Amartya Sen: The Uncertain Glory

 

  • Private Distribution of Public Servicesà Examples replacing public schools and hospitals with private ones and so on.
    • Case Against Private Distribution of Public Services: 
      • Cash Transfers or ‘cash relief’ during famine may work better than arranging other means of relief as it is quick (speed matters during famines) and can lead to people acquiring the goods they need to survive quickly.
      • However, this also have potential of leading to creation of monopoly of traders, hence artificially controlling the prices, and defeating the purpose of such relief.
      • Same is true for disposal of cash wages, as done under MNREGA
      • Asymmetric InformationHowever, these arrangements of private distribution may not work in the case of healthcare, education, sanitation, immunization etc. This is because of the presence of asymmetric information, for example, between patients who may know a little about the treatment they need or are given, unlike the doctors who may know much more. Here, this asymmetric information leads to failure of the market model.
      • Externalities: Example those associated with communicable diseases and public health – the difference between social benefits and costs is pretty large in such cases
      • Inequitable Distribution: Supply side may leave the poor behind when they are provided direct cash transfers for various services. These services need to be built on the supply side as well.
      • Consumer Sovereignty: Liberals argue that consumers are best judges of what they need, however, it may not be true for many people as they may not be educated or aware about the outcomes of various decisions in their lives. Their decisions may also get affected by aggressive advertising, herd behavior, misplaced optimism, procrastination, and other psychological factors. For example, the government passed the IMS Act to control the marketing of infant food supplements below the age of 2 years for infants.
      • Case of Latin America: Cash Transfers in Brazil and Mexico don’t act as substitutes but complements for public provision of health, education and other basic services. Hence, these cash transfers must not be treated as a golden cure for all the public programs. Basic services in health, education, immunization etc. are needed to make the cash transfers work.
      • “Privatization is an alluring short-cut, but it can have the effect of merely replacing one serious problem by another no less grave.”
    • Indian Government Schemes to Alleviate Poverty (notes in written)
      • MNREGA
      • National Rural Livelihood Mission (NRLM)
      • National Food Security Mission
      • Public Distribution System (PDS)
      • Indra Awas Yojana
      • Social Security for Unorganized Workers

Education

  • Tagore – “the imposing tower of misery which today rests on the heart of India has its sole foundation in the absence of education”
  • Why important?
    • Quality of Life
      • Freedoms to communicate with the rest of the world, to lead an informed life, to communicate with others, and to be generally in touch with whats going on.
      • Sen: “Being illiterate is like being imprisoned, and school education opens a door through which people can escape incarceration”
    • Employment
    • Enhances political voice of people
    • Tackles Health Problems
    • Awareness about Human Rights
    • Awareness about Legal Rights
    • Women’s Empowerment
    • Reduces class and caste inequalities
    • Recreational in itself, creative engagement and enjoyment
  • Does Education Lead to Development? (Relationship between the two)
    • Europe and USA’s commitment to public education leads to industrialization and economic growth:
      • Government delivered free education lead to massive social and economic improvements over 18th and 19th centuries.
    • Japan’s focus on education transforms the country in a global economic, military and social power:
      • Transformation of Japan in the late 19th century from an agrarian and feudal economy to the largest industrial power in Asia and one of the most prosperous countries was achieved by rapid advances in education after the Meiji restoration
      • Fundamental code of education issued in 1872 expressed a clear public mandate to achieve 100% literacy in the country. 
      • Between 1906 and 1911, education consumed as much as 43% of the budgets of towns and villages, for Japan as a whole.
      • By 1913, Japan was fully literate, and even if much poorer than Britain and America, it was publishing more books than Britain and twice as many as the US. 
      • Concentration on Education determined the rapid industrialization and development in Japan during this time.
      • Later, countries of Taiwan, South Korea, China, Singapore and Hong Kong have embarked on similar missions to educate their masses. This is an important indicator of the rapid progress of East Asia.
