In the 1980s, when India was beginning to stir out of relative economic stagnation, the curmudgeonly ex-colonial writer V.S. Naipaul made another visit to the country and wrote his third book on the topic. Unlike his previous two efforts, in this case he was able to find some reasons for hope: He found energy and experimentation where he had not before. Unfortunately, his own demons could only allow him to see what was happening in India through a colonial lens, and he titled his work A Million Mutinies Now, evoking the Indian rebellion of 1857 against the British.
Despite his inapt metaphor, Naipaul was right in detecting a sea change in India. The process has been cumulative, in fits and starts, as growth and openness have begun to create a different dynamic in Indian society and governance institutions. It has not just been liberalization, though that was the catalyst for so much of what has happened subsequently. Greater decentralization, both to states and new local governments, has been an enormous new development that will continue to reshape the nation. Rapid growth has also helped create a sense of possibilities, as well as generating more resources for tackling India’s challenges.
Faster growth, increasing inequality and greater political competition together created an urgency with respect to addressing citizens’ basic needs, in areas such as income security, education and health. Various new welfare schemes have been introduced, perhaps still subject to some of the old problems of leakage and waste, but often with creative new features, and with an ambitious new scope. The National Rural Health Mission (NRHM) is a prime example of the new approach. In a recent column (“Women and children first”, 21 September), I had noted the sprawling nature of NRHM, and a concern that it might be stretching efforts too thin. That is certainly an issue, but after having talked with a range of practitioners in India, I can see the energy and excitement that NRHM has generated.
There are certainly benefits to a comprehensive view of healthcare, as provided by NRHM. First, it allows policymakers and practitioners alike to understand the scale and scope of the challenges. One thing that has emerged from my conversations is the poor use of information in the health sector, even when it is available. Generating more complete, more usable data is an important step forward. Second, there are benefits to coordination across different components of healthcare. It is still not clear to me what the optimal mix of focus and breadth is in healthcare delivery, and it probably varies by place and other specific circumstances. Third, even without benefits of joint delivery of services, a sectoral approach allows for better cost-benefit analysis and prioritization. Some of this prioritization is taking place.
I also have a sense that the commitment of funds is creating a change in attitudes, signalling the importance of the issue to those within government as well as to their constituents. NRHM seems to provide a focal point for foreign aid efforts as well, since health is an easy area for conscience money to be given. Certainly, more money does not guarantee better outcomes, but I have been struck by the resultant real effort being generated to try to make sure the money is spent well. States are beginning to understand that money through NRHM can be used to make a difference to their constituents. They are seeking and getting technical assistance for capacity building, to create the organizational structures that can deliver health services and improve outcomes.
There is also a new openness to the private sector, at least partly a result of the change in attitudes that accompanies more conventional economic liberalization. The public-private engagement does not come without tensions. The public side is suspicious of private motives, as well as being concerned with its own image and role as provider for citizens (however much it has stumbled in that role in the past). The private side struggles with corruption and inefficiency when it interacts with the public sector. Nevertheless, considerable learning and experimentation is taking place in creating and managing public-private interfaces and collaborations.
Finally, NRHM is creating a new space for discourse, I believe. One thing I have been reminded of is the complexity of the Indian institutional landscape, far beyond what is captured in “public” and “private”. Each of these sides covers a wide range of stakeholders, who need to be engaged and to participate in constructive ways. If this process of engagement expands, we would have a million missions, together moving things forward. Perhaps healthcare quality could become as important as consumer goods and cricket in the minds of people, something to be desired, discussed and demanded.
Nirvikar Singh is professor of economics at the University of California, Santa Cruz. Your comments are welcome at firstname.lastname@example.org