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A consultancy organization providing a range of support services to NGOs, CBOs, NGO networks and social development agencies. |
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A consultancy organization providing a range of support services to NGOs, CBOs, NGO networks and social development agencies. |
This section provides insights into the extent to which social development rights of the poor including literacy, education, and primary health care have been responded to. While literacy has been initiated at different points of time in fits and starts, the concern for Universal Elementary Education and Health Care have found significant articulation in the constitution of India.
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The present report argues that community participation is one of the significant strategies to attain universal literacy and education in India. The various governments in India have unfortunately relied on centralized models of literacy and education planning; after nearly 48 years of centralized planning, some attention is being paid to the possible gains from decentralization. However, decentralization appears to exist still at the level of concept rather than an operational strategy. The conceptual explanations often appear to rely on centralizing tendencies within decentralization. Earlier, the Centre did not have much faith in the wisdom of the states; now, the states do not appear to trust the districts, block, and villages. The district authorities often feel threatened at the prospect of blocks and villages assuming greater role in planning and implementation.
Universal literacy and universal primary education is a goal which India has cherished as part of her socio-cultural vision of freedom. We envisioned this goal in terms of the right of children to free and compulsory education for a period of eight years. We believed that this segment of the Indian population would spur the adults in the families to make conscious attempts to acquire education required for meeting basic minimum needs of life.
It was a goal which we were supposed to attain within a period of ten years (i.e., by 1960); while the years have gone by, the goal appears to be receding into a distance. One wonders if the goal can be attained even in the next twenty to twenty-five years at this rate. Among other things, the goal has become somewhat unattainable on account of growing size of population and excessive reliance on centralized mechanisms of planning and management, despite professing decentralization.
India has been missing out on gains which have accrued to other societies on account of universal primary education. The missing gains include the following:
The search for meaningful management modes in the task of achieving universal primary education has led the country through a meandering path of programmes to projects to missions without any substantial changes in the quality of the human resources being utilized and enriched at various levels.
The number of children not in school is almost half of those who are in school. The percentage of dropouts adds to the magnitude of the crisis in elementary education. The number of children in 6-10 age group attending school is in the region of 67 million; the number of children in 6-10 age group not in school is around 32 million. The total number of children in the 0-14 age group is around 296.9 million, with 213.0 million residing in rural areas.
Who are these missing children? Child workers in rural and urban areas, girls confined to sibling care, other domestic chores, and work on the farms, or classes (Scheduled Castes, Scheduled Tribes, Other Backward Classes) which are denied access to education on account of socio-cultural and economic biases? How do we bring these missing children either in school or respond to them through an alternate education programme without necessarily expecting them to give up their current involvement in some work activity?
Where are these missing children located? These are frequently the states which have the highest incidence of child labour - Andhra Pradesh, Rajasthan, Orissa, Karnataka and Madhya Pradesh. These are frequently the states where the biases against the girl child is at its highest - Andhra Pradesh, Karnataka, Maharashtra and Himachal Pradesh.
Are the above three missing groups or low-performing groups of children engaged in other - both paid and unpaid - activities? Can we compensate their families adequately if such children were to be weaned away from their existing commitments to activities? Can we plan incremental educational inputs for such children based on the value of existing learning acquired from within the existing work environments? Can we really blame the parents/community for the fossilized school system? Are the parents/community totally unjustified in rejecting/undervaluing the existing school system?
The answers to these questions can be found both in the community and within the school system. It is also being suggested that the school system would need to be made responsive to the demands of the community for quality education in the primary school.
However, it is not the stage of primary education, but the stage of pre-primary education wherein a meaningful answer could be found. Can we make pre-primary education a fundamental right before we do the same in case of primary education? A section of the community is currently paying for the pre-primary education of their children. This movement could grow further if the state could come forward to provide the necessary infrastructure - a one-room pre-primary school with part subsidy to the salary of the teacher - and place it under the control of the community-based organizations?
