Two pet hypotheses in India are as follows:
- That economic growth is not reaching "poor people"
- That government is central to improvements in education and health; conversely, that the only way to have educated and healthy people is to have a government spend more and/or spend it better.
Different people share these `pet theories' to different extents. Many liberals are skeptical about the usefulness of more spending by the government on education and health as long as spending consists of a mere intensification of existing programs. This is because there is now ample evidence that existing programs work pretty badly, as is borne out by evidence of absenteeism by health/education workers, the poor learning accomplishments associated with Sarva Shiksha Abhiyaan, etc. Many liberals would support a view that more government spending would help - or is essential for obtaining - better health and education outcomes, as long as fundamental surgery is made to the way in which programs work - e.g. shifting from teachers as civil servants to vouchers.
In recent weeks, fascinating new information about household level health and fertility has come out through NFHS-3. In terms of methodology, NFHS is the best household survey in India - it's the gold standard against which all surveys compare themselves. The first survey was conducted in 1992-93, the second in 1998-99 and the third in 2005-06. Every other survey aspires to NFHS quality resources and methodology. If you are one of those who loves to hate the NSS dataset, you needn't carry this skepticism on to the NFHS: it is the first world class household survey in India.
Kamla Gupta, Sulabha Parasuraman, P. Arokiasamy, S. K. Singh and H. Lhungdim have an article in the EPW of 21 October 2006 titled Preliminary Findings from the Third National Family Health Survey which shows some first findings from NFHS-III for five states (Chhattisgarh, Gujarat, Maharashtra, Orissa and Punjab) [pdf]. The quick summary is: the public health service delivery was terrible, but the health and fertility outcomes got tremendously better. Ila Patnaik has a great article in Indian Express summarising and interpreting their results. In this, she says:
The percentage of infants dying before they attain the age of one has dropped significantly in the last seven years in all five states. It has reduced in Punjab by 26 percent, in Gujarat by 21 percent, in Orissa by 20 percent. When compared to the data from NFHS-1 carried out in 1992-93, Orissa, one of the poorest states in India in terms of per capita income, has witnessed a decline in infant mortality by 40 percent.
For many years, the sense in India was that Kerala and Tamil Nadu had achieved replacement-level fertility (2 children per woman) but fertility in the rest of the country remained stubbornly high. The NFHS findings indicate that over the past 13 years, significant progress in fertility has taken place in all five states. Punjab and Maharashtra have achieved replacement fertility. Women in Orissa, Chattisgarh and Gujarat now average 2.5 children each. These trends in fertility indicate that India will reach replacement level fertility in 2010.
Preliminary evidence shows that the quality of public health services has been worsening. As NFHS data shows, immunisation, which is largely done by the government, has worsened in Gujarat, Punjab and Maharashtra in recent years. This data is in conformity with the data from the report on Reproductive and Child Health Program of the World Bank which found that out of 274 districts in the country, child immunisation declined in 197 districts.
Similarly, indicators of maternal health from the NFHS data show that while antenatal care is now universal in all five states, only 55-75 percent of women are getting the recommended three antenatal visits. Moreover, the report on Reproductive and Child Health Program found that the increase in in-hospital childbirth is caused by a rise in in-hospital births in private hospitals. There has been a decline in in-hospital births in public hospitals. The data on antenatal care and assisted deliveries showed that the pecentage of deliveries assisted by health workers went up from 39.6 percent in 1998-99 to 47.5 in 2002-03, the percentage of women delivering in public health facilities declined from 24 percent to 18.5 percent. The increase took place in deliveries in the private sector, where they rose steeply from 9.4 percent to 21.5 percent.
Moreover, women in richer states were seen to be using public health facilities less and turning to private health. In Andhra Pradesh, the percentage of women delivering in public institutions declined by 9.8 percent, in Kerala by 28.9 percent, in Karnataka by 10.2 percent, in Maharashtra by 9.1 percent and in Tamil Nadu by 15.3 percent. Further, the number of women who received post natal care by public health workers (ANM) through home visits within 2 weeks of delivery also declined from 14.1 percent to 12.7 percent. The Planning Commission's midterm appraisal of the 10th Plan observed that when people first seek treatment, an estimated 70-85 percent visit a private sector provider for their health care needs.
This result flies in the face of the two pet hypotheses cited above. If you believe that the lot of poor people is not improving, then this evidence is inconsistent with this position, because it suggests that poor people were a lot better off in 2005-06 when compared with 1998-99. If you believe that government spending and/or program design is important, then this evidence is inconsistent with this position: the NFHS (and other sources of evidence) show that the government system did badly, but that people got healthier and had fewer kids anyway.
What is going on? I think the main insight is that the health of the people reflects lots of things. It reflects nutrition, sanitation, knowledge, private purchases of health services and the outcomes delivered by the public health system. It is by no means controlled exclusively by the public health system; when people talk about improvements to the public health system as the only channel to having a healthier population, this is flat wrong. When people get richer, they buy better food, better sanitation and cleanliness, more knowledge (e.g. education within the family), and services of private doctors / hospitals. India has been experiencing powerful economic growth, which is trickling down to poor people. So even though the public health system is doing badly, health outcomes have improved, amongst poor people.
What I'm saying is not at all surprising when you think in terms of common sense. When people get richer, they have fewer children, buy more soap, buy more vegetables, are more likely to go to a private doctor when faced with a health problem, and are more likely to buy education services thus inducing more knowledge within the household. This makes them more healthy. But this common sense flies against the orthodoxy in India, which equates "the health of the public" with the spending on and the design of "public health programs", and assumes that poor people are not sharing in economic growth. NFHS-3 suggests that if you completely froze the spending on the Ministry of Health in nominal terms, and just had high GDP growth, you would most likely continue to get strong improvements in health outcomes.
Such an understanding - where health outcomes are not equated to the public health system - is consistent with the history of health in Europe, where a great deal of improvements in health took place owing to rising incomes feeding into nutrition, cleanliness and private purchases of health services. Such an understanding is also consistent with analysis of NFHS-1 and NFHS-2, where the basic story which emerges is that the presence of a Primary Health Centre does nothing for health.