Services for all

IN India we are used to living with contrasts. We were earlier used to the jet set and bullock cart set coexisting; now we are used to being seen as the new dynamic economic region of the world even as large parts of our population continue to not only stagnate but also experience absolutely terrible conditions of living. We are also used to large regional differences in income, consumption patterns and even access to basic needs.

Yet, the extent of inequality prevailing across the subcontinent now is something rather new. It is becoming simply repetitive and cliched to note that the recent rapid economic growth has been associated with unexpectedly large increases in consumption by the rich and the flaunting of lifestyles by the upper-middle class and the deterioration of the living conditions of large numbers of ordinary people, cultivators and workers in the unorganised sectors.

The inequalities in assets, incomes, employment conditions, consumption patterns are all well known. But what makes the situation particularly offensive is that the disparities stretch across every aspect of life, including the provision of basic services. In many other developing countries, not to mention the developed world, economic inequalities are to some extent mitigated by the public provision of basic services. There is at least a modicum of access to all citizens and some empowerment and mobility across all sections of the population.

But in India, disparity, exclusion and discrimination are particularly marked in terms of access to the basic services of health, sanitation and education. This is largely because of a persistent history of massive underspending in the area of public services. This has led to inadequacy and incapacity of the physical infrastructure and human resources that are required to provide essential services. And to this we must add the inefficiencies that persist in public delivery systems as well as the inequalities of access that are determined by gender, caste, community, income and class.

The point is that for some reason our policymakers fail to realise that ensuring quality requires a significant increase in the quantity of resources in addition to administrative and other reforms and decentralisation, which would improve the delivery of public services. For example, it is often pointed out that the quality of education in government schools is poor and occasionally abysmal, but it is rarely noted that this closely tracks the spending per student. The Kendriya Vidyalaya system is run by the government, and there are few complaints about its quality. Yet this is a privileged part of the government school structure, with the cost per child currently in excess of Rs.13,000 per annum. By contrast, most school education in the country is operated on a pittance, of an average of around Rs.600 per student per year. So it is not surprising that there are inadequate facilities and uneven quality of teaching in such schools.

The official resistance to providing more resources for quality schooling in the government school system continues to be widespread. This is also why we have an elaborate caste system of schools of different qualities even in the government-run system. We are unwilling to shell out the money required to ensure that all children in the country get the kind of education that the children of our policymakers automatically receive.

Similarly, even when we want to improve health conditions and place a greater emphasis on public health services delivery, we want to do it on the cheap, without creating the necessary structures that would provide proper quality.

The National Rural Health Mission has a laughable budget for a country this size. It earlier sought to base its entire programme on unpaid female workers (the accredited social health activists, or ASHAs) who were effectively expected to donate their services; now these workers are being offered a pittance each month that is not even close to the minimum wage. When it comes to universal basic service provision, the tendency is inevitably to hold the purse strings tightly. We are then very surprised when the facilities are overcrowded, understaffed, without proper infrastructure or working requirements.

In this matter, there is a lot that the Indian government can learn from some of its smaller neighbours. Currently, our neighbours are outperforming us not only in T20 cricket but also in the far more important area of public service provision.

Within the South Asian region, the superior performance of Sri Lanka in terms of human development indicators is recognised, but the critical role played in this by public provision and government regulation is less advertised.

For example, universally accessible free health care is provided at a basic level in Sri Lanka, subsidised by progressive taxation measures, ensuring that the rich pay for out-of-pocket health expenses more than the poor. This is in fact the opposite to the system in the other countries in the region, such as India where inadequate and poor public provision forces even the poor to spend out-of-pocket for private health care and where private spending accounts for more than four-fifths of total health expenditure.

An even more startling contrast emerges in education. Private schools covering Classes I to IX have been banned in Sri Lanka for decades. Yet educational achievements, especially in school education, are the best in the region. User fees were also eliminated early on, yet Sri Lanka has managed to achieve and sustain universal elementary education. Currently, the government of Sri Lanka spends only 3 per cent of its gross domestic product on education, but it is benefiting from a legacy of higher spending in the 1950s and 1960s, which built up the basic educational infrastructure.

There is also greater recognition of the importance of recurring expenditure, which is all too often ignored in planning for expansion of public education in India. Sri Lanka allocates at least 27 per cent of its educational spending on recurrent items such as textbooks and school uniforms (which are provided free) and on running expenses apart from salaries. Other important lessons emerge from the successes of Bangladesh in improving school access, particularly for girl children, over the 1990s and the early part of this decade. Similarly, health indicators have also improved more rapidly than in India: fertility rates in Bangladesh have been reduced by more than half and infant mortality rates by two-thirds since the early 1990s.

Of course, all this is in sharp contrast to Pakistan, where several of these indicators have stagnated or worsened despite comparable economic growth rates. It is unfortunately also in contrast to India, where we are lagging behind much smaller and poorer Bangladesh in terms of improving the conditions of preventive and curative health care and school education for all citizens.

The most significant lesson that can be drawn from the comparative experience of countries in our region is the absolute importance of providing as far as possible free and universal access to basic services. User fees for essential services have contributed to increased inequality and have even effectively excluded the poor from benefiting from such services. There is, therefore, a strong case for the abolition of user fees and for the increase in public allocations to provide essential services to all.

This is important not only in welfare terms or because the poor have a human right to health and education. As the social costs of poor health and inadequate educational development are large now and will be even larger for future generations, it is in societys interest to invest substantially in these areas.

If the governments stated intention of making growth more inclusive in both economic and social terms and ensuring access for all is actually to be achieved, it must commit itself strongly to the universal provision of quality public services. This necessarily means more financial outlays, removal of user fees and recognition of related expenses. But it also means organisational and administrative changes that will make public service delivery more flexible and adaptive and more responsive to the needs of citizens.

So along with more public resources, it is necessary to rebuild the public sector work ethos: by rewarding public workers adequately, encouraging a more responsive work culture with community and civil society participation and supervision, and weeding out corruption. The continued denial of equal access that is inherent in poor public service provision can have very unfortunate consequences in a world in which knowledge about possibilities is becoming more widespread and peoples aspirations are changing rapidly. It can dramatically increase social and political tensions with all sorts of adverse consequences. So a commitment to public service provision is essential not only for greater equality and democracy but also for the very future of our society.