Why is there a decline in the number of pre-primary education institutions? Has the Aanganwadi assumed the socialization and educational role for children in the 3-6 age group? Why are we thinking in terms of dropping the Balwadi when it serves a set of altogether different functions as compared to the Aanganwadi? Can we let the local communities own and manage the pre-primary and primary school system in its capacity as a trustee of the state?
The other issues of change and reform within the school would be automatically raised by the concerned communities once they have been entrusted the ownership of the pre-primary and primary schools within their areas. They would then find answers in terms of an integrated strategy to link enrollment with retention and social utility of education, expanding the right to enrollment to the right to learning and holding the school/teacher accountable for it, and link the incentive structures for girls' education to enrollment with retention and achievement? They would also initiate realistic measures to upgrade existing skills of girls engaged in family-support activities to the level of economically productive skills.
It is being suggested that a matrix of the diverse manipulable variables supportive of change in the situation needs to be developed for a comprehensive response to the crisis in primary education. Some of the variables include the following:
The management issue in education needs to deal with the question of institutional policy with clearly defined roles for each type of grassroot institution - the Mahila Mandal, the community-based organization, the local NGO, the Village Education Committee/the Mandal level Education Committee/the Standing Committee at the district level under the Panchayat Raj system. These decentralized structures of public administration (not necessarily government-managed administration) need to be created and sustained on the basis of cooperating relationships between state, society and the organized pressure groups.
The civil society institutions and the local self-government institutions below the district level need not be viewed as competitors to the state-controlled institutions. These institutions need to be viewed as more locally relevant and effective institutions for planning and management on the one hand and as those capable of creating innovative and low cost approaches to service delivery.
The local self-government institutions need to be encouraged to plan targets and manage the implementational process at their level with adequate resource support. Alongside, such institutions need to be encouraged to acquire managerial and institutional capacity to undertake such functions. The governmental mechanisms at the Central, State and District levels need to reduce their own visibility to let the village and block level communities occupy the centreplace in planning and management.
The report argues that the health care system in India suffers from an urban and excessively curative biases at the cost of neglecting the health needs of millions of rural population. Preventive health care has been part of the Indian socio-cultural tradition; however, the modern health systems have tended to rely on excessively curative approaches. The health care system has also tended to neglect diseases which affect the mass of population; it has at the same time paid excessive resource attention to excessively urban health infrastructure.
Several studies have pointed out that even in industrialized societies, the main contributing factor responsible for the decline in mortality and morbidity rates is improvement in the standard of living. Access to health care services should thus seen as part of the larger effort to combat poverty. The Primary Health Centre was thus visualized in this holistic framework intended to provide preventive, promotive, curative and rehabilitative services to the rural population. The PHC needs to be strengthened as a health service support mechanism for the poor.
Poverty has a set of associational factors including low consumption of food, inadequate and poor housing, low utilization of education and even of health services, loss of income caused by illness among the productive adults in the family, low social status, loss of competitiveness in the labour market, vulnerability to being trapped in casual labour markets, etc.
Despite spending large amount of money on its health care system, the "health achievements" of the country cannot be compared to the achievements of other countries spending lesser amounts; the other countries include China and Sri Lanka. The reasons for the comparably lower achievements appear to lie in what can be termed as "misplaced priorities"; the secondary/tertiary care and medical training and research receive more attention than the primary health care.
The aggregate health spending by the Central and State governments was 4.3 percent of GNP in 1987; only Korea among the countries in Asia spent 5.1 percent. The inter-state differences in health spending indicates wide variability. "Bihar and Uttar Pradesh spent less than Rs. 45 per person on health, while Gujarat, Tamil Nadu and Rajasthan spent more than Rs. 90 per person.
