By Teres Sajeev
In these precarious times, different stakeholders and activists are on the lookout for accurate policies to address the manifest issues that the pandemic has caused or otherwise exposed. Dr. Dipa Sinha, particularly known for her work in the Right to Food campaign, has also worked extensively in the fields of Public Healthcare and Gender.
Talking about the Public Distribution System, she asserted that it is equipped to cater to 60% of the population, but it had failed during the pandemic due to sheer insensitivity towards the plight of the people. In the context of our failing Public Healthcare System, she highlighted the importance of putting a united front to fight the pandemic along with our Private sector after due negotiations with them. However, universal healthcare is a long-term goal that can be secured only through increased spending on healthcare, particularly the public healthcare because that alone will ensure access.
The key to Atmanirbhar Bharat is to create demand for domestic goods from the domestic economy. The way to make this happen she said, “is through external stimulus in the form of fiscal spending by the government”. Referring to the package for agriculture, she said that it is not a crisis response for sure and elaborated on the necessary steps that can be taken to support farmers.
She also talked about the status of women altering after the lockdown, primarily because the few jobs available will be secured by men first. To handle the migrant workers crisis in the long term she advocated the strengthening of Migrant Workers Act and thereby ensuring their registration to provide them entitlements.
While concluding she pointed out that in India, we don’t have the luxury to talk about the lives vs. livelihood debate as people don’t have lives if they don’t have livelihoods. “The question for us is how do we allow livelihoods to continue while ensuring that the infection spread is slowed down and that people who get infected can access healthcare.”
In this interview with Seasonal Magazine, Dr Sinha (DS) shares her insights on some of the pressing issues of this crisis: the role of public services, the effectiveness of Atmanirbhar Bharat and the impact of the situation on vulnerable populations.
In the past 4 months, 6.5 million tonnes of grains rotted in the godowns, more than what was distributed through the Pradhan Mantri Garib Kalyan Anna Yojana. Should this be considered as pure negligence or is there a deeper systemic failure that needs to be addressed with respect to our Public Distribution System?
DS: We have to understand that our Public Distribution system does have some inefficiencies, but it has been a system that has been in place for a very long time. Firstly, relative to its size its infact quite efficient in reaching out to the largest number of beneficiaries in the country. Secondly, whatever few phone surveys have been there till now shows that of the various schemes the government has undertaken to provide relief as a result of the lockdown, the PDS has been the most successful. It has been managed in a manner to reach the most number of people.
But on the other hand what we see is a situation of very high food stocks in the FCI godowns. In fact the highest amount historically, 80 million tons, which actually allows us to give more people and give more grain. That is something that has not been forthcoming. It is more because of the insensitiveness towards the plight of the people than anything else. I will give you one example, the Garib Kalyan Anna Yojana announced 5kg of additional grain for the poor for three months during the period of lockdown for those who have ration cards. Whereas people who were outside the PDS network, who did not meet whatever eligibility criteria there was to get a ration card or because the population figures were not updated, did not receive ration during this time of crisis.
Since we have grain in hand, it would have been very simple to distribute it even to those who don’t have a ration card. That would not have required any additional infrastructure because there are already fair price shops that provide ration to 60% of the population. So it would not take any additional effort to do it. Infact it is insensitivity, because on the one side you had huge stocks of grain and on the other side, you had the infrastructure to distribute the grain. But you still did not distribute it.
Several reports demonstrate that the public healthcare system in India is succumbing to the excess demand and is not equipped to fight a pandemic. Do you think that this makes a case for India to follow suit like several countries who have passed an order to bring hospitals in private sector under public control for a limited period? What are the steps we can take to ensure universal healthcare at this crucial juncture?
DS: So taking your first question, I do think this should be done. It is not something that should be set in the context of India alone as many countries are already doing this. This is a global pandemic. It is a situation of crisis and we need to pool in all our resources so that we ensure that they are not just efficiently distributed, but also equitably distributed. Data shows that due to the neglect of the public healthcare system over the years, people are now largely dependent on the private sector. This is the case for both out-patient and in-patient care. Additionally, we also know that the regulation of the private sector in health in India has been very weak. This is the reason why it has been possible for things like overcharging to happen. To avoid this and ensure that there is some equity in the system, the government has to bring in the private sector as well. That cannot be by force. It should be done after negotiations with the private sector. Some kind of coordination so that beds and human resources which is very important is made available for the government to be able to address this crisis.
