A report on the 2013 deliberation of the
Kolkata Group at its 10th workshop which focused on healthcare, the status of women and social justice in India.
A K Shiva Kumar (
akshivakumar@gmail.com) is convener of the Kolkata Group workshops which are organised by Pratichi (India) Trust, the Harvard Global Equity Initiative and UNICEF India.
At the 10th annual Kolkata Group workshop in February this year, 40 policymakers, development practitioners, non-governmental organisation (
NGO) representatives, scholars, activists, journalists, politicians and development experts convened to take stock of the state of women, health equity and social justice in India. The group focused on two major areas of concern. First is the abysmal state of healthcare in India driven by the lack of strong governmental policies, investments and direct operations, and the growing size and exploitive practices of commercial providers. And second is the limited progress in women’s rights, indeed sometimes retrogression, that is reflected by a host of inequities, insecurities and injustices.
The Kolkata Group is an annual forum that deliberates on ways of advancing social justice, human development and human security in India. The group examines available information, seeks positive solutions, and shares its recommendations with wide audiences – government, civil society, the media, and the public. The group believes that bringing together outstanding people from different walks of life to discuss “good practices” and “lessons learned” can blend values, knowledge and discourse as part of a process of public reasoning for social action. Every year the group discussions have a particular focus. Themes in the past have included equity, security and basic education, rights and resources, child rights and development, economic progress and social values, and eliminating injustices in India. The theme in 2013 was “Public Action and Its Future”. The main focus was on health and nutrition as well as the alarming status of women in Indian society.
Amartya Sen opened the workshop by underscoring that economic growth in India is good and necessary, because average incomes must be raised to achieve reasonable living standards and extensive income redistribution alone would not be sufficient for shared well-being. Growth generates private income, and even more importantly, it generates public resources which can be spent on the provision of a host of essential goods and services that contribute to decent living standards. Having noted this, Sen argued that it would be a mistake to “sit back” and rely on economic growth alone to transform the living conditions of the unprivileged. While India has much to learn from growth-mediated development elsewhere in the world, it must avoid unaimed opulence – an undependable, wasteful way of improving the living standards of the poor. Even today, after 20 years of rapid growth, India is still one of the poorest countries in the world, something that is often lost sight of, especially by those who enjoy world-class living standards thanks to the inequalities in the income distribution.
On several health indicators, India has fallen behind many of its neighbours. Overall in 1990, India had the best social indicators in south Asia, next to Sri Lanka. But now India ranks
second-worst, ahead of only Pakistan. This is despite the fact that during the last 20 years, India has grown richer much faster than its neighbours. Take for instance
Bangladesh. India’s per capita income was estimated to be 60% higher than Bangladesh in 1990. By 2010, India’s was 98% higher (about double). However, during the same period, Bangladesh overtook India in terms of a wide range of basic social indicators: life expectancy, child survival, fertility rates, immunisation rates, and even some (not all) schooling indicators such as estimated “mean years of schooling”. Bangladesh’s relatively rapid transformation of social indicators seems to relate closely to the much greater participation and agency of women in the social services as well as in private economic activities, compared with India.
Equally intriguing is that Nepal is also catching up rapidly with India, even overtaking India in some respects. Around 1990, Nepal was way behind India in terms of almost every development indicator. Today, social indicators for both countries are much the same (sometimes a little better in India still, sometimes the reverse), in spite of per capita income in India being about three times higher than in Nepal. Looking at their south Asian neighbours, the Indian poor are entitled to wonder what they have gained – at least so far – from the acceleration of economic growth.
Even though India is still managing to achieve comparatively high growth rates, despite its very insufficient public provision of basic services, this is undoubtedly a source of future concern, and may already be playing a part in India’s contemporary slowdown. High growth in east Asia has been led by, and reinforced by, rapid formation of human capabilities, and this is the shared experience of Japan, China, South Korea and other fast moving economies and societies in Asia. The contrast with India cannot be sharper. Apart from the very limited reach of good quality healthcare and basic education, even today 48% of the population do not even have toilets in their homes. India suffers a chronic power shortage as the breakdown of the grid in
north India last year highlighted, but it is also worth bearing in mind that a third of the population in the “black out” area did not ever have any electricity connection anyway. But Sen said you would not think that power supply was a problem in India if you visited government offices where the air-conditioning is kept at a bone-chilling 16 degrees celsius in the summer. This was quite unlike government offices in other Asian countries, which keep the temperature around 23 degrees, which is comfortable enough. It is hard to detect any sign of power supply being a problem if one visits over-chilled offices, restaurants, or hotels, patronised by the comparatively rich, and it would be hard to guess that a third of the Indian population is without electricity altogether. Is it also not ironical – or worse – that political parties support, rather than object to, subsidising electricity for the “middle class” in the name of the
aam aadmi? This goes along with support for other middle-class consumptions, such as diesel, cooking gas, and other ingredients of a lifestyle from which the poor are excluded.
Health Inequities
Discussions drew attention to the Asian experience, beginning with Japan in 1860 after the Meiji Restoration, South Korea, Taiwan,
Hong Kong, Singapore, Thailand and China, where economic progress was driven by rapid human capabilities formation. We, in India, are trying to target a high growth rate without investing adequately in basic health, nutrition and education. In this connection, several participants pointed to the appalling state of India’s health system. Public healthcare has been relegated to low priority by the government, given that public spending on
health in India is around 1.2% of its
gross domestic product (GDP) – and has remained so for the past five years – whereas it is 2.7% of GDP in China.
