Excerpt: Why India's Social Development Indicators Lag Behind its Neighbours

The following is an excerpt from the book UNEQUAL: Why India Lags Behind Its Neighbours by writer and activist Swati Narayan, published by Westland on November 27, 2023.

The health centre was a joke. The only living beings on the premises were grazing in the courtyard. ‘The sacred cows are the doctors,’ laughed my research coordinator, Ismael. The entire building was dilapidated—floors broken, walls collapsing, paint peeling and weeds growing in the rooms and roof. In the village we were visiting, this was the only health centre within a kilometre radius. The doctors and health workers had obviously abandoned this workplace despite continuing to draw a hefty government salary. The only other health facility was more than 14 kilometres away. Bihar does have better health centres. But in the Muslim-majority Kishanganj district, most government services we saw were similarly in shambles.

We also went to the homes of two accredited social health activists (ASHAs) who worked in the village as doorstep health workers. Neither of them had received any medicines for two years and we heard a litany of complaints. Their kits only had old oral rehydration salt (ORS) packets and a few government brands of condoms and contraceptive pills.

I was even more shocked when I walked up to a neighbouring house. Peeping through the window, I saw a severely disabled boy huddled inside a dark room. I was heartbroken to find that he had been kept hidden away like this. His mother, with teary eyes, asked us if we could help in any way. Unfortunately, I had to tell her that neither of us were medical practitioners but that we would love to speak to her son. When Bhim was brought to the courtyard, he flashed an unforgettable smile. I impressed upon his mother that, ideally, he should be exposed to some sunlight daily. 

Bhim’s unspeakably poor parents were at their wit’s end. There was no healthcare facility in the vicinity. They loved their son, but simply did not know what to do for him. I felt just as helpless. On the spur of the moment, I asked them to stand together for family photo. Later, I was able to print the grainy image along with a disability pension form to hand over to Bhim’s mother. But I knew fully well that, at best, these were only symbolic gestures of comfort. 

This was just one home. During our survey in Bihar, we met many families in similar or even worse predicaments, struggling with chronic ailments. They wage a daily battle against the criminal neglect of public healthcare in India. The poorest families pay the indescribably heaviest price. 

To reach this distant village, we had crossed a river on a precarious boat that two men somehow rowed using only bamboo poles. The narrow deck of the dinghy had been packed with fifteen-odd bicycles and a few motorcycles (including our own). A bevy of weary villagers with their jute sacks, chickens and household wares had jostled for space. It was a miracle we hadn’t toppled over. In the midst of the monsoon, such rickety boats were the primary means of transport across the flooded plains of Bihar. 

Travelling in the hilly regions of Nepal was equally tricky. One of the randomly selected villages for my survey was said to be three hours away from the district headquarters. But the journey ultimately took seven hours. After two hours on the rickety bus, we came across the raging Kamlamai river, which had flooded due to the rains. The veteran driver calmly stopped the bus midstream. Two conductors stepped out and, walking with meditative steps in the rushing current, surveyed the riverbed. After three hours of these rudimentary explorations, the driver finally figured out the best route to navigate the bus across the river. As passengers stuck inside, we had our stomachs in knots. Finally, when the bus reached the shore, all of us broke into a spontaneous round of claps. 

Despite the perilous terrain, this far-removed Nepali village had relatively good healthcare, in contrast to Bihar next door. When I suffered a sudden bout of severe vertigo, my Nepali translator Bijeta literally saved my life. The private pharmacy she took me to was a blessing, even with its limited stock of medicines. The shop even had beds in a room at the back to administer saline drips to patients. Later, when we finally reached the well-stocked government clinic an hour away, we met the health worker Gopal. Though he was not a doctor, he had 17 years of experience under his belt. Gopal used his stethoscope and blood pressure instrument to check my extremely low BP. Both his medical skills and endearing pidgin English lifted our spirits instantly. 

Many health posts in Nepal are also managed by junior doctors. Unlike India, the Nepali government insists that all private medical colleges offer some students free education with full scholarship. After completion of their degrees, these young doctors have to serve in rural areas as a part of their two-year mandatory government service bond.

Excerpted with permission from Unequal: Why India Lags Behind Its Neighbours, Swati Narayan, Westland Books, Context Imprint.

Swati Narayan is an academic and activist. Currently, she is an Associate Professor at the School of Public Health and Human Development at O.P. Jindal Global University.