Over time, the experiences of patients and communities have hardened into expectation. It is taken for granted that doctors, medicines, time, and even physical clinics are scarce. Even when they are available, they will be of limited benefit. Patients who can afford private treatment bypass the public system altogether, creating a feedback loop where doctors and health workers are drawn into the private system as well. Others who cannot find a private health provider in their own area, travel to the largest, most reputable public hospitals. And some find healthcare so expensive, they endure illness instead of seeking treatment.
As a result, while the primary healthcare network is underutilized and widely distrusted, the secondary and tertiary hospitals are swamped with far more patients than they were ever designed to serve. A well-intentioned system, designed to provide the highest quality of care to the largest number of people, has instead driven them away. They can pay to see private care providers, or crowd into the halls of increasingly overburdened public hospitals. The tertiary care hospitals—meant to be centres of emergency and specialized care—are struggling under a burden of cases that should have been resolved elsewhere.
The cost of this topsy-turvy world is very real. Because healthcare isn’t close to where they live, patients travel great distances, to new and unfamiliar places, to seek advice. There, language and culture gets in the way. They mistrust specialists, and turn to informal practitioners who speak their language. While they may receive good care in certain environments, the risks stemming from oversight run high.
One such case in early 2018 involved an unlicensed, self-styled doctor in the Unnao district of Uttar Pradesh, who may have infected dozens of his patients with HIV when he reused infected needles. Chief among his virtues for his patients was that he visited their neighbourhood on his bicycle, and charged only ₹10 ($0.15) to treat them. 5
The service was a fraud, but the need is genuine.
The irony of India’s healthcare sector is that this patchwork domestic healthcare system sits alongside a flourishing medical tourism sector which treats roughly 500,000 foreign patients a year and is set to grow to $7-8 billion by 2020. 6 India clearly has the potential to deliver the highest standards of medical care; the challenge is in turning this potential into reliable and affordable access for the majority of Indians who cannot afford to seek care at high-end private hospitals.
Timing is important. A working primary health system isn’t just necessary to handle the pressures of today, but the problems of tomorrow. India is going through an epidemiological transition. It is confronted by an increasing prevalence of non-communicable diseases that are now the largest contributor to illness and death in India, in addition to infectious and nutritional diseases common in many low- and lower-middle income countries. Non-communicable diseases like diabetes and heart ailments are typically chronic, requiring periodic visits to a health facility. Beyond genetic factors, they are largely tied to lifestyle choices. 7
Primary care providers play a pivotal role in prevention education and early detection, and primary care is the key way to treat chronic diseases at scale. To do so, the system needs to be made more available, accessible and functional.
10
Outreach
A more effective public health system is in everyone’s interests, but effectiveness requires large-scale interventions. Recently, to help stem the cost of healthcare for its poorest, India introduced the National Health Protection Scheme, the world’s largest healthcare scheme. ‘Ayushman Bharat Yojana’, as the programme is formally called, will provide about 500 million low-income Indians with free health cover for a range of treatments that require hospitalization. 1 This should place life-saving care in the reach of households that could not have afforded it before.
Ayushman Bharat will go a long way in relieving pressure on Indians, but for the programme to be truly effective, it needs to succeed in quickly improving primary care—a stated but less discussed aim. Without fortifying this layer of the health system, insurance will only send more people to the already stressed secondary and tertiary tier of healthcare.
Increasing public financing, putting better procurement procedures in place, and providing more insurance options can all help improve healthcare. But it isn’t enough. Healthcare can’t be tinkered with any more; it needs to be transformed. Education needs to be stepped up; regulation needs to be made more flexible. The healthcare sector needs to use existing resources more efficiently, and explore the potential of digitally-enabled systems to create new resources.
Roles need to be reimagined. Instead of relying predominantly on doctors, a separate cadre of health administrators could take on administrative tasks. Electronic medical records could be made available any time and any where to patients and their doctors—whether today, ten years later, or half a century later. A new force of lower-qualified workers (such as health assistants, especially for rural India) could build on the success of India’s community health worker model and deliver essential services cheaply in the most distant reaches of the country.
At the same time, a large swathe of currently informal roles, like Nikhil’s, can be brought into the formal fold: Their contribution acknowledged and documented with real-time record keeping; their capacity enhanced by establishing proper protocols and providing training; and their own income and job security improved by affiliation with a formal institution.
To do this, India’s health system must be fixed from the bottom up, and this must happen with the workers and resources it already has. What’s common to all the solutions mentioned above is innovative, advanced technology. The country simply cannot afford to wait for new doctors to turn up and fill its vacancies.
11
Bridging Access
If the healthcare needs of Indians, especially in rural India, are to be addressed reliably and effectively, trust and community are vital. This means healthcare close to home. That is where hurdles to access should be removed.
It is at the primary health centre itself that patients and providers are most familiar and comfortable with one another. They speak the same language, their concerns overlap.