    • India’s poor state of education – “shockingly low quality”
      • Rampant Absenteeismamong teachers and students – 20% among teachers and 33% among students
        • Shocking lack of teaching by teachers who are present in schools
        • This leads to only 50% teaching days out of total 200 teaching days that are required to educate these children
      • Massive shortage of teachers:12% Schools with only one teacher
        • Low teacher hiring by authorities due to high teacher pays leading to hiring unmotivated contract teachers
      • Low quality of teaching or Poor standards of Education
        • Mindless rote learning prevails
        • Poor knowledge of basic concepts and facts
        • PISA Plus (conducted by Australian Council for Educational Research), an international survey conducted in 2009, placed India (states of HP and Tamil Nadu) at the bottom of 74 countries in assessing reading ability of 15 year olds.
        • India was also ranked at lower positions in writing, science and mathematics.
      • Evaluation Gap
        • SSA and RTE does not entail proper evaluation. It guarantees automatic promotion from one class to another irrespective of what the child has learnt.
        • No detention policy is harming students’ learning
        • It does not encourage school tests as there is no repercussions to students failing end of the year class tests.
        • Standardized Tests are important to understand what kinds of help, attention or encouragement particular children or schools need.
      • Low allocation of funds
      • Poor Accountability mechanisms and standards to monitor teacher and student performance
      • No-detention policy leading to low performance and plunging learning outcomes
        • India’s no fail policy for students up to standard 9th has skewed the learning system. It has resulted in students not learning appropriate skills in respective grades due to lack of accountability among government schools for children’s learning outcomes.
      • No results despite High Salaries of Teachers (3.0 times national per capita GDP, highest in the world). Also results in massive social gap between teachers and the families of children (these families are landless laborers etc. with low income). This has also resulted in hiring contract teachers to expand the education system, however, this has only resulted in further degradation of quality of teaching.
    • Achievements
      • Right to Education 2010 (Article 21 A) ensures free and compulsory education for children between 6-14 years of age
      • All India Sarva Siksha Abhiyan
      • Increased school enrollment ratios – from 80% in 1996 to over 95% in 2006 (among children aged 6-12 years). These have caught up for children in Dalit and Muslim segments as well.
      • Improvement in amenities: By 2006, 73% schools had at least two all-weather rooms compared to only 26% in 1996
        • By 2006, 60% schools have their own toilets  and 75% have drinking water facilities
        • Free textbooks in nearly all schools by 2006 as compared to only 50% in 1996
        • Mid day meals functioning in 86% of the schools by 2006
      • Private schooling as an alternative (issues)
        • Affordability
        • Even if affordability is resolved, informational asymmetry for first time school goers makes them less likely to benefit the most from private schools’ just on the basis of their school vouchers provided by the government. School authorities may not provide the best educational experience or equal to that of other students who are actually paying fees.
        • Lack of competition can make private schools money extractive machines (evident in the fact that private schools are not doing as well as public schools in many parts of India)
      • Government Schemes in Education:
        • Sarva Siksha Abhiyan
          • New provision added for reimbursement for expenditure incurred for at least 25% admissions of children belonging to disadvantaged and weaker sections in private unaided schools from academic year 2014-15.
        • Mid Day Meal Scheme (National Program Nutritional Support to Primary Education)
        • Rashtriya Madhyamik Shiksha Abhiyan (RMSA)
        • Skill Development Mission
        • Scheme for setting up 6000 Model Schools at Block Level as Benchmark of Excellence
        • Scheme for providing education to Madrasas, Minorities and Disabled
        • Support for Educational Development including Teachers Training & Audit Education
        • Scholarships – various scholarships etc. to students of SC, ST and OBC and religious minorities for higher education and coaching classes. Maulana Abul Kalam National Scholarship for Meritorious Girl Students.
        • Rashtriya Uchchatar Shiksha Abhiyan (RUSA): CSS that aims at providing funding to institutions of higher education in various states.
