1.1 Introduction
In his review of trends in health outcomes in the world, Deaton (2013) referred to “The Great Escape” that occurred in most countries in the aftermath of World War II. By this, he meant that, in the decades since 1945, the quality of life in most countries, but particularly in low-income countries, improved considerably—inter alia people lived longer, children were taller and better nourished and went to school, the incidence of mothers who did not survive childbirth fell, family size grew smaller as women had fewer babies, partly because their children were less likely to die in childhood but partly because more educated mothers recognised the importance of investing in the health, diet and education of their children. Furthermore, this has all happened without there being a commensurate narrowing of income differentials between rich and poor countries.
The improvement in health outcomes in many countries of the world can be ascribed to several factors. First, and foremost, were medical advances, particularly improvements in public health . These advances enabled countries to bypass the constraints of economic development by achieving health outcomes which, in an earlier age, were the preserve of much richer countries. As Deaton (2013) observed, although India’s per capita income in the middle of the twentieth century was no higher than Scotland’s in the mid-nineteenth century, it had achieved a life expectancy which was higher than that of Scotland in 1945. In a similar vein, as Gwatkin (1980) reported, countries such as Jamaica, Malaysia, Mauritius and Sri Lanka saw annual increases in life expectancy of more than one year in the 10 years around the 1950s.
Leading the charge against early deaths in developing countries was the chemical assault on malaria-bearing mosquitoes. Accompanying this were programs of mass vaccination of children in Europe against tuberculosis and the WHO ’s Expanded Program on Immunisation, launched in 1974, which vaccinated children against diphtheria, whooping cough and tetanus, as well as extending coverage against tuberculosis, polio and smallpox. UNICEF , as a major sponsor of children’s welfare, extended its remit to sponsoring clean water and sanitation . Another important innovation in the fight against early mortality was the discovery, in the refugee camps of Bangladesh and India in 1973, of Oral Rehydration Therapy (ORT): this was a solution of glucose and salt in water and was found to be very effective in preventing the dehydration that killed children with diarrhoea . Under the aegis of international agencies and governments, these medical and technical advances could be implemented even in countries which might have had limited capacity to do so themselves.
Complementing these medical and public health innovations were, first, a greater awareness, instilled in parents by the spread of education, of their importance for the health of children and, second, an increased ability to seek medical attention, engendered by growing prosperity. In terms of its effect on children’s well-being, most studies focus on the education of the mother and hypothesise that the higher the mother’s education, the better will be her feeding and care practices towards her children (Caldwell 1979, 1986; Hobcraft 1993). So, as pointed out by Deaton (2013), the major drivers of health advances are, on the one hand, income and, on the other hand, medical innovation and treatment, with education mediating between them by improving the effectiveness of both. In assessing the relative contributions of these two broad sets of factors, Preston (1975) estimated that the bulk of the increase in life expectancy between the 1930s and the 1960s was brought about through medical innovation and public health improvements with about a quarter being due to rising living standards.
Table 1.1 shows the life expectancy at birth and the infant mortality rate (IMR) —the number of babies who died before their first birthday per 1000 births—for a selection of South Asian countries (India, Pakistan and Bangladesh ) and two emerging countries (Brazil and China ) for 1960 and 2015. An important point that emerges from this table is that Bangladesh, which, with a per capita GDP in constant US dollars of $972 in 2015, was considerably poorer than India, with a 2015 per capita GDP in constant US dollars of $1758, nevertheless had a higher life expectancy than India (72 versus 68 years) as well as a lower IMR (28.2 versus 34.6) in 2015. The second point to emerge from Table 1.1 is how far China has pulled ahead of India both in terms of life expectancy and in terms of IMR. In 1960, there was only a three-year gap between China and India in terms of life expectancy (44 versus 41 years); by 2015, this gap was eight years (76 versus 68 years). Although information for China’s IMR was not available for 1960, the IMR in China in 2015 (8.5 infant deaths per 1000 births) was less than one-fourth that of India’s 34.6 infant deaths. So, while all the countries shown in Table 1.1 evidenced considerable improvement in two important health indicators (life expectancy and IMR) between 1960 and 2015, these achievements were not constrained by economic performance: China was a poorer country than India in 1960 (per capita GDP in constant prices of $191 in China versus $304 for India) and Bangladesh was a poorer country than India in 2015, but this did not prevent these two countries from recording superior health outcomes compared to India by the middle of the twentieth century.1
Table 1.1
Health outcomes in India and selected countries
Life expectancy at birth, years | Infant mortality rate, per 1000 births | |||
|---|---|---|---|---|
1960 | 2015 | 1960 | 2015 | |
Bangladesh | 46 | 72 | 174.9 | 28.2 |
Brazil | 54 | 75 | 128.8 | 13.5 |
China | 44 | 76 | NA | 8.5 |
India | 41 | 68 | 163.8 | 34.6 |
Pakistan | 45 | 66 | 190.7 | 64.2 |
Indeed, Dreze and Sen (2013) commented that India’s achievements, relative to other countries, with respect to national income and to social indicators, suggested that it had been improving its position in terms of per capita income but slipping in terms of social achievements. Bangladesh , with half of India’s per capita income, has exceeded India’s achievements not just for life expectancy and IMR (as noted above) but also for immunisation rates for children, child undernourishment and girls’ schooling (ibid.). In 2014, public expenditure on health in India was just 1.4% of its GDP , which contrasts with 3.1% in China , 3.8% in Brazil and 7.8% in the European Union. Another feature of note in India is that the proportion of public expenditure on health as a share of GDP was substantially less than the proportion of total expenditure on health in GDP: in 2014, India spent 4.7% of its GDP on health care but only 1.4% of its GDP on public health care. This means that, in 2014, of total health expenditure in India, only 30% was spent on...