SUNANDO ROY JANUARY 1996
The provision of welfare services in India are severely constrained by the inequality in access, mainly due to the chasm between urban and rural areas, and between high income and low income groups. This inequity in access to welfare facilities becomes amplified due to glaring disparities in utilisation of such government facilities . A visible gap between `potential ‘ and `actual ‘ access to welfare services thereby limits the effectiveness of government welfare policies in terms of desirable human development and demographic outcomes .
The presence of utilization gap is crucial from the policy angle. As utilization falls behind provision, the allocative efficiency in welfare budget suffers and provision of additional services does not produce intended policy outcome. For instance, we find a low positive correlation of welfare spending in health care and a reduction in infant mortality rate. In this context, the paper examines the presence of `utilization gap’ in public provision of health care, housing and food.
Causes of Underutilized Public Health Care
A large number of studies have reported underutilization of health facilities particularly in rural areas. Despite inadequate facilities reflected in high population per Primary Health Centre(PHC) ratios, the PHCs have remained underutilized. In a sample study, Shah (1989) found 80 percent of hospital beds unutilized as only 8.6 percent of the population utilized PHC facilities. Kapur (1989) observes that a high percentage of people did not utilize PHC facilities in the districts of Maharashtra. Deliveries in the PHC though a small fraction of all deliveries remained unused or wasted as noted by Reddy (1989) and Talwar and Bhandari (1989). Lower utilization of these inadequate facilities thus is a cause of concern for policy makers. Proportion of reported illnesses which went untreated was 19 percent in rural and 11 percent in urban areas (National Sample Survey , 1986-87- 42nd Round).
The reasons for existence of the utilization gap is discussed below :
Non Availability of Qualified Medical Staff in Primary Health Centre : Many observers have noted that qualified medical staff like Doctors and Nurses when transferred to Primary Health Centres were reluctant to go and work there. Many of them commuted from nearby towns or cities making their available hours extremely short. In fact, FRCH (1992:105) shows that the training of doctors and nurses involves a large properties of expenditure on medical education in India. Such training efforts as a share of expenditure on hospitals and dispensaries was 21.2 percent in 1980 and 23.68 percent in 1985.
The missing para-medics in rural India
In fact, an alternative local- resource based system, of training a set of health workers with roots in villages have long been stressed by various committees on health care. The Sub Committee on National Health appointed by National Planning Committee felt that the huge task of providing health care in rural areas faced by us cannot be solved on a bureaucratic basis. They felt the importance of training health workers from villages who will in turn impart basic medical education to the villagers. The Srivastava Committee (1975) also felt the need to build up para medical forces to facilitate rural health care.
Perennial Shortage of Medicines :
Another important deterrent to utilization of public health facilities by the weaker section is the shortage in medicines that hampers health delivery systems. Bose et al (1978), Reddy (1989) and Mouriya (1989) have all highlighted that prohibitive cost of medicines in the market prevent weaker sections to avoid public dispensaries which cannot provide free medication. Even the most essential medicines are not available in the rural health centres. Shortage of supplies coupled with corrupt practices by health staff. NSS 42nd Round Study on Morbidity and Utilization of Medical Service found that financial reason was cited by both the rural and urban lowest 50 percent of population as an important reason for untreated spells of sickness. The lower half of rural and urban poor accounted for 67.37 percent and 84.78 percent of the total number of persons who cited financial reasons for not seeking health services.
Thus, even when free services are available, there is utilization gap due to non-availability of medicines in public health centres. Supply of subsidized medicines through mobile dispensaries have been suggested as a remedy to this problem by Bose et al (1978).
Overcrowding in Health Centres
Overcrowing and queues are typical in a shortage economy and poorer half of the population in urban areas found it difficult of approach health services due to the long waiting hours. As many as 67.4 percent of urban respondent complaining long waiting hours for non-utilisation belonged to the lower half of the population for whom the opportunity cost of waiting in the queue was too high.
Cultural Alienation
Cultural alienation, defined as the inability to comprehend the necessity of modern health measures and placing greater reliance on local non-scientific health remedies as a factor causing utilization gap was more prominent in rural areas and among the illiterate poorer section – because the people of the village are not adequately informed about role of modern medicines and health centres,[Antia and Bhatia (1993)]. The role of village leadership (panchayat) in disseminating information on the benefits of modern medicine was limited to employing the lower level employees at health centres with no oversight on health awareness [Bose et al (1981)]. The trained doctors and nurses coming from the urban areas often were detached from the needs and perceptions of local populace and contributed to the distancing of service providers and the recepients. Banerjee (1985, 1986) and Antia(1993) attributed this to overemphasis on the western reference systems of medicine. GOI (1989) reveals that although the statistics of illness reported increased in rural areas (64 per thousand as compared to 31 per thousand in urban areas) the proportion of rural illness treated was much less when compared to urban population that reported to public health facilities (81% as against 87%).
