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Economic growth and women’s health outcomes: A deepening divide?

Jayati Ghosh is Professor of Economics at Jawaharlal Nehru University in New Delhi, India, and delivered the Lancet Lecture 2011 at University College London on the subject of “Economic growth and women’s health outcomes: A deepening divide?” Here Ghosh gives some highlights of her lecture for Global Health Check, with a focus on the deepening divide between economic growth and women’s health in India:

Even though economic growth and human development do not always move together, GDP growth is still expected to be associated with better health conditions, for various reasons. Rising per capita incomes typically involve an improvement in food and nutrition standards among the poor, which is obviously an essential precondition for better health. Deterioration in nutrition due to poor eating habits is more likely to occur after incomes cross a certain level. Increasing national income also puts more absolute resources in the hands of governments to spend on essential public health. Even if the proportion of public health spending to GDP remains unchanged, rising per capita GDP means rising per capita public spending on health. And governments may get greater fiscal space to even increase their health expenditure as a share of GDP. Either way, this can mean greater spread and better quality of basic public health services such as clinics, hospitals, doctors, nurses and subsidised medicines. It can also allow governments to spend on infrastructure that has a direct bearing on health, such as better housing, transport and communications that reach health facilities to poor or remote areas, safe drinking water and sanitation.

So how has recent growth in one of the most dynamic parts of the global economy – India – impacted on health? In particular, how has India fared relative to other countries that are at similar levels of per capita income or are even poorer? Consider India in relation to Sri Lanka, Vietnam and Bangladesh. Of these, Sri Lanka has the highest per capita income (in US $ terms) but India has had the fastest rate of growth in the past two decades.


Despite this, India’s health indicators are either worse than or show slower improvement, than these other countries. It is useful to consider health outcome indicators for women and girls in particular, since these may be taken as the “floor” conditions of health in the society. Since gender discrimination continues to operate to reduce the access of women and girls to health services of various kinds, female health indicators are the most effective way of assessing the general progress of health conditions. Consider two basic indicators: the female infant mortality rate (IMR – number of female deaths below the age of 1 year per thousand live births of females) and the maternal mortality rate (MMR – number of women dying because of childbirth-related complications per 100,000 live births).

 Maternal mortality ratios

The female IMR In India is more than double that in Vietnam, at 51 per thousand, and it declined by only 40 per cent over the two decades – one of the slowest rates of improvement in the region. The MMR at 230 per hundred thousand in 2008 was nearly 5 times that in Vietnam and nearly 6 times that in Sri Lanka. What is even more shocking is the slow improvement – even Bangladesh has outperformed India in terms of decline in IMR, though it is a poorer country with slower GDP growth.

By contrast, Vietnam and Sri Lanka have both achieved indicators that are close to those of developed countries (female IMRs of 11 and 10 respectively in 2009 and MMRs of 39 and 48 in 2008). So obviously it is possible to get better women’s health outcomes even without reaching higher per capita income levels.

What explains the paradox of high growth and relatively poor health outcomes in India in particular?  Of course India is also very regionally diverse, with some states like Kerala showing excellent health outcomes for women, similar to those in Vietnam. And three states have also shown much improved health indicators in the past two decades: Tamil Nadu, West Bengal and Maharashtra. But in the bulk of the country, female IMR and MMR are still very high and have declined very slowly.

One important reason for this is under-nutrition, which has actually worsened in recent times according to indicators like calorie consumption. Rising prices of food are making this problem worse as women and girls in poor households take the brunt of food scarcity. The declines in per capita food grain availability in the country as a whole, already show the problem, but they do not reveal the disproportionate impact on poor and more vulnerable groups.

Related to this is the distributional issue: income growth has been concentrated among the top ten per cent of the population, whose health indicators were already more like those in rich countries, and there is little improvement of consumption patterns in the bottom half. Another reason is poor sanitation, reflecting low governmental priority to critical concerns like clean drinking water and toilets. A third cause is lack of good and affordable health services for women especially in the reproductive age group. Nearly three quarters of all health spending is by households out of their own pockets, which contributes to many families falling into indebtedness and poverty.

All of these factors are crucially determined by government policy. Despite much publicly expressed concern on all these issues, the Government of India has simply not put its money where its mouth is. Public spending as a share of GDP has not increased, and per capita spending on some essential activities like immunisation and primary health centres has actually gone down.

Instead, the government has sought to provide essential health services on the cheap, using the underpaid labour of local women working for much less than the minimum wage, and not properly trained regular public employees with adequate facilities.

So the apparently growing divide between economic growth and women’s health outcomes in India is really the result of the wrong orientation of public policy. This is not inevitable: the experience of other Asian countries shows that a more positive synergy can be created. This requires a shift in economic approach, since it can be argued that it is not just that health spending has been neglected by the government. Rather, it is an outcome of an economic strategy based on corporate profitability as the main driver of growth, which in turn is associated with reduced government spending. This is because the focus on incentivising private investment reduces the capacity to tax and therefore spend public revenues, with consequent fiscal constraints; and also because the state then stays away from or even moves out of activities that may generate private profits, including medical services.

The point is that with sufficient political will, this can be changed. Health spending needs to be valued not just for its own sake, but as an essential element in an overall macroeconomic and growth framework oriented to better conditions of human life (rather than just GDP expansion). This would be part of a wage- and employment-led strategy of ecologically sustainable growth, with a focus on improving human development.


Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni