Find the side effects

Indian Express, 10 August 2009

A recent amendment to the NREGA includes working on small and marginal farms as permitted activities under the Act. There remains, however, a lot to be done in the sphere of providing public goods in Indian villages. The most important public good that needs urgent attention is rural sanitation. This should be on the top of the priority list of the NREGS. Not only will this fill part of the gap in the rural health policy, the NREGS is better suited for this work than the myriad central government schemes that have tried to address this issue.

India contributes about 25 percent of the world's child deaths. Among the most important causes of child death in India is diarrhea. In 2006, 33 percent of Indian children under the age of 5 received diarrhea treatment. The disease needs to be addressed by improvements in sanitation. UNICEF says that easy measures like sanitation can prevent 90 percent of diarrhea deaths. However, India's rural sanitation programme has not been successful. In 2006, only 18 percent of the country's rural population had access to sanitation.

One of the main reasons for the failure of rural sanitation schemes has been attempts to implement schemes designed at the centre or state capitals which are unable to take account of local conditions. The one-size-fits-all approach, such as, when subsidies are given for construction of facilities by BPL families has not resulted in increased usage or improvements in outcomes measured by health status. For example, there are instances of centralised schemes which understood the importance of sanitation and built septic tanks and latrines, but these were never utilized, as the community was not involved in the decision-making process. The lack of awareness about hygiene and sanitation is pervasive. The task involves not merely construction of facilities as a mechanical task to get a subsidy from the government, but of education and awareness. This can, to some extent, come through involvement in decision making.

The power of the NREGS is that the projects taken up are conceptualised at the local level. In this regard, the NREGS has an advantage over Central or State government sponsored schemes, which cannot create public assets suited to the needs of each village. Although some of these top-down schemes mean well, they still do not have the potential for taking account of local conditions and needs. Effectively, the NREGS provides untied money to the block or village as long as the money is spent on labour intensive work.

While it has been seen that in developed countries one of the most important contributions by the government to improvement in public health status has been through interventions that lead to better sanitation, cleaner drinking water and reduction of rats and mosquitoes, in India health policy has focussed on medical services. Any discussion of a health budget for rural areas allocates funds for tangible assets such as new clinics and wards, as well as towards subsidies on medication and treatment. The number of doctors or nurses, the number of hospital beds and primary health centres have been the focus of health policy and health reports. The policy has not been about doing what it takes to improve the health status of the population. Instead of preventing a diseases from spreading, the government takes credit for providing medical care once a child has fallen ill.

The first step in meaningful public intervention for improving rural health is not to provide subsidised treatment and medicine, but to prevent the occurence of such diseases by focusing on preventive measures. Simply by ensuring clean drinking water and proper segregation of waste, we can prevent many episodes of diarrhea. Similarly, malaria can be averted through good drainage systems. The focus of public policy needs to be clean drinking water, well-functioning drainage and sewerage, systematic garbage disposal and elimination of pests.

Under the NREGS, several measures can be implemented that aim to improve sanitation - cleaning of community ponds to prevent stagnation, as well as drainage of unused tanks, building cement-lined gutters on the sides of roads to channel water and prevent collection of waste, and building culverts for streams which otherwise spill onto roads. These are public goods. They are a classic case of market failure where no individual will provide them at her own expense. They impact the health of the whole community, and only the state can sponsor them in an effective, consistent manner. By using the NREGS, which mandates local decision-making, we can ensure community participation and efficient allocation of resources.

Other health measures under the NREGS can also include the decision to create assets which are private goods having externalities, for example covered pit latrines and ditches for irigation. These may belong to a particular household or family, but their construction and use improves the health of the whole village. Along with such creation of assets, mainatainance work such as proper garbage collection and disposal, which prevents pests and thus outbreak of epidemics should be included.

All the above works fit the mandate of the NREGS, which emphasises on work that does not require any special skills, and on creation of public works proposed by local government. The only thing that needs to change in the focus of the government towards public goods, both in the case of using NREGA funds and in health policy.

In summary, a focus on rural sanitation under the NREGA has the potential of solving one of rural India's most important problems. It allows expenditure for creating cleaner villages taking into account the needs of the community and the enviroment. It has a greater chance of success than sanitation schemes that have failed in their mission. Along with a change in focus in NREGA, the government should put in place awareness campaigns that support this focus. This will help make up for the biggest gap in its health policy which has failed to provide effective intervention in this field.

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