Health and Education Consultations

New Delhi, 30 August 2007

Background

Investing in the health and education of citizens is basic to any human capital development and economic growth.   In India, the fiscal space and opportunity created by the current economic growth and a renewed political commitment has seen greater involvement of the government in these two vital sectors.   But serious challenges remain. Increase in life expectancy, reduction in infant mortality rates and progress in controlling communicable diseases have been some of the achievements in the past decades.  

In 2005, the Union Government launched the National Rural Health Mission.   A higher health budget and reorganisation of government departments at the national and state levels has infused a new energy in the health sector.   However, stark disparities in access to health in urban and rural areas, poor service delivery, and inequities between and within the states remain challenges.   At the same time, malnutrition, prevalence of HIV and a slowing down in the decline of infant and child mortality rates are jeopardising India’s chances of achieving the MDG targets for health.

The education sector faced challenges of inequality, lack of access, and poor quality of education services, despite basic education being recognised as a fundamental right.   To universalise primary education, the Union Government in collaboration with the states has implemented the Sarva Siksha Abhiyan (SSA).   A National Mission for Skills to increase the skilled workforce and a centrally-sponsored programme for upgrading Industrial Training Institutes are on the anvil.  

In keeping with its traditional portfolio of support to government programmes, the World Bank has committed over US $1 billion to the education sector, while in the health sector the commitment is over $2 billion.   This support is on IDA terms, with a 10-year grace period and a 35-year repayment period at less than 1 per cent per annum interest.

Fourteen members from civil society groups participated in the dialogue on this subject(Agenda and List of Participants). The session was opened with a brief presentation by Bank specialists on Health and Education (Part 1 and Part 2). This open house discussion were followed up with break-out sessions and groups came up with series of recommendations. Ms. Isabel M. Guerrero, the World Bank's Country Director for India closed the session.   The following is brief summary of the consultation:  

Key Issues and Suggestions

Political commitment: The participants recognised that there is high political commitment at the National level to improve educational and health facilities and provide quality services to people.   However, at the state level there is distinct deviation from this national agenda.   Increased growth has led to increased investments in these sectors but to translate the investments into advances for the poor remains a big challenge.   The disparities in access to health care and education services between rich and the poor, rural and urban, as well as among and within states are significant and needs urgent attention.

The 11^th Plan estimated that there are around 35 million children who are ‘at risk’, ‘displaced’ or ‘missing’.   The plan document has emphasised that programmes and initiatives must work on “protection of the child” and guarantee all rights to the children of India.   The CSO members added that there is a lack of systematic and comprehensive mapping of children in need of care and protection and moreover, there are practically no services available for them at the district, sub-district and village levels.   The health sector    should be understood as an investment rather than expenditure as currently being recognised. Restricting universalization to primary education defeats the purpose of overall growth and development of human resource. Rather compulsory education should cover the entire schooling.

Governance: Members strongly recognised that accountability is the weakest link in the entire chain of delivery of services in both these sectors.   Extremism is at its peak in the ‘Red Districts’ i.e. central India and part of North East and are largely inhabited by tribal population.   These areas are excluded from most of the basic services including health and education.   The existing infrastructure facilities in many cases are being used by the para-military forces thereby denying children access to education.

There is an inherent systemic and structural weakness such as inadequate planning, lack of management and monitoring of services, and inadequate systems to enforce accountability and assure quality.   It was felt that even CSOs functioned in “comfort zones” where the same beneficiaries were targeted repeatedly through multiple projects and schemes.   There was a need to come out of these “comfort zones’ and work in the remote areas and ‘Red Districts’.

People are largely dependent on the private sector for services, over 80% of the population access private health care services and education is growing outside the government systems and poor are unable to access such facilities as the services are priced and most often are not affordable for the poor. But the government has done very little to regulate the private sector and enforce existing regulations.  

