Can Short-term Economic Policies Hurt the Health of the Poor? Demonetization in India

Abstract

In November 2016, the Government of India (GOI) demonetized the commonly used Rs500 and Rs1,000 denominations. This was a short-term economic policy, known as notebandi, implemented as a means to address black money, counterfeit currencies, and terrorist activities. Notebandi was unrolled in a chaotic, confusing, and complex manner, leaving many people with limited access to cash in their daily activities. And the poor, who tend to earn their livelihoods from cash, were faced with economic exclusion and even destitution. In this paper, we argue that demonetization had disproportionately negative consequences on the poor and trace the main pathways between demonetization and the health of the poor. We conclude by calling on public health researchers to monitor and evaluate the health consequences of India’s latest demonetization and to rapidly assess future policy initiatives in order to help advise governments in devising and implementing economic policies that does not harm the health of people, especially the poor.

Keywords

economic policy health India demonetization

On November 8, 2016, during a live, unscheduled televised event, the prime minister of India, Narendra Modi, made an announcement: all Rs500 and Rs1,000 banknotes were demonetized. Demonetization involves stripping a currency of its legal tender. In India, this meant that the Reserve Bank of India (India’s central bank) officially withdrew the commonly used Rs500 and Rs1,000 denominations, 86.4% of the country’s currency. The Government of India (GOI) initially rationalized demonetization as a “surgical strike” against black money (which in India refers to money for which people have avoided paying taxes on), counterfeit currencies, and terrorist activities (which the GOI argues is funded by black and counterfeit money).¹ There is broad consensus that action needs to be taken to address India’s black money – estimates of black money range from a quarter to three quarters of the country’s gross domestic product.² Apart from inflationary impacts in certain sectors (e.g., real estate, gold), black money reduces government revenues that could otherwise be used for public services and infrastructure in health and social sectors, thereby exacerbating inequalities. Following the implementation of its demonetization plan, Modi apparently modified the government’s justification of demonetization, as a way to move towards a “cashless society.”

A number of key Indian economists have spoken out in support of the latest demonetization as an important step in the fight against corruption and money, including Arvind Vimani, Bibek Debroy, and Surjit Bhalla. While other leading economists, such as Amartya Sen, Jean Drèze, Kaushik Basu, Jayati Ghosh, Prabhat Patnaik, and Arun Kumar, have spoken out against the harmful effects on India’s economy, the inability of demonetization to curb corruption, as well as negative consequences on the poor. In this article, we focus our attention on the public health implications of demonetization in India. Assessing the health consequences of economic (and other non-health sectors) policies are part of a “health-in-all-policies” approach to improving population health that moves away from a purely sectoral approach and toward viewing health as a central societal goal that requires consideration in policymaking agendas across levels of government and the private sector.^3,4 This approach echoes calls for increased involvement of public health researchers in assessing economic policies.⁵ We draw on pieces of evidence that emerged immediately following the implementation of demonetization as well as the broader literature on economic policies and population health. We are unable to draw on experiences of other countries who have demonetized their currency (see Table 1), due to a lack of research on the population health consequences of demonetization.

Table 1.

Select Global Experiences in Demonetization.

County and year of demonetization	Official rationale	Implications for economy	Broader social consequences
Ghana, 1982	Reduce liquidity; curb tax evasion, corruption, and currency smuggling	Loss of confidence in banking system, boom in black market	Led people to hold physical assets and foreign currencies, and to conduct business on a cash basis
Nigeria, 1984	Address debt burden and inflation	Collapse of economy	Helped fuel a coup in 1985
Myanmar, 1987	Curb tax evasion and currency smuggling	Severe inflation, rising food prices, influx of Chinese goods	Fuelled uprisings and protests against government in 1988 that led to fatalities
Russia (previously USSR), 1991	Combat parallel economy	Economic collapse, hyperinflation	Job losses, erosion of confidence in state, long-term political consequences

