Bengaluru: Why does India lag behind its neighbours Nepal, Bangladesh and Sri Lanka in terms of health, nutrition, education etc. despite being an economic powerhouse? India has a lower female life expectancy at birth, higher prevalence of stunting for children under five years, marginally higher neonatal mortality rate, and with the exception of Bangladesh, has fewer pregnant women receiving prenatal care. In four decades, Nepal and Bangladesh have caught up with India in terms of female youth literacy rates.

In her research-related travels to Nepal and Bangladesh, academic Swati Narayan found that support for social welfare access and entitlements around health, education and sanitation are much better than neighbouring regions of India.

In Bihar’s Kishanganj, some Accredited Social Health Activist (ASHA) workers, who are crucial for delivering health services in rural areas, had not received any medicines for two years while Nepal’s community health centres were better equipped. “Ironically, many of the medicine strips that I saw in the Nepali government health posts were ‘Made in India’,” said Narayan.

While women community health workers relentlessly work towards improving the community’s progress, women’s work is devalued in India, Bangladesh and Nepal, said Narayan. They are not recognised as workers and “neither earn a salary nor are they eligible for pensions, but are expected to survive on honorariums and incentives”.

Narayan is an academic and activist who teaches social policy and public health. In an interview based on her book, UNEQUAL: Why India Lags Behind Its Neighbours, she talks about social welfare access and delivery in India compared to its neighbours, Nepal Bangladesh, and Sri Lanka, the role of women community health workers, and the impact social movements on the caste and social inequalities.

Edited excerpts:

In your book, you mention an interaction with ASHA workers in Bihar’s Kishanganj who have almost no medical supplies to support their work compared to a remote village in Nepal which was better equipped and managed. How would you attribute the different circumstances in both regions? Is it increased scrutiny on government services or a stronger autonomy within local systems of governance where people are able to demand welfare entitlements?

Ironically, many of the medicine strips that I saw in the Nepali government health posts were ‘Made in India’. But, the majority of health centres across the border in Bihar’s Kishanganj were closed. Under the Nyano Jhola (Warm Clothes) programme, the Nepali government even provides new mothers with a baby care kit with diapers, bibs and even a mosquito net. This disparity across borders is not only due to differences in state capacity and/or local accountability.

In the case of Nepal, there is a shared vision of ‘Naya Nepal’. This slogan arose during the Jan Andolans (People’s Movements) and the Maoist War (1996-2006). After the return of democracy, the 2015 progressive constitution has guaranteed the right to education, food, employment, housing, social security, information, equality, privacy, affirmative action and life with dignity. It also explicitly promises that every citizen shall have the “right to free basic health services”. So, not only are free medicines easily available, but the Nepali Supreme Court also ordered that all Covid-19 treatments should be free.

On the other hand, in Bihar’s Kishanganj some ASHA workers I met hadn’t received any medicines for two years. One reason is that Kishanganj is 400 km away from [the state capital] Patna.

The district also has a majority Muslim population. Even a Hindu ASHA worker I met confided that she wished that more Muslim women had been appointed. Based on her long years of experience, she had observed that village women find it easier to trust health workers from their own communities (with lesser social distance), especially to discuss contraceptive options. Across Bihar many health worker posts are also vacant. This reflects the overall neglect of the welfare state.

Though “development” is the buzzword before every election, there is a lack of a shared social contract between the state and citizens. On top of that, the common refrain everywhere was ‘Hum aage badhenge jab log hamare saath badhenge. Teen log aage. Dus log peeche. Lekin koi saath mein nahi hai. Koi judna nahi chahate.’ (We will progress when other people unite with us. Three people in front. Ten behind. But nobody is with us. Nobody wants to join hands).” There seems to be a clear lack of social unity, across caste and religious divides, to fight for basic rights.

ASHA workers, who are crucial for healthcare delivery in India, have for long complained of inadequate remuneration and incentives. There have been multiple protests across states. During your research, how different were roles for women volunteers in providing public services in Nepal and Bangladesh compared to India? Are there interventions that you feel can be adopted in India?

Since 2005, ASHAs have been appointed in India. But, Bangladesh and Nepal have a longer history of recruiting women as doorstep healthcare workers.

Since the 1970s, the Bangladeshi government has hired a permanent cadre of Family Welfare Visitors (FWV). With free contraceptives and medicines, they have been going door to door for decades with a focus on family planning. I met many FWVs who had more than 30 years of experience. One FWV recalled that when she started working four decades ago, people did not like contraceptive pills and there was no bharosa (guarantee) that if they had only two children, they would survive. They faced a lot of problems, and the chairman and member of the union parishad would accompany them to convince families, she said. Now, with improved education, vaccinations, and regular maternal health check up, families have realised the importance of contraception and small families. Huzoors (religious leaders) were also trained to convince people.

As a result, Bangladesh, a Muslim-majority country, has had a historic fall in fertility in the last four decades from 6 to 1.9 children per woman. Unlike India, the country has also managed to simultaneously improve child-sex ratios. BRAC, Gonoshasthaya Kendra and other Bangladeshi NGOs also have their own cadres of community health workers who conduct check-ups and sell low-cost medicines door-to-door.

Nepal’s doorstep health volunteers, Swasthya Sevika, are unpaid volunteers. But they command a lot of respect in the community. Many of them are wisened grandmothers who know the names of women in their village by memory rather than registers. As one Auxiliary Nurse Midwife (ANM) described to me ‘Swasthya Sevikas are the backbone of (our) society’.

However, the problem of devaluing women’s work remains across the three countries. None of these community health workers, except the Bangladeshi FWVs, are even officially recognised as workers. So they neither earn a salary nor are they eligible for pensions, but are expected to survive on honorariums and incentives. As frontline workers, they especially risked their lives during Covid-19.

