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CHALLENGES AND OPPORTUNITIES FOR SOCIAL SECTOR
Sonalde Desai, NCAER and Univ. of Maryland
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12th Plan…
One of the best written plans
Both reflective in achievements of 11th Plan and thoughtful in future strategies
Inspires broader thinking on future policy challenges than simple tinkering of existing programs
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Overivew
i. Burden of success
ii. Quality: The next frontier
iii. Challenges in a changing world
iv. Need for policy realism
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I. The Burden of Success
“The measure of success is not whether you have a tough problem to deal with, but whether it is the same problem as last year” – John Foster Dulles
Our challenge is to recognize that the problem we face has changed – all because of our success over the past decade
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1. Rising Education, Declining Quality
0%
10%
20%
30%
40%
50%
60%
1930s 1940s 1950s 1960s 1970s
Year of Birth
The Paradox of Increasing Rate of College Graduation and Decreasing English Fluency among Graduates
Source: IHDS 2004-5, Males ages 25-75
Percent College Graduates Fluent English Speakers among College Graduates
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Success of educational expansion
0%
20%
40%
60%
80%
100%
120%
10 15 20 25 30 35 40 45 50 55 60 65
% L
ite
ra
te
Age
Literacy Rates for Males by Age, IHDS 2005
Forward Caste OBC Dalit
Adivasi Muslim Other Religion
0%
20%
40%
60%
80%
100%
120%
10 15 20 25 30 35 40 45 50 55 60 65
% L
ite
ra
te
Age
Literacy Rates for Females by Age, IHDS
2005
Forward Caste OBC Dalit
Adivasi Muslim Other Religion
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Education system’s inability to keep pace
Vast expansion of student population
Many first generation learners
Hurly burly growth of private schools and colleges
Very little quality control
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2. Improving nutrition, increasing inequality
Wealth Quintile
NFHS – 1 NFHS-3 % Decline
Lowest 20% 49% 44% 10.8%
21-40% 48% 40% 16.4%
41-60% 47% 35% 25.9%
61-80% 46% 29% 36.4%
Top 20% 35% 21% 40.7%
Decline in Percent Children With Severe to
Moderate Stunting between 1992-93 and 2005-6
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Malnutrition affected by many factors…
Food shortages, nutritional composition and disease prevalence due to poor water and sanitation
As long as disease prevalence is high, income makes only a minor difference
But as disease prevalence declines, role of income is greater
So success in controlling diseases and improving water/sanitation results in increasing nutritional inequality
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3. Improving women’s education, declining employment
30%
40%
50%
60%
70%
80%
90%
None 1-4 5-9 10-11 12 & some Coll
Graduate
% E
mp
loye
d
Education
Women's Employment by Education and Household
Income (Rural)
Poorest 2nd Q 3rd Q 4th Q Richest
0%
10%
20%
30%
40%
50%
60%
70%
None 1-4 5-9 10-11 12 & some Coll
Graduate
% E
mp
loye
d
Education
Women's Employment by Education and Household
Income (Urban)
Poorest 2nd Q 3rd Q 4th Q Richest
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Paradox of declining female employment
Higher family incomes associated with lower female work participation
But even controlling for family income, educated women tend to withdraw from the labor force
Difficulties in finding “suitable” jobs
Some of the same phenomena associated with rising youth unemployment
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II. Quality: The next frontier
For nearly 10 years, the ASER surveys have documented that barely 50% of the students can read simple paragraphs.
These simple results hide a more acute problem.
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Real Concern – Flat Learning Profiles
One would expect learning levels to rise with more time spent in school
But a recent paper by Lant Pritchett and Amanda Beatty and work by Karthik Muralidharan documents very low levels of improvement in basic skills with more time in school
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APRESt results in AP (Source: Pritchett and Beatty, citing Muralidharan)
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Grade 2 Grade 3 Grade 4 Grade 5
Pe
rc
etn
co
rr
ec
t
Vertical Single Digit with carry (class level 1) Vertical Double Digit (class level 2)
Vertical addition, triple digits (class level 4)
Horizontal addition (class level 5)
9 +8 ----
32 +21
200+85+400=600+___
695 +505 _____
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Skill/competency Average
percentage point
increase per year
of schooling
Of students who
didn’t know
skill, percent
who learned by
next grade
X in Y children
who learned
skill per grade
(of those who
didn’t know in
previous grade)
APRESt* Vertical single digit addition (w carry) 0.100 17.6% 3 in 17
APRESt Identify which shape is a triangle 0.053 7.0% 3 in 43
ASER 2010
(AP)
Division (3 digit by 1 digit) 0.113 20.2% 1 in 5
ASER 2010
(Himachal)
Division (3 digit by 1 digit) 0.123 30.4% 1 in 3
ASER
2010 (UP)
Division (3 digit by 1 digit) 0.105 15.4% 2 in 13
EI 19+X=32 0.075 16.9% 1 in 6
EI Measuring length of object with a ruler
(when object is placed at 1cm instead
of 0cm)
0.029 3.93% 2 in 51
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Parents and patients recognise the problem
Health care in India has always been private
Education is getting rapidly privatised
While the rich are more likely to move to the private sector, the poor are also not particularly happy with government services
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Middle class flight from government schools may reduce the quality of schooling for the remaining children
15% 13%
22%
39%
45%
58%
14%
19% 19%
24% 25%
34%
None 1-4 std 5-9 std 10-11 std 12 Std Plus Graduate
Household Education and Reliance on Private Schooling
Private School Private Tuition
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Even when government facility is the only one available, people go outside the village to see private doctors
0%
10%
20%
30%
40%
50%
60%
70%
80%
No Dispensaries Sub Centre Only PHC/CHC Only Private Only Sub Centre & Private PHC/CHC & Private
% o
f si
ck in
div
idu
als
gett
ing
care
Use of Public and Private Care by Availability in Village, IHDS 2005
Use Public Use Private Facility
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Nearly 80% of health care is private…
Sharp increase in health expenditure envisaged under 12th Plan
How is people’s preference for the private sector to be balanced with growth in public spending?