Source: Government of India,1 Ayittey,6 and Abdelal.7

India’s Poor

Over the past 30 years, the World Bank has documented important global declines in poverty rates, particularly extreme poverty.⁸ In India, income poverty rates have also declined to under a quarter of the population (depending on the measure used, estimates range from 21.2% to 12.4% for 2011–2012), while adopting a multidimensional lens to poverty analysis (which encompasses health, education, and living standards) suggests that the decline in India has been much slower.⁸ Drèze and Sen⁹ argue that regardless of how the poverty line is measured and despite the country’s economic growth, the decline in poverty rates has been slower in India compared to other low- and middle-income countries over the past 20 years. The poor are predominantly engaged in work in the unregulated informal and unorganized sector, which operates on a predominantly cash economy, lacks labor protection, and engages over 90% of India’s workforce.^9,10 This type of work often necessitates the poor to adopt multiple livelihood strategies for survival. Surviving on a dollar or two a day is not easy; most money is allotted to the basics of life, notably food. India’s poor, however, tend to manage their money through complex savings and borrowing habits of their small, irregular, and often unpredictable incomes, thereby enabling them to cover expenses, such as medical costs and marriage ceremonies.¹¹ Many poor – especially in rural areas (where there are still unbanked villages) – lack adequate access to formal financial services and access to credit (Table 2). In a move toward financial inclusion, the GOI and the banking sector have been developing policies and approaches to improve access to financial services among the poor and “hard to reach groups,” such as including options for no-frill bank accounts with low or zero minimum balance and fostering formal bank linkages with microcredit groups.¹² And while government schemes have increased the number of bank accounts, the number of people with bank accounts hovers at just over 50%, with the majority of new accounts lying empty. Women in particular are unbanked due to a variety of reasons, including lack of banking literacy, difficulties in accessing banks, and male control over banking and finances that often requires women to obtain permission to open and operate an account.¹³

Table 2.

Literacy and Financial Inclusion, Selected Indicators.^a

Indicator	Percentage
Literacy rate, 2011	74
Females	65
Males	82
Holds an account at a financial institution, 2014	52.7
Females	42.6
Males	62.5
Poorest 40%	43.8
Richest 60%	58.6
Rural	49.8
Holds a credit card, 2014	4.2
Holds a debit card in own name, 2014	19.7
Females	9.3
Males	29.7
Poorest 40%	8.7
Richest 60%	26.8
Rural	12.8

^aAll indicators are for individuals who are 15 years or older.

Data source: Census of India (2011); World Bank financial inclusion indicators, available online: http://datatopics.worldbank.org/financialinclusion/.

Demonetization in India

Demonetization has been done before in India, just prior to independence and again in 1978 (see Box 1). Modi’s scheme, notebandi, differed due to its secrecy, speed, and scale. Demonetization came as a sudden shock, without forewarning Indians to prepare. According to Modi, demonetization would lead to overall gains, albeit with some short-term pain – a phrase often quipped during the era of structural adjustment programs (Following the second oil crisis, many low- and middle-income countries heavily in debt with skyrocketing inflation implemented structural adjustment programs, a series of policy interventions, principally designed by the World Bank and the International Monetary Fund, to restructure economies through privatization, liberalization, and retrenchment of the state. The short-term pain of structural adjustment programs was supposed to lead to economic stability and growth. Instead, structural adjustment programs failed to deliver on promises of economic growth in sub-Saharan Africa and Latin America, and created havoc on health care systems, with deleterious effects on the health of the poor). In this case, Modi specified the period of time that people would need to suffer: 50 days. People had until the end of December 2016 to exchange these banknotes for new ones. Compared to previous demonetization efforts, the bank notes pulled out of circulation represent the majority of bank notes in circulation (Box 1), and the Rs500 note can hardly be described as a “high bank note,” since it is commonly used, even by the poor. As Modi began to emphasize modernizing India toward a cashless society that relied on digital transactions, the speed of notebandi seemed a strange logic for a country for which over 90% of transactions were cash based. Box 1.

A Short History of Demonetization in India.

