Reimagining India: Unlocking the Potential of Asia’s Next Superpower (29 page)

I therefore propose a new metric by which to measure India’s progress in the coming two decades: the healthy life expectancy of a tribal girl born in Madhya Pradesh.

As imperative as it is for moral reasons to advance toward that goal, the potential benefits to society provide another powerful incentive, because poor health is exacting a rising toll on the Indian economy. In addition to being afflicted with disorders of underdevelopment, India is rapidly racing to the pole position in cardiovascular diseases and diabetes, with cancers, respiratory diseases, mental illness, and injuries also impairing productivity. Due to a high proportion of cardiovascular deaths occurring in the age band of thirty-five to sixty-four years, India is estimated to have lost 9.2 million potentially productive years of life in 2000 and is projected to lose 17.9 million years in 2030 (570 percent and 900 percent more, respectively, than the comparable losses in the United States). The cost of treating these diseases is also staggering, estimated at 254 billion rupees (about $5 billion) in 2004 and projected to rise rapidly over the next two decades.

Multiple handicaps burden India’s health system as it faces these challenges. Public financing of health, at 1.04 percent of gross domestic product, is among the lowest in the world, especially when measured in per capita terms. As a result, the average Indian consumer pays 70
percent of his or her health care costs out-of-pocket—again a mark of dubious distinction at the global level. About sixty million Indians are estimated to sink below the poverty line each year, due to unaffordable health-care expenditure, while one out of five Indians cannot afford even to seek medical treatment.

The health workforce is also deficient in numbers and maldistributed in favor of cities. There are shortages across the board of specialist and basic doctors, nurses, allied health professionals (such as technicians and paramedics), and community health workers. Public health expertise is not available for policy development or program design, delivery, and evaluation, since India neglected to establish schools of public health until very recently. Managerial expertise is sparse in the health sector. At 0.9 hospital bed per 1,000 population, India is well below the global norm of 3 per 1,000.

Yet positive trends abound, in addition to the international acclaim accorded Indian doctors. The state of Tamil Nadu offers a rare example of a well-run health system, with effective primary health-care services and free medication. The launch of the National Rural Health Mission (NRHM) in 2005 has improved access to maternal and child health services in many states with an increase in institutional deliveries and accelerated decline in infant and maternal deaths. Janani Suraksha Yojana (JSY), a central-government-sponsored program that offers cash incentives to encourage pregnant women below the poverty line to give birth in medical facilities rather than at home with an unlicensed midwife, has proved particularly effective. JSY, the world’s largest conditional cash transfer program, has unleashed the energy of nearly a million village women who act as social mobilizers (accredited social health activists) for stimulating health-care-seeking behaviors, especially for institutional deliveries and immunizations. Rashtriya Swasthya Bima Yojana, a national health insurance program that subsidizes hospital care for unorganized workers and other vulnerable groups, now has more than three hundred million beneficiaries.

Such developments offer at least a faint ray of hope for the firm commitment to universal health coverage expressed in India’s five-year
plan for the years 2012 to 2017. The plan proposes to make the National Health Mission (with an urban component now added to NRHM) the principal vehicle for its implementation. The plan also envisions increasing the level of public financing for health to 1.87 percent of GDP by 2017, though the recent fall in India’s economic growth rate is beginning to cast a cloud on that prospect. It is likely that the government will soon commence its efforts to reduce out-of-pocket expenditure by providing essential drugs free of cost at public facilities.

Though the Indian health system was originally designed to deliver most of the services through the public sector, resource constraints progressively weakened its capacity to do so. The private sector consistently grew in strength from the 1980s and has now become the major provider, by default. However, the care offered ranges from the unqualified solo rural practitioner to the large urban corporate hospital. The weak regulatory systems do not ensure quality or cost control. If universal health coverage is to be carried out in such a mixed health system, it is necessary to ensure that both public and private sectors work in tandem, within a well-designed and adequately regulated framework that ensures equity, access, quality, and affordability.

The need to overcome current financial and human constraints and rapidly advance the outreach and effectiveness of health services, especially in primary care, has become a stimulus for innovation. Widely cited in public health and business schools, for example, is the Aravind Eye Care model, which is based on the principle that clinics can subsidize care for the poor with funds charged to patients who can afford to pay. The success of low-cost, high-volume surgery, even in complex fields such as cardiac surgery, has won admiration in high-income countries that are burdened by escalating health-care costs. India’s strength in information technology and the ubiquitous use of mobile phones are the sources of several innovations in health service delivery and monitoring, which are now under evaluation for impact and scalability. The organization I head, for example, has undertaken an initiative to promote the use of a tablet device called the Swasthya Slate (
swasthya
is the Hindi word for “health”), which enables users to perform various diagnostic tests including
ECG, blood sugar, blood pressure, and heart rate. Rural clinics and community health centers can transmit data for individual patients to central servers once an Internet connection is established; doctors can then dispense care remotely.

All these favorable signs may come to naught, however, unless policy makers take far-reaching action on the social determinants of health, ranging from water and sanitation to nutrition and environment. From agricultural policies to urban development and from gender equity to energy policies that reduce indoor air pollution by replacing biofuels, action in other sectors can have a major impact on health. Substantial gains in health will accrue only by an effort throughout all of society that addresses the factors influencing health rather than just disease management.

Can India assure good health to every citizen at all stages of life, with every state matching Tamil Nadu for efficiency and Kerala for social determinants? Of course it can, but doing so will entail an enormous collective effort, dedicated to addressing the needs of that baby girl from Madhya Pradesh.

Salman Khan and Shantanu Sinha

Salman Khan is founder of the Khan Academy, a free online education platform. Shantanu Sinha is president of Khan Academy.

