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Learning Objectives
analyze the different health outcomes in India and China emerging over the last half century relate health outcomes to country policies in force during this period describe possible reasons for Keralas remarkably different health outcomes from the rest of India
Plan of session
Indias history Chinese history India/China comparisons in 1950 1980 and after China before and after reforms in 1980 Chinese famine in 1958-61 Family planning policies:
Coercive Social Welfare
Kerala Model MAIN POINT: if health and human welfare are goals Kerala and China (to beginning of reforms), had policies that achieved those ends
Infant Mortality
200
200
39
130
30
70
India
GDP Growth Hierarchy Economy
Low ($444 US- 2001) $564 2003, $2800 ppp Increasing (4.0% 90-01), 7% (ppp), 8% in 2005 Getting Higher (4th 2007, 6th 2006, 9th 2005, 12th 2004, in Billionaire Olympics)
Agriculture declining (as % of GDP), Services increasing growth of computer industry through foreign capital results in limiting job growth in that sector
Indian History
Ancient cultures and religions Sultans and princes with their states 1700s Britain and France fought for territory
suppressed better quality Indian cotton steel industry as good as Englands
1805-on, a part of the British Empire Impoverished with GNP declining in 1900s British infrastructure
Rural propertied classes benefited Periodic famines, miserable health Gandhi and mass peaceful protest
Little spread of development (HALF of worlds poorest in India, 500 million on <$1)
70-80% still agricultural 135 million people without access to health care 226 million without access to drinking water Half of population illiterate (2.5 times that of S-S Africa)
Resulted in growth of
middle class Entrepreneurs (Forbes Billionaires -36 in 2007, -23 in 2006, 12 in 2005, ) China has 20 only (+21 if add Hong Kong)
US trans-nationals dump cheap Indonesian palm oil when local farmers told to plant mustard/ground nuts for oil, cotton
Amount owed by 800 industrialists in India to banks that have not been paid for decades is:
Rs. 62,000,000,000,000 ($1 trillion or $1 million million) Non-performing assets in Indian banks 98,000,000,000
P Sainath MIT June 5, 2001
Oldest, most populous civilization with dynastic history, producing political culture
Confucius (551-479 BCE) (harmony and order):
Legalists: human nature selfish, society sustained by strict laws ruthlessly enforced Taoists: humans sociable, perverted by excessive government Middle Way: altruism instinctive, but need to socialize humans
Socialization via family with hierarchy by generation, age, sex (parental respect still strongly felt by majority of Chinese in 1982)
Chinese History
Han dynasty (200 BCE) emperors became supreme sages Manchu conquest 1644, communities governed selves 1830s opium imports exceeded tea & silk exports
Attempts to stop this led to Opium Wars and instilled foreign presence
22
..
..
Shanghai
Chinese Revolution
1800s on, Chinese cultural supremacy confronted wealth production of industrial revolution 1912 republic took over from Manchus
Descended into warlords/civil wars Nationalist government fighting communism
Dependent on US aid and finance, corrupted Miserable health Urban migration, horrible conditions, large families to care for elderly
INDIA
490 million
January 1950,
Oct 1949
700
600
500 India
China
400
300
200
100 44 0 47
GDP/cap
life Exp
IMR
Sen 1999
Rural
Based on communes Family and communes took care of aged State had Five Guarantees System (for vulnerable rural people (aged, orphans, sick, without family), given
(1) free food, (2) fuel, (3) clothes, (4) health care (barefoot doctors) (5) funeral services
Remarkable hindsight
China: Reforms
-concept of rural reform began after Nixons trip in 1972 -communes dismantled, land leased out to families -foreign trade promoted, foreign direct investment permitted -government allowed a non-state sector -township and village enterprises proliferated, absorbing rural labor force -government spending declined as share of GDP -rush into capitalism
industrial production grew at 11% per year agricultural production grew at 5.4%
Maximize personal wealth, suppress unrest Decline in educational distribution achievements Decline in womens status bicycle (540 million) to automobile-boosts industry
1994 produced 30 million bicycles,
1999 1 million all exported Try to ban bicycles in parts of Beijing
NYT 021124
14 0 12 0 10 0 80 60 40 20 0 Ch ina Indi a
Ke ral a
So uth K orea
Sri La nka
Growing labor force in private sector Aging population Flexible labor market
1/5 to 1/3 of labor force is redundant
Urban migrant communities under less strict neighborhood controls, so get growth in crime, prostitution, drug use Migrants excluded from schooling, health care Feminization of agriculture at 60% of work force
Kerala has similar birth rate as China (CBR 18 lower than China 19),
Kerala has lower TFRs, higher adult female literacy, and slightly higher life expectancies
women played important role in Keralas economic and political life, property relations and educational movements dont need coercion to bring down fertility in poor countries dont have selective infanticide Keralas IMR is lower than Chinas both were about the same when China introduced its one-child policy Chinas IMR is lower for males than females, while opposite true in Kerala
2.5
1.5
0.5
Kerala Model
Kerala's economy is predominantly agrarian in nature. In terms of per capita income and production Kerala is lagging behind many of the Indian States. But in terms of Human Development Index and life standard of the people Kerala is much ahead of most other states in India, and, in fact, in certain development indices it is on a par with some of the developed countries. This peculiar paradox often termed as the KERALA PHENOMENON or Kerala model of development by experts, which is mainly owing to the performance of the State in the Service Sector.
