Neglect of Primary Health Care and Education in India Is a Reason for Its Backwardness

The Annual Status of Education Report published by the NGO Pratham in January 2019 surveyed about half a million rural children across India. It found that among rural children in the fifth grade, fewer than half could read a text meant for the second grade, and barely a quarter could do a simple division sum. The children were in school, but they were not learning. In the same years, a study by the Public Health Foundation of India estimated that medical expenses push around fifty five million Indians into poverty each year, because the public system is too weak to protect them. The topic claims that neglect of primary health care and education is a reason for India's backwardness, and these figures give the claim force.

The economic argument is well established. Education and health are not only goods in themselves but forms of capital. A healthy, literate worker produces more, learns faster and adapts more easily to new technologies. The East Asian economies of South Korea, Taiwan and Singapore invested heavily in universal primary schooling and basic health before their growth took off, and when factories came, they found a workforce ready for them. Amartya Sen has compared India with China at the time of their reforms, noting that China started from a higher base of literacy and public health, which allowed it to take better advantage of markets.

Evidence from within India supports the point. Kerala, with modest income, put early emphasis on schools and primary health care, helped by missionary education, princely state reforms and later political mobilisation. It achieved a literacy rate above ninety per cent, an infant mortality rate comparable to those of some developed countries and a life expectancy well above the national average. Himachal Pradesh and Tamil Nadu, which also invested in schools and clinics, similarly show better human outcomes than richer states that neglected them.

The scale of the shortfall is large. India's public spending on health has hovered around one to one and a half per cent of gross domestic product, among the lowest of major economies, and the National Health Policy of 2017 set the target of two and a half per cent by 2025. More than half of health spending is paid out of pocket by families. Public spending on education has remained at about three to four per cent of gross domestic product, short of the six per cent recommended by the Kothari Commission as far back as 1966. Primary health centres in many districts lack doctors, and schools lack teachers or toilets.

Primary health centres in many districts lack doctors, and schools lack teachers or toilets.

The consequences are visible in the figures that define backwardness. More than a third of Indian children under five are stunted, according to the National Family Health Survey of 2015 and 2016, a condition that harms brain development and later earnings. Maternal and infant mortality remain higher than in many countries with similar incomes. Poor learning in the early grades compounds as children advance, so that many who finish school lack the skills for jobs, and employers complain of a shortage of employable workers even as millions of young people are unemployed. The nation's demographic dividend, the large population of working age, risks becoming a burden.

Inequality follows. Rich families buy private health care and send their children to private schools, while the poor depend on a weak public system, and the gap in opportunity grows from the cradle. Girls, rural children and those from Dalit and tribal communities fare worst. A child born into poverty and attending a poor school is unlikely to escape, and so poverty is passed from one generation to the next. This is why neglect of basic services is not merely a cause of backwardness but also a mechanism by which it is perpetuated.

The government has not been inactive. The Right to Education Act of 2009 guaranteed free and compulsory schooling for children aged six to fourteen, the mid day meal scheme feeds more than a hundred million children, and the National Rural Health Mission, begun in 2005, trained community health workers and raised institutional deliveries. In 2018 the government announced Ayushman Bharat, a scheme for health insurance for the poor and for health and wellness centres at the village level. These efforts have produced gains, such as higher enrolment and lower maternal mortality, but the quality of what is delivered remains a concern.

The topic needs one important qualification. Neglect is not only a matter of the amount of money. A study by Michael Kremer and colleagues in the early 2000s found that about a quarter of primary school teachers in India were absent on a given day, and only about half of those present were teaching. Health workers too are often absent. The failure lies in accountability, in management and in the incentives of public employees. Increasing budgets without fixing delivery may produce more buildings without more learning. The problem is partly one of governance, and no budget line can substitute for a teacher who turns up and a nurse who stays.

It is also a problem of politics. Citizens vote on caste, religion and promises of subsidies, and health and school quality rarely decide elections. The poor, who most need public services, have the least voice in demanding them. Reform therefore needs both resources and pressure, from parents' committees, from local governments with real powers and from a press that makes failure visible. Where this has happened, as in Himachal Pradesh and parts of Tamil Nadu, services have improved. Where it has not, they have decayed.

The topic speaks of backwardness, which is itself a contested word. A country may be advanced in space missions and software and still be backward in the capacity of its ordinary citizens to read, to be healthy and to live without dread of a medical bill. If backwardness means the condition of the least advantaged, then the neglect of primary health and education is not merely a reason for it. In the end it may be the thing itself, a nation measured by what it has done for the children at the back of the class.