February 25, 2014 — Professor Harsh Mander, Director of the Centre for Equity Studies in India and Special Commissioner to the Supreme Court of India for the Right to Food, visited the FXB Center last week to deliver a talk entitled, “Inequality and Indifference: Challenges of Designing Public Health for the Urban Poor in India.” Professor Mander is chair of the Indian government’s committee on the design of public health services for the urban poor, which will soon release a report that includes recommendations for improving the health status of the urban poor in India. Click here for his bio.
Below is an excerpt from our Q&A with Professor Mander.
FXB: What is the context for this report on the delivery of public health services to the urban poor?
HM: I think the largest context is of an extraordinary gap in public health services in India generally. We spend approximately 4% of GDP on health, of which about two thirds is actually private expenditure out of pocket. So public health expenditure is close to 1%. This should be close to 6% ideally. What that means on the ground is that illness is an extraordinary catastrophe for the poor and it’s a major cause of impoverishment. I also work on the right to food and I study people in starvation and starvation deaths, and there again you find that health emergencies are the principal reason for people slipping not just into poverty but from poverty into destitution. Within that, the urban neglect is actually in some ways more profound … At a superficial level one would imagine that providing health public services in a city would be much easier, but the experience has been quite the reverse.
In recognition of this [public health services] gap, the government constituted a National Rural Health Mission. The government only recently talked about a National Urban Health Mission. [This model is] unusual because it suggests offering universal public health in cities with a focus on primary health care for the urban poor.
FXB: Did the National Rural Health Mission pave the way for the National Urban Health Mission?
HM: The most significant thing the National Rural Health Mission did was to create a nation-wide cadre of community health workers who were equipped with basic skills around preventative and emotional health. That foundation for the first time allowed people to take some control over their problems … It strengthened community health outreach and then primary care services in rural areas. It has been one of the best things that the government has done for the poor. That did pave the way.
The government set up this committee, which I was asked to chair, with the mandate of suggesting what kind of design one should have of public health services, primarily health services, which work for the urban poor. I was delighted for many reasons that they even asked this question. Traditionally the government’s attitude [toward the poor] has been [that they are] dealing with a set of people without rights – an implied hierarchy of citizenship in which [the poor] are seen as illegitimate citizens. And the state has not had positive duties toward them but only negative duties against them – to block, to demolish. This is the first time that the government was clearly saying that this is a huge population which is unreached and lives in extraordinary distress and we don’t know how to do it.
The fact that there’s virtually no public health services at present is a huge problem but also an opportunity. It’s much harder to demolish an established structure and rebuild – this is a substantial opportunity to build afresh, and this comes once in a rare time in public policy. I felt that if we got this right in some basic ways, we could perhaps lay a foundation which cumulatively would be equitable and passionate.
FXB: What is the road toward implementation?
HM: I take solace in a Buddhist proverb that says: “Better than running and leaps in bounds in the wrong direction is to be at least facing the right direction.” If our report even helps us face in the right direction but we don’t run in leaps and bounds, that might be some kind of service.
The last ten years of our history have seen a paradoxical movement in two different directions simultaneously. It has been a time of rapid economic growth, but simultaneously India has taken the lead in the past ten years of rights-based legislation which has been quite profound in the imagination of the good state in a sense.
There can be a lot of legitimate contestation of why this rights-based legislation has arisen and what role it will actually play, but I believe that in a country that is extremely unequal and in which markets are the primary instrument of change, millions of our people are being left further behind.
FXB: How should this inequality be addressed?
HM: Change will never happen until the poor are able to organize and assert and society must preserve spaces for non-violent dissent.
But at the same time, I do believe that the struggle is to build greater public compassion in public life. There is a much greater normative acceptance of not just the inevitability but even the legitimacy of one set of people having unprecedented levels of wealth and another set living most unacceptably deprived lives. [A study was done calculating] … how many people die in India every year from purely avoidable causes. About two million people die every year. That is like an ongoing holocaust, really. The fact that it happens and is not an issue troubles me profoundly. I feel that there is in a sense a normalization of poverty, like we have hills and mountains and rivers and poor people – they were always there. Not recognizing that poverty is something that is done to people. This is less and less acceptable in a context when we have the means in every way to prevent that.
Poverty is so dramatically manifest in places where the middle class live but our ability to see and turn our faces away worries me. I have always made claims when I see injustice from the state, but I increasingly feel that we have to make demands from ourselves. A just and caring state can only be located in a just and caring society.