http://www.kerala.gov.in/
Kerala's Health
Political economy
Socialist government Strong trade unions Five year economic plans Vibrant public discourse
Various Parameters
DROP OUT RATE Class 1-X: 24% 19989 (India's 67%) and in 2002-3 Kerala reduced it while in India it increased
Subsistence economy
Government distribution shops
Anti-big business Religious Diversity (Hindu, Muslim, Christian) Primary Health Care Basic education
Kerala's Health
HEALTH CARE One health center for every 1.5 villages cf 1 for 26.4 in all India) Low cost of services High demand from rural and urban
97.3% of women received antenatal care 97% of deliveries took place in health institutions (cf. 26% for India)
Health Parameters
Life expectancy 73 cf US 77 and India's 63 Infant mortality 11 Total fertility rate 1.9 90 % literate Matriarchy
Kerala 2001
India 1961
India 2001
1022
39
1058
86
941
13
933
54
IMR Rural/Urban
Mean Age at Marriage M/F Life expectancy M/F
60/48 17/15 (1991) 138/82 86/52 (1991) (1971) (1971) 11 (02) 66 (02) 26/20 28/22 (1981) 20/15 23/19 (1981)
46/50
42/41
http://www.kerala.gov.in/
61/62(1991) 68 (02)
Share of public subsidy for curative care benefiting Income Groups, India 2000 (WB)
35 30 25 20 15 10 5 0 Poorest 20% 2nd Middle 20% 4th Richest 20% 13.4 10.1 17.8 25.6 33.1
West Bengal
NEFA
Maharashtra
Tamil Nadu
Rajasthan
Punjab
All India
Madhya Pradhes
Gujarat
Andhra Pradesh
Haryana
Uttar Pradesh
Karnataka
Himachal Pradesh
Kerala
Orissa
Bihar
Child malnourishment
53% cf 20-25 % Sub Sha Af
Landless laborers found 123 days of work/yr in 1982 (then 74.6 million)
Had 72 days of work in 2003 Now 107.4 million
NYT 050515
China Today
ballooning beggars (NYT 040407) migrate from rural to urban areas
Organized begging rings fronted by children Debate: intellectuals push for greater individual rights so "people have the right to beg"
Police no longer repatriate people for not carrying proper ID and now try to send them to shelters, but with major meetings, they are rounded up and carted away Guangzhou ban on begging in fancy places
-Chinese born professionals returning from abroad to join establishment in private sector -Huge migrant labor pool discriminated and harassed -Fatalism among laid-off state workers, esp. if have son or daughter getting an education -Demonstrations by young professionals left out
5.4
Zhao 2006
15 10 5 0 High Medium
Low
Fa mil y Inco me
The rate of overweight is positive associated with parents educational level by family income
China Seven Cities Study: Ming-Chen Lee Harbin, Shenyang (Northeast) Wuhan (Central) Chengdu, Kunming (Southwest) Hangzhou, Qingdao
11 2 66 15 .9 29 3
32 4 4.5 78
China Pov erty Po p bel ow $1 /d ay Po p bel ow $2 Na tiona l Pov erty line (%) Ru ra l Urba n 16 .1 47 .3 4.6 <2
India 34 .7 79 .9 30 .2 24 .7
Summary
India and China started at comparable places in health in 1950 China pursued egalitarian promoting policies for 30 years and made remarkable health gains India, despite democratic institutions, did not promote egalitarian development, nor provide basic social welfare services India continues to have mass poverty and poor health and reforms will increase health inequalities Chinese reforms have limited health gains or worsened some Kerala provides an example of a social welfare state that achieves good health and low fertility