In most cases, projects and programmes were thrust on the people without taking their needs and aspirations into account.   Participants repeatedly emphasized the need to engage with decentralized democratic institutions for better service delivery in both sectors.   Resources need to be directed towards capacity building of the Panchayati Raj Institutions (PRIs).   Participants said there was a need to empower these institutions and facilitate a process to ensure their accountability.

Flow of Information: Communication is a two-way process and the goals and vision of any mission.   The government and policy makers have knowledge and information, but they do not share with the people so the flow of information is blocked.   People who are the real clients understand their needs and need to have full information and be involved in developing programmes and projects which are tailored to address these needs.    

Participants suggested setting up resource centres using simple technology such as wall computers.   Forums and mechanisms for periodic sharing, monthly or quarterly reviews and measurement of successes were other means to improve communications.   Forms of communication could be standardized for all schemes, programmes and projects.

Government managed Civil Society: Members of CSOs felt projects which should be implemented by them were being hijacked by Government operated non-government organisations (GONGOs).   The stipulation by the World Bank to set up systems to implement projects and programmes had led to creation of these parallel structures, which were managed by bureaucrats and had only a token presence of independent, outside workers.   On the ground, they functioned like any other government department.   

The GONGOs need to be done away with completely, while CSOs genuinely involved with the community at the grassroots need to be revitalised and their efforts supported.   There were numerous projects that could be up-scaled through resources and capacity building.   There were, for instance, CSOs in the remote areas of North-East who were so effective that the state administration had entrusted them with the responsibility of running all the primary health centres.   

Funding: Traditional medicine systems in India stressed prevention and promotion but were overlooked when it came to substantial funding.   The credibility of practitioners of these systems was questioned and they were asked to provide proof of efficacy. Participants called upon the Bank to fund research in alternative medicines.   It was felt by the participants that policy planners must create maps denoting these as “red areas”, evaluate the existing infrastructure and direct resources and funds here.   Programmes and projects specially directed towards children in difficult circumstances need to be encouraged.   It was also pointed out that although there was international cooperation on research in health care and medicines, there was very little by way of South-South cooperation.   The Bank could encourage this through adequate support.

Roles of Government,  World Bank, CSOs & Private Sector: The Government, participants felt, had an overarching role to ensure that citizens enjoyed their rights.   It could provide legitimacy to any effort and has the responsibility to deliver to the last, for it alone has the requisite resources and organizational structure.

The World Bank, the participants said, had significant influence with the Government and therefore, could affect policies.   The Bank could use its influence to affect suitable policy changes.   Since the World Bank perceived itself not merely as a lending body but as an organization working for development, it must ensure that the funds reaches the intended beneficiaries.   It could build pressure for good governance through decentralised democratic institutions, promote evidence-based planning, and ensure that monitoring and evaluating processes were in place when a project was planned.

The World Bank must fund innovations and research and invest in skill-building capacities that go beyond training of trainers.   There is an urgent need to develop human resources.   In addition, the World Bank must restructure its own bureaucracy that often comes in the way of reacting quickly.   CSOs need to remember their role as watchdogs, conscience keepers and facilitators.   They must come up with innovative solutions, create models and support structures to the state.   Working at the grassroots, they were the best vehicles to bring a cultural and contextual role to all processes.

The private sector, participants said, could bring in resources by way of tools, techniques and management skills; carry out innovative pilots and; be involved in the actual delivery of services at a small scale.   

Recommendations

• It was suggested that a “feedback loop” be established by which the Bank could learn how bank supported projects were implemented to achieve better outcomes. At regular intervals, meetings with key CSO members could be organised to share results and views.
  
• The new country strategy should consider the suggestions on reaching difficult areas and ‘Red Districts’, marginalised societies, and especially children in difficult circumstances.
   
• Expressing satisfaction at the level of interaction, the World Bank would need to introspect, acknowledge and correct the faults within its own system to establish a better image.
  
• The World Bank should works towards strengthening decentralized institutions to improve service delivery at all levels.
  
• Improving flow of information is an area which should be given priority