“One billion people worldwide have come out of poverty since 2000,” asserts the just-released report, ‘The Bill & Melinda Gates Foundation’s Goalkeepers: The Stories Behind the Data, 2018’. China and India played a key role in the achievement, the report contends.
Yes, that wouldn’t have been possible without factoring in the numbers in these two countries for the simple reason that no other country among the world’s 195 is close to them in terms of population. China with 1,415 million and India with 1,354 million together account for 36.2 per cent (18.5 +17.7) of the world’s population, close to 7.6 billion today.
More importantly, the report has rightly identified the crucial role played by health and education in catalyzing the pace of poverty reduction. So, it reiterates the need, rather, the duty of the governments, to adequately spend in the health and the education sectors, in other words, in what is called, human capital. Economists define human capital to mean the sum total of the health, knowledge, and skills of the population. It wants Sub- Saharan Africa to follow the Indian example of curing the disease of poverty with health and education.
More than celebrating the acclaim that it received from the Gate’s Foundation report, it is time for India to reflect on its commitment towards improving health and education, its actual investment in these sectors, the deficit between the actual and optimal and the outcomes. More particularly it should look at the deficit in governance which is responsible for the suboptimal results of the expenditure, to whatever extent it had been made.
The health spending in India ~ both by the Centre and state governments put together ~ has been hovering around 1.3 per cent of the GDP against the global average of 6 per cent. The National Health Policy 2017 proposes to increase this to 2.5 per cent of GDP by 2025. This would mean we don’t have plans to adequately raise the government spending on health even in the distant future to reach the international average, not even to the 3 per cent level by 2022, recommended by the high-level expert group on Universal Health Coverage under the chairmanship of Dr.K. Srinath Reddy (2011).
As a result of the poor spending by the government, 70 per cent of the health expenditure is met by the people themselves. As a result, 7 per cent of the people above the poverty line are pushed below that line every year due to huge medial expenditure. It would be pertinent to consider the National Sample Survey 71 report.
A high 72 per cent of ailments in the rural and 79 per cent in urban are treated in the private sector. Despite the government’s boast of several health schemes, as high as 86 per cent of the rural population and 82 per cent of the urban population were not covered under any scheme.
In terms of total medical expenditure, around 72 per cent in rural and 68 per cent in urban areas was made for purchasing ‘medicine’ for non-hospitalized treatment. It is disturbing to note that 20 per cent of child births in rural areas and 11 per cent in urban areas are reported to be non-institutional.
The percentage of aged persons was 7.7 per cent in rural areas and 8.1 per cent in urban areas. Among economically dependent aged persons, 82 per cent in rural and 80 per cent in urban areas had to depend upon their children for financial support. Naturally, the poor with subsistence income are not able to meet the minimum health requirements of their dependent parents.
Unfortunately, people do not get quality medical service that is commensurate with the money they spend, or the government spends on their behalf, due to the failure of the administration. The unscrupulous hospitals focus more on the paying capacity of the patients than on the severity of the disease. Rich or insured persons are overtreated while the poor and uninsured get little or no treatment.
There have been instances of feigning treatment by some hospitals to patients even several days after their death and fleecing the gullible relatives. There are innumerable instances of wrong and unnecessary tests and surgeries conducted only to make money.
The nexus between corporate hospitals, pharma companies and doctors has increased the risks and costs of health care to such an extent that millions of middle-class Indians are driven to penury when they fall sick. While people are crushed under the burden of medical expenses, the health sector flourishes as a commercial enterprise. There are 10.4 lakh healthcare enterprises, if the very small to the very big are counted.
In money terms, the industry’s size in 2017 was equal to $ 160 billion; poised to grow to $ 280 billion by 2020. The Foreign Direct Investment it received between 2000 and 2017 was $4.34 billion. The number of medical tourists in 2016 was 2,00,000 against 1,30,000 a year before. This means that our health sector is attractive not only to the Indian wealthy but to the affluent from abroad.
On 23 September, the Prime Minister launched the Pradhan Mantri Jan Arogya Yojana-Ayushman Bharat (PMJAY-Ayushman Bharat). This scheme is targeted to cover 100 million families which means 500 million persons whose names feature in the socio-economic caste census of 2011. It covers 1300 diseases with the insurance cover of Rs 5 lakh cover per family.
There are doubts on the efficacy of this programme in reaching the universal health coverage although it is a step different from the existing health schemes. Five states, Telangana, Odisha, Delhi, Kerala and Punjab, are not willing to implement the scheme. They have questioned its feasibility on the plea that their schemes are superior to PMJAY-Ayushman Bharat. Whatever the claims to the contrary it is not a universal health care system. It excludes a large number of people, describing them as ‘non-poor’ even after witnessing the so-called ‘nonpoor’ becoming poor following one or two major ailments in the family.
Turning to educational spending and its outcomes, government spending has been declining over the years. In 2012- 13, education expenditure was 3.1 per cent of the GDP, according to the economic survey 2017- 18. It fell in 2014-15 to 2.8 per cent and registered a further drop to 2.4 per cent in 2015-16. The slight rise to 2.6 per cent since 2016-17 is not an enviable achievement; it is nowhere near the 6 per cent of GDP target accepted way back in 1966 on the recommendation of the Kothari Commission which had specified that the level must be achieved by 1985-86 itself.
The Annual Status of Education Report (ASER) has been reflecting the deteriorating educational standards year after year. ASER’s 2017 report says: “About 25 per cent of the age group 14-18 still cannot read basic text fluently in their own language; more than half struggle with division (3 digit by 1 digit) problems. Only 43 per cent are able to solve such problems correctly. Even among those who have completed eight years of schooling, a significant proportion still lack foundational skills like reading and math.”
There could be several outside- the-school reasons and socio economic problems, for pushing the students out of school; but, one reason within the school, relating to the persons who run and control the schools, particularly, to teachers among them, is the most disgusting.
Many teachers are found not only to be incompetent but cruel to the students. An earlier ASER’s policy brief noted that the teachers had not been following child friendly practices as evident in the data analysis of 850 hours of classroom observations. Teachers were not even smiling, laughing or joking at least with some students in the classrooms.
As noted in the government’s own publication, ‘Child protection: A handbook for teachers’, crafted by the ministry of women and child development, “many street and working children have pointed out corporal punishment at school as one of the reasons for running away from school and also from their families and homes.”
The same report further asserts, “almost all schools inflict corporal punishments on students” and “in the name of discipline, children are known to have had their bones and teeth broken, their hair pulled out and forced into acts of humiliation.” All this suggests the failure of the system to discipline and punish the guilty although not doing that causes an irreparable damage to the society.
It is high time that governments stopped neglecting health and education. It cannot eternally leave these two sectors to the mercy of market forces. The politicians should not fit these two sectors into their populistic schemes which they hurriedly work out and announce keeping an eye on the ensuing elections.
It is better if the government realises that their all other poverty alleviation programmes cannot be efficacious without adequate controls and investment in education and health. The development of these two sectors is the primary responsibility of the government. It should not delegate its control to the private sector, which works purely with the motive of making maximum commercial profits.
The writer is a Hyderabad based development economist and commentator on economic and social affairs.