The The medical education needs to be reoriented towards the needs of the villagers and their capacity to utilise the services. At the same time, villagers also must be made conscious about healthy living.
Lack of Clear Implementation Plan
The staff at the health centres often lack clear goals in front of them. More often than not, they are presented with multiple objectives and tend to overemphasize one at the cost of others. The presence of family planning services is an example of this. Excessive emphasis on family planning and its target -orientation leads to a misplaced emphasis of health workers. Poorer sections, by and large illiterate, and unable to appreciate the utility of family planning, become disturbed by this repeated pressure from the health workers for adopting family planning devices stop visiting health centres leading to inequalities in utilization. [Banerjee (1992), Gupte (1995)]. Presence of such conflicting objectives disrupts service delivery.
Behind underutilization of Public Housing Facilities :
Some Interesting Facts
The need for housing is more pronounced in urban than in rural areas. Rural masses in India have land and some form of housing within their access, though often not of the pucca variety. The urban poor, mostly migrants in search of jobs lack even a decent living space. The need for housing is so great and the share of public sector housing activity so low that the availability gap is going to affect the housing availability for a long time. Currently, majority of housing activities are carried out in the private sector, which automatically excludes the weaker sections of the Indian population [ Kumar (1989)].
Even for this inadequate effort towards public housing, the schemes encounter a large number of impediments leading to utilization anomalies. Housing is an activity which is crucially dependent on a large number of factors like ownership of land, security of tenure and legal requirements that deter the entry of weaker segments in accessing public housing. In the context of urban poor, the Task Force on Housing and Urban Development (1983) noted that :
“From time to time in recent years, legal impediments have been recognized as factors inhibiting the poor from improving their housing. These include zoning regulation, standard of services, minimum plot sizes, maximum densities, building byelaws, construction standards and so on. Although relaxation of standards to suit the circumstances of the weaker sections have often been recommended, it is seen that progress has been slow. In the absence of this essential and urgent reform, even minimum housing continues to be beyond the reach of the urban poor” (Task force Report IV : XIX).
Access to Land as precondition
Land policy also crucially affects the utilization pattern of housing facilities. Land is a scarce commodity in urban areas. The Government introduced the Urban Land Ceiling Act, 1976 to acquire to ensure a more equitable distribution of the surplus land through redistribution of acquired land. In practice, however, very little land has been acquired by the Government and its redistribution has mainly benefited the richer sections of society [Task Force (1983) : XVIII)]. In recent times, the National Housing Policy (1988) has once again reiterated the need for an equitable distribution of land. But without ensuring equity in land distribution, utilization of benefits of the housing schemes by weaker sections remains challenging.
Regulations and Red Tape
The presence of too many regulations for availing public benefits also leads to poorer utilisation by weaker sections. Lall (1984 : 112) noted various norms like minimum plinth size, initial down payment, acceptable collateral, strict repayment schedule create difficulties for the poor. Bakhru (1984) while reviewing the Peoples Housing Scheme in Karnataka finds inconsistency in rules of the housing schemes for the poor. In reality, the authorities have imposed an impractical frame of implementation which led to the exclusion of target groups from the schemes.
Implementation of housing schemes have often ignored the importance of location. Policies have given high value to legal tenures and low value to locational aspects of housing . Observers of weaker section housing schemes have noted that location is more important to the urban poor than security to tenure because of the huge transport cost associated with distance from work place [Wadhwa (1988)]. The urban poor are willing to trade security to tenure for locational advantage [Mohan (1977)]. The lack of recognition of the location factor has diluted the success of policy implementation. The policy designswithout locational concerns have resulted in transfers where the beneficiaries sell off their house in urban fringes and go back to the location near their workplace at the heart of the city. This is probably the reason for which the schemes meant for the weak quite often ends up in the hands of relatively higher income groups. (Report of the Working Group on LIG and MIG : 1976).
Tenure Concerns in Slum Redevelopment
For the urban poor, insecurity of tenure is a factor which creates significant utilization gap. The housing schemes often involves a proportion of investment by the beneficiary which a person having tenurial uncertainty hesitate to provide. This is mostly true for urban slums in which security to tenure is doubtful. The Slum Areas (Improvement and Clearance) Act, 1956 made Government the only competent authority to evict slum dwellers in notified slums. But many slum dwellers in non-notified slums do not get any such protection. Eviction without proper rehabilitation has been a common feature of slum redevelopment [Bapat (1985), Abraham (1985), Dogra (1986)].
Neglect of Low Cost Technology
The development and promotion of low cost building materials for weaker sections has remained a neglected aspect of housing. Although there are several proposals on low cost building materials for public housing from housing research institutions in our country, the research failed to find traction in policy choices and as a result, the fruits of their research are yet to be translated into action. Promotion of low cost housing materials will also reduce the inequality in utilization of public housing facilities by making them cheaper and accessible.
Why the Indian Poor Fails to Get Ration
when the affluent has access to PDS?
The food distribution system disproportionately favors the urban residents regardless of any income criterion. Weaker sections in rural areas pay a higher price for foodgrains as procurement operations tend to push up market prices. So their dependence on the market makes them worse-off in an economy with rationing. [Subba Rao (1980) de Jenvry and Subba Rao (1985)].
The utilization data presented below gives a picture of low level of dependence on PDS by the rural poor as well as rural rich. While the unwillingness of rural rich who are net sellers of foodgrains for not buying their requirements from the PDS seems quite normal, for the rural poor, however, this is not the case as they are net buyers of cereals and dependence of market seems to be the result of compulsion rather than choice. The market dependence and purchase from PDS by different sections of the rural and urban population are still considerably high.
Irregular Supplies
The major reason for not depending on PDS is the irregularity in the supply both in respects of time intervals and quantity [PEO (1985)]. This is more pronounced in rural than in urban areas (NSS 42nd Round). Amar (1983) has shown that PDS supplies did not consider the seasonality of demand in rural belt.
Problem of Bulk Sale
The bulk sale of rationed foodgrains once in a month or a fortnight also creates difficulties for poorer sections who are used to buy small quantities on a daily basis [Venugopal (1992)]. This sale in bulk quite often leads to an utilisation gap with weaker sections using PDS infrequently.
Information Gap
The poor also face an information gap which is a very important factor causing for utilisation gap [Mayur (1986)]. Quite often, in villages, the ration shop owners do not declare arrivals of commodities in the fair price shop, wait for a small period and then sell the items in the black market. [PEO (1985)] has attributed poor offtake of essential items to this informational gap.
Legal Impediments
In the urban areas, a major reason for the utilization gap is the illegal nature of residence of slum dwellers. Many of the new migrants the city do not get ration cards and remain outside the public distribution system.
Seasonal Migration and Utilization Gap
With the introduction of new technology in agriculture, seasonal rural to rural migration has also gone up significantly. Then agricultural laborers migrate from labor surplus to labor deficient areas at least three times a year. Consequently, for about six months they remain outside the PDS. NSS 42nd Round (1986-87) therefore shows that a large proportion (one fifth) of urban respondents have pointed out non-entitlement of ration card as the major source of the utilization gap.
Concluding Remarks
The distribution of basic necessities of life is of crucial importance in a developing country like India where a large segment of the population are extremely poor and are unable to fulfill the base minimum standard of living. Provision of facilities like food, housing and health care to them can have a strong positive impact on their quality of life well as on human resource development. Unfortunately, even after four decades of independence, considerable inequalities persist in the access to basic necessities of life among different sections of the population in the case of health care, housing and food distribution. The paper tries to underscore various facets of “ utilization gap” in the provision of welfare services in India. It tries to explore the reasons behind the poor utilization of scarce public welfare resources in the country, both in rural and urban areas. Policy inadequacies and implementation gaps both contribute towards the continued exclusion of poor from public welfare services.
BIBLIOGRAPHY
Amar, G. K. (1979) : Public Distribution System for Essential Commodities : Some Relevant Issues, Working Paper Series No. 1, Indian Institute of Public Administration.
Antia, N. H. (1993) : The Consumer Net, Economic Times.
Antia ,N. and K.Bhatia(1993) :Peoples Health in Peoples Hands
Bakhru, M (1984) : Distribution of Welfare: Peoples Housing scheme in Karnataka, Economic and Political Weekly,Vol.XXI, No.10 , March 10 and 17, 1984.
Bose, A. et al (1978) : An Assessment of the New Rural Health Scheme and Suggestions for Improvement, New Delhi.
Bose , A.et al. (1981) : Health Services in Rural Areas ,(Mimeo), Institute of Economic Growth.
Bose A & P. B. Desai ed. (1982) : Studies in Social Dynamics of Primary Health Care, Delhi, Hindustan Pubhlishing House.
Government of India (1973) : Committee on Multipurpose Workers Under Health and Family Planning. Programme (Kartar Singh Committee) New Delhi, Ministry of Health and Family Planning.
Government of India (1975) : Health Services and Medical Education : A Programme for immediate action, Shrivastava Committee Report, New Delhi, Minister of Health & F.P.
Government of India (1976): Report on Task Force on LIG and MIG Scheme , Ministry of Works and Housing.
Government of India (1977) : Health Care Services for Rural Areas, New Delhi, Planning Commission.
Government of India (1979) : Primary Health Care in India. Ministry of Health and Family Welfare.