        • Kasturba Gandhi Balika Vidyalaya: Educational facilties for girls belonging to SC, ST, OBC, minority communities and families below the poverty line in Educationally Backward Blocks.
        • Kishore Vaihyanik Protsahan Yojana: Scholarship program to encourage students to take up research careers in the areas of basic science, engineering and medicine.
      • New Scheme: 
        • Pradhan Mantri Kaushal Vikas Yojana approved by the Cabinet The Pradhan Mantri Kaushal Vikas Yojana was approved by the Union Cabinet on March 20, 2015.
          • It is a scheme for skill training of youth to be implemented by the Ministry of Skill Development and Entrepreneurship through the National Skill Development Corporation (NSDC).
          • Skill training would be imparted based on the National Skill Qualification Framework. 
        • Coverage: The scheme will cover 24 lakh people. It will focus on first time entrants to the labour market and will target Class 10 and 12 drop outs. A one-time monetary reward of around Rs 8,000 per trainee will be given under the scheme.
        • Outlay: The Cabinet approved a total outlay of Rs 1,500 crore for the scheme. Out of this, Rs 1,120 crore will be spent on skill training, Rs 220 crore on recognition of prior learning, Rs 67 crore on awareness building, mobilisation and mentorship support, and Rs 150 crore for training of youth from the North-East region.
        • Assessing demand: Skill training would be done on the basis of demand assessed by skill gap studies, conducted by the NSDCfor 2013-17. A demand aggregator platform would be launched.
        • Implementation: The scheme would be implemented through NSDC‟s 187 training partners (with 2,300 centres), in addition to government affiliated training partners. Training would include soft skills, personal grooming, good work ethics, etc. A Skill Development Management System would be put in place to verify and record details of training centres. A grievance redressal system will also be instituted.

Health care in India

  1. Why Important: 
    1. Social: An End in Itself: 
      1. It is the duty of the state to ensure holistic development of people of all classes. Good health is a fundamental need to achieve such goal as it ensures mental and physical ability required for citizens to be at par with each other.
      2. Good health promotes freedoms of people. It enables people to achieve other freedoms such as freedom of education, secure income and so on, and hence choose their own life path.
      3. The right to health is enshrined in binding international treaties and constitutions. The National Health Bill is currently under consideration as well. The Bill aims to “…provide for protection and fulfillment of rights in relation to health and well-being, health equity and justice.”
    2. Social: Leads to High Quality of Life
  • Economic: Increases productivity of people, hence contributing to GDP 
    1. Large part of differences in growth rates between countries is attributable to differences in their health status.
    2. For example, if residents of UP were to have life expectancy of Kerela’s people (nearly 15 years greater in 1995-96), the net effect on the State’s output would be 60% higher than its current levels.
    3. Large part of expenditure for poor households, pushing them into bankruptcy
  1. Problems with healthcare in India:
    1. Low Spending (“massively inadequate” according to Sen and Dreze): India spends only 1.3% of GDP on healthcare. This is not only below but almost half of even countries in North Africa, Sub-Saharan Africa and the middle east and much below other developing and developed countries.
    2. No Universal Healthcare: India has not achieved universal health care as compared to China, Thailand and Mexico, all developing countries that have achieved universal health coverage for their entire populations. In China, such program was launched under the New Cooperative Medical Scheme and in Mexico under the Seguro Popular health insurance program.
  • Poor Condition of Facilities: Infrastructure is shabby, acute shortage of medical staff (50-70% shortage of physicians, specialists and lab technicians and radiographers at Community health centers) and widespread leakage and corruption in government hospitals and health care centers.
  1. Massive Private Health care industry: Almost 80% of outpatient and 60% of inpatient visits are to private health care providers. Hence, private health care providers are an important part of the equation when trying to provide universal health care coverage in India.