A Family Welfare Visitor (FWV) with more than 30 years of experience in a Bangladeshi village who walks door-to-door with her bag of medicines and contraceptives.

Recently, at the World Social Forum in Kathmandu, it was heartening to see several unions of community health workers from across South Asia, including Lady Health Workers from Pakistan, uniting to demand their recognition as permanent “workers” and payment of a dignified living wage.

Caste has a severe impact on access to education, healthcare, and development and upward mobility particularly for communities that are placed lowest in the caste order. You illustrate it with the differences in access to healthcare of a Nepali Dom family in Bihar and in Nepal. How and why has the impact of caste relatively diminished in accessing state support in Nepal and Bangladesh?

Nepal had a caste system which was in many ways more rigid and entirely different from India’s caste system. Till 1963, the Muluki Ain (Social Code) legally institutionalised different punishments for the same crimes for different castes. Even uncontrollable farts in public drew different fines based on the caste of the ‘offender’ and the ‘victim’. In 1991 only 33% of Nepalis were literate. Social interaction between castes was highly restricted and discrimination was rife. But, after the Maoist People’s War (1996-2006) and since the return of democracy in 2006, Nepal has witnessed a transformation in caste equations.

The war itself was as much a caste war as a class war. The majority of the cadres were from the marginalised castes and indigenous tribal communities. Eventually, the pro-democracy Jan Andolan (Peoples’ Movement) street protests with support from all political parties led to the creation of a progressive 2015 constitution which abolished untouchability.

Since the 1950s, the Dalit movement has also grown in Nepal. Now, the National Dalit Commission has been formed and in the 2017 local panchayat elections with sub-quotas, 47% of the women elected were Dalit. International migration has also brought newfound prosperity to migrant families. Many migrants from marginalised families work in India, the Middle East and East Asia and send remittances home to purchase farmland, which also alters traditional caste equations.

On the other hand, in the East Bengal frontier, since the mass conversion of the population to Islam in the 13th century, amongst the Muslim population the stranglehold of caste has diminished.

Southern states like Kerala and Tamil Nadu have experienced powerful social movements much before Independence and have a legacy of public investment in health and education. Both states and Sri Lanka have “roughly simultaneous development arcs,” you wrote in the book. They had long periods of “accelerated human development, even in times of stagnant economic growth”, through investments in universal public services, progressive social movements, women’s agency and cultural ties. Can you draw parallels in terms of the social and political events in these two states and Nepal/Bangladesh and how they have impacted development indicators?

It is not easy and wise to draw straight parallels between specific social and political events in these different regions or states. Each country and region has had its own unique history. However, the commonality between all these high achievers is that they have achieved robust human development, despite modest economic growth. Women in these regions live longer, have a lower maternal mortality rate, are more literate and in most regions also more likely to work outside the home than the average Indian.

Diminishing inequalities seem to hold the key. Not only between genders, but also classes, communities, castes, and ethnicities. Only then can the majority of the population share a slice of economic prosperity, however modest it may be. Let me illustrate a concrete example.

The low-cost Amma Canteens in Tamil Nadu are now magnets for all classes--labourers, IT sector workers, migrants, students and even backpacking tourists. But 100 years ago, even the existence of these eateries would have been unthinkable in the British Madras province. There was extreme social segregation between castes. This led to the 1920 Non-Brahmin Manifesto and later the Dravidian Self-Respect Movement. The Amma Canteens are but the fruits of this long history of anti-caste social movements.

Similarly, in Kerala till the 1800s, there was not only untouchability but unseeability. Till the 1890s, children from oppressed castes could not enter government schools. Around a century later, Kerala was recognised as the poster child for human development. But this was achieved only after a series of social movements from the Channar Upper Cloth Revolt (1813-1852) against the “breast tax” to the Vaikkom Temple Entry Satyagraha (1924-25), which drew both Periyar and Gandhi to the temple town [Vaikkom].

So, in highly unequal regions, redistribution of opportunities and resources are essential for human development advances.

You have worked on the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) extensively. It has been a lifeline for rural households during Covid and has been so for women particularly. Women’s labour force participation is a serious concern in India. How would you compare rural wage work programmes in India and some of the neighbouring countries? Are women adequately represented in the labour force? Your comments?

MGNREGA is not just the largest in the world but an inspiration for our neighbours. In 2008, Bangladesh started a 100-day Employment Generation Program for the Poorest (EGPP). In 2019, Nepal similarly started a 100-day Prime Minister Employment Programme. But unlike India both these are only short-run schemes and not legal rights.

Still, in the last decade, within India MGNREGA has been severely underfunded. However, consistently, women have accomplished more than half the MGNREGA work. Especially in southern states like Kerala, more than 85% of work is done by women. Of course nationwide the wages are often too low to attract men. But women are paid equal wages as men on MGNREGA worksites, unlike market wages. In addition, the Kerala government has encouraged a synergy between MGNREGA and the Kudumbashree neighbourhood women’s groups. This can be replicated nationwide with 67 million women who have joined 6 million women’s self-groups under the Aajeevika - National Rural Livelihoods Mission. This is particularly important as too few Indian women work in the labour market.

A Kudumbashree neighbourhood savings group of women in a Kerala village who also do collective farming to grow vegetables.

On the other hand, more women in Bangladesh work outside the home, often in factories and the ready-made garment industry. The 1971 Liberation War and the 1974 famine were historical turning points for Bangladeshi women to break purdah norms and enter the workforce, in the quest for survival. Bangladeshi women are also now more literate.

Women’s literacy, employment and freedoms in India sorely need to soar.

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