Government of India(1979a): Report of the Committee on Controls and Subsidies,
Government of India(1981): Report of the working Group on Health for All by the Year 2000 A.D., Ministry of Health and Family Welfare.
Government of India (1983) : National Health Policy Lok Sabha Secretariat, New Delhi.
Government of India (1985) : Bullatin on Food Statistics, Ministry of Agriculture, New Delhi.
Government of India(1988) : National Housing Policy. Ministry of Housing and Urban Development.
Government of India(1991) : Health Information of India. Central Bereau of Health, Intelligence, Director General of Health Services.
Griffin C.C. (1992) : Health Care in Asia : A comparative Study of Cost and Financing, World Bank Regional and Sectoral Studies, The World Bank, Washington D.C.
Housing and Urban Development Corporation (various year) – Annual Report and Accounts.
Jain A. K. (1985) : `Determinants of Regional Variation in Infant Mortality in Rural India’, Population Studies, 39.
Jena B. and R.N.Pati (1987) : Health and Family Welfare Services in India, Ashish Publishing House.
Kapur, Indira (1989): Factors responsible for low utilisation of Health and Family Welfare Services in India In Jena and Pati (Eds) Health and Family Welfare Services in India ,Ashish Publishing House.
Lall, Vinay D (1984) : Housing Finance in India, National Institute of Public Finance and Policy, New Delhi.
National Housing Bank (1992) : Report on Trend and Progress of Housing in India.
National Building Organisation (1988) : Directory of Institutions providing Finance for Human Settlements in India, Ministry of Works and Housing.
National Building Organisation (1988) : Significance of Housing and Human Settlements, Ministry of Works and Housing.
National Building Organisation (1989) : Metropolitan Housing Statistics, Ministry of Works and Housing.
National Planning Committee (1940) : Public Health.
National Sample Survey Organisation, (37th Round, 1981-82) : Report on Land Holdings-2, Some Aspects of Operational Holdings, 37th Round, Report No. 33, October 1986.
National Sample Survey (1986-87) (42nd Round) : `Results of Consumer Expenditure Survey’, Sarvekshana, Vol XII, No. 4, Issue No. 39, April-June, 1989.
National Sample Survey (1986-87) (42nd Round) : `Utilisation of Health Services’, Sarvekshana, Vol XII, No. 4, Issue No. 39, April-June, 1989.
National Sample Survey (1988-89) (44th Round) : `Results of Consumer Expenditure Survey’, Sarvekshana, Vol XII, No. 4, Issue No. 39, April-June, 1989
Reddy, P.H. (1989): Utilisation of M.C.H. and Family Welfare Services in Madhya Pradesh in Jena, B. and Pati, R.N. (Eds),Health and Family Welfare Services in India, Ashish Publishing House.
Shah,M.H.(1989): Factors responsible for low performance of Family Welfare Programmes in India, in Jena, B. and Pati, R.N. (Eds),Health and Family Welfare Services in India, Ashish Publishing House.
Subba Rao, K (1979) : `Producers Levery, Evasion and Income loss : Empirical Evidence from Coastal Districts of Andhra Pradesh’, Economic and Political Weekly, March 10.
Subba Rao, K (1980) : `What is a surplus State Public Distribution of Rice in Andhra Pradesh’, Artha Vignana,Vol XXII,March, page 111.
Suryanarayana, G. (1989) : Public Distribution in India, Chugh Publishers.
Talwar P.P. and S.C.Bhandari (1989): On Utilisation of Rural health services in Madhya Pradesh ,in Jena, B. and Pati, R.N. (Eds),Health and Family Welfare Services in India, Ashish Publishing House.
Task Force Report on Housing and Urban Development IV (1983) : Shelter for the Urban Poor and Slum Improvement, Planning Commission, Government of India, New Delhi, September.
Town and Country Planning Organisation (1984); A Compendium on Indian Slums, Ministry of Works and Housing, Government of India.
The Telegraph : Selected Reports on Health Situation in West Bengal, 1980.
Tyagi P.S. (1990) : Managing Indias Food Economy – Problems and Alternatives, Sage Publications.
Unied Nations Development Programme (1990, 1991); Human Development Report.
Venugopal, K. R. (1992) : Deliverance from Hunger : The Public Distribution System in India, Sage Publications.
Vyas, . and Bandopadhayay (1975):National Food Policy in The Framework of a National Food Budget, Economic and Political Weekly, Vol. X, No.13, March 29, Review of Agriculture.
U.N.D.P.(Various Years): Human Development Report.
Wilson, J. Q. (1989) : Bureaucracy : What Government Agencies Do and Why they do it, Basic Books.
Wadhwa, K (1988) : Housing Programmes for the Urban Poor – Shifting Priorities, Economic and Political Weekly, Vol.XXIII, No. 34,August 20.
Yesudian C K (1984) : Health Services Utilization in India, Ashish Publishing House..
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