  2. Absence of discussions on health care in popular press and media
  3. Underachievement in Maternal and Child Health: 
    1. India has failed miserably at maternal and child health improvement.
    2. India has recorded one of the worst performances on undernourishment and child health
    3. India has been unsuccessful at delinking maternal health from that of her children that results in transmission of ill health from the mother to her children.
    4. Regional variations are abnormally high in India with some regions lagging extremely behind others and the national average.
    5. Almost 60% children in India were undernourished in 1998-99 according to CIAF (composite index of anthropometric failure) and 45.2% stunted, 15.9% wasted and 47.1% underweight.
    6. Neo-natal mortality (NM) – number of deaths within 28 days of life per 1000
      1. Reflects the both maternal and new born health and care
    7. Infant Mortality (IM) – number of deaths within 1 year of age or younger per 1000 births
      1. Reflects the state of health care services at the time of birth of child
    8. Child Mortality (IM) – number of deaths within 5 years of age or younger per 1000 births
  4. Problems with Private Healthcare:
    1. Efficiency Issues:
      1. Health insurance is likely to attract people who are prone to illness thus driving up premiums and leading to exclusion of low-risk customers. This is termed as adverse selection and may lead to “Screening” of patients and hence is against the principle of equity in health care.
      2. Another efficiency issue is called moral hazard– that both insured patients and private providers have no incentive to contain costs. At the same time, if the rates are prefixed by the government, the health providers may be forced to cut costs and minimize them regardless of the quality of healthcare provided to the patients and may even go against the interests of patients. They may indulge in “cream skimming”, i.e. focusing on patients who can be treated at low cost and turn away the rest.
    2. Distortion Issue:  
      1. A commercial health insurance system is generally biased against non-hospitalized care and preventative care.
      2. health insurance tends to be aimed mostly at hospitalised care. This creates a bias against preventive health. This challenge is big especially for India since a large amount of the disease burden is that of communicable diseases. It will also lead to a general overlook and reduced focus on public health systems and give a boost to private health care – this is against the route by which countries like China, Thailand, Brazil, Mexico, etc. have achieved near universal health care, i.e. a strong public healthcare system
  • Targeting Issue:
    1. All problems associated with BPL targeting like unreliability. The problem is graver in the case of health since a single ailment is enough to push an entire family below the poverty line. It is simply not possible to revise the BPL line so frequently.
    2. Further, BPL line is based on per capita income. However a person may have sufficient income in general but the nature of disability could be so severe that he cannot finance the care on his own
  1. Inequity: 
    1. Sources of inequity are – potential screening by insurance company, inefficient targeting, general obstacles in using a health insurance system like low education, powerlessness, etc.
  2. Irreversibility Issue:
    1. A major shift to private health insurance could be irreversible as it would emerge as a very powerful lobby
  3. Not successful in US: The model is essentially what is followed in the US. And the American experience is not encouraging: One of the most costly and ineffective in the industrialized world. The per capita health expenditure is nearly double that of Europe but the heath outcomes are poorer
    1. Highly inequitable as nearly 20% population is excluded from it
    2. Reform has been difficult due to the power of the insurance industry
    3. On the other hand China, Brazil, Mexico, Thailand and Vietnam have achieved near universal coverage with publicly funded health services
  4. The Nutrition Issue (Asian Enigma)
    1. Just like immunization, the nutrition situation as measured by proportion of underweight (weight for age) children under 5 is poorer than sub-Saharan Africa and Least Developed Nations. The broad patterns are same for stunting (height for age)
    2. The entire Indian population also suffers severe deficiencies including iron, vitamin A, etc.
  • This is partly due to inadequate supplementation programmes
  1. The oft repeated argument that Indians are genetically shorter and international anthropometric standards should not apply has been proved to be a myth by many studies.