With improvements in primary care, expenses will decline. Patients will no longer need to travel long distances and sacrifice earnings.
The benefits will trickle up.
If larger hospitals are not inundated with more patients than they can manage, the quality of service they can offer—as well as the experience of working in a hospital itself—will see dramatic improvements.
All these transformations will only happen with a new approach to healthcare. A health sector rife with scarcity at every level of expertise will not be able to see more patients and provide better care. It will not be able to address the access challenge to any significant degree, any time soon. India doesn’t just need more doctors, it needs a better-designed healthcare system that makes smarter use of clinically trained personnel.
Healthcare is just one of the innumerable areas where the access challenge rears its head. But it is an essential example to understand. It spans the many dimensions of struggle that translate into bleak statistics. The lack of skilled workers. The problems with quality. The breakdown of systems. The inordinate burdens placed on patients, and how their responses reinforce the status quo. The sheer frustration—on the part of both patient and provider—of living through the systemic deficits of access.
India’s access challenge has many faces and affects hundreds of millions. These themes play out in variations of degree and form across different sectors.
Education. The gap in the number of teachers is large, though not as problematic as that of doctors and nurses. Quality and consistency are the defining issues. So, too, are the pressures on their time, limiting their ability to train themselves, dedicate time for lesson planning, and provide students individual attention. Students suffer the consequences. India’s poor education outcomes are well-documented. Enrolment drops off from around 97 per cent in elementary
school to about 56 per cent in higher secondary school, and 25 per cent at university level. In rural India, a little over half the children enrolled in fifth grade can read a second-grade text, and less than 30 per cent in the third grade are able to do basic arithmetic like subtraction. The gap in grade-appropriate skills persists through school and college, and as they make their way into the workforce. 1
Logistics. Being a truck driver in India means long hours and distances traversed, with little by way of returns. Finding work can be a regular struggle, followed by weeks on end away from home, and a gruelling quality of life on the road. It is no wonder India has a reported 22 per cent shortage in commercial vehicle drivers. 2 It is typical, but misguided, to blame drivers for the delays, transit losses and goods damage that result in the high cost of moving goods in India. A systemic fix is needed. Micro, and small and medium businesses feel the logistics access gap the most. Farmers feel it as well, along with the larger agriculture networks located outside urban and peri-urban transport hubs.
Judiciary. The judicial system is no different from most other sectors when it comes to shortfalls of manpower and efficiency. There are more than 30 million cases pending before the different levels of India’s judiciary, while nearly a quarter of sanctioned judicial posts lie vacant. A time-use study of district courts in one of India’s states shows that as much as 30–50 per cent of judges’ time may be devoted to hearings that are primarily administrative or procedural in nature. Unsurprisingly, delays and deferments are rife. Delays in criminal matters disproportionately affect the poor, who are unable to afford bail. Delays in civil and commercial matters give rise to India’s rank of 163 out of 190 countries on the ‘enforcing contracts and efficiency of judicial system’ metric of the World Bank’s latest ease of doing business survey. 3
Part of the answer to the access challenge is making better use of the facilities India already has, in ways hitherto unexplored. Digital approaches can reimagine service delivery, and decentralized technologies can shorten the distance between people and systems. This is what Bridgital seeks to address.
The other part is about making better use of the human capital available to India. It demands a more thoughtful approach to our people and our potential. It is about designing diverse channels for people of different education and skills levels to move flexibly and match job opportunities. Here too, people need lower barriers to access. As the next chapter will show, the challenges that affect India don’t require a miracle to solve. The resources needed are abundant. They only need a conducive setting to flourish.
XX Factor—The Talent Dividend
12
An Unlikely Officer
Whenever Bathinda’s marital problems got out of hand, they became Jasleen Kaur’s problems. 1 Every morning, the women’s cell officer arrived at the police station and sat on the same swivel chair, the light from outside falling on her large wooden desk, in a room with iron and wood cabinets full of cases from all over town. They never stopped coming.
Among the files placed on her desk for her immediate attention was one such case—a woman whose businessman husband had tortured her for durable goods and furniture, and then tortured her some more for a car. The stories melted into each other. The Bathinda women’s cell that she was a part of had become involved in so many disputes that the godown they ran had no more room to store disputed dowry gifts. 2 Jasleen had come to believe that all this could be avoided if women were more educated.
In her early thirties, Jasleen was filled with notions of justice, but she knew that, sometimes, hashing out differences was better than the grind of the law. Nobody wanted that. She preferred to resolve cases outside the system, before they became cases, by taking everyone aside to have a quiet chat. This involved persuading husbands and in-laws to behave themselves and receive mandatory counselling. If the approach worked, wives returned home.
