At a time when the public discourse is all about the falling GDP growth rate and India’s economic troubles, Professors Amartya Sen and Jean Dreze shake you up with their latest book, An Uncertain Glory — India and Its Contradictions. It is not the slowdown that is a worry — indeed, growth will return presently. The bigger concern for India today should be the continuing deep disparities in society that are only widening with every percentage point growth in GDP.
India’s democracy, say the authors, has failed to rise to the challenges the country faces in the economic and social fields; and worse, it has been compromised by the extent and form of social inequality. Whether it is education, health care, female literacy, sanitation, or nutrition, India fares only marginally better than countries in sub-Saharan Africa.
And this should shock you: even Bangladesh has better social indicators than India. It has higher life expectancy (69 vs India’s 65), better sanitation (half of all homes in India have no toilets compared to 10 per cent in Bangladesh), lower infant mortality (37 versus India’s 47) and lower fertility rate (2.2 against 2.6 for India). For those arguing that Bangladesh is a much smaller country, the answer is that its GDP per capita is roughly half that of India’s. So, if a country with poorer resources can do it, why not India?
The authors argue that India, unlike the East Asian countries, has failed to make use of the two-way relationship between economic growth and the expansion of human capabilities. The resources generated by growth should be spent on expanding health care, education and nutrition. The resultant expansion of human capabilities will in turn help drive economic growth. The biggest failings are seen in health care and education.
Lamenting the total absence of health care in public debates, Sen and Dreze point out that child immunisation rates in India are only better than in sub-Saharan Africa and conflict-ravaged countries like Afghanistan, Haiti and Iraq. The state’s utter failure to provide a viable health care system is evident from the allocation for the same in its budget.
India spends more on subsidy on fertilizer and petroleum products (1.5 per cent of GDP) than on health care (1.2 per cent). In comparison, China spends 2.7 per cent of its GDP and the developed world’s average is 6.5 per cent. Simply put, India spends $39 per person per year compared to $203 in China and $483 in Brazil. Even Sri Lanka spends $66 per citizen on health care every year.
The state has simply abdicated its responsibility to provide universal and importantly, preventive health care to its citizens in favour of the private sector. Public expenditure accounts for just a third of total health care expenditure in the country; in the enlightened parts of the world as in the EU and North America, the ratio is more than three-fourths. The U.S. is an exception at 50 per cent and we all know how it is grappling with reform in the face of resistance from the private health care and insurance lobby.
The authors argue, correctly, that India cannot afford to go the U.S. way and there is simply no alternative to investing public funds to provide cover to citizens. Should Right to Healthcare be the next affirmative action?
The problem with India though is wrong policies followed from the start over dividing the economy between the public and the private sectors.
The public sector is present in strength in industries such as steel-making and mining, which are better left to the private sector with strong regulatory safeguards. And in areas where it has to make its presence felt overwhelmingly, such as in education and health-care it has abdicated responsibility to the private sector.
The result is that education has become a money-spinning business opportunity for private capital. The recent case in the Supreme Court over a common entrance test for medical admissions in the country is a direct fallout of the state’s inability to provide adequate medical colleges.
In a country of 1.2 billion people, you simply cannot have just 43,000 doctors passing out every year. Private entrepreneurs have smartly capitalised on the scarcity value. Ditto in healthcare where private hospitals are largely unregulated both in terms of the fees that they charge and the quality of care that they provide.
The authors dwell on the relative merits of the public (social benefit motive but no accountability) and private (profit motive and no social benefit objective) sectors but leave the question unanswered on how to resolve the dilemma of choosing one or the other. Surely, it is not impossible, at least in the non-social sectors, for private capital to be allowed with adequate regulatory safeguards?
There is also strong criticism in the book of the media and its lack of interest in “the lives of the Indian poor”. Sen and Dreze note that media institutions are owned by the rich; media professionals are predominantly from the privileged sections; and the business is advertisement-driven. It is indeed true that the business is ad-driven. How else can you sell a product that costs about Rs.10 or more to produce at less than Rs.3 as is the case with most newspapers in the country?
Newspapers will cater to their constituencies and if the readers are middle-class consumers, then obviously the news selection will also be slanted towards them. That said, it is true that standards of media coverage have fallen to abysmal levels where wardrobe malfunctions are written about more than starvation deaths. This is a reflection of the prevailing standards of public discourse in society itself and it needs a brave media house with deep pockets to stick to principles and report substantive issues.
What we need to do is raise the pitch on public reasoning of inequalities and issues of the under-privileged. One surefire way of doing this is, as the authors argue, increasing the political participation of the underprivileged. The relatively better social indicators in states such as Tamil Nadu and Kerala are mainly because of the active political participation of Dalits and other underprivileged people in the political process.
Democracy itself, thus, offers the answer to the problem of tackling inequalities and deprivation. And as the book points out, change is likely to be at a glacial pace, and will not be an avalanche.
(Raghuvir Srinivasan is the business editor of The Hindu)