  2. Actually, the numbers for nutrition are uniformly poor across South Asia even compared to many sub-Saharan African countries. This fact has been termed as the “Asian Enigma”
  3. Studies point to various possible reasons for this – one is the poor status and health of women. Poor nutritional status of women during pregnancy leads to low birth weights affecting th nutritional status right from birth. And poor nutritional status of women is also a reality across South Asia
  • Further, just like immunization, the lack of improvement over time is disconcerting. Between ’92-’93 and 2005-2006 the dates of NFHS 1 and NFHS 3, nothing much has changed. (However, recent reports i.e. last year if a survey done by UNICEF and MoWCD found the figure to have come down to 31% from 43% of NFHS-3)
  • The unavailability of credible data on the issue is another challenge for timely course correction in policy. Last NFHS was in 2005-06
  1. The (successful) example of Tamil NaduHealth care
    1. TN has a clear commitment to free and universal health care covering a good range of services
    2. Correspondingly, most of the health indicators are also much better than the national averages including IMR, MMR, Life expectancy, proportion of underweight/stunted children, institutional deliveries, antenatal and post-natal care, breastfeeding, etc. In fact TN is expected to soon cover the gap with Kerala – the state with the best set of health indicators
  • The health policy and outcomes actually fit into a larger pattern of creative, inclusive and comparatively active social policies
  1. The foundation of TN’s health care system is an extensive network of primary health centres – all well organised, supplied with essential medicines and well staffed
  2. The geographical density of health centres, ratio of doctors and nurses to population and presence of women staff is much higher in TN than other states
  3. There is timely supply of free medicines which is handled by a pharmaceutical corporation set up by the state machinery unlike other states where patients are given prescription and have to buy drugs from commercial pharma shops
  • The focus on basics i.e. preventive health care is also commendable – including child immunization and public health (basically sanitation, hygiene, waste disposal, disease surveillance, health education, food safety regulation, etc)
  1. ICDS
    1. Characterised by well built infra, large attendance rates even within 0-3 age group, good quality of education, positive mothers’ perception of the scheme.
    2. The state has taken initiative and ownership of the scheme and incorporated many innovations – There is a sophisticated training system for the staff, the entire programme is run by women from top to bottom.
  2. Other public services
    1. There are many other examples of creative activism in public service delivery in TN
    2. The PDS of TN is often cited as an example to emulate. TN was the first state to provide free and universal mid day meal scheme even before it was launched at the national level
  • A common thread amongst all these programmes in the state is their universal nature. The PDS is universal unlike most states where it is targeted. This principle is present across services including water and electricity, health, employment, food, etc.
  1. How did TN develop this commitment to free and universal provisioning of well functioning public services?
    1. early social reformsg. self respect movement in 1920s
    2. empowerment of disadvantaged classes
    3. respect for women
    4. long history of democratic action in public policy related to social welfare – public discussion on social issues and the prominence of these in the electoral politics of the state. There is a culture of protest for public services in TN. This is exactly what happened much earlier in Kerala


Suggested focus areas based on above analysis

  1. Increase public spending on health as % of GDP
  2. Commitment to universal coveragethrough public financing and not relying on private sector. This doesn’t mean pvt sector has no role at all. But it can only supplement and not supplant the public health care system. This is the route through which a large no. of countries in East Asia and Latin America and transitioned to near universal health care in the recent past. So the foundational role has to be played by the public sector.
  3. Need to go back to the basics – Focus on both preventive and curative care, making PHCs the foundation of our public health system, empowering and educating village level health workers.
  4. Consolidate on gains made by innovations like the Janani Suraksha Yojana, role of ASHAs in vaccination programmes, etc while simultaneously learning and absorbing the lessons from outside – China, Thailand, etc. and also within from India – TN and Kerala.
  5. Bring health care at the centre of attention of democratic politics and public debate. Just like the example of TN, the experience of Thailand also shows the importance of public involvement in health policy and issues – There is a “Health Assembly” in Thailand which holds regular meeting where complaints and reviews on health policy are aired by the citizens