RSBY offers an interesting experiment but is unstable in the long run with focus on hospitalisation rather than preventing and outpatient care
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III. New problems of a brave new world
A society in transition
Many changes both within Indian society and in the global conditions
New challenges need different responses and not more of the same
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Dealing with contagious diseases and chronic diseases require different strategies
Our public health strategies most successful when they rely on a campaign approach rather than ongoing service delivery with follow-up contact
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Vaccination Coverage: Diverging Trends
Polio: Rising coverage due to pulse polio campaigns
DPT: Stagnant coverage rates
54 63
78
0
20
40
60
80
100
1992-93 1998-99 2005-06
Proportion of Children in Three
NFHS Surveys Receiving 3 Doses of
Polio Vaccination
52 55 55
0
20
40
60
80
100
1992-93 1998-99 2005-06
Proportion of Children in Three
NFHS Surveys Receiving 3 Doses of
DPT Vaccination
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But dealing with diabetes and cardio-vascular diseases requires…
On-going screening
Focus on laboratory testing
Medication that is continually monitored and adjusted
Behavioral and nutritional counseling
High rates of CVD among Indian origin populations in the Western countries (e.g 1.5 times higher death rate from heart disease in UK). Genetic or food habits? Either way a major impending challenge for India.
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Rapidly growing threat of antibiotic resistence
Antibiotic proliferation in India is rapidly becoming a worldwide threat
Growth of antibiotic resistent bacteria can make it difficult treat a variety of infections
Global Antibiotic Resistence Partnership’s India working group documents striking increase in antibiotic sales
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Rapid increase in antibiotic use in India (Source: GARP, 2011)
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Recommendations of GARP
1. National surveillence of antibiotic resistence and use
2. Increasing use of diagnostic tests inside and outside the hospital
3. Setting up infection control mechanisms in hospitals
4. Patient and pharmacist education and monitoring to reduce antibiotic proliferation
5. Reduce use of antibiotics in agriculture
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Need to move towards more technically oriented health care
Focus on community based health care, used in an era of contagious diseases
But new needs require greater technical sophistication and regular monitoring and testing
Manpower and laboratory equipment challenges
Could we focus on simple diagnostic and monitoring technologies?
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IV. Need for Policy Realism
Public policies result from diverse pressures and often do not match instruments to outcomes
The discussion of health needs above clearly reflects greater need for laboratory and technical inputs, yet policies seem to focus on strengthening grass roots community workers rather than laboratories
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Counterproductive provisions in Right to Education
RTE focuses on age specific placement of children and mandates automatic promotion to the next class
But educational research documents difficulties of teaching a heterogenous student body in the same class
What do we need? Skill or age specific placement?
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PDS and National Food Security Act
Focus on targeted subsidies to “priority groups”
But it is difficult to identify the poor
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Diverse challenges in identifying the poor Conceptual
BPL card that lasts 5 years or based on automatic inclusion/exclusion criterion assumes chronic poverty dominates. But what if a large proportion of poverty is transient (illness, job loss, crop loss)?
Measurement Ultimately self reported --- at least unless some major
Aadhar based data collation is possible (will it ever be possible? Desirable?)
Political Economy Local authorities certify poverty so possibility of elite
capture and nepotism
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Monthly Consumption Expenditure by Ration Card Type
Exclusion
Leakage
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Monthly Per Capita Income by Ration Card Type
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Suggests that…
Targeting food subsidies is going to be impossible
We will need to focus on alternative strategies for meeting nutritional security needs
Millets instead of sugar or jaggery?
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Social inclusion in education
Focus on higher education
When skill deficits begin in early childhood
Very little attention to inequalities in learning outcomes in primary schools
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Inequalities in Educational Quality – Males 25-54
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Fluent in English First Dvisiion in Secondary School Exam First Division in College
Inequalities in Skills and Performance
Forward Caste Dalit Adivasi Muslim
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Lower reading (and arithmatic) skills for dalit, adivasi and Muslim children
0%
10%
20%
30%
40%
50%
60%
70%
Forward Caste Dalit Adivasi Muslim
Predicted Probability of Ability to Read and Subtract (Kids ages 8-11)
Reading Subtraction
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12th Plan Scorecard
i. Dealing with challenges of success – Poor. Success is recognised but its implications are dealt with
ii. Quality focus – Moderate Quality concerns are identified, particularly in education. But
problems seen as teacher problems rather than structural problems.
iii. Identifying new challenges – Moderate. Focus still on old problems, little attention to emerging threats with
the exception of skill training requirements of new economy
iv. Policy realism – Non existent Debates around poverty line and benefits for the poor seem to exist in
vaccum with no recognition of impossibility of targeting the poor
How can we address social inequalities when groups elgible for benefits keep growing? Affirmative action for 65% of the population is an oxymoron.