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Tuesday, Dec 10, 2019

To grow, India must invest in public health

There is a clear pattern. Countries and states which have prioritised health saw a corresponding economic rise

columns Updated: Nov 29, 2019 19:09 IST
Ashok Alexander
Ashok Alexander
Malnourished children earn 20% less as adults than other children
Malnourished children earn 20% less as adults than other children (HT FILE PHOTO)
         

While there is much debate about the current state of India’s economy, it is pertinent to ask what factors might slow economic growth over the longer term. In this context, the poor state of our nation’s public health is important. Despite some vigorous steps by government, we still rank among the weakest performers in the world in crucial areas like maternal and child health.

Professors D Bloom and JP Sevilla (Harvard TH Chan School of Public Health) and D Canning (Queen’s University) studied more than 100 countries to prove that a one-year improvement in life expectancy of a population increases economic output by 4%. Researchers Amiri Shiraz (Iran) and UG Gerdtham (Lund University, Sweden) found that changes in under-five mortality impacted economic growth in over 85% of 180 countries studied. Malnourished children earn 20% less as adults than other children (Save the Children). Micronutrient deficiencies alone cost India 0.4% of its GDP each year, according to the World Bank. Investing in a child’s health and nutrition sets her up for a productive life.

China’s meteoric economic growth has more often been attributed to infrastructure building, and labour-intensive business models. Its remarkable health story is often overlooked. In 1949, when the People’s Republic of China was established, its health status was worse than that of India. Under-five mortality was 317 per 1,000 births (India was then 290), while infant mortality was 195 (India, 164, as per Gapminder). China consistently raised public health spending from 1.3% of GDP in 1960 to 3% in 1980, and has retained this level ever since (India today is at 1.2%). The new republic doubled down on prevention — focusing on health promotion, inspection and disease surveillance even in the most remote villages. In 1952, patriotic health campaigns were launched to get people to focus on sanitation and disease prevention. Informal rural medical workers with basic medical knowledge played a critical role in delivering health services at the last mile. China also invested early and aggressively in health insurance. India has lagged behind China by decades in aggressively pursuing such steps.

The results are evident. China’s Infant Mortality Rate (IMR) is as low as seven (in India, it is 30, as per The United Nations Inter-agency Group for Child Mortality Estimation). Its total fertility rate is down to 1.7 (in India, it is 2.2). The average Chinese citizen can expect to live till age 76 (in India, it is 69, as per United Nations/World Bank). Chinese men, on an average, even gained 3cm in height over Indian men in the two decades till the 1990s. This has a clear impact on GDP figures, where China now is way ahead of India.

The east Asian economic miracle is well-known; its investments in human development less so. Professors Roy Kelley (Duke University) and Bob Schmidt (Robins School of Business) deduced that 44% of growth in per capita income from 1960 to 1990 could be attributed to demographic changes, notably reduction in fertility rates. For instance, South Korea reduced fertility rate from 5.7 in 1960 to 1.1 in 2005 (Word Bank). South Korea launched its national family planning programme focused on ensuring that basic maternal and child health and information services reached its large rural, agrarian population. Its health care system has been ranked the best in the OECD, achieving universal health care coverage as early as 1989. Concurrently, it registered an average annual per capita GDP growth of over 5% — comparable to China (World Bank).

The stand-out example in India is Tamil Nadu. The state has the second largest economy in the country and routinely features among the top three large states on social indices. This wasn’t always the case. In 1960-61, Tamil Nadu’s Net State Domestic Product (NSDP) grew by only 0.1%. It grew each decade to stand at 5.8% in 1998-99 (Mospi). Related history: In 1967, CN Annadurai announced that rice would be provided for just ~1 per measure (1.5 kg). MG Ramachandran, the chief minster of the state in the 1970s and 80s, took this a step forward with the visionary mid-day meal scheme. Once labelled as unviable, these schemes are today held up as a model for the country. Tamil Nadu has produced healthy, well-nourished citizens. Stunting among children of age 0-4 is 19.7%, well below the national average of 34.7% (CNNS). China, Korea and Tamil Nadu — coincidence or evidence?

It can be argued that Kerala, with health outcomes comparable to the developed world, is not among India’s strongest states economically.A closer look at Kerala will show that despite its proud social indicators, its labour laws have scared away private investment.

The message is clear: It is time to step up public investments as well as private philanthropy in primary, preventive health, and other human development initiatives to prepare India for its next wave of growth.

Ashok Alexander is founder-director of the Antara Foundation

The views expressed are personal