Trickle down economics is good for health

Indian Express, 24 November 2006

High GDP growth in India since the reforms has often been accused of being growth without a human face. The rich have been getting richer while those who live in poverty are getting worse off. Recent data showing an improvement in health indicators, in particular a 40 percent decline in infant mortality over the last 13 years in Orissa, tells a different story. This improvement could not have been possible without the quality of life of the poor improving. It is a better measure of changes in poverty than the poverty data which depends heavily on the methodology used to measure poverty.

Recently collected data from the Third National Family Health Survey (NFHS) shows that in many important health indicators that measure the quality of life such as infant mortality, there have been marked improvements over the last 13 years. A study based on the survey data from NFHS-3 by Gupta, Parasuraman, Arokiasamy, Singh and Lhungdim, published in the Economic and Political Weekly of October 21, 2006, reports preliminary findings from five states - Punjab, Gujarat, Orissa, Maharashtra and Chattisgarh compared to the previous survey in 1998-99.

The percentage of infants dying before they attain the age of one has dropped significantly in the last seven years in all five states. It has reduced in Punjab by 26 percent, in Gujarat by 21 percent, in Orissa by 20 percent. When compared to the data from NFHS-1 carried out in 1992-93, Orissa, one of the poorest states in India in terms of per capita income, has witnessed a decline in infant mortality by 40 percent.

An improvement in an indicator like infant mortality is a reflection of an improvement in a large number of factors. These include income, drinking water, sanitation, education of women and health services. Often no single indicator can be identified as the reason behind the improvement in infant mortality. This also means that it can often not be "rigged": a decline in infant mortality cannot be engineered by simply improving one factor. It is, therefore, considered to be a better indicator of the quality of life as compared with any other single measure.

The NFHS is considered to be the most scientific survey conducted in India. It is carried out by the Ministry of Health and Family Welfare and the International Insititute for Population Studies, Mumbai, using high quality survey methodology. The first survey was conduted in 1992-93, the second in 1998-99 and the third in 2005-06. In the third survey held between December 2005 and August 2006, more than 2,30,000 men and women were interviewed by 18 research organisations. Blood tests for HIV and anaemia were part of the survey.

Like infant mortality, another indicator that reflects many aspects of development is total fertility, the number of children a woman has in her lifetime. A decline in fertility is associated with economic growth. Poor countries have high fertility levels, and a growing population, while countries that have seen high growth in incomes like Japan or Sweden find that women are unwilling to have many children, and population growth starts stagnating, or even declining. In India, the debate has been about whether economic growth is reaching poor people, and if it is not, we would see a dichotomy of high fertility rates accompanying high GDP growth.

For many years, the sense in India was that Kerala and Tamil Nadu had achieved replacement-level fertility (2 children per woman) but fertility in the rest of the country remained stubbornly high. The NFHS findings indicate that over the past 13 years, significant progress in fertility has taken place in all five states. Punjab and Maharashtra have achieved replacement fertility. Women in Orissa, Chattisgarh and Gujarat now average 2.5 children each. These trends in fertility indicate that India will reach replacement level fertility in 2010.

Where is this progress coming from? Crudely speaking, there are two stories at work. On one hand, sheer GDP growth makes people richer, and generates improvements through ability to buy better food, nutrition and education. On the other hand, better public health services that provide better facilities to people can improve health outcomes. In principle, both these factors could be at work in India.

Preliminary evidence shows that the quality of public health services has been worsening. As NFHS data shows, immunisation, which is largely done by the government, has worsened in Gujarat, Punjab and Maharashtra in recent years. This data is in conformity with the data from the report on Reproductive and Child Health Program of the World Bank which found that out of 274 districts in the country, child immunisation declined in 197 districts.

Similarly, indicators of maternal health from the NFHS data show that while antenatal care is now universal in all five states, only 55-75 percent of women are getting the recommended three antenatal visits. Moreover, the report on Reproductive and Child Health Program found that the increase in in-hospital childbirth is caused by a rise in in-hospital births in private hospitals. There has been a decline in in-hospital births in public hospitals. The data on antenatal care and assisted deliveries showed that the pecentage of deliveries assisted by health workers went up from 39.6 percent in 1998-99 to 47.5 in 2002-03, the percentage of women delivering in public health facilities declined from 24 percent to 18.5 percent. The increase took place in deliveries in the private sector, where they rose steeply from 9.4 percent to 21.5 percent.

Moreover, women in richer states were seen to be using public health facilities less and turning to private health. In Andhra Pradesh, the percentage of women delivering in public institutions declined by 9.8 percent, in Kerala by 28.9 percent, in Karnataka by 10.2 percent, in Maharashtra by 9.1 percent and in Tamil Nadu by 15.3 percent. Further, the number of women who received post natal care by public health workers (ANM) through home visits within 2 weeks of delivery also declined from 14.1 percent to 12.7 percent. The Planning Commission's midterm appraisal of the 10th Plan observed that when people first seek treatment, an estimated 70-85 percent visit a private sector provider for their health care needs.

The data thus indicates that public health services in India is worsening rather than improving. This suggests that the real story in the improvement in health in India, as was the case in the history of rich countries, might be sheer growth of income. India's GDP growth might, after all, have had more of a trickle down than many would care to admit.

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