The Kolkata Group reiterated that the most urgent need in healthcare in India today is for an affirmative approach that advances universal health coverage through reversing the financial neglect of public healthcare and the removal of debilitating illusions about what private healthcare and commercial insurance can achieve without firm and active public policies. Influential policymakers in India seem to be attracted by the idea that private healthcare, properly subsidised, or private health insurance, subsidised by the state, can meet the challenge. However, there are good analytical reasons why this is unlikely to happen because of informational asymmetry (the patient can be easily fooled by profit-seeking providers on what exactly is being provided) and because of the “public goods” character of healthcare thanks to the interdependences involved. There are also major decisional problems that lead to the gross neglect of the interests of women and children in family decisions. Nearly every country in the world which has achieved anything like universal health coverage has done it through the public assurance of primary healthcare (whether in Europe, Canada, or much of east Asia).
India’s leaders ought to recognise the necessity for the state to ensure comprehensive quality primary healthcare for all. Related to the main focus of the recommendations, the Kolkata Group urged the government to increase public spending on healthcare to achieve its well-considered pledge of devoting at least 3% of GDP to healthcare. It is particularly important to recognise that there are good reasons for demanding universal entitlements to primary healthcare for all. Effective regulations and ethical professionalism are also essential. The steady increase in public revenues generated by economic growth can and should be fruitfully committed to this extremely important cause.
Child Nutrition
Related to health is India’s worrisome record in reducing child malnutrition. Noting the unusually high levels of under-nutrition in India, the Kolkata Group argued for a firm recognition of the Right to Food in general and legislation to guarantee the entitlements to food for all. Recent experience (including Supreme Court orders on the right to food as well as the National Rural Employment Guarantee Act) shows the value of putting economic and social rights in relation to a legal framework. Legislation should recognise that food and nutritional security depends not just on food but on a set of related interventions that promote women’s health and nutrition, safe drinking water, proper sanitation and healthcare.
The Kolkata Group had earlier endorsed the proposal for creating durable legal entitlements that guarantee the right to food in India. A Right to Food Act covering justiciable food entitlements should be non-discriminatory and universal. Entitlements guaranteed by the Act should include foodgrains from the public distribution system (PDS), school meals, nutrition services for children below the age of six years, social security provision and allied programmes. Ensuring non-discriminatory access and universal entitlements requires special initiatives that focus on the discriminated, disadvantaged and vulnerable groups in society. Last but not least, design and implementation should include effective public participation, grievance redress provisions and independent oversight.
Women’s Rights
The Kolkata Group also drew attention to the limited progress in women’s rights that continues to be plagued by a host of inequities, insecurities and injustices. Discussions were grounded in the developments following the incident of gang rape on 16 December 2012. Nirbhaya’s statement, “I want to live”, provided a very strong emotional impetus to the protests by large numbers of women and men from different sections of society. The fact that many people went past without helping when Nirbhaya was lying there with her friend wounded reveals something awfully callous about us. Similarly, it is not to our glory that dalit women have been violated and raped again and again. And there has been relatively little noise or protest. Underlying causes for the neglect and abuse of women include patriarchy as well as deep cultural factors.
Increasing the enormity of punishment in cases involving crimes against women does not necessarily solve the issue of rising crime against women. Awarding the death penalty, for example, can serve the purpose of revenge but it does not help in social reform. Society needs to ensure that the police are serious about such crimes, there is a system that will punish those responsible for the crime, and that such matters are tried expeditiously in a court. Indian women experience much greater difficulties in getting help from the police, and consequently do not trust the police to work in a professional manner. Protocols should be adopted to protect female complainers and in moving the court swiftly enough to get a judgment quickly.
The Kolkata Group noted that the violations of women’s rights are related to the continuation of early child marriage, violence against women, discriminatory practices, the impunity and bias that permeate the functioning of the legal and police systems, malnutrition of women and children, increasing prevalence of sex selection at birth as well as inadequate women’s autonomy, health, education, and freedoms. The steps ahead must recognise the recommendations of the Justice J S Verma Committee report promoting women’s bodily integrity, dignity and sexual autonomy. Serious attention should be paid to health, education, nutrition as well as the lack of adequate recognition of women’s well-being and agency. The group also underscored the importance of public protests and the need to keep raising the demand for a police and legal system that protects the rights of women. Women’s needs have to be more centrally recognised as a political priority for their voices to be heard.
[Chaired by Amartya Sen, Kolkata Group attendees this year were Sabina Alkire, Louis-Georges Arsenault, Shabana Azmi, Abhay Bang, Countess Albina du Boisrouvray, Lori Calvo, Achin Chakraborty, Gregory Chen, Lincoln Chen, Abhijit Chowdhury, Asim Dasgupta, Keshav Desiraju, Antara Dev Sen, Jean Dreze, Shiban Ganju, Dilip Ghosh, Joaquin Gonzalez-Aleman, R Govinda, Shaibal Gupta, Pratik Kanjilal, Manabi Mazumdar, Surjya Kanta Misra, Nachiket Mor, Poonam Muttreja, Sridhar Rajagopalan, Kumar Rana, Sujatha Rao, Srinath Reddy, Nidhi Sabharwal, Abhijit Sen, Amartya Sen, Nandana Sen, A K Shiva Kumar, Amarjeet Sinha, Shantha Sinha, Sukhadeo Thorat and Sitaram Yechury.]
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