Neera Chandhoke
INTRODUCTION
What is the relationship between democracy and the well-being of citizens? There are two sorts of answers that we can offer in response to this question. First, people are not themselves responsible for poverty, illiteracy, or ill health that afflicts them. The causes of ill-being lie outside the control of the victims. For example, due to the distorted pattern of resource distribution, some people have more land, some have no land, and some have command over their incomes such as wages or rents, while others have nothing except their labour power. If the social distribution of resources is responsible for the ill-being of citizens, then society, or more precisely, the democratic State, which is the political organization of that society, has the responsibility to prevent this through the enactment of social policies. To put it strongly, a democratic state has reason to exist because it is charged with securing the well-being of the citizens. After all, citizens elect representatives on the assumption that the representative will take care of the needs and interests of his or her constituent. This is the bare minimum that a democratic state can do for its citizens. This is the minimum we expect of a
democracy.
Citizens should not suffer from ill-being such as illiteracy, ill health, homelessness or poverty, for another reason. Democracy is based on two main principles. The first principle is the participation of citizens in the political process. Citizens participate in the political process not only by voting in elections, but also by taking part in public debates, e.g., contributing to readers’ columns in
newspapers, taking part in demonstrations, campaigns, and social movements, or simply by being informed and aware of the crucial issues that confront the polity, so that they can vote for the best person when the next election comes around. The second principle of democracy is that of State accountability to the citizens. Both these principles can only be realized when the citizens are informed and aware of the basic issues that confront society.
But citizens can only be informed and aware when they are provided with education, healthcare, shelter and when they have an income; in short, when they do not suffer from any serious harm. Any citizen who has been deprived of education, or suffers from malnourishment, will neither be able to participate in the political process, nor be able to hold State officials accountable. This is not to say that non-literate persons cannot be democratic. The issue is deeper; that the realization of full
democracy demands an educated, informed, and politically aware citizenry, and that ill-health and non-literacy can impede the democratic process. In other words, basic needs for education and health have to be met before people can do anything else. Unless these needs are met, human beings will not be able to do anything else—take up a satisfying job, form enriching friendships, engage in leisure
activities or, indeed, participate in an activity that the Greeks called politics.1
Basic needs can be met in two ways. For that section of the population that can afford to buy services such as education and health, the provisioning of basic needs can be routed through the
market. But the market is indifferent to the needs of those who cannot buy goods offered in the market.
For the poorer sections of the people, therefore, democratic governments are obliged to provide basic needs irrespective of the ability of the poor to pay for these goods. To phrase it starkly, the goods that satisfy basic needs—education and health—are of such overriding importance that they have to be placed outside the realm of market transactions for those who cannot pay for them, through the enactment of a social policy. Social policy subsidizes food, housing, education and health, so that the poor can afford these goods.
There are, therefore, two main reasons why a democratic State should secure the well-being for its citizens through the fulfilment of basic needs. First, it is not the victim of ill-being who is responsible for her or his State, but society which, through the unjust distribution of resources, renders some people harm. A democratic State, which is responsible for its citizens, has to remedy this harm through the provision of goods to meet basic needs on non-market principles. Second, the realization of democracy demands an informed, educated, politically aware, and healthy citizenry so that citizens can participate in the making of political decisions, and can ensure accountability of the State
officials. If people are poor, without shelter, sick, or non-literate, the concept of democracy is left unrealized.
However, the relationship between democracy and well-being is not a causal or a straightforward one; political democracy need not always lead to social and economic democracy. On the other hand, political democracy can coexist quite happily with extreme poverty, illiteracy and ill health. Consider the case of India. The country has held regular, and free and fair elections,2 institutionalized a
competitive party system, established a functioning rule of law, granted legal sanction to political and civil rights, and established a free press, all of which have led to a vibrant and active civil society.
India, without any reservation, can be called a political democracy. A majority of the people, however, continue to suffer from harm, with the most vulnerable among them— the poor among the Scheduled Castes and Tribes, hill people, forest dwellers, tribals, and women, particularly the girl child—at tremendous risk in matters of both lives and livelihoods.
It is true that we have seen an improvement in the basic parameters of human development.