As the children of South Asian immigrants growing up in New Orleans, we benefited from parents who cared deeply about education, even though our public high schools were not exactly world class. When we met as sophomores on a national math team, however, that’s when things really got interesting. Suddenly each of us had someone who could challenge the other to see just how far he could go. At MIT, where we were freshman roommates, we competed to see how many courses we could take—and between us ended up getting seven degrees. We pulled each other up.

Now imagine a world where everyone is able to pull himself or herself up through online education. In such a world, a self-taught genius like the famous southern Indian mathematician Srinivasa Ramanujan, who died nearly one hundred years ago at age thirty-two, wouldn’t have to scribble his groundbreaking insights into number theory in a private notebook, isolated and uncomprehended by family and neighbors. He’d be able to connect, ask questions, and swap answers with teachers and peers, whether they lived in Tamil Nadu, California, or São Paulo. Instead of reinventing basic theorems, he’d have access to the entire sum of human knowledge, literally at his fingertips, and a community of global learners with whom to explore it.

That world, of course, already exists, and it’s benefiting not just a few geniuses but millions of ordinary people, including many in India.
Society is hitting another “printing press moment.” When the printing press came along, it broke the elite’s grip on the essentials of literacy and education, and made content available to a broadly dispersed population. Today the game is changing once again, thanks to the ongoing ed-tech revolution. Replicating for hundreds of millions of aspiring learners what a few thousand previously experienced in the lecture halls at Harvard, Massachusetts Institute of Technology, or Stanford through traditional teacher training and textbooks would require an absurdly large investment. But we no longer need to do that, now that all this information is available to anyone with a cheap laptop and an Internet connection.

True, universal access remains a challenge, especially in a country like India, where hundreds of millions lack even basic access to electricity. But Moore’s Law is on our side. We already have fairly sophisticated tablets that cost less than $100, and the cost of these devices is going to plummet over the next few years. Given this opportunity, at Khan Academy we’re continuing to make a huge effort to ensure that the right content is available, by creating freely licensed open-source education resources that can move out to the parts of the world that so desperately need them.

What’s really driving the advance of online education, however, isn’t simply broader access to great content but also the ability to combine that with intense personalization and real-time assessment. That’s when deep learning takes place. Think of it as ed-tech meets big data.

At Khan Academy, just as important as our growing library of four thousand–plus videos teaching math, science, and art history is the fact that we recently passed the one billion mark in terms of the number of math problems students have solved on our platform. We can track
how long it takes them on each problem, where people tend to get stuck, where they’re pausing and rewinding videos. Not only does this enable us to reengineer and continuously improve our broad approaches—by adding new hints, say, or by tinkering with our sequences—it also allows us to understand what
you
as an individual need and where
you
specifically are going wrong.

For example, maybe in algebra your big hang-up is that you never quite nailed fractions. With good assessment, we can get the prerequisites right, give you problems in the correct sequence, and also recommend, just as Amazon and Netflix do, the best possible additional readings and resources to help you learn quickly—and, most important, to retain what you learn.

But to complete the coming education revolution—to get to a world where individualized learning replaces one-size-fits-all lectures and where the goal is not simply to pass a “course” and get a “degree” but to develop mastery of a broad set of specific skills that you can continuously build upon—we need to do two more things: develop the right blended model of delivery and revise our antiquated system of credentialing.

No matter how good online systems get, they’re never going to entirely replace the need to combine innovative technology with some kind of active in-person interaction between students and instructors. That’s especially true for K–12 education. And to move away from thinking that the four years of college, plus graduate school, are the only time where advanced learning takes place to a world where you are constantly upgrading specific skills throughout your life, we need to agree upon a new system in which microcredentials, continuously updated, become what really matter.

And it’s here, in modeling these big societal shifts, where India should play an important role. First, it needs to continue accelerating access to the required technology, especially in its villages and rural areas. But even when that’s done, a billion-dollar challenge will remain: creating
enough mentors and teachers to really support these students, especially in English, which is the language you need to connect to a global community of learners. That won’t be easy. Scaling this human infrastructure will require a massive common effort on the part of governments, nonprofits, and businesses. But the good news is India does not have to build a thousand new Indian Institutes of Technology or turn millions of local instructors into deep-content experts. The skill building and assessment can come through online. What’s needed is a vast cadre of people sophisticated enough in an Internet world to help connect students to the resources they need and reinforce them as they connect the dots for themselves. For a country like India, this is a much easier model to scale up and a far more efficient way to reach the goal—an education system capable of more rapidly lifting the broad population versus just a top tier.

India’s other big opportunity is to show the way in addressing our antiquated system of credentialing. For more than a century we’ve used the degree as a kind of basic signal: If you attended an Ivy League college or one of IIT’s, a prospective employer assumes that you must be smart, so you will probably be a high-quality employee. But there’s always been a disconnect between the skills companies are actually looking for and what the education system delivers. This is a huge and growing global problem. Studying French literature may have been a great experience and made you a well-rounded individual, but you need different skills to join a call center or become a programmer. In general, traditional education is a terribly inefficient way to train a broad population and match those efforts against the skills employers truly need.

In India that problem is especially pronounced, in part because of the economy’s rapid growth over the past fifteen years and in part because of the shortcomings of its education system. Any Indian graduate who has even a vaguely technical degree is valued tremendously. Employers take them in, work with local universities to try to teach relevant
additional courses, train them for six months, and then, because it’s such an unbelievably competitive market, lose them six months later. In a country with more than one billion people, such a persistent shortage of trained talent suggests a daunting supply-side problem.