Ms. Urvashi Prasad is currently working as a Public Policy Specialist in the Office of the Vice Chairman at NITI Aayog providing policy and directional inputs in a variety of economic and social sectors. She has extensive experience in health, nutrition, sanitation, gender, and public policy. She is also a part of the core team supporting the work of the Government of India's Empowered Group 1 for managing the Covid-19 Pandemic in the country. She is also a member of the task force for overseeing the implementation of Sustainable Development Goals in India and co-authored India’s first Voluntary National Review presented at the UN's High-Level Political Forum on Sustainable Development in 2017.
Q1. What are your views on India’s health expenditure?
Ms. Urvashi: The health expenditure has been a very long-standing issue for India. We have historically been ranked as a country, which spends amongst the lowest on health as a percentage of the GDP. The spending has stagnated at around 1% for decades, in recent years this figure has gone up to around 1.8% but it still needs to increased further as the pandemic has hopefully taught all of us that health is not just a social sector. It is equally an economic sector and if you do not focus on health, the productivity of the workforce suffers. So, you cannot expect to have strong economic growth if you are not investing in health, education, and nutrition. These are very critical and fundamental sectors for the economy as well and that is a very important principle to understand.
Now in terms of the expenditure per se, we've just had the union budget and of course, a lot has been discussed on the health expenditure. In terms of the positives, it's good that we are looking at health in sort of an integrated fashion. You know, a lot of people have said, why have we clubbed health with nutrition, water, and sanitation. It is important to integrate these areas, not just from a budgetary perspective, but beyond that as well, because eventually, progress in one areaa impacts the outcomes of another. If your nutritional status is weak, it will impact your health, if you don't have access to clean drinking water or sanitation, it will impact your health and nutrition indicators. So, these are very interlinked.
Also, the increase in allocation for drinking water is important because many people still do not have access to piped drinking water or water supply in their homes. So, women have to queue up for hours on end to collect water. You have all sorts of waterborne ailments. Contamination with heavy metals, like arsenic and fluoride, can also increase your risk of heart disease, cancer, etc. So, for all of those reasons, investments in water, the Swachh Bharat Mission 2.0, solid-liquid waste management, clean air, etc. are all good things. While we need to focus on all these areas, the expenditure on health expenditure per se also needs to go up.
A partnership between Centre and States is very important, because a lot of the times when we talk about Government expenditure on health, we only talk of the Central Government, but States spend about 66% of the money on health, out of the Total Government Health Expenditure. So, states also need to raise their expenditure on health to at least 8% of their budgets in line with the National Health Policy and also recently the 15th Finance Commission Recommendations.
Q2. What lessons have we learned when it comes to preparedness to tackle a pandemic? Do you think that we took a massive hit because we weren’t ready for it?
Ms. Urvashi: This is a complex question because if we look at how we have fared, on the one hand, we might have done much better than other countries on COVID management. Yes, we have data issues. Our actual case count might be higher but what is reassuring is that the fatality rates in the country are also much lower than in other high-burden countries. It is, after all, much harder to hide deaths beyond a point in large cities. If people are dying in large numbers, in Delhi, Mumbai, or Chennai, it's much harder to hide or fudge those numbers. And this relatively good performance so far is despite the fact that we are a very large and densely populated country. Having said that, the pandemic has highlighted many of our long-standing health system challenges including lack of access to physical infrastructure across the country, shortage of trained human resources for health, inadequate availability of essential drugs and diagnostics, etc. Another front that we have done fairly well is on catalyzing changes in public and personal health and hygiene behaviors like wearing masks, handwashing, etc. These gains need to be sustained. Going forward, the inequities in the health system across India must be addressed on priority. In a complex federal structure like India, one size can never fit all.
I hope that we can learn from this pandemic and bring about large-scale changes. Even now, when I listen to many economists and commentators, they keep referring to health as a social sector. You cannot have a productive workforce that is suffering from tuberculosis, cancer, heart disease, depression, etc. Steady high growth cannot be achieved in such a scenario.
So that is the biggest lesson. I hope we will learn to stop categorizing, health, education, nutrition as social sectors, and treat investments in these as investments in the economy and prioritize public health because. Also, we are still a predominantly hospital-based health system. You cannot put 1 billion people into hospitals. You need to prevent diseases; you need to have early detection and all of that needs a focus on public health where the Government naturally has a very big role to play.
Q3. LASI or Longitudinal Ageing Study in India in its study found out that every fourth senior citizen in India rates health as poor. What can be done to improve the same and what necessary steps are needed? Please comment.
