Amarjeet Sinha: Don't knock public systems

Recent experience suggests that they are capable of raising health and education standards

India’s failure to match social development with its high rates of economic growth over the last two decades has rightly been highlighted at the highest levels. The world’s fourth-largest economy in terms of purchasing power parity continues to be in the three-digit zone of human development. But the current thinking in some quarters that private initiative or public private partnerships are solutions to this problem is misplaced. Privatisation is not the solution for human development.

Indeed, if there is one lesson from programmes like Sarva Shiksha Abhiyan ( SSA) and the National Rural Health Mission (NRHM), it is that we must continue to invest in crafting credible public systems. The task is tough, the deficits massive and public systems have their own inertia to counter. Solutions may take a decade or more, but there is no going away from a well-funded public system for social development. As the human development indicators of many erstwhile Soviet bloc countries have demonstrated, social development needs public systems.

Neoliberal economics may be good for achieving high rates of economic growth; it is not the route for sustained human development and inclusive growth. Given the fact that almost a billion people live in over a million towns and villages, it is only through enhanced public capacity that we can reach out to all households to guarantee human development. Sectors like health have added problems of information asymmetry and the likelihood of market failures.

Take the case of malnutrition. Again, the current focus on the efficacy of cash transfer misses the point. Conditional cash transfers are not a solution when basic services are missing. Let us not forget that Brazil’s Bolsa Familia cash transfers to poor households took place after an investment of eight per cent of public expenditure for health and an adequate provision for universal education. Cash transfers can only be a source of additional disposable income in the hands of the poor to seek services. The child, the adolescent girl and the pregnant woman require universal entitlements to food and health care for our nutrition status to improve. It is no rocket science; it is in the realm of the possible. NRHM is clearly demonstrating in many states that the health Millennium Development Goals are achievable if we continue to invest adequately in a credible public system with new public management skills, and accountable and innovative policies for public recruitment.

Though limited in their impact, the changes that SSA and NRHM have brought about are significant. At the turn of the century when SSA was launched, we still had 60 million children out of school. Today, the most independent of surveys finds this number to be only a few million. It is also a fact that infrastructure in schools has remarkably improved with the success of SSA.

The reduction in the infant mortality rate (IMR) of three points between 2008 and 2009 – the rate of reduction being double in rural India compared to urban areas – in the last two years confirms the slow but steady success of NRHM. Even hard-to-convince international agencies acknowledge that India’s maternal mortality ratio in 2008 is 230 instead of the 450 reported by UNICEF. UNDP in its 2009 publications, confirms the silent but significant change that NRHM is bringing about in India. The fact that a four-point reduction in IMR between 2008 and 2009 was recorded in hitherto BIMARU states like Bihar, Rajasthan, Orissa and Uttar Pradesh confirms that the gains of NRHM have started showing in high-focus states. While Tamil Nadu, Kerala and Karnataka are using NRHM funds to improve their health system, the change and priority for the health sector is now visible in all states and union territories.

NRHM has been designed as a state-led platform for flexibility, innovation and change since health is a state subject. The central government saw its role in pushing reforms with resources and in sharing good practices for cross-learning. Partnerships with the non-government sector for achieving public health goals allowed the harnessing of all human resources in health for a public purpose. A public system is required in the health sector as it does not lend itself to market principles. The countervailing presence of a well-functioning public system has positive consequences for the cost and quality of care even in the private sector.

India’s public expenditure has barely moved from a little less than a per cent of GDP to a little more than that, which is some distance from the promised two to three per cent of GDP. India continues to have one of the lowest public expenditures on health in the world. NRHM has demonstrated that even a slight increase in resources for public systems can considerably improve the availability of services, efficiency, effectiveness and achievement of health indictors. There is clearly a case for greater provision of resources for public systems, both for rural and urban areas.

Good health is not only about hospitalised medical care; it is also about wider determinants like clean water, sanitation, women empowerment and social access. Mere provision of insurance for tertiary and secondary care without adequate regulation may lead to distortions of market with surgeries taking place even when they are not required.

India needs a public health revolution like the West that fought public health challenges with clean water and better hygiene. We are trying to do it with antibiotics and that is why we do not succeed. We need to debunk the economic capacity of the state argument and create public systems for human development that are built on principles of service guarantees, reformed public recruitment systems and skilled public management systems with all the expertise needed to guarantee quality services.

The writer is a civil servant with a deep interest in the social sector. The views expressed are personal.
amarjeetsinha@hotmail.com