The latest edition of  Dev 360, my  fortnightly column, in The Asian Age and Deccan  Chronicle

Jan 18, 2011

The list of threats that can derail the India growth story typically includes inflation, a creaking infrastructure, corruption, Maoists and the Kashmir tangle. Rarely is ill health flagged as a major strategic concern within the country. Heartwarmingly, 2011 has kicked off with a host of heavyweight thought leaders reminding us that poor health is not only a problem of the poor. It can eventually scupper our economic and geopolitical aspirations.
In an interview to a national daily earlier this month, Kishore Mahbubani, academic-author-diplomat and one of the most ardent evangelists of Asia’s growing role on the world stage, pointed out that healthcare and education are the basics for “high growth” and that India would have to go “all out” to improve its record in these areas if it wants to maintain the momentum that the world is envious of. It is hard to imagine that Singapore, where Mr Mahbubani lives, was once a mosquito-infested swamp. Today, this city-state of five million people is lauded not only for its spectacular economic success but also for its high standard of healthcare. That Singaporeans, by and large, are healthy and wealthy is no accident. This has happened because of a series of decisions taken by the Singapore government over four decades.
India is not Singapore and what is best for Singapore is not necessarily best for India, given our size and heterogeneity. But Mr Mahbubani’s core message — the urgent need to dramatically improve the health of our people — holds good.
In an article titled Learning from Others published this month in the Lancet, one of the world’s most influential medical journals, Prof Amartya Sen makes a comparison between India and China in healthcare that is worth paraphrasing. China went in for a massive expansion of public healthcare shortly after the revolution. By 1979, when China started its economic reforms, it had already raised its life expectancy at birth to the impressive figure of 68 years. China’s market-oriented economic reforms led to tremendous successes in many fields such as agriculture and industry. But the mantra of the market was less useful in healthcare, since it led to the replacement of universal health insurance through the states and the communes by private insurance that had to be bought in the market. This, Dr Sen points out, was something “the vast majority of the Chinese did not buy and could not afford, despite rising incomes”.
The outcomes are interesting — China’s lead over India in life expectancy shrank sharply in the period that followed the Chinese reforms. But Dr Sen, who visits China often, was excited to find that the Chinese authorities “were gradually appreciating what had been lost”. As a result, they started reintroducing, through one means or another, health insurance for a larger and larger proportion of its people.
As things stand today, China has a much higher proportion of people with guaranteed healthcare than does India. “The gap in life expectancy is now around nine years (with China at 73.5 years and India still confined only to 64.4 years), and although there are many factors behind this contrast, the issue of healthcare coverage is clearly central to the difference”, notes Dr Sen.
The Lancet has just come out with a special series on India. Launched by Dr Richard Horton, the journal’s editor-in-chief in Delhi on January 11, the Lancet India series has contributions from some of the country’s best-known public health advocates, including the incarcerated Binayak Sen. The series calls on India “to ensure the achievement of a truly universal healthcare system by 2020” and begins with a piece by Horton and his colleague Pam Das who say that “a failing health system is perhaps India’s greatest predicament of all”. Why is this so?
Consider the facts. In recent years, India has taken several initiatives to improve the health of its people.
Much-talked about innovations include the National Rural Health Mission, Janani Suraksha Yojana which offers cash incentives to women who give birth in a hospital or a clinic and the Rashtriya Swasthya Bima Yojana providing health insurance coverage to Below Poverty Line (BPL) families. But more than three-quarters of health spending in India is still out-of-pocket and health expenditures push almost 39 million Indians into deep poverty every year.
Why is this a rights issue as well as an economic one? The answer lies in two words we hear often these days: demographic dividend. India’s greatest demographic asset is its young people. Almost 650 million out of the billion plus population is below 30. These youngsters will not be able to fully participate in the India growth story and in shaping the country’s future unless they are in good health. Never mind if India’s economic growth in recent years has been much more rapid than any other country except China and India has weathered the recent recession better than many other countries.
India’s poor health system also has ramifications beyond its borders. In today’s world, diseases don’t respect boundaries. They can spread across borders as in the case of the pandemic influenza H1N1 and tuberculosis. If poor health systems and inadequate surveillance results in India exporting and importing diseases, it could eventually affect trade and tourism.
The Economic Impacts of Inadequate Sanitation in India, a new report from the Water and Sanitation Programme (WSP), a global partnership administered by the World Bank, estimates that inadequate sanitation costs India `2.44 trillion ($53.8 billion) a year — this was the equivalent of 6.4 per cent of India’s gross domestic product in 2006. Health-related economic impact of poor sanitation, estimated at `1.75 trillion ($38.5 billion), accounts for the biggest chunk of the total cost.
I am not overly enthused by figures but these numbers and economic arguments are handy weapons in case someone somewhere starts labelling universal healthcare a jholawala idea and tries to shoot it down just as it is moving up the policy agenda. As an occasional contributor to the Lancet, I attended the day-long symposium where the journal’s papers on India were presented. From what I could see, neither Dr. Horton nor any of the other authors carried a jhola. As far as I know,  Mr Mahbubani and all the others urging India to improve the health of its people have any particular preference for the cloth satchel either.

n Patralekha Chatterjee writes on development issues in India and emerging economies and can be reached at


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