The Indian government aims to increase investments in its health sector to 2-3 per cent of the total GDP, according to union Health and Family Welfare Minister Ghulam Nabi Azad. That compares with current spending of 1.1%, so if true, it represents a massive leap.
Success has many fathers, and doubtless loads of people and organizations will take the credit, but two jump out. First the Wada na Todo Abhiyan or “Nine is Mine” campaign, which calls for increased spending on education and health – 6 and 3 % GDP accordingly. Second is Amartya Sen, who had an astonishingly timely piece in the New York Review of books this week. Excerpts below:
“The steadily rising rate of economic growth in India has recently been around 8 percent per year (it is expected to be 9 percent this year), and there is much speculation about whether and when India may catch up with and surpass China’s over 10 percent growth rate. Despite the evident excitement that this subject seems to cause in India and abroad, it is surely rather silly to be obsessed about India’s overtaking China in the rate of growth of GNP, while not comparing India with China in other respects, like education, basic health, or life expectancy.
Some statistics about China and India, drawn mainly from the World Bank and the United Nations, are relevant here. Life expectancy at birth in China is 73.5 years; in India it is 64.4 years. The infant mortality rate is fifty per thousand in India, compared with just seventeen in China; the mortality rate for children under five is sixty-six per thousand for Indians and nineteen for the Chinese; and the maternal mortality rate is 230 per 100,000 live births in India and thirty-eight in China. The mean years of schooling in India were estimated to be 4.4 years, compared with 7.5 years in China. China’s adult literacy rate is 94 percent, compared with India’s 74 percent according to the preliminary tables of the 2011 census. Only 66 percent of Indian children are immunized with triple vaccine (diphtheria/pertussis/tetanus), as opposed to 97 percent in China. Comparing India with China according to such standards can be more useful for policy discussions in India than confining the comparison to GNP growth rates only.”
Even more damning in some ways is Sen’s comparison between India and Bangladesh:
“In income, India has a huge lead over Bangladesh, with a GNP per capita of $1,170, compared with $590 in Bangladesh. This difference has expanded rapidly because of India’s faster rate of recent economic growth, and that, of course, is a point in India’s favor. But we must ask how well India’s income advantage is reflected in other things that also matter. I fear the answer is: not well at all.
Mean years of schooling amount to 4.8 years in Bangladesh compared with India’s 4.4 years. While India is ahead of Bangladesh in the male literacy rate for the age group between fifteen and twenty-four, the female rate in Bangladesh is higher than in India. Interestingly, the female literacy rate among young Bangladeshis is actually higher than the male rate, whereas young women still have substantially lower rates than young males in India. There is much evidence to suggest that Bangladesh’s current progress has a great deal to do with the role that liberated Bangladeshi women are beginning to play in the country.
What about health? The mortality rate of children under five is sixty-six per thousand in India compared with fifty-two in Bangladesh. In infant mortality, Bangladesh has a similar advantage: it is fifty per thousand in India and forty-one in Bangladesh. While 94 percent of Bangladeshi children are immunized with DPT vaccine, only 66 percent of Indian children are. In each of these respects, Bangladesh does better than India, despite having only half of India’s per capita income.”
But Sen acknowledges India’s lead over China in some non-GDP indicators, notably some forms of freedom:
“Most Indians are strongly appreciative of the democratic structure of the country, including its many political parties, systematic free elections, uncensored media, free speech, and the independent standing of the judiciary, among other characteristics of a lively democracy. Those Indians who are critical of serious flaws in these arrangements (and I am certainly one of them) can also take account of what India has already achieved in sustaining democracy, in contrast to many other countries, including China.”
Interestingly, he portrays the Indian system as messy and difficult in the short-term, compared to the more command and control approach taken by China, but sees the latter as ultimately more fragile – a fragility that “revealed itself in a catastrophic form in the Chinese famine of 1959–1962, which killed more than 30 million people, when there was no public pressure against the regime’s policies, as would have arisen in a functioning democracy.”
Sen also blames lack of democratic feedback for an important recent setback on healthcare in China (worth noting, given the recent exchange on this blog over health insurance in Ghana):
“The [Chinese] economic reforms of 1979 greatly improved the working and efficiency of Chinese agriculture and industry; but the Chinese government also eliminated, at the same time, the entitlement of all to public medical care (which was often administered through the communes). Most people were then required to buy their own health insurance, drastically reducing the proportion of the population with guaranteed health care.
In a functioning democracy an established right to social assistance could not have been so easily—and so swiftly—dropped. The change sharply reduced the progress of longevity in China. Its large lead over India in life expectancy dwindled during the following two decades—falling from a fourteen-year lead to one of just seven years.
The Chinese authorities, however, eventually realized what had been lost, and from 2004 they rapidly started reintroducing the right to medical care. China now has a considerably higher proportion of people with guaranteed health care than does India. The gap in life expectancy in China’s favor has been rising again, and it is now around nine years; and the degree of coverage is clearly central to the difference.”