According to the approach paper to the Eleventh Five- Year Plan, the literacy rate for the population above the age of seven is 75.3 per cent for males, and 53.7 per cent for women. In 1990, the
corresponding figures were 64.1 per cent for males and 39.3 per cent for females. The infant-mortality rate per thousand live births is 60 according to 2003 figures, compared with 80 around 1990.3 Yet, this progress is unevenly spread across the population—across income groups, castes and religious minorities, and gender and regions. This has led to large disparities in health, nutrition, education, and skills. Kerala, for instance, has a literacy rate of 92 per cent, which is comparable to that of Vietnam; but Bihar continues to have a literacy rate of only 47.5 per cent. Also striking are urban-rural disparities, whereas the literacy rate in urban areas is 80.30 per cent, the corresponding literacy rate for rural areas is only 59.40 per cent. ‘The most important challenge’, states the
approach paper, ‘is how to provide essential public services such as education and health to large parts of our population who are denied these services at present. Education is the critical factor that will empower the poor to participate in the growth process’.4
The coexistence of political and civil freedom alongside social and economic unfreedom is cause for some regret. For the leaders of the freedom movement, the task of attaining political freedom had to be accompanied by social and economic freedom, and vice versa. The leadership had, for that reason, conceptualized an integrated agenda of political, civil, social, cultural, and economic rights in the 1928 Nehru Constitutional Draft5 and in the Karachi Resolution on Fundamental Rights adopted by the Indian National Congress in 1931. This integrated agenda was, however, split into its two constituent units in the Constituent Assembly. Whereas political, civil, and cultural rights in Chapter Three of the Constitution are backed by legal sanction; social and economic rights, which are placed in Chapter Four of the Constitution under the title of Directive Principles of State Policy, are not backed by such sanction. The opening clause of the report of the sub-committee on fundamental rights clearly stated that ‘[w]hile these principles shall not be cognizable by any court, they are nevertheless fundamental in the governance of the country and their application in the making of laws shall be the duty of the State’.6 Dr Ambedkar, the president of the Constituent Assembly, assured members that though the principles were not legally binding:
whoever captures power will not be free to do what he likes with it. In the exercise of it, he will have to respect these instruments of instructions, which are called Directive Principles. He cannot ignore them. He may not have to answer for their breach in a court of law. But he will certainly have to answer for them before the electorate at election time.7
The legal historian Granville Austin argues that though Directive Principles of State Policy are not justiciable, ‘they have become the yardstick for the measurement of government’s successes and failures in social policy’.8 However, the downgrading of social and economic rights to the status of mere objectives, and what one member of the Constituent Assembly was to term pious wishes’ has had expected consequences. Whereas political and civil rights have functioned in some cases fairly effectively as a constraint on State power, social and economic rights have just not been treated with the seriousness that these deserve. Drèze and Sen point out that even though ‘the expansion of social opportunities was very much the central theme in the vision that the leaders of the Indian
Independence movement had presented to the country at the time the British left, rather little attempt has, in fact, been made to turn that vision into any kind of reality’.9
It is not as if policies have not been designed to implement these objectives, and it is not as if programmes have not been initiated for provision of social goods to the needy section of the people.
But when it comes to the implementation of these policies, the necessary political will vanishes, perhaps because no one can take the government to court for a violation of the Directive Principles.
Either social policies have not been accompanied by necessary financial outlays, or both have been provided for and the policy itself not implemented. Even if policies have been implemented, the process is attended by massive instances of corruption and mismanagement. Moreover, though the provision of social goods falls more or less within the provenance of state governments, the Planning Commission through the five-year plans determines strategy, priority, and allocation of resources.
However, the conceptualization of planning, as Prabhu and Sudarshan argue, is not embedded within
a ‘redistributive ethos’. Therefore, ‘the distribution of benefits of economic growth has not been egalitarian. Social-sector policy, which could have acted as a redistributive measure, did not don this mantle. Further, the very approach of the State towards social sectors has been ambivalent. They have been considered either as constituting welfare, or as a means of enhancing human capital’.10
In sum, social policy in India has proved far too inadequate when it comes to addressing the challenges confronting the nation. Though Chapter Four of the Constitution lays down directives for social policy, successive central and state governments just do not seem to have taken this charge seriously enough. For instance, according to one of the main Directive Principles, the State is obliged to ensure that health care is provided to all, that maternity relief is available to women, that levels of nutrition are raised, and that free and compulsory education is provided to all children till the age of 14. Yet, as the discussion below shows, the record of the government in these two areas, which are crucial for human well-being, is not too good.
Health
Between June and July 2004, 11 children in the age group of 0–5 died in the Dongiriguda Adivasi (forest dwellers) settlement located in the Jharigaon block of Nawrangpur district in Orissa. Other children living in the block were being treated for similar symptoms, and reports stated that the understaffed and ill-equipped Community Health Centre at Jharigaon was admitting about 40 ailing children per day. The proximate causes of death of these children were diarrhoea, acute respiratory infection and fever. The generic cause for these deaths, however, was malnutrition, which has been identified as the biggest cause of infant mortality in this district—as high as 97 deaths per 1000 live births. Since the Dongiriguda forest hamlet is a village existing within reserve forests, none of the below-poverty-line (BPL) families possesses a ration card, which would entitle them to buy rice at a subsidized rate. The only benefit that the village receives is under the Integrated Child
Development Programme. It is not surprising that when their meagre supplies of food ran out during the monsoon, villagers were forced to survive on mango kernel, wild mushroom, tubers and leaves.