The issue of universal healthcare is much larger and would require longer time, because we have such a weak public healthcare system in the country. For example, India has the highest out of pocket expenditure on healthcare in the world. Almost 67% of the health expenditure that people make in our country comes from their own pocket. And this is really high even compared to a country like the US where healthcare is largely privatised. There are huge gaps in availability of infrastructure and availability of human resources.
All of this ultimately relates to the fact that we have been underspending on health for a very long time. While the WHO recommends that the national health policy of the country should spend at least 3% of the GDP, we spent only 1.2% of the GDP: Centre and States combined. First thing to do to move towards universal healthcare is to increase the spending on health. Increase in spending should be in a manner by which public health systems are strengthened because they reach out to the far corners of the country and they are more accessible to the poorest of the poor.
India has witnessed an unprecedented level of unemployment even before the lockdown and now the situation has become worse. Would adapting the NREGA by increasing its ambit be enough to address this crisis?
DS: To address the issue of unemployment NREGA is an important piece in the puzzle. NREGA is available for unskilled work for whoever demands work at minimum wage and that is something that can be done immediately where work sites are open. But that can’t be the solution to the employment problem in our economy where we have been facing a jobless growth. For employment more would need to be done. You would also have to look at the skilled labour. The biggest problem with employment currently is due to the lack of demand in the economy. The purchasing power is less, production is not happening and employment is not being generated. For the immediate need, NREGA and something similar in the urban areas would take care of the immediate livelihood issues of the people. But that cannot be your only employment strategy.
The pandemic has brought the discussion on implementing universal basic income back to the table. Do you think this is viable for India? If yes, what is the best mechanism and infrastructure that India can use for this?
DS: While the pandemic has brought the issue back on the table, all these are issues of long term welfare policies. Many of the concerns regarding universal basic income was raised before the pandemic and still continue. Firstly, the policy of Universal basic income in the context of India has been talked about as a supplement for the other services that the state provides. Whereas in advanced country it has been talked about as an additional input, and this makes a huge difference. Thus in India it comes at the cost of NREGA, at the cost of PDS, at the cost of health services and at the cost of free education. Then I think there is a problem. Because it is not that money is the only gap and market takes care of everything else. We know that there are market failures. Secondly, the amount of universal basic income that needs to be transferred to have a significant difference is very high and that will have a much higher fiscal cost than all other programmes put together.
On the other hand, it doesn’t mean that there is no space for cash transfers within the welfare system in the country. We have always had cash transfers which are important cash transfers like the old age pension, disability pensions, scholarships at schools and so on. All of these definitely need to be enhanced and at the time of the pandemic I think we should use all of these available list and these bank account numbers to make cash transfers, because like we have been saying people have lost their livelihood, there is a huge food insecurity going on. So it is not enough to run the PDS or community kitchens. Alongside these we need to make cash transfers as well.
I think currently the best platform that it can be done is using the couple of lists that the government have including the NREGA job card list because that is linked to the bank account and we know that it is a fairly reliable list. We could use other lists of old age pension, maternity entitlements and other social security pensions. Some transfers have been done but the concern was regarding the quantity that has been transferred. For instance, Rs.500 was transferred in the Jan Dhan Yojana account. The opportunity cost of going to the bank during the lockdown and withdrawing the money was so high that one wonders what help it would have done to the people. From studies we also know that it is not predominantly the poor who have the Jan Dhan account. So it is better to use this from the social welfare schemes and make the transfer. The transfer also has to be a significant amount.
The agrarian economy has faced a backlash due to disruptions in activities such as harvesting, sale of produce and purchase of inputs during the lockdown. Added to this the Minimum Support Price by 2.9% for kharif crops is the lowest increase in the past 5 years. How do you think the Atmanirbhar policy that contained an explicit promise for an era of opportunities for our farmers, contribute to this distress?