January 12, 1946: Following World War 2, inspired by the United Kingdom and other European nations, high bank notes (over Rs500) were demonetized in India as a way to curb black money and tax evasion. According to Sir C. D. Deshmukh, the first Indian to be appointed as the governor of the Reserve Bank of India (RBI), demonetization: . . . was really not a revolutionary measure and even its purpose as a minatory and punitive gesture towards black-marketing was not effectively served. There was no fool-proof administrative method by which a particular note brought by an individual could be proved as the life-savings of the hard-working man who presented it or established as the sordid gains of a black-marketer. (cited in the RBI History, 1935–1951, p. 709)

January 16, 1978: Under Prime Minister Morarji Desai, leader of the Bharatiya Janata Party (BJP), the Government of India announced on the radio the High Denomination Bank Notes Act. According to this act, 3 bank notes of high denomination – Rs1,000, Rs3,000, and Rs10,000 – were demonetized. These notes represented about 0.6% of currency in circulation. People had 3 days in which to exchange their currency. I. G. Patel, who was the RBI governor at this time, disagreed with the act, stating that “such an exercise seldom produces striking results” given that people who are holding substantial amounts of black money rarely keep it in the form of cash.

November 8, 2016: Narendra Modi, India’s current prime minister and leader of the BJP, made a surprise television appearance to announce that the GOI demonetized 2 bank notes: Rs500 and Rs1,000, which represented over 85.4% of currency in circulation. People were given until the end of December 2016 to exchange their currency. The current RBI governor, Urjit Patel, has endorsed the demonetization, calling it a “very bold” step. Sources: Ghosh,² Bhattacharya,¹⁴ Reserve Bank of India,¹⁵ and Rajakumar and Shetty.¹⁶

In practice, notebandi was rolled out in a chaotic, complex, and confusing manner. There was a lack of preparation, including insufficient printing of new notes and several days required for recalibrating the ATMs post-notebandi for dispensing new notes. Frequently, facilities where notes could be exchanged were effectively closed prior to the deadline. Lines for banks and (often dysfunctional) ATM machines were distressingly long; bank machines quickly dried up. No direct exchanges were allowed without a bank account – individuals were required to deposit demonetized money into their account and subsequently withdraw from their account. Also, since not enough money had been printed, many bank clients found themselves facing strict withdrawal limits. Over the course of the money exchange period, the Reserve Bank of India revised guidelines for money exchanging and depositing 60 times. Often people were unable to queue in lines due to work obligations. For many women, queuing for long periods of time was not always feasible due to safety concerns, especially at night. People who were unable to change their money on time were forced to deal with brokers, which meant commission fees costing as much as 20% of cash exchanged. This left people with limited access to cash in their daily activities, and many of the poor, who earn their livelihoods from cash, were left without any money.¹⁷

Health Effects on the Poor

Ultimately, a successful demonetization that effectively curbs black money could portend positive effects on health. Tax dodgers – including many physicians who are often paid in cash – will be held accountable for paying their fair share of taxes, thereby enlarging the country’s tax base. These public funds could then be redistributed to a range of public goods and services, including programs that especially benefit the poor. This may include increasing public health expenditures and other objectives detailed in the 2017 National Health Policy. However, the latest data indicates that demonetization failed to capture the bulk of black money, which is held predominantly in real estate and foreign bank accounts.¹⁸ Furthermore, to sidestep government rules of trading in a maximum of Rs4,000 of demonetized notes, people used “money mules” – multiple agents charged with changing over smaller amounts of money that would not raise suspicion.¹⁸ One type of organization immensely benefitted from demonetization – online health pharmacies. However, some business experts think that though there is positive movement towards e-pharmacy, the country still lacks a robust health care system to secure its full growth.

The chaotic manner in which demonetization rolled out has affected population health, especially the poor. We outline 6 key pathways in which demonetization has led to harmful effects on the poor.

