December 18, 2013
Amartya Sen says India ranks alongside Haiti and Sierra Leone when it comes to government spending on health as a share of the total health expenditure of the people
Any self-respecting country has to regard provision of health-care to its citizens a primary responsibility and it’s amazing that the Indian government never thought of that, says Amartya Sen, Nobel Laureate and Thomas W. Lamont University Professor, and Professor of Economics and Philosophy at Harvard University. Excerpts from his interview with Raghuvir Srinivasan:
After Right to Work and Right to Food, do you think that the time has come for a Right to Healthcare legislation given the poor state of public healthcare infrastructure in this country?
Absolutely! Let me just say that it is incredible that we have got to this state. If you take any country in the world with the possible exception of the United States among the richer countries, they have always regarded it as absolutely elementary for people to have a right to healthcare. The fact that you have to do it through a separate Act itself indicates how backward we have been. Consider the history of the world.
With the end of the Second World War, European countries gave the right to healthcare to all residents and other countries, including in Asia, went in that direction. Japan already had a very well established medical system but they extended that. Singapore, Hong Kong, South Korea and Taiwan also had it. China had healthcare for all but when it marketised in 1979, they made it necessary like in the U.S., which was affecting their thinking very much at that time, for the citizens to buy their insurance cover themselves. So the coverage of health insurance which was automatic until 1979 moved from 100 per cent to 12 per cent. It took them a quarter of a century from 1979 to 2004 to admit that they made an error. And they moved to cover everyone. Now, 96 per cent of the population is covered.
Basically any self-respecting country has regarded this to be a primary responsibility of the government. Therefore it is amazing that the government of India never thought of that. The whole engine of Asian economic development has been the expansion of human capability and the recognition that there is nothing as favourable not only for development but also for economic growth. Since this country is single-mindedly concerned with growth rate, to maintain high growth rate for a long time there is no better recipe than to have a healthy, educated population. So, coming back to your question, if the government won’t do it, will it be right to force the government to do it through a Right to Healthcare Act? Yes. But why shouldn’t the government do it? Why isn’t this a big public issue? Even the Aam Aadmi Party didn’t raise it. The media has a role to play here. In general, the Indian media, print and electronic, should pay much more attention on this subject.
That brings me to the next question. More than 85 per cent of the revenue of Indian publications comes from advertisements which are aimed at the affluent and middle-class readership. Therefore, its focus is on issues that concern this segment of the population rather than on the poor and the deprived. How do you get over this handicap?
I’ll say three things on that. One, yes, it is a problem. Two, is India unusual in depending on advertisement revenue? No, it is not. How come this is not a problem in say, South Korea, Hong Kong, Singapore, Thailand, Japan, Brazil or Mexico? We are not uniquely dependent on ads. It is a question of with what imagination and with what level of independent reasoning can newspapers, acting together, deal with advertisement revenue. There should be some convention on that. We have a vibrant media which has made many innovations. It can get more innovative on this. Third, the advertisers are competing with each other and they are playing one newspaper up against another. It should be possible for newspapers to have a code wherein certain types of news are covered and that code is important to seek.
This is about the two-way relationship between growth and enhancement of human capabilities. How do you break the chicken and egg situation of which comes first?
No, no, there is no chicken and egg situation at all. It is a win-win situation. Every bit of growth generates more revenue that you can spend on health and education. More spending on health and education solidifies the foundation of growth as well as development. You can start anywhere anytime and each of them will work. It’s not that you wait until one gets down and start working. Unfortunately I know that some economists talk like that but that’s a terrible way of thinking about economics. It is one of the things that Adam Smith said with absolute clarity in 1776.
Asked a question why is it that they want to go for a political economy, the answer he gives is that it makes an economy advanced. What is the advantage of that? First, it increases the people’s income. A higher income gives people the ability to do things which they value doing. And it increases public revenue which allows the government to do those things which governments alone can do such as education.
But you have this anomalous situation in India where the government is practically absent in areas such as education and health care leaving them to the private sector and is present in strength in manufacturing steel and refining oil which are better left to the private sector….
That’s just unclear thinking. You should clear out unclear thinking. Every time I come here, a lot of people tell me that the government cannot do anything at all and therefore education and healthcare should be left to the private sector. They don’t recognise, for example, that governmental share of health care in India as a percentage of total health expenditure that people make is one of the three lowest in the world. We are in the company of Haiti and Sierra Leone. We spend one quarter of what the Chinese government spends on health care. We spend 1.2 per cent of GDP while China spends close to 3 per cent. And there is no evidence for this idea that the private sector can do better.
At the level of basic health care it doesn’t work like that. Even the intervention schemes that exist don’t cover preventive medicine or preventive health care but if you become catastrophically ill then the government will pay the money, often to the private hospital, to treat you. That is no way of running public health care.
And this whole idea that the government cannot do anything, you have to look at the examples of Tamil Nadu, Kerala and Himachal Pradesh. When we discussed them a long time ago that they were doing well, I was told that they cannot sustain it because Kerala, for example, is a poor economy. But now it has the highest disposable income per capita in India. The same thing that improves the quality of your life also enhances the economic development. And that story you will not hear. You will hear that [Narendra] Modi has brought such transformation that his State’s growth rate is much higher than [that of] the others. We had a hurricane recently which was expected to be in the news for a month. But it ended the first day because the government could move a million people off the coast. And this was a hurricane five times bigger than Katrina. The problem is that we have convinced ourselves that the government cannot do anything and we give it to the private sector, provide additional money and tie ourselves into a knot from which we cannot exit.
There are some interesting developments in the recent elections. We have a party formed out of a civil society movement which has captured the imagination of the electorate and we are seeing a resurgence of centre-right politics manifested by the success of the BJP. How do you see these developments?
The practice of democracy depends very much on what kinds of issues are brought into the public domain and into the debate connected with elections. The Delhi election was the more interesting one because it brought in many issues which people had neglected in the past. It didn’t bring in all the issues that we want to emphasise as much. It didn’t talk so much about the neglect of education, the lack of public health care and so on. It was concerned more about the delivery of existing services in an efficient and non-corrupt way.
That is important too but I would have liked a broader agenda discussed. However, one cannot get everything and certainly not in one go. But I’m happy that the AAP did bring in some public concerns into the politics of the election. The fact that they could get the people to focus on these issues rather than on issues of religion or caste is also a very positive thing, as also the fact that they won the election in many areas of Delhi without getting into these issues.
The rest of the elections were not unpredictable. The results were connected with traditional politics where religion and caste have played a part. The BJP has been able to project the image of a party that led powerfully even though the nature of the leadership raises deep questions in people’s mind, including mine. The Congress has looked rudderless. So, there’s nothing terribly exciting. Is that an indicator of what’s going to happen in the general election? Is it a wake-up call for Congress? Well, it’s not clear that Congress can be woken up!