Except for the fact that a health worker distributes free medicines once a month, the villagers are not entitled to any medical facilities.11
The tragic incident foregrounds the main problem with the public health policy adopted by the Government of India: the thrust of the policy is curative rather than preventive. A preventive health policy would provide nutrition, safe drinking water, sanitation, hygiene, and education as essential preconditions of health. It would also demand the institutionalization of an extensive public health system: immunization programmes, clinics and community health centres staffed by trained medical personnel and para-health workers. All this requires a great deal of public investment. Yet, according to the latest Reserve Bank report on State finances, expenditure on the social sector, and health and education in particular continues to be appallingly inadequate. The Eleventh Plan draft focuses on these sectors and has earmarked substantial increases in outlays for health. Apart from the National Rural Health Mission, government spending on health is aimed at 2 per cent of the GDP by the plan end.12 This is a figure that is far lower than other developing countries. Cuba spends 6.2 per cent and
Namibia 4.7 per cent of their respective GDPs on health. In India, health is a state subject and states are expected to contribute to a major part of the finances allotted to the sector, but the budgetary allocation of state governments has shown a consistent decline over the years.
The general neglect of preventive healthcare and the increasing push towards the involvement of the private sector in the delivery of health services highlights a dramatic lessening of public
commitment to health. In 1946, on the eve of India’s Independence, the report of the Bhore Committee had suggested a detailed and comprehensive plan for health security. The plan, which was
intentionally biased in favour of rural areas, recommended that a uniform and comprehensive public health act be enacted, and plans made for the implementation of an Indian National Health Service.
The Bhore Committee Report envisaged the establishment of a massive state-managed infrastructure for health, which would have required the State to allocate almost 10 per cent of the GDP for
healthcare. Stressing that the provision of healthcare is an indispensable function of the government, and that this should be provided to all irrespective of their ability to pay, the report suggested that the focus of the health programme must be preventive rather than curative, that health services should be placed as close to the people as possible to ensure maximum benefit to communities, and that the doctor should be a social physician who combines remedial and preventive measures. If it had been implemented effectively, the Bhore Committee Report would have rendered the private sector in health irrelevant, and the level of health services in the country would have reached three-fifth of that in Britain during the Second World War.
Though the health minister’s conferences in the first few years of Independence ritually referred to the report, and though the First Five-Year Plan attempted to incorporate its recommendations, very soon, policy makers dropped the recommendations. From the Fourth Five-Year Plan onwards,
budgetary provisions for health shrank drastically, reaching a new low in the first decade of the 21st century, though the World Health Organization (WHO) has recommended that a minimum of 5 per cent of the GDP should be allotted to healthcare. India has one of the lowest health budgets in the world. Health does not seem to be a priority area for the nation. Neither does it seem an important priority area for political parties. For instance, in the 2004 general elections, health issues were not raised by any candidate.
In fact, we can discern an odd gap between the stated objectives of health policy and the financial outlays made by the government, for the Government of India has been sensitive to the need for a sound and fully functioning health system, which can deliver efficient services particularly to the rural poor. The public health system that was laid out in the early years of the post-Independence period consists of a three-tiered layer of primary health centres, sub-centres, and community centres, providing multi-functional outpatient facilities. The number of centres is in direct proportion to the population being served, with special provisions being made for hilly and tribal areas. The
government has also initiated and implemented several disease-control programmes and immunization schemes, some of which have shown remarkable success. Under the Central
Government Health Scheme, healthcare is provided to government employees, pensioners, and public officials living in big cities. The global debate on health strategy, the signing of the Alma Ata
declaration of ‘Health for All’ by 2000, and the recommendations of various specialized bodies have
resulted in the enunciation of a comprehensive, integrated, approach to healthcare in the form of the National Health Policy in 1983. The 2002 National Health Policy aims at achieving basic standards of good health among the population through national public health programmes, extension of
infrastructure, medical education, research, enhanced role of stakeholders such as NGOs, enforcement of quality standards in food and drugs, and women’s health.
It is also not as if India has made no progress in the past several decades in the field of health. As detailed above, infant-mortality rates have dropped and life expectancy has risen. There have been no reported cases of small pox since 1985, of guinea worm disease since 1996; and of plague since 1969 with the exception of Surat (August–September 1994). Cholera epidemics and related deaths have become more infrequent. In 1950, cholera cases numbered 176,307 with 86,997 deaths; by 2001, the total reported cases of cholera were 5000.13 The incidence of measles, polio, whooping cough, and tetanus is lower than before. The proportion of children without immunization declined
It is also not as if India has made no progress in the past several decades in the field of health. As detailed above, infant-mortality rates have dropped and life expectancy has risen. There have been no reported cases of small pox since 1985, of guinea worm disease since 1996; and of plague since 1969 with the exception of Surat (August–September 1994). Cholera epidemics and related deaths have become more infrequent. In 1950, cholera cases numbered 176,307 with 86,997 deaths; by 2001, the total reported cases of cholera were 5000.13 The incidence of measles, polio, whooping cough, and tetanus is lower than before. The proportion of children without immunization declined