht or a villa but not medical treatment. But what you can do is to rely on the private sector precisely for that because these are people who are wealthy or fairly well off, and it's a question of their being able to get medial treatment of a very specialised kind which may not be available to others, on the basis of their high income. I don't like the system — I see that as an inescapable necessity — but if this is done by the private sector, at least it is not a drain on the public sector.

I think public sector resources have to provide basic medical care for all, basic medicine, basic diagnosis, blood and urine tests, x-rays and so on, which go with the normal practice of medicine, and providing treatment for well known ailments and doing the best that the doctors can to help the patient, without going into an extremely expensive system of medical care.

In some ways we have gone particularly wrong here. Rather than the public sector providing basic coverage to all Indian residents, you end up in a situation where a large proportion of the population remains under-protected by the public health sector.

On the other side, there is always an attempt to use public money to expand the cutting edge of medical treatment. Now, I have nothing against the cutting edge of medical treatment. Indeed, I would not be alive today but for the fact when I had cancer at the age of 18, I could get radiation in Calcutta that cured me, that was 52 years ago, so I take it I am cured now! I did pay for it, it was in a hospital in Calcutta, and indeed my father could just about afford it. So I have nothing at all against getting this type of treatment, and indeed, hopefully cancer treatment of a standard kind should be available for all, and if you look at the costs of that, they are within an affordable budget.

I think specialised health care, including sophisticated medicine and surgery, should be available. But quite often what happens is that one is trying to go at the very extreme cutting edge of medicine. When that happens for AIDS, it makes a lot of sense since there are a great many patients involved. But generally, the idea that first, basic healthcare should be covered by the public sector and second, that if rich people want to have specialised services, they should be able to access this through the private sector — seems to me a kind of compromise that the Indian political economy would tend to regard as quite natural. It's the kind of system that exists in Britain ...

Are you then advocating a dramatic increase in budgetary outlays on health at the Central level?

I am advocating that if it is part of a broader package. My difficulty in dealing with some of the debates that are going on today is that you cannot separate one of the elements of a composite package and say that this is our priority. Well, there are a number of things that have to be done, and if you look at the health sector, yes, I would strongly recommend that we spend a lot more on public healthcare. But along with that, we have to introduce a better monitoring system for the delivery of public health services, and we also have to introduce a system of weeding out quackery.

I think the combination of quackery and crookery which takes place in the form of private medicine in some of the poorest areas of India and which mainly has the effect of making poor people part with whatever little money they have, rather than providing a cure, is something which has to stop. So if one just puts in more money, without making any other change, we would be caught in a very sticky ground, but we have to do these things together, and yes, along with the other changes, there is a case for a very dramatic increase in public health expenditure.

Another possible component of a broad package for social policy would be the role of mid-day meals in providing nutrition to pupils in schools. Most State Governments have introduced cooked mid-day meals in primary schools during the last two years. What are your impressions of this initiative?

I am very encouraged. Obviously we haven't yet had a chance of studying this programme systematically yet in those parts of India that have just introduced it, but we have a number of separate pieces of evidence on the basis of which we can construct a plausible story. First, there are areas like Tamil Nadu where mid-day meals have been provided for a long time and we do know what the favourable impact has been. Last year, a survey initiated by the Centre for Equity Studies found encouraging results in three other States.

In the area of the country where the Pratichi Trust has studied the introduction of this scheme, namely West Bengal, the reports are also extremely positive.

It's important to recognise what we expect of the mid-day meal. I would say there are five things. And they are all equally important.

First, India has a higher level of under-nourishment than almost any other part of the world with the possible exception of our neighbours in South Asia. It's not often recognised that the regular level of under-nourishment in India is higher than that of sub-Saharan Africa, where about 20-40 per cent of children are chronically undernourished in terms of criteria like weight for age and other anthropometric criteria. In India, the figure is 40-60 per cent, a very high proportion indeed. Our level of anaemia is much higher, our level of maternal under-nourishment is much higher. Providing meals in schools is one good means of dealing with this vast problem of chronic under-nourishment.

Second, it increases the attractiveness of schools, from the point of view of attendance, because of the fact that while we often have much higher enrolment ratios than before, the attendance levels have remained systematically lower because of a lot of dropouts. So you can achieve higher attendance and lower dropouts by making it attractive for the kids to come to school.

Third, the imparting of education is badly affected by under-nutrition. In the context of my forthcoming book, The Argumentative Indian, I was looking at a discussion in the Chandogya Upanishad where Shvetaketu's father is giving him an education. At one stage Shvetaketu decides not to eat. After 15 days, when his father says, can you follow me, he says, no I cannot. And the father says that is because your intelligence doesn't work if you are starved. If you eat now, you will be able to understand what I am telling you.

