random thoughts: item numbers

how much can the efforts of private individuals and organizations help improve access to education and healthcare in a country of india's size? or in any country of any size? read an interesting article on a related subject, today, by a member of the faculty of one of the best private medical institutions in the country.

prof. k.s.jacob of the christian medical college, vellore, writes:

Caste plays out in India just as race plays out in the U.S. and the social class in Britain. Birth seems to determine health, education, employment, social and economic outcomes. Systemic injustice requires much more than a change of heart; it requires changes in social structures. Social injustice is killing people and mandates the ethical imperative of improving the social determinants of health.

he also refers to evidence on how caste affects health outcomes, in particular:

Data from the National Family Health Survey-III (2005-06) clearly highlight the caste differentials in relation to health status. The survey documents low levels of contraceptive use among the Scheduled Castes and the Scheduled Tribes compared to forward castes. Reduced access to maternal and child health care is evident with reduced levels of antenatal care, institutional deliveries and complete vaccination coverage among the lower castes. Stunting, wasting, underweight and anaemia in children and anaemia in adults are higher among the lower castes. Similarly, neonatal, postnatal, infant, child and under-five statistics clearly show a higher mortality among the SCs and the STs. Problems in accessing health care were higher among the lower castes. The National Family Health Survey-II (1998-99) documented a similar picture of lower accessibility and poorer health statistics among the lower castes.

and his approach to improving health outcomes?

The structural determinants of daily life contribute to the social determinants of health and fuel the inequities in health between caste groups. Viewing health in general as an individual or medical issue, reducing population health to a biomedical perspective and suggesting individual medical interventions reflect a poor understanding of issues. Social interventions should form the core of all health and prevention programmes as individual medical interventions have little impact on population indices, which require population interventions.

prof. jacob's overall message is quite simple, really: an aiims, or an apollo, in every state capital in the country wouldn't improve health statistics.

just as an iit in every state in the country wouldn't solve the problem of illiteracy. nothing but social intervention would solve the problem of inadequate access in healthcare and school education. in my view, private efforts can do very little and in the long run could even harm everyone's interests by taking the issue off public consciousness and policy makers' priorities.

social intervention means everyone should get a basic, assured level of attention. neither aiims nor iits/iims are social interventions: they're the policy equivalent of item numbers in indian films. they enhance the marketabilty of exclusionist projects of keeping the great majority of the underprivileged illiterate and vulnerable while seducing a few with the promises of individual advancement.

why isn't any dalit bahujan thinker demanding the dismantling of these exclusionist institutions? or opposing this sustained system of stratification in the delivery of public goods like education and health?

why is everyone focussed on issues like english, when it is quite evident that the ruling classes have no plans to deliver the same kind of education to everyone, whether in english or in any other language, now or in the foreseeable future, unless their exclusionist mindset is challenged?

this tyranny is okay

Any criticism of the market as God these past two decades led to being branded a heretic. The market had all the answers. There was no miracle it could not perform. Some, like Swaminathan Aiyer, argued that markets alone could save the environment. Others, like Time magazine, asserted that hunger was but a function of anti-market systems. Want jobs? Leave it to the market. The market wasn’t just good for democracy. It was Democracy. This was the baloney of the last 15-20 years. There were other possible positions. Such as that you might need the market. As a tool, not as a tyranny. As just one instrument amongst many, not as an all encompassing ideology. But that would have been blasphemy. [italics mine]

p.sainath in the essay 'The globalisation of inequality'.

the indian left liberal, or whatever anyone whose politics hovers around the same concerns and interests as sainath voices would like to call himself, is quite a character. he would look away when the market is allowed free play in schools and health, but would object strongly if airlines or hotels owned by the government are privatized. it's okay to throw small change at farmers to get them to ensure your food security, but it's irrelevant how big a role nonexistent public healtcare (or expensive private healthcare) plays in driving farmers to suicide. in a country where the unorganized sector forms 93% of the workforce (almost half of those workers, i think, have to look for a new job, if you could dignify the worst kind of manual labour with that title, every day or week or month or couple of months) the best kind of social security he can offer is a job scheme that involves worse than the worst kind of manual labour (because it offers no scope for learning about new tools or technologies, no training or retraining and not even minimum wages most times) and reaches not more than 2 to 5 percent of that 93%,..the point i am driving at now (as i did many times earlier), is that that the indian liberal is not a mere hypocrite. he is much more lethal.

one reads swaminathan aiyar and understands what kind of people he's concerned about. swaminathan aiyar recommends a bigger role for private players in schools, swaminathan aiyar thinks the family is the best social security an indian worker needs, swaminathan doesn't seem to care about public healthcare because i've never seen a column by him on the subject.

swaminathan aiyar likes private schools because the india he lives in doesn't need government schools (except of the kendriya vidyalaya kind), swaminathan aiyar doesn't care about social security because his kind of indians mostly work in the organized sector where they have job security, pensions and benefits and insurance coverage (insurance penetration is less than 5% in india- most of it is bought by aiyar's india). and they also have urban and rural property-for them private healthcare can never cost the earth because they can always hike its price.