DS: Unfortunately the one concrete intervention that the Atmanirbhar package had for the farmers was the increase in MSP. But when we look at the MSP data, it is the lowest increase in the last 10 years. So this is not going to help so much. Another intervention was the PM Kisan. Here again the amount of cash transfer has not been specified. One of the things that could have been done and still do is to expand PM Kisan to include tenant farmers, wage labourers and give a higher amount as well.
The Atmabirbhar has otherwise announced things that have been there in the policy field for a very long time and some of them have been done in some states. For example, opening up of Agriculture Produce Market Committe, relaxing the Essential Commodity Act and so on. I don’t think these things are going to make a huge difference to farmers’ income. This is not a crisis response for sure. This is part of other reform processes which is opening up agriculture to the market which is on the agenda of the government. I don’t agree with a lot of them. But that is not something that can be anyways be seen as something of a relief response for the current crisis.
For me as a relief response, there would be a higher increase in the MSPs. There would be procurement of not just of rice and wheat but of other crops as well, as currently access to market was a big issue. There should be decentralised procurement. For example, making procurement possible in every Panchayat so that farmers don’t have to go far away and distancing norms can be applied. These are the kind of things that I looked forward to, but did not come.
The announcement of Atmanirbhar was followed by several provisions for MSME’s including dues worth Rs.5 lakh crores to assist them. However experts opine that the micro enterprises that comprise a majority of MSME’s are still largely neglected. What are the measures that can be taken to combat this?
DS: While there are some credit easing measures: the MSME’S need easier access to credit, writing off outstanding loans. All of these measures would matter when these micro enterprises will be able to restart their business and even take these loans when there is a demand in the market. We know that there is a demand crunch. So apart from measures that directly target them we should have other measure like wage support for those working in micro enterprises. It is easy to say that you have to continue to pay your workers even when there is no production, but this is not easy to do.
On the other hand what we need to do to revive the sector, is to revive demand in India where it has been stagnant for some time now and the situation is even worse now. We need to put money and thereby purchasing power into people’s hands. People who demand these small manufactured goods which are labour intensive. This will generate the classic Keynesian model multiplier mechanism and that is what is required now. Here I will come back to cash transfers, PDS, NREGA etc. All of this contribute to increasing purchasing power of people who spent a large proportion or all of their income on consumption goods which tends to be labour intensive. We should do this along with whatever we are doing like credit and skill enhancing, market access and so on.
If we really want to be Atmanirbhar, we need to get the demand for our domestic goods coming from our domestic economy itself. In the current crisis where GDP is falling at such huge rates and wages are stagnant, this can happen only when there is an external stimulus and that stimulus can come in the form of fiscal spending by the government which is missing in the Atmanirbhar package.
The lockdown has exposed a huge population of migrant workers in our country that is left unattended to in the policy spectrum. What are the immediate measures that should be undertaken to protect migrant workers who have returned to their homes with their livelihoods lost? Moreover, what are the long-term policies that can be undertaken to cater to this population?
DS: Now there are millions of people who have gone back to their homes. They have gone back at a time when the economy is at a low. Therefore, immediate livelihood would be the primary concern with the meagre resources available in the rural areas. We must note that these migrants went out looking for work precisely because there was no work or resources available in the places where they come from. So now when they have gone back in an even worse situation, then obviously that is going to put pressure on everyone in the rural areas. Therefore the NREGA for example should be something that has to be immediately started. It has been started in several places and we can see that the demand is very high. The wage rate of NREGA has to be increased and the current NREGA provision that provides 100 days of work for per household should be expanded. Now with migrant workers going back that limit will has to be done away with. Either it has to be converted into an individual entitlement and not per household or it has to provide work double the quantity for whoever is demanding work.
Then how do you deal with it in the longer term would depend on the overall economic model that the country has been following. We have to go back to the structural reasons for such an uneven development, where every few years we have a crisis in the agriculture sector and agriculture is absorbing fewer and fewer labour which is seemingly a normal process of the structural transformation. But on the other hand the manufacturing sector or the good quality employment and services are not able to absorb people. So we have a large amount of self-employment and casual employment but very few regular employment available both in rural and urban areas and that is also uneven across states. Migration is not something that will end. People will go back looking for livelihood opportunities and we are one country where that should be allowed.
