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HSERV 482 # 14. INDIA and CHINA. Review so far: Key ideas. Primordial Epidemiology: "caring and sharing" Conception to age 2-5 is most critical period for producing health Vulnerabilities for populations having poor health Russian upheaval and single-middle-aged men

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hserv 482 14

HSERV 482 # 14


review so far key ideas
Review so far: Key ideas
  • Primordial Epidemiology: "caring and sharing"
  • Conception to age 2-5 is most critical period for producing health
  • Vulnerabilities for populations having poor health
    • Russian upheaval and single-middle-aged men
    • Understanding as good as any other level of life
  • Causal relationship
learning objectives
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 Kerala’s remarkably different health outcomes from the rest of India
  • Who has traveled to or is from
plan of session
Plan of session
  • India’s 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






Public Expenditures

Health outcomes

•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

1.1 billion

low (and limited to rich)


indian history
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 England’s
  • 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
india since 1950
India since 1950
  • Parliamentary democracy, with disparate ethnic and religious groups “modified socialism”
    • Nehru experimented with Soviet style Five Year Plans
    • Attempted land reforms
    • Affirmative action for untouchables
    • One third of seats in local government reserved for women
  • Little spread of development (HALF of world’s 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)
india since 195013
India since 1950
  • 62 million+ under-five children malnourished
  • 88% of pregnant women are anemic
  • One third of children <16 years work
  • Independent press
  • Recent foreign investment (second largest exporter of computer software)
  • Increasing unemployment (jobless migrating, buses)
  • Little public investment in education - health care
  • Reforms (Structural adjustment)1991 increased poverty
    • food subsidies reduced,
    • mechanized agriculture reduced demand for local labor
indian reforms 1991
Indian Reforms 1991+
  • Eased foreign exchange restrictions
  • Devaluated rupee
  • Lower import tariffs
  • 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
  • Food grain surplus (50 M tonnes) and HALF of world's hungry
    • Families rotate person going hungry each day (P. Sainath)
  • Depend on foreign remittances, vast migration for work
agriculture collapse in 1990s
Agriculture collapse in 1990s
  • Growth of agriculture
    • 1980s rate 3-4%
    • 1990s rate halved US subsidies to cotton wiping out India
  • Rural credit collapsed in countryside today
    • Ads in papers for notices of banks auctioning property of small farmers (collateral for loans of < Rs. 5000), often wife's jewelry, leading to increased pesticide suicide by farmers, 24 hr morgues, no power outages, illegal
  • 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

chinese history
Chinese History
  • 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)
    • 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



The opium wars 1839-42, 1856-60

Opium – for rich or poor


























Hong Kong


Some ports forced open by British

(Map modified from “The Opium Wars”, W.T. Hanes III & F. Sanello, SourceBooks Inc., Naperville, 2002; old photographs reproduced in “Opium Regimes”, T. Brook & B.T. Wakabayashi, Univ. of California Press, Berkeley, 2000 & “Narcotic Culture”, F. Dikötter et al, Univ. of Chicago Press, Chicago, 2004)

chinese revolution
Chinese Revolution
  • 1800s on, Chinese cultural supremacy confronted wealth production of industrial revolution
  • 1912 republic took over from Manchu’s
    • 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
  • 1949 Communist Revolution
    • Hierarchy dismantled, equitable distribution of resources
    • Industrial investment in smaller cities, towns
india and china in 1950 60
INDIA AND CHINA in 1950-60


490 million

January 1950,


715 million

Oct 1949

1949: both countries among poorest in the world, high levels of mortality, undernutrition, illiteracy

  • Population
  • Constitution came into force

1960 India China















life Exp


china before after reforms in 1979
CHINA before / after reforms in 1979

interdependence between achievements BEFORE and AFTER reforms in 1979

accomplishments in education, health care, land reforms and social change in pre-reform period made significant contributions to lesser achievements in post-reform period

china pre reform achievements
China: Pre-reform achievements
  • GNP per capita growth in pre-reform China not really higher than India,
  • Grain production averaged 301 kg in 1955-7 and 305 kg in 1975-77,
  • chronic undernourishment declined because of:
    • redistributive policies
    • nutritional support
    • health care
  • health much better than India’s before reforms
china pre reform achievements25
China: Pre-reform achievements
  • literacy rates were high for 15-19 year olds in 1981 (96% for males, 85% for females)
social security pre reform china
Social Security Pre-Reform China


Health care benefits


Elderly cared for by state

State dictated wages, welfare standards, and took profits


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

famines of 1958 61 in china killed between 23 and 30 million people
Famines of 1958-61 in China killed between 23 and 30 million people
  • result of Great Leap Forward
    • rapid collectivization of agriculture crashed badly, and organization aspects collapsed
  • arbitrary nature of distributional policies
    • including features of communal feeding
    • communal kitchens led to over-consumption in some areas, while starvation in others
    • difficulty distributing between town and country
        • - urban areas got more when food output plummeted
famines of 1958 61 in china killed between 23 and 30 million people32
Famines of 1958-61 in China killed between 23 and 30 million people
  • Chinese government not aware of famine problem, so policies not revised for 3 years
      • partly because of a controlled press which suppressed information about the famine, but also duped the government as well
      • local leaders sent rosy reports, trying to outdo regional rivals
      • government thought it had 100 million more metric tons of foods than it did
famines of 1958 61 in china killed between 23 and 30 million people33
Famines of 1958-61 in China killed between 23 and 30 million people
  • Government immune to public pressure, with no dissent or opposition
    • no organized demand for government to resign despite starvation and mortality
    • no substantial famine has ever occurred in democratic country where government tolerates opposition
    • Great Leap Forward could not have occurred without debate in a democracy
china reforms
China: Reforms
  • -concept of rural “reform” began after Nixon’s 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
between 1980 and 1994
Between 1980 and 1994
  • economic growth: 7.6% per year
      • rate implies per capita income doubles every 10 years
        • (India’s growth rate has been 2-3 % per year for 50 years)
    • 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 women’s 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

Foreign Direct


china health improvement post reform
China health improvement post reform
  • moderate in comparison with pre-reform period and with what other countries have achieved
imr 1960 90 india china s korea
IMR 1960-90 India, China, S. Korea

Kerala had no economic growth

chinese economic growth in 1980s
Chinese economic growth in