This points to the elementary fact that under-nourished children don't find it easy to learn, and the attention deficit and ability to comprehend is a serious problem. Fourthly, there is the problem of teacher absenteeism in a number of schools in India. As long as the teachers are just providing education and students go and find no teacher, they know in some sense their long-run future is being affected. But it is dramatically different if they go and find there is no teacher to unlock the store on the basis of which the cook will cook the meal. It deprives people immediately. So the pressure to be present is much stronger, the monitoring becomes much easier also because there is a genuine interest on the part of students to make sure the entire teaching staff — teachers and cooks — are present every day, and it has had this effect of increasing the regularity with which schooling and education takes place. Fifth, and this is very dialectical, one of the objections had come from `upper' caste parents who did not want their children to have meals with `lower' caste children. While this has often been seen as a criticism of the mid-day meal scheme, the fact is that the other side of the story is very positive. If one actually insists on providing meals of this kind, the system adjusts. People get used to eating together, get used to eating food cooked by someone whose caste you do not know, I think that is a positive thing from the point of view of cohesion of society.

In all these respects, the results are positive. These are early days and we'll do a fuller study in the summer of 2005 but for the moment what we have seen is very positive. There are problems — the nature of food is quite elementary — it might be fine for kids who have no food at all, but not for the richer kids, but if you take the rough with the smooth, there is no question that it is having the effects desired. And attendance has increased. In the villages we studied in West Bengal, there was 60 per cent attendance in the pre-mid-day meal days, now it is 70 per cent, and seems to be going up continuously.

So this is one of the very positive things happening in India.

Does it surprise you that despite such an obvious rationale for this scheme — and positive political payoffs for parties and politicians — the implementation of mid-day meals required so much pressure from activists and the Supreme Court?

Yes, it did surprise me. The Pratichi Trust was set up with my Nobel money in 1999 and right from the beginning, this has been one of our strong demands. Jean Dreze and I had written about it before as well, and it seemed to us that the rationale for it was extremely clear and simple. Most political leaders want to do things that will make them popular, and this certainly would. I think the fear here was of three kinds. Some people thought too much time may be taken in cooking and eating and that this would take time away from education. Now the fact is that the time taken in education was small anyway because of the absenteeism of teacher and student, but when the meal is well organised, it need not take any time off from teaching.

Second, it was feared that there would be an `upper' caste opposition, and this has happened, and these people are quite vocal. So given the power structure in rural areas, it was felt mid-day meals would be a bit of an uphill battle.

Third was the question of finance. As it happens, most of the States are pretty bankrupt, especially after the Fifth Pay Commission award, and the States would have found it quite difficult to pay for it, though a number of States had. But the Supreme Court judgment, combined with the present Government's commitment to Central support for mid-day meals, has certainly removed that barrier.

Could one make a case that the success in providing mid-day meals through the public education system could lead the way to a broader revival of public provision of social services — in education, health, and even income support?

I think that's exactly right. The need for radical thinking on this is very strong in India now. I think the health services, including nutritional arrangements, suffer badly from reasons that have to be investigated along with the problem of educational under-performance and under-attendance. In fact, I would go further. Even the much debated question of Employment Guarantee, to a great extent, has to be integrated with the issue of child under-nourishment because what the school meals do in providing publicly supplied food in schools and thereby reducing under-nourishment can be supplemented by private income generated by employment, especially of very poor people who are ready to work for a low wage.

The removal of massive under-nourishment in India requires a combination of health initiatives, nutrition interventions such as mid-day meals, and the creation of extra income, particularly for those whose families are hungry because they have no work.

So we have to think of these things as a package, and that is one of the reasons why I felt slightly hesitant about the way the debate has unfolded about the Employment Guarantee — that to some extent it is being seen as a stand-on-its-own scheme when it is really a bigger package that requires talking about many things together.

As an economist, I don't dismiss the argument that the budgetary implications have to be looked at. Fiscal responsibility isn't a dirty word for me, one has to look at that. But one has to see what the objectives really are and how they link with each of these schemes, and since I'm very ambitious, I really do think the time has come for us to make a dramatic change, in public health delivery requiring a lot of money. So one has to look at the financial implications together.

I think in any way of looking at the financial implications, the manifest gigantic problems in India — the biggest child under-nourishment in the world, very defective public health delivery system along with an utterly exploitative private health care arrangement, and consistently under-performing schooling system, all these have to be thought through together and put through together. And with the new Government at the moment, I think this is a very good moment to do just this. And I get the impression that there is at the very highest level a great deal of sympathy for talking of this kind of comprehensive approach to the deprivations in India. Prime Minister Manmohan Singh has himself made strong statements on this.

If you link these issues in the way you have just done — education, health and the notion of some kind of private income through a well designed employment guarantee mechanism — this too could become a strong political asset for any party in the same way as mid-day meals.

Absolutely. I think politically this could be very useful for the parties. I am not a politician myself so I am seeing it mainly as an economist and social activist and from that point of view the case is strong but you are right, this is something which has a political payoff. I know our Prime Minister well since his days as a student and as a colleague; his commitment comes not from strategic political reasons but from a commitment to removing the basic deficiencies.

Whether your suggestions are followed through or not, isn't the sea change that has taken place in the political terrain in India amazing? This time last year, the topic of discussion everywhere was the mandir controversy, etc. Now, the whole country is discussing employment and other basic issues.

In my book, The Argumentative Indian, which was written a year ago in the time you mentioned, I discuss how one of the penalties of the sectarian politics we have was not only that secularism had been threatened and the minorities' lives have been made less secure, but also it has deflected discussion from the constructive agenda which we could have taken up.

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