At other times, the patterns of behaviour Jasleen was called on to stop were simply too far gone, and she advised victims to pack up their things and leave. These were the extreme cases, where in-laws questioned a woman’s character and integrity, and the abuse was so intense that Jasleen had to step in to counsel the woman. Those cases went to court, requiring her to deal with gathering mountains of evidence, and shepherding everyone into court for hearings. The paperwork was a bother, and court took up a lot of time, but it was all preferable to dealing with dowry deaths. Those she really struggled with.
When they spoke about her, her colleagues could see only her calmness and composure. They praised her track record, which they all thought commendable. The sub-inspector had official admiration for her: ‘Jasleen not only tries to solve these cases without pushing the family into any legal problem, but also ensures that the victim is not harassed until a decision is taken on the matter.’ In turn, Jasleen was grateful for the support they gave her.
Technically speaking, Jasleen was an outlier, and that she had come far enough to a high-ranking position at the women’s cell at Bathinda was a matter of quiet pride. But the seeds of her success were sown before she was born, of this she was sure. Her father, a rural daily-wage worker, and her mother, Amanjot Kaur, were both convinced that their children had to receive an education. As a Dalit family, they had witnessed first-hand the caste discrimination that hobbles generations. Amanjot remembered days when there was little to eat because her husband’s earnings were spent on the children’s studies. ‘Being a Dalit with four children and no financial resources was a burden on my life,’ she said. Life only improved once her elder sons began to work.
When the 2011 census data was published, it showed that Giana, the village where Jasleen was born, had a literacy rate of about 57 per cent, well below the overall state literacy rate of 76 per cent. The literacy rate for women in Giana was even worse, because women simply did not complete their education.
It was clear, very early on, that Jasleen would chart a different path. Jasleen, her mother recalled, had a relentless curiosity beyond her textbooks. Her friends remembered her as one of the few students devoted to school. The government schools she attended were near the village, and they welcomed students of every caste. It was here that she began to dream of becoming a teacher.
In 2007, her father died. Immediately, Amanjot came under pressure to have Jasleen married. Jasleen wanted no part of it, but she also had very little say in the matter. Amanjot agreed to a proposal from a debt collection agent with a financial services firm, whose father was a retired driver from Punjab’s irrigation department. The marriage took place in 2008 in a gurudwara, with close family and friends in attendance. Jasleen was twenty-three. Weddings in Punjab are typically spectacular occasions, but this one was low-key. The families’ finances did not allow the slightest extravagance.
13
The Talent Dividend
A ten percentage point increase in India’s overall female labour participation ‘would surely be the easiest half-trillion-dollar boost available to the global economy.’
—The Economist (July 2018) 1
In India, a woman’s path from education to work is often permanently interrupted—by marriage, family wishes, children, societal pressures. Their absence comes at a cost. India has an enormous number of secondary-educated women who are inaccessible to the workforce.
This means the economy gets hit twice: first, just 33 per cent of all workers in India have a secondary (or above) education. 2 Second, millions of educated people remain outside of the workforce. Nearly 120 million women in India—more than double the entire population of South Korea—have at least a secondary education, but do not participate in the workforce.
For a country that needs millions of professionals urgently for vital skilled jobs, these millions of women provide a powerful answer. If even half of this group entered the workforce, the share of workers with at least a secondary education would jump from 33 per cent of the total workforce to 46 per cent—the equivalent of the last decade and a half’s worth of improvement in t
his metric. In one stroke, their engagement could add ₹31 trillion ($440 billion) to India’s GDP. 3
Indian women want to work. Three-quarters of teenage girls in a national survey of over 70,000 girls said they wanted a career after graduating, and expressed specific career aspirations. In a national survey in 2012, when researchers surveyed women engaged in domestic duties, almost one in three said they would accept paid work if a good opportunity arose. If every woman who said they would take up paid work ended up doing so, India’s workforce participation for women could touch nearly 80 per cent. 4
Despite the pressing case for women working, just 23 per cent of Indian working-age women are in the labour force. Among G20 states, India is second-to-last in terms of women’s participation, with Saudi Arabia alone ranking lower. India is not only well below its neighbours (roughly 80 per cent of Nepali women work), but also countries of similar income levels. 5
Women’s Labour Force Participation Noticeably Lags in India
Worryingly, trends show that women’s work participation in India is not only low, it’s falling. At a time when India’s economy reportedly grew over 7 per cent on average over the past decade, increased opportunities should have set the stage for a rise in women’s work. Instead, the opposite has happened: 19 million fewer women participated in paid work in 2017 than in 2011.
There are complex reasons for the steep decline. Some of them are good. As households have become wealthier, more women have been able to stay in school (this explains a third of the decline). Other trends are more disturbing. In agriculture, a large number of roles that have been mechanized since 2005 belonged to women. Of the jobs created by mechanization, 80 per cent were filled by men. In looking at all the jobs lost across the economy in 2018, the Centre for Monitoring Indian Economy posits that over three-quarters of the jobs lost were held by women. 6
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