Ms. Urvashi: We talk a lot about India’s demographic dividend. Of course, we have a lot of people under 30-35 years but we also have a significant and growing aging population, especially as the fertility rates have stabilized considerably. So firstly, we need to acknowledge this shift in our policies. Non-communicable diseases like heart disease, diabetes, chronic kidney disease, cancers, mental health, etc. become more prominent in the aging population. We, therefore, need to focus on prevention and early detection. What we also need to do is look at-home care in a much bigger way as the pandemic has opened up opportunities for providing health services in the homes of people. For the elderly in particular, this has huge potential because you can train, an entire cadre of caregivers, people who can provide home healthcare services.
We also need to focus on nutrition because as much as it impacts younger people and children, it also impacts the elderly. We need to design specific nutrition interventions for the elderly because those will be different from what we do for children or pregnant women. Of course, many senior citizens are still from poor backgrounds, so we do need to provide social security and support as well. We need a new, re-energized look at the policies for elderly care. Because it is multi-sectoral. On pension for instance – are the amounts adequate? Are they even reaching the elderly? So, these are questions that we need to very holistically address. Many of us have been speaking about it and the longitudinal study is a very important step because it gives us granular data which is a prerequisite for policymaking. So, we should use this and come up with concrete steps for addressing the welfare issues and productivity of the elderly. Because the elderly can also contribute to the economy as envisaged in the ‘silver economy’ concept.
Q4. The Bombay High Court has recently ruled that the act of groping a minor without skin-to-skin direct physical contact cannot be categorized as sexual assault and hence the accused cannot be penalized under Section 8 of the Protection of Children from Sexual Offences Act. What are your views on this?
Ms. Urvashi: I am not a legal expert so I won't get into the legal aspects of it but the message that such a judgment sends out is pretty shocking and we need to be very careful. The legalese is all well and good but, in a country, where you still have a big challenge of sexual violence, abuse, including of minors and women, the words we use need to be chosen with a great deal of sensitivity and responsibility. We have to call out these acts for what they - it does not matter whether inappropriate touch or groping is above or beneath someone’s clothing.
5. What according to you are the policy measures that need to be taken to curb the vast gender inequalities in India to achieve the SDG5 Gender Equality in light of the agenda 2030?
Ms. Urvashi: Gender is again a very complex multi-sectoral area. There’s health, education, nutrition and each of these areas requires its own set of interventions. But I think the biggest challenge is still the mindset, which is very difficult to change. You can keep doing things, you can keep implementing Government schemes and programs, but if people in a household still believe that the male child has to be given more importance, vis-a-vis the female child then nothing is really going to change. Even when you look at nutrition often it's not that the household does not have enough food, but what happens is that the male child will be fed first and whatever is leftover can be given to the girl child or the woman of the household who will always be the last to eat.
Now, of course, the government has to do its bit, has to implement a variety of schemes and policies and we also need legislation to protect the rights of women, but more than anything, we need a massive societal movement. The Government alone cannot do everything, the private sector, civil society, every individual needs to come together. Every time there is a publicized crime against a woman there is hue and cry for a few days, then everyone forgets about it. We need a determined and sustained large-scale social movement.
Young people also have a big role to play as they are the ones who can change age-old mindsets and beliefs. So, it is a much broader issue, I think. For instance, if you talk about the private sector, there are hardly have women in leadership positions. Women have to work doubly hard to achieve the same position.
Due to the pandemic, many more women have dropped out of the workforce. The female labor force participation was already quite low, to begin with, and has suffered a further blow. While men might get their jobs back, women are likely to struggle for longer. The reason why you want gender equality to be a priority is not purely humanitarian, but equally economic. Women make up half the country’s population and if they are left behind, it will be very difficult to achieve the aspirational and ambitious growth targets. Technology is creating new types of opportunities. We need to ensure that women are not left behind on this front as well.
Q6. As per the Oxfam report, the wealth of billionaires increased by about 35% while lakhs lost their jobs. This clearly depicts the inequalities and suffering of several lakh people. What could have been done differently or now what is possible to improve the situation?
Ms. Urvashi: Inequality in India is stark and the pandemic can widen the gap between the rich and the poor in many areas. The Government will have to step in. Many packages have already been announced by the Government and we will perhaps need to do much more – be it providing immediate income support and additional cash transfers or creating work opportunities for women in rural areas by leveraging the network of Self-Help Groups. We also need to focus on boosting micro, small, and medium enterprises. Further, we need to address the technological divide. In addition to Government initiatives, it will be good to see continued, heightened and socially responsible efforts from India’s wealth creators and billionaires.
Interviewer- Sara Bhasin and Visaaya Bamba
Image Source- Twitter