Implementation of the Right to Education Act and the National Rural Health Mission should lead to better outcomes but we see the reverse
There is something ironic about politicians making announcements
about the Right to Education or the Right to Health when the only thing they
can ensure is allocation of funds. Their control over the usage of these funds
is somewhat weak; the overall quality of services is even weaker; their control
over actual health or educational outcomes is the weakest.
Looking at education and health behaviours and outcomes using
data from the India Human Development Survey (IHDS) of 2004-05 and 2011-12
paints a picture of striking dissonance between government programmes and
experiences at the ground level. The period between 2004-05 and 2011-12 saw
initiation of several new programmes. The Right to Education Act (RTE) was
implemented in 2010; the National Rural Health Mission (NRHM) began in 2005;
the Janani Suraksha Yojana (JSY) began in 2005, to be implemented alongside the
NRHM. Substantial expenditure was incurred in each of these centrally-sponsored
programmes. Below we look at changes in education and health to see how these
programmes line up with outcomes.
Privatisation
The implementation of the RTE should, in theory, lead to higher
enrolment in government schools and better educational outcomes. Ironically we
see the reverse. Private school enrolment increased from 28 to 35 per cent
between 2005 and 2012 for children of 6-14 years, even before poor students in
private schools were reimbursed. At the same time, in keeping with the findings
of various Annual Status of Education Report surveys, the IHDS also found a
small decline in reading and writing skills among children of 8-11 years. While
54 per cent of children could read a simple paragraph in 2005, there was a
modest decline to 52 per cent in 2012. A similar decline was observed for basic
arithmetic skills like two digit subtraction, from 48 per cent to 45 per cent.
For government schools the decline was higher — nearly 5 percentage points for
both outcomes, but a shift from government to slightly better performing
private schools limits the overall decline in skill levels.
This growing privatisation of education was matched by continued
and slightly increased privatisation of health care. The NRHM is supposed to
strengthen preventive and curative care, particularly in rural areas and in
States with poor health infrastructure such as Uttar Pradesh, Bihar, Rajasthan,
Madhya Pradesh. However, a very small proportion of the Indian population
relies on public facilities. About 70 per cent of patients visit private
providers — either as their first choice or once they are frustrated with
public services.
Between 2005 and 2012, years when the NRHM was implemented,
instead of increased usage of government services, we see a modest growth in
the use of private services for minor illnesses such as cough, cold and fever
(from 69 per cent to 73 per cent) as well as for treatment of major illnesses
like diabetes, cancer and heart problems (from 67 per cent to 72 per cent).
Ironically the greatest increase in the use of private services is in
high-focus large States like U.P., Bihar, Rajasthan, M.P. and Orissa. Here the
proportion of patients going to private providers increased by nearly 5 percentage
points.
The disenchantment of parents and patients with government
services is widespread. When asked in 2012 about their confidence in government
and private schools and medical facilities, 53 per cent of the respondents
expressed confidence in government schools compared to 72 per cent for private
schools. Similar differences are observed for confidence in government doctors
vis-à-vis private doctors. What explains this? There is no reason to believe
that private doctors and teachers are more qualified than government doctors
and teachers. Typically government recruitment standards are more stringent
about training and qualifications while there is little control over the
private sector. It is hard to imagine that anyone would prefer a self-styled
private “doctor” in a distant village to an MBBS doctor in a Primary Health
Centre (PHC). Yet, this is exactly what we see around us.
The reasons for these preferences are myriad. Parents and
patients feel disrespected by government service providers and may find they
get better service if they pay. For example, about 6 per cent of the patients
see a government doctor or nurse in their private practice rather than in the
government dispensary where the same services could be practically free.
Government facilities are often irregular in their opening times and teacher
and doctor absenteeism adds to the disenchantment. The classroom environment is
often not friendly and supportive. The IHDS finds that children are scolded and
physically punished in both government and private schools. Indeed, our
qualitative interviews suggest that parents consider this to be a sign that the
teachers care about students. But this scolding is not balanced by positive
reinforcement in government schools. Only about 33 per cent parents of
8-11-year-olds in government schools claim that their children received any
praise in the school in the prior month; this proportion is about 55 per cent
for private schools.
These observations reflect our pessimism about the potential for
improving government health and educational services, regardless of the
“rights” that get enshrined in the Constitution. Any service delivery system
that insists that a doctor live in a remote village is doomed to failure since
doctors must also think of their children’s education. But instead of focussing
mainly on village-based sub centres — which patients rarely seem to use —
enhancing PHCs which are located in slightly larger and perhaps better
connected towns may have a greater potential for improving the quality of
services. Thoughtful organisation of services has a far greater potential for
enhancing health and educational outcomes than ideologically influenced
discussions of rights.
Some good news
The success of the JSY in increasing hospital deliveries is
heartening. The years following the initiation of the JSY document a striking
increase in hospital deliveries. This increase is greatest in large focus
States. Here the hospital delivery rate has jumped from 25 per cent to 56 per
cent between 2005 and 2012. Most of this improvement is in government hospitals
— from 14 per cent to 40 per cent. This success may be due to the efforts made
by medical personnel in response to cash incentives they receive, and the fact
that hurdles to hospital delivery like transportation have received
consideration in programme design. Although the quality of maternity care
remains a concern, increasing utilisation certainly points to the success of
the programme. This suggests that focussing on smarter organisation of public services
that aligns with provider incentives, and enhances efficiency, offers
potential.
SOURCE: SONALDE DESAI, HINDU
No comments:
Post a Comment