By Abhijit Das
During the last week, the apparent success of the twenty-five years of economic liberalization has been extensively celebrated. Today, India is an economically much stronger nation, seeking to solidify its position as a global leader. However, this twenty-five year period also presents an opportunity to review our performance as a country in domains other than the economy.
Holistic Growth, or Lack Thereof?
Since countries comprise primarily of people, the health status of the citizens and the Human Development Index, or HDI (a composite index consisting of educational status, life expectancy and per capita income) can provide reasonable alternative paradigms for comparing change and progress.
In 1991, India’s HDI was 0.428. In 2014, it rose to 0.609—an increment of approximately 40% over a 23-year period. Life expectancy for the average Indian, which was a little over 58 years for men in 1991, has risen to over 69 years today. Thus, we are living a full 11 years more than we did, just 25 years ago. This is a remarkable achievement.
Lagging Behind in the South Asian Neighbourhood
However, these absolute figures are nugatory, unless they are compared to the progress of other nations in the same period. Undeterred in the face of a civil war, Sri Lanka had an HDI of 0.757 and a rank of 73 in 2014. In comparison, India ranked 130. On the life expectancy scale as well, it is leading at 72 years.
Bangladesh and Nepal, which are in no way comparable to the economic might of India, too, provide interesting comparisons. Bangladesh continues to rank lower than India, having moved from 0.386 to 0.570 between 1991 and 2014. The same is true for Nepal – it moved from 0.384 to 0.548 in the same period.
But what is truly noteworthy is that the annual change in HDI has been 1.49% for Nepal, 1.64% for Bangladesh and 1.48% for India.
Hence, even Nepal seems to have performed better than India on the Human Development Index. This is despite the fact that it is amongst the poorest countries in the world, marked by political turmoil and disorder.
An alternative set of indicators for understanding and comparing change, in this period, lies in the domain of health. The Millennium Development Goals (MDGs) on maternal and child health (MDG 4 and 5) called for a definite reduction in maternal and child mortality from 1995–2015. Looking at Bangladesh and Nepal, there has been a considerable decline in maternal mortality. Bangladesh moved from 556 deaths (for every lakh childbirths) in 1995 to 174 in 2015. Nepal, too, moved from 901 to 258 deaths. In India, this decline has been from 556 to 174, similar to that of Bangladesh. However, the annual decline in India is the lowest among these three nations.
A Long Way to Go?
The situation is similar for the reduction in the deaths of children under 5 years. India witnesses the lowest annual percentage decline. Population control has been India’s health policy in the form of the Family Planning programme for many years.
It is surprising to note that despite this, data regarding contraceptive use and reduction of child-bearing among women, has been in favour of Nepal and Bangladesh. In 1995, the data showed 4.7 children for every mother in Nepal compared to 3.7 children in India. In 2015, Nepalese women had 2.2 children compared to 2.4 for Indian women. This is a remarkable turnaround.
According to the data on health expenditures from 2013, the average per capita health expenditure in India was $215.
When adjusted for Purchasing Power Parity (PPP), this is much higher than the numbers in Nepal ($135) and Bangladesh ($95). The data seems to indicate that both these countries are doing something dramatically different. At the same time, despite its technical and financial superiority, India still has a long way to go.
Getting the Health Sector Out of its ‘Critical’ Condition
From the data that is available, 3 broad areas appear to be different in the case of Bangladesh and Nepal when compared to rural India.
For one, the proportion of out-of-pocket expense, or conversely, the government contribution to health care, is much higher.
In India, the proportion of healthcare cost supported by the government is a measly 30%. This proportion is amongst the lowest in the world.
Even in the US, which has a predominantly private health care model, the government contribution exceeds 60%. In the UK, it is an even higher 85%. To paint a further dismal picture of India’s health status, more than 40% of the total healthcare costs are met by the Government, even in Nepal. Thus, the first lesson is evident. Without substantially increasing the healthcare budget, the improvement in the health status of the poorer Indian will continue to trail.
Reading Between the Gaps
The monitoring of the MDG progress of different countries provides an opportunity to compare performance across different healthcare indicators.
The juxtaposition of maternal and child health-care in India, Nepal and Bangladesh, furnishes two insights worth noting. Equity in health-care indicates the gap in coverage between the rich and the poor. An equity comparison across 10 indicators of care, ranging from antenatal care to care of children with pneumonia, shows that Bangladesh and Nepal surpass India with a ratio of 7:3 and 6:4, respectively. For most of the indicators, the coverage and equity are much higher in these countries.
This gap not only reflects the differences between the rich and the poor but also indicates a plethora of other gaps. These are gaps between the rural and the urban, the slums and colonies, between Dalit, Adivasi and other marginalized communities and the mainstream, between forest dwellers and others living in remote areas to those in more accessible places. These differences culminate into what is often known as social determinants of health. These factors are shaped by conditions in which people are born. They are determined by where a person works, lives and grows.
These gaps are not only inequitable but also avoidable. They are determined by the choices a country makes in its distribution of resources. Thus, it would appear that despite all our economic strengths and dizzying growth, we are more unfair as a nation as compared to our more humble neighbours.
An additional lesson arises from the areas in which we seem to be clearly lacking. India is trailing on those indicators which require little technology and higher community level effectiveness—the early initiation of breastfeeding, higher immunization, and greater use of oral rehydration therapy. Meanwhile, it is clearly ahead in a technical intervention like care seeking in pneumonia. Today, India is often praised in the international arena for its success in reducing maternal mortality. Nonetheless, a closer examination indicates that the reduction is low in areas where the maternal mortality was already very high.
The push for technical solutions like universal institutional delivery in all areas of the country through the Janani Suraksha Yojana (JSY) incentive and the Janani Shishu Suraksha Karyakram (JSSK) does not appear to have provided better results in the areas that need it the most, bringing us back to the question of equality. The National Rural Health Mission (NRHM) and its successor National Health Mission (NHM) do provide some boost to the flagging health system. However, they failed to ameliorate the health status of the citizens. This is especially true when a comparison is made with our regional neighbours.
As a nation, while we should certainly celebrate our successes over the past 25 years, we also need to introspect and calibrate our aspirations for the future. Can we morally justify the fact that the poor in India seem to be getting a far worse deal than the poor in countries in the same region, while we claim our economic growth is parallel to none?
Dr Abhijit Das is Director of the Centre for Health and Social Justice, in India and Clinical Assistant Professor of the Department of Global Health at the University of Washington, Seattle, USA. He is also Co-Chair of MenEngage Global Alliance, a network of organisations working with men and boys on gender equality, and Convenor of COPASAH, a global health rights and social accountability network.
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