First, since the majority of Indians are not covered by any form of health insurance, which would enable patients to seek care without cash (Table 3), out-of-pocket payments in a time of cash shortages created difficulties for uninsured (poor) people. There were reports of health care services being denied to patients who held old currency notes, especially at private facilities which were banned from accepting old notes.¹⁹ Since the majority of the population uses private health facilities (paying out-of-pocket), health needs were left untreated, leading to suffering and in some cases infant deaths (According to the latest NSS estimates in India, private facilities account for 58 percent and 68 percent of inpatient cases in rural and urban areas, respectively. For outpatient cases, the figures are much higher at 72 percent and 79 percent for the rural and urban areas, respectively).^{19–
21} Health care providers noticed increasing numbers of patients either opting out of or postponing medical procedures, such as cancer treatments, or drawing on credit,²² thereby exacerbating already high rates of medical impoverishment across the country.²³ Some patients reverted to the public health care system – which is typically viewed as much poorer quality – since use is largely free or with relatively lower charges. Old notes were being accepted at public facilities and pharmacies but only until a certain date (the date was revised several times). People who needed to travel for health care, particularly outside of their home state or territory, were especially vulnerable to additional cash distress. According to the latest round of India’s National Sample Survey (NSS) data (2014), 6% of hospitalizations and 4% of outpatient services are sought by patients outside of their home state – these rates are even higher for people living in smaller states and unions, notably Arunachal Pradesh, Chandigarh, Dadra and Nagar Haveli, Himachal Pradesh, Lakshadweep, and Pondicherry. According to the same NSS estimates, in a typical case of hospitalization, medicines – purchase of which was allowed through old notes – only account for slightly higher than 20% of the total cost. For many other components, such as doctor’s fees, transport, and other nonmedical expenses (which together account for a large share of hospitalization cost), old notes were not allowed.

Table 3.

Percentage Distribution of Persons, by Health Insurance Status, 2014.

Coverage	Rural	Urban
Not covered	85.9	82.0
Govt. funded insurance scheme	13.1	12.0
Employer (other than govt.) supported health protection	0.6	2.4
Arranged by household with insurance company	0.3	3.5
Others	0.1	0.2
All	100	100

Source: Authors’ estimates from National Sample Survey, 71st round (2014) unit-record data.

The sudden unavailability of cash also affected Indians’ capacity to cover medical care and associated costs, since borrowing money, notably through family and friends, as well as selling off assets are key strategies for covering medical expenses (according to NSS estimates, for 26% of the hospitalization episodes, the major source of finance was borrowing money, selling assets, and similar means). Being denied timely access to care can have long-term effects, such as worsening severity of health conditions and the erosion of people’s trust in the health care system.^24,25

Second, the chaos and unpredictability of how demonetization was rolled out led to stress and anxiety. Many expressed tension, since they had to suddenly cope with meeting daily needs without cash. Children expressed humiliation when they were sent home from school, since their school fees had not been paid.²⁶ Such stressful events can lead to a distortion of one’s sense of coherence, which according to Aaron Antonvsky²⁷ influences a person’s ability to make cognitive sense of their environment and their ability to manage this environment through control over available resources. Weaker sense of coherence can lead to poorer health status to address stressful external events, while a strong sense of coherence has been associated with better mental health.²⁸ Following demonetization, there were reports of rising anxiety and even suicides due to financial distress. In India, episodes of acute indebtedness have been identified as an important determinant of suicide²⁹ and have been observed among farmers experiencing agrarian distress.^30,31 By January 2017, food prices were plunging, leading to the crashing of farmer incomes and concomitant stress.¹⁷ Suicides and deterioration of mental health among populations following economic crises have been found globally, linked to rising unemployment and alcohol consumption,^32,33 and require critical community support and care initiatives in place – interventions that are lacking in India.³⁴

Third, demonetization thwarted the informal sector, where lack of cash freezes transactions. There were massive layoffs as firm owners and contractors were unable to pay laborers, which particularly affected migrant laborers, Dalits (people with low caste affiliations or Scheduled Castes) and Adivasis (Scheduled Tribes). According to Barbara Hariss-White, demonetization struck the agricultural sector first; agricultural producers lost money due to a variety of factors, including time and travel costs required to exchange notes, distorted preparations for rabi crops, and declining marketing of produce, and reverted the selling of produce to bartering based on trust-based credit, which disadvantaged marginalized groups, such as Dalits.³⁵ Job layoffs among migrant workers and unorganized workers were massive, with masses of migrant workers forced to return to their place of origin, destitute.^36–38

Fourth, there were reports of people reducing their food consumption, particularly in rural areas and among migrant workers who were laid off and no longer able to find work.^26,37 While demonetization has certainly impeded people’s right to food, the fuller impact, in terms of nutritional levels and health, is difficult to discern in the absence of empirical studies.

