We have a dysfunctional healthcare system: Amartya Sen
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New Delhi: Amartya Sen, winner of the 1998 Nobel Prize in economics, says China outperforms India in providing access to healthcare and education. In New Delhi for the relaunch of his 1970 book, Collective Choice and Social Welfare, the 83-year-old also spoke in an interview about inequality in India, which he described as particularly vicious because it involves a lack of healthcare and education for a lot of people, and why these issues never translate into big political issues in India. Edited excerpts:
Your book, the new edition of Collective Choice and Social Welfare, has come out. How does it relate to India of today?
The book is not about India but it has implications for India as it has for the United States and Europe. In the book, I discuss the importance of public reasoning and why democracy is not just a matter of votes, but also of people arguing with each other. Some of these issues which I discuss in the book apply critically to India. The space for public reasoning has tended to shrink a lot in India. I also discuss the importance of understanding that majority rule is not the same thing as plurality rule (the government has a plurality—nowhere near a majority). Perhaps even more importantly, we must not forget that citizens are not just voters but (are) also participants in public discussion, and anything that shrinks the space for public discussion takes the society away from democratic rule.
Is the space for public argument shrinking in India?
The space for public reasoning is still considerable in India but it has shrunk compared to what it was earlier. There has been a number of new things that did not exist earlier, like charging people with sedition—essentially for having a view different from that of the government. That could be quite scary for people, especially if students are charged and arrested. This could have a stifling effect on public discussion. This is a new phenomenon, and so is branding people as anti-national. This could be bad even if the government had an overwhelming majority, but it is terrible when the government doesn’t even have a majority. The ruling party had support from 31% of the voters, and even with its coalition partners, only 39%. That is fair enough for being in charge of governance with a parliamentary majority, but for these minority rulers to describe a point of view different from theirs as “anti-national” involves a level of arrogance that is absolutely breathtaking.
Making political arguments is more dangerous now than it used to be because of charges of being “anti-national” (accompanied often enough with a case of “sedition”), with orchestrated harassment and sometimes with the arrest of those thus charged.
There is also a confusion between the government and the state, which the government has tended to promote. The government does many things on behalf of the state, including giving money to the universities. That doesn’t mean the government should dictate how universities should be run or make the crucial appointments. Academic autonomy is critically important for the advancement of educational quality and originality, and for the emergence and flourishing of a great academic institution. If Europe and America followed that confusion we would not have the great educational institutions which developed there and of which India has none. The problem is not just with the present government, but they have been more repressive and more hostile to academic autonomy.
How do you think India has addressed the challenge of inequality?
Inequality in India has been particularly vicious in terms of lack of healthcare and education for a lot of people. In my judgement, this is a much bigger problem than what is shown by some of the traditional measures of inequality, including inequality of income. Some people not having the opportunity of going anywhere, even for elementary medical treatment (or for basic preventive care), or being able to send their children to a decent school is an enormous deprivation of the possibility of living as citizens of a modern country. If you compare India and China, inequality of income is not dissimilar but China scores enormously over India in giving access to all to healthcare and school education.
But education and healthcare never translate into big political issues in India.
It is precisely because it does not become an issue in the Indian elections that the problem survives. That is a failure of political parties, not just the ruling party but also the opposition—the inability to capture the big reality of unequal India and instead replacing it with the smaller realities, which also exist, like battles between castes.
The current government, rather than moving in the direction of correcting the bias, has moved away further from giving elementary healthcare and education to all. Money spent on public healthcare and education has gone down and the expansion has been for specialized healthcare. That helps only if you survive your childhood, and could be valuable only to the extent basic healthcare is looked after first. For that, we need most urgently a reform that provides public healthcare at the primary level for all. India has come to rely on private healthcare even at the elementary level in a way no other country does, not even the United States. India has left it largely to the private practitioners, some of whom don’t even know much medicine, and all of them know how to charge money. I think we have a most dysfunctional healthcare system.
What is your take on the demonetisation exercise, will it root out corruption and bring more transparency?
It would be amazing if it could come even close to capturing all the black money. Only 6-7% of black money is held in cash. Even if it is completely successful, it will make a relatively small difference to corruption. And taking these draconian steps without doing anything about illegal foreign holdings, as was promised by Mr Modi earlier, seems an odd approach to battling corruption. Mr Modi had told us earlier on that every Indian citizen will get some money from the captured illegal foreign holdings. People are still waiting for that money, which hasn’t come. Similarly a lot of black money is held in the form of jewellery and other assets. The big steps needed for removing — or even restraining—corruption were not taken, and the chances of doing much about corruption through demonetisation was very limited.
The other objective of demonetisation, which the government revealed gradually, is to make a sudden jump towards a cashless society possible. That may or may not have some merit but you can’t get there so quickly because a lot of people simply are not able to use electronic transactions. There is nowhere near an adequate supporting infrastructure. We are also dealing with a country where a quarter of the population is still illiterate. It really is an enormous hardship to impose on people. Those who have argued for a cashless society, like my colleague Professor Kenneth Rogoff, suggested doing it over many years, making sure everyone developed the skill to use electronic transactions and having an adequate infrastructure.The economy may well be hit, and it has to some extent, but I worry much more that the people who are losing out—whose losses are only a part of the inanimate numbers of GDP (gross domestic product)—are often the worst off people. The overall shock to the GDP underestimates the hardships caused to the economy because it is falling on people who are least able to take it.
Do you see the emergence of Donald Trump as a disrupting factor in the world economy?
It is not so much disruption. I think he has a fundamentally different understanding of the needs of the world economy as well as of the American society, He does not seem to see global trade as a good thing. But clearly, global trade is a good thing and closer relationship between people has the effect of helping each other. Given that, I cannot enthuse about his wanting to move towards a protectionist society, penalizing industrialists for making goods elsewhere where labour might be cheaper (and wanting instead everything to be done in America). That does not seem good for the global economy and ultimately it is not good even for the people who might be artificially supported in America through these means, because technology in the world is changing, the workplace is changing, and you can defy that for a while but ultimately you have to adjust. So, I do not agree with him on economic policy, and I don’t agree with him on the view that getting rid of immigrants without proper papers is the way to recapture the former greatness of America. America has prospered always on the basis of people living in America. Lots of people came from Germany in the 1930s, and from elsewhere in Europe, and later on too. The entire approach of making a sharp distinction between “we”, as opposed to “they”, is a way of getting rid of what has tended to make America so successful—the ability to absorb people from anywhere—something (which) Europe has found much harder to do for quite some time now. And Trump’s idea of targeting Muslims as a group is, of course, altogether terrible.