The Central and State governments spending on health care is characterized by a distinct urban bias. A study conducted on the subject in four states - Gujarat, Tamil Nadu, Uttar Pradesh and West Bengal - indicated that average per capita health and family welfare expenditure was 2.5 times more in the urban municipalities than the corresponding expenditure at the district level. The highest degree of urban bias in the allocation of resources was found in Tamil Nadu and the lowest in Gujarat.
Non-involvement of the Community
The Government of India, in its 1982 National Health Policy document, itself admitted that the health services in India are curative and urban-oriented, catering mostly to the upper crust of society. A wide cultural gap existed between the providers of health services and the masses; instead of promoting self-reliance, the public had been made dependent on the government health services for the health problems faced by them. The document had called for involvement of the community "in the identification of their health needs and priorities as well as in the implementation and management of health and related programmes." However, the specialists hijacked all such good intentions at democratization of health care in India.
The Alma Ata Declaration of 1978 favoured social control over health services through involvement of the people in every phase of development of health services.
More Burden on the Income of the Poor
Some studies have indicated that the poor spend more on health than the non-poor; a national probability sample survey by NCAER in 1990 revealed that the lowest income group spent 24.1 percent of its annual income on health as against the highest income group which spent a mere 3.4 percent on health-care.
There is considerable variation among the states; Kerala and Tamil Nadu have crude birth rates of 17.4 and 19.2 respectively while Bihar (32.5), Madhya Pradesh (33.0), Rajasthan (33.7) and Uttar Pradesh (35.4) indicate higher than the national average. Incidentally, these four states constitute about 40 percent of the Indian population.
There are variations again in terms of the infant mortality rates. Kerala has an IMR of only 16 per thousand live births; Madhya Pradesh (98) and Orissa (103) are higher than the national average. The total fertility rate in Bihar (4.6), Madhya Pradesh (4.2), Rajasthan (4.5) and Uttar Pradesh (5.2) are again higher than the national average.
Women in rural areas appear to lag behind in receiving health care attention as compared to their urban counterparts. "The most direct effects of poor health and nutrition among females in countries such as India are high mortality rates among young children and women of childbearing age and high morbidity rates throughout the life cycle." There are, of course, adverse effects on other members of the family. A woman's health and nutritional status influences the newborn's birthweight and chances of survival. Women often contribute the unpaid portion of labour to all family and farm activities; any ill-health implies larger costs and lesser income for the families.
The Integrated Child Development Services have been launched in community development blocks (about 100000 people), tribal development blocks (about 50000 people), and slum populations (about 100000 people). The Aanganwadies provide services to a population of about 1000 persons. While the Aanganwadi workers are expected to provide preschool support, supplementary meals for children, health and nutrition education for mothers, making home visits, building community support, and assisting health workers with immunization and other services. However, in reality the part-time Aanganwadi workers are overburdened with a great deal of other work in the communities and are thus forced to neglect several services including pre-school education.
The rural areas have a three-tier health infrastructure as per following details:
These centres are staffed by 628301 trained dais and 409958 village health workers, apart from other personnel. There is one Community Health Volunteer/Health Guide and a trained Dai for every 1000 persons. There is also a 25-bedded hospital for 100000 to 400000 people. More than 5000 registered health-related NGOs, varying in size and in orientation and concentrated in the southern states, Maharashtra and Gujarat add to the infrastructure of the health care system in India.
Role of the Private Sector in Health Care Services
The private sector provides health care to nearly 80 percent of the population. One estimate reveals that in all systems of medicine, fewer than 15 percent of qualified doctors and about 40 percent of health care providers with paramedical qualifications work for the government, suggesting the probable extent of the private sector. There is also a very large informal private sector, with a range of other persons performing health care roles, both in urban and rural areas, with predominance in rural areas.
Thus the scenario indicates a vast network of institutions for delivery of health care services in India. However, the quality of service delivery, as also its outreach, is both inefficient and limited, with interior rural areas, tribal cluster settlements and urban slums continuing to remain the neglect geographic zones.
