Shankar Acharya: Governance & Health

A PIECE OF MY MIND

A fortnight ago India celebrated 60 years of independence. There was much justifiable satisfaction expressed about the deep roots democracy has put down in Indian political soil over the last six decades. At the same time apprehensions were voiced about the declining standards of governance, not least during the extended debate over the election process for the President. On the economic front, the euphoria from four successive years of 8 per cent plus growth and the booming asset markets were tempered by the rising tides of uncertainty in global finance and, more importantly, the growing appreciation of the dualities in India's economic performance: between an ever more confident and dynamic private sector and an increasingly sclerotic government sector; between the winners in the booming market economy and those left behind at its periphery; and between the rising remunerations of skilled labour and the many millions more of under-employed and uneducated youth, desperately seeking jobs and security.

Underlying these dualities is the massive under-performance in the provision of public services by all layers of government. Much has been written of the perennial inadequacies of public infrastructure (power, roads, water, sanitation, etc) and the well-documented weaknesses in government education systems. There has been rather less discussion on the performance of our health sector. That is the focus of this piece, helped by the recently published National Family Health Survey 3 (NFHS-3) for 2005-06.

To begin with, how do India's key health parameters compare with other major developing countries, including our neighbours, China, Bangladesh and Pakistan? The short answer is not well at all. On all the parameters in Table 1, India does substantially worse than China and Indonesia, let alone richer countries like Brazil, Mexico, Thailand and Turkey. The World Health Organization (WHO) constructs an indicator of "Healthy Life Expectancy at birth" (HALE), which adjusts the normal life expectancy measure for years of serious illness/injury predicted from the data. By this measure, HALE for a girl baby in India in 2002 was only 54 years, compared to 65 in China, 68 in Mexico and 71 in the US. On a direct measure of health service delivery, immunisation coverage of one-year-olds for DTP, India scores particularly badly, even in comparison to Pakistan and Bangladesh. Perhaps most shocking, 46 per cent of young children in India are underweight for age, compared to 6 per cent in China, 20 per cent in Indonesia, 31 per cent in Pakistan and 27 per cent in Nigeria.

Perhaps even more pertinent and interesting (or should I say disquieting?) are the trends in key health indicators, especially for children, in the last 15 years presented in Table 2. The time period with comparable data is relatively short because the NFHS survey series was only launched in 1992-93. The data suggest that India's children (our future?) have been getting a very raw deal, with little progress in key indicators over the last 15 years of unusually strong economic growth. Indeed, if you compare 2005-06 to 1998-99, there is hardly any improvement at all. True, the proportion of children under 3 years who are "stunted" has come down. On the other hand, the proportion of children in that age group who are anaemic has increased from 74 to 79 per cent. So has the incidence of anaemia in married women. Sixty years after Independence four out of five Indian children suffer from anaemia "" surely a devastating commentary on our health and nutrition policies. The proportion of one-year-olds receiving 3 doses of DTP vaccine remained unchanged. So did the percentage of children with diarrhoea receiving oral rehydration salts, at a low 26 per cent. This suggests that the health delivery services at the grassroots level have not improved despite rising allocations of funds and manpower.

India is a big and diverse nation we were repeatedly reminded at the 60th anniversary. So it behooves us to look at health indicators across some Indian states. There are not too many surprises here (Table 3). As expected, Bihar and UP define the bleak end of health parameters, while Kerala and Tamil Nadu provide the beacons of hope. Most people know this but it is worth reminding ourselves that the infant morality rate in UP is five times higher than in Kerala and two and a half times higher than in Tamil Nadu. (Parenthetically, it is interesting to note that after nearly 30 years of CPM rule, 44 per cent of children under 3 years in West Bengal are underweight for age.) This enormous variation defines both the challenge and the potential for bringing about improvements in future. But they won't happen by themselves. It requires both sustained increases in income and employment in the lagging states and major upgrading of health service (including clean water supplies) delivery. And all this will largely depend on the policies and efforts at the level of the respective states. There are no magic wands that the central government can wave, with the possible exception of loosening the current anti-employment labour laws.

So, as we celebrate 60 years of political independence and take pride in our dynamic private sector, our remarkable IT successes and all the other usual dimensions of success, let us remind ourselves that a great deal remains to be done to improve the foundations of India's human resources "" the health and wellbeing of our hundreds of millions of children. Without reasonably good health the prospects for learning and skill development are bleak ... and without that so is our long term future as a thriving and prosperous nation.

The author is Honorary Professor at ICRIER and former Chief Economic Adviser to the Government of India. The views expressed are personal