What we should do is that Migrant workers Act can be strengthened. We have to think from the point of view of the migrants and the entitlements of the migrants and their families and not look at them as cheap labour for the destination space. One of the things that came out quite starkly in this crisis is that many states use the labour of migrant workers for essential services or for our cities to continue functioning. But the minute there was a crisis and they could not work on the services due to the lockdown they were suddenly, the Bihari construction worker who was helping us in Delhi and not a worker who helped us built buildings. He was a Bihari who was not the headache of the Delhi government and they were sent back. I think this attitude should change and we need to have better laws for their welfare.
Registration of workers is something that was being talked about for a very long time and once again now. This will enable them to access their entitlements. All of these things have been in the pipeline for a very long time. I think as the middle class also, we must really now acknowledge the fact that migrant workers contribute to our lives and to keep the city functioning. Therefore they have to be paid minimum wages, given housing and other basic facilities.
I just want to add one more point that is something even I am doing while I am speaking to you. When we speak of migrants we are only speaking of the working class. There itself you can see the class bias and difference that we are making. I am a migrant in Delhi and teach in a university but I don’t feel like a migrant here. It has not become impossible for me to live here in this crisis. But a migrant construction worker, migrant vegetable seller, migrant domestic worker, as soon as their activity stopped, they were made to feel as if they don’t belong her. And that they have to go back. So this crisis at one level showed us how badly we treat our workers. This is where I think the change needs to begin. There are also many policy initiatives that are required, starting from legislation to having programmes, regulation, registration, social security and so on.
In your book, “Women, Health and Public Services in India: Why do States differ?” you point towards women’s status, specifically education as one the most significant factors that contribute to better health outcomes in states. How do you think the ramifications of the pandemic will alter the status of women?
DS: Already we are seeing a lot of reports on the gendered impact of the pandemic. Much more than the pandemic, it is a combination of pandemic and the lockdown, both in the household and in the labour market. Firstly, for instance all over the world domestic violence rates have surged with men staying at home, with general high level of stress and domestic violence is one of the ways in which it has been coming out.
The mainstream definition of labour market participation and the data around it since the last three NSSO surveys and even before that with a slight improvement in between we find that the female labour force participation has infact declined. The number of women who can participate in what is termed as economic activity is very low in India and among them who can participate in paid employment is even less. That is becoming more in this context with returning migrants, high levels of unemployment, the few jobs that are available will be all taken away by the men. So there will be even fewer opportunities available for women as far as employment is concerned.
On the other hand there are certain sectors that have exclusively women workers where there has been an increased pressure on them to work much more. For example, frontline health workers, like the ASHA and Anganwadi workers, ANM etc. These are all, all women cadre and from day one of the pandemic they have been involved in various activities in the community, to create awareness, contact tracing, bringing people to the health system and so on. They did not even have proper safety equipment. These are also very poorly paid cadre of work. If you look at the policy, ASHA workers are honorarium workers who are just paid for the work they do as an incentive, without a regular salary. An additional Rs. 1000 to do what has almost become a full day work for them like taking surveys, accompanying people to the healthcare. Then there are Anganwadi workers who are poorly paid. The pressure on all these workers have increased with the health crisis that we now have, at the same time the conditions of work are very poor and they need training, handholding support and better incomes.
Finally the other way in which we see women being unevenly affected by the pandemic is the burden of care work within the household, increasing. So now in our country, most of the household work and caregiving work is undertaken by women, among all classes and more so among the poor because there is no support of technology. With schools closing, mid-day meals not happening, Anganwadis not running, there is more work in terms of cooking and taking care of people. With more people falling sick there is additional caregiving required and this falls on women. As of now we are not seeing a gendered response to this crisis. As far as the mainstream understanding goes, men are affected with Covid more than women. However, they have been affected by the lockdown and the crisis both within the household and outside.
In terms of malnutrition we already have 37% of our population stunted, huge prevalence of anaemia among women and children. Firstly, we know that diets have reduced in terms of quantity and quality. Within the household women eat least and eat last and this will make it worse for women. We don’t know what effect it will have on anaemia prevalence. Regular doses of immunisation are also disrupted and we don’t know what is happening to child malnutrition as well.
Adding one more thing regarding women and healthcare, there are several reports on women finding it hard to access delivery and pregnancy care during this lockdown. Because all other health services have been disrupted with hospitals and health centres being put aside completely for Covid services. There is also an impact that you will see on other kind of health conditions and this is also uneven with women getting lesser access than men.
In your recent report ‘The Twin Crises of Covid-19 and the Modi government’s response’, it was estimated that around 750 people have died due to the lockdown. What is your stand on this lives versus livelihood debate? Do you think such a trade-off really exists?
DS: Firstly, the number is likely to be a huge under estimate. We didn’t do the estimate but quoted from reports of researchers that estimated the number of deaths that are reported in the media and are likely to be due to the lockdown due to starvation, suicides etc. This number has risen to over 850 already.
That is to highlight that the cost of the lockdown has been tremendous on people’s lives, many more could have died, many lives have been disrupted. I think posing this as a lives versus livelihood contradiction is misplaced, particularly in a poor country like India, There is no lives versus livelihood where so many people have no lives if they don’t have livelihood. In our country it is not like people have savings and people can work from home for a few months or so. More than 90% of the Indian labour force most of them are paid either daily or weekly wages and they really lead a hand to mouth existence. So if for so many months they do not have incomes that means hunger and otherwise an economic distress. That is why I think the kind of lockdown we had was misplaced for our conditions. We had the most stringent lockdown in the world. In an economy which cannot afford it, without even preparing for the kind of protection mechanism that needed to have been in place. This lockdown would have made sense if those six weeks were used to improve the health capacity and put in place mechanisms to slowdown the spread of the disease. Therefore we really need to move ahead from this debate. The question for us is how we will allow livelihoods to continue while ensuring that the infection spread is slowed down and that people who get infected can access healthcare. That is how we need to pose the question.
The recent ICMR report stated that India’s peek is likely to occur in Mid-November. This would necessitate the adherence to physical distancing measures for a longer period. How do you think this will affect the vulnerable population who cannot afford physical distancing?
DS: I am not an epidemiologist. So I don’t know about the data and the ICMR data which says the peak will come in November has not been owned up by ICMR. But I know that the peak has not come yet and the peak is not going to come at the same time across the county. The infection started at different times in different countries and States and infection soared quickly in states which had a higher number of people coming from abroad. Therefore Maharashtra, Delhi were most affected initially. But now with migrants going back, there is spread of virus to newer states.
Physical distancing, we have to recognize that it is not something that can be equally practiced and that is not because of anything else other than it not being possible. In slums, they stay in congested houses 10x10m rooms and use common toilets. We have to think about what physical distancing would mean in this context. We could avoid crowding in places like malls and schools. But even in the day to day lives of so many people, physical distancing is not possible. Along with physical distancing, we should focus on other measures as well. Which is to ensure hygiene, particularly hand washing and providing masks. This again requires infrastructure and support. Even though we may not be able to provide larger living spaces to people in slums, arrangements can be made so that there is water supply, soap and masks are available.
Soaps could be distributed through public distribution system. There was a video that showed that in Kerala auto rickshaws had hand washing systems installed in it. All slums should have public places where people can wash their hands. Bus stops should have places where you can wash your hands. We also have to provide mask and sensitise people to wear it because now the WHO and GOI is saying that masks are helpful. Of course all this should be done along with this physical distancing, but the viability is limited given the living conditions.
There should be continuous circulation of messages without stigmatising people who are infected or are potentially infected. Currently in this environment of fear we can also see a lot of stigma. It is as if anybody who has Covid is to be blamed because they did not take enough care. We have to understand that the disease has progressed and it is coming from places that you don’t know.
(This interview originally appeared in Seasonal Magazine's podcast. You may listen to it here: https://anchor.fm/seasonal-magazine/episodes/Seasonal-Magazines-Interview-with-Dr-Dipa-Sinha--Assistant-Professor-Economics--Ambedkar-University-efm5jc)