Fifth, demonetization had specific effects on women. Women were forced to give up their hidden savings, a secret stash that many poor women have squirreled away from husbands or other family members who might otherwise squander the money. Since the majority of Indian women do not have bank accounts, hidden savings have been used as a key strategy for women to acquire financial autonomy and as their own safety net. Following demonetization, there were stories of women harassed and even beaten for having concealed money from the family.²⁶ According to the One Stop Crisis Center for Women (OSCC), cases of domestic violence spiked following demonetization, not only due to the revealing of secret cash savings as a threat to the control over wives but also because of the stress of job losses among men.^39,40 Historically, a variety of financial crises, especially in contexts where women have a low status, have demonstrated gendered effects that can especially harm the health of girls and women.⁴¹ As access to resources becomes increasingly constrained, female decision making can weaken and powerlessness can rise, leading to various impacts on health, such as rising domestic violence, rationing of household resources that prioritizes boys and men (food, access to health care), and increasing unsafe sex practices as girls and women engage in survival sex to help meet the basic needs of the family.^42,43

Finally, there are broader health equity consequences, since those populations that did not contribute to India’s black money problem – including the poor who are not expected to pay taxes – are left to suffer consequences.^17,18 Some populations have been particularly hard hit, including refugees (lack documents to exchange money), Scheduled Tribes (lack bank accounts), daily wage workers (no work), farmers, and others working in the informal sector who depend on cash and have been subject to heavy job losses.

Those whom the policy was attempting to target (i.e., the wealthy with large amounts of black money) appeared to have been left untouched as they hide their “black money” in land titles, off shore accounts, gold, etc.

Conclusion

Notebandi is illustrative of how even a short-term economic policy can wreak havoc and impact the health of the poor. While the scheme was temporary and unique to India, the implications are far-ranging as it is part of a broader strategy to shock the country’s economic system. Furthermore, experiments with radical economic policies are being pursued elsewhere, such as Japan’s recent attempts to spur short-term economic activity with a large injection of funds from the Bank of Japan as part of the country’s economic reforms known as Abenomics.⁴⁴ A key approach to improving the health of the poor is through the implementation of a pro-health economic policy. Demonetization in India diverges from other policy initiatives since it was not implemented as a response to a specific crisis that required quick intervention: tax evasion and the black market have been longstanding issues facing the country. Often it is difficult to separate out consequences of economic policies from the crises that spurred them. This case illustrates the need for undertaking health impact assessments on economic and other public policies a priori. Public health researchers should monitor and evaluate the health consequences of India’s latest demonetization and to rapidly assess future policy initiatives in order to help advise governments in devising and implementing economic policies that do not harm the health of people, especially the poor. Other countries could benefit from reviewing India’s experience and consider population health implications of any future tinkering with economic policies that may appear to have only negligible, short-term implications – but may potentially translate to suffering and long-term health consequences for its people.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

K. S. Mohindra is a global health researcher and consultant, specializing in subaltern health. She holds a PhD in public health (Université de Montréal) and has worked on collaborative, transdisciplinary research projects in Asia, Africa, and Latin America. She is the author of Women’s Health and Poverty Alleviation in India and is currently coediting the volume Handbook of Global Health Politics (with Ted Schrecker).

Subrata Mukherjee is an associate professor of economics at the Institute of Development Studies Kolkata. He is a founding member and former joint secretary of the Indian Health Economics and Policy Association and was engaged in the evaluation of rural health care provider training and community-based health care management initiatives in West Bengal. He specializes in the areas of perceived quality, inequality, and financing in health and health care, economic burden of chronic illness, and the health of the elderly.

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