what does sainath think of schools, social security and public health? except in a very general sort of way i don't think he has ever wandered deep into those mostly rural hells- like swaminathan aiyar, he doesn't seem to care. i suppose the tyranny of the market can be an effective tool in those areas?

kapil sibal seems to have stirred no one except a few trade unions.

even the 'reformers' want more of the same

mihir sen in the hindu:

Yes, reforms in India correctly entail privatisation of sectors such as airports, airlines, hotels, and cars but throughout the world, public goods like health, education and environment have been provided for or protected by governments. Ever since the Great Depression of the 1930s, capitalist democracies have seen major investments by the state in the fundamental rights of its citizenry. The difference is that in the U.S., Europe, South-East and East Asia, the state has invariably delivered. In India it has failed — both in the magnitude of its effort and in its quality. Thus, the suffering of our people is not just a tale of market failure. It is also a failure of governance. Which is where reforms for the poor must focus.

the reaction of those sections of the articulate classes in india which have welcomed the return of the congress has essentially been: thanks, for saving our jobs, our banks, our lifestyles. now, please do something about higher education, terrorism and...oh, the nrega was a great idea.

health, education, environment weren't on the agenda before the elections. and health and education of the poor never were the concerns of the brahminized classes- if sen seems radically different, please read on:

Livelihoods, education and health are not polio drops to be mechanically administered to the people. They represent complex outcomes that demand participatory processes and imaginative solutions. Merely throwing money at the people through direct cash transfers is not only insulting, it does not work. What ensures translation of outlays into outcomes is the software we put into place. This includes deployment of high quality human resource and systems that ensure accountability and stakeholder participation.

now how is this different from what was being done until now? the whole rural development package until now has always aimed to combine participatory processes and imaginative solutions, hasn't it? what the author seems to advocate is a larger presence for the bureaucracy, through such measures as increased administrative allocation under NREGA and other poverty alleviation schemes and also strengthen the public sector involvement in health, nutrition, education, banking, watershed, irrigation, NREGA and the Forest Rights Act through deployment of high quality human resource and systems that ensure accountability and stakeholder participation.

i repeat, what has the government been doing until now? how's doing more of the same going to produce better results?

health, education, drinking water and sanitation are public goods, as the author himself acknowledges in the earlier part of the article- how do banking, nrega, irrigation (which in india mostly means large dams) fit in? if the government's involvement in those areas serves the purpose of improving livelihoods, why can't direct cash transfers do that? this mixing of functions- public goods, large infrastructure and poverty alleviation- has always resulted in: lower emphasis on public goods, leakages in poverty schemes and bad planning, delays and corruption in irrigation projects.

the author wants reforms, but would like to keep the bureaucracy. he might as well be saying: thanks, go on saving our jobs, our banks, our lifestyles. in fact, we would like you to improve our job opportunities, our banks, our lifestyles.

a related piece of news- unicef attacks india's record on poverty:

India has failed to use a period of high economic growth to lift tens of millions of people out of poverty, falling far short of China’s record in protecting its population from the ravages of chronic hunger, United Nations officials said on Tuesday.

Unicef, the UN’s child development agency, said India, Asia’s third largest economy, had not followed the example of other regional economies such as China, South Korea and Singapore in investing in its people during an economic boom. It said this failure spelled trouble as the global economy deteriorated, while volatile fuel and food prices had already deepened deprivation over the past two years. (italics mine).

India has failed to use a period of high economic growth to lift tens of millions of people out of poverty.

in the last five years, when the congress-led government at the centre talked about increased allocation to education and health all that resulted in was more iits and iims and greater spending on elitist higher education. in andhra pradesh, while the rajashekhar reddy government spent nearly rs.50,000 crores on large irrigation projects, without adding an extra acre to total irrigated area, hundreds of government schools in the city of hyderabad itself closed down. while the public health infrastructure in the state is breaking down with less than a 1,500 doctors working or not working in 30,000 villages, the state government has made a large donation of hundreds of crores to private hospitals in the state through a health insurance scheme that emphasizes: prevention is impractical.

the hidden nation-state: that's where all the money the unicef talks about went to- some directly, and some indirectly through leakages in the nrega and other schemes.

how india pays for america's health

there is an organization called the American Association of Physicians of Indian Origin (AAPI) in the united states which boasts of a membership of 46,000 doctors.

if you wanted to form an organization called the indian association of physicians of indian origin (iapi) as a forum to facilitate and enable physicians working in rural india to excel in patient care, teaching and research etc., i bet you wouldn't find half as many members.

all state governments together don't employ half as many doctors in rural india, in over 6 lakh villages. and i am not even talking of absenteeism among those paid to work in the villages. vote for a government that'll send a chandrayaan-like mission to rural india to explore how people live there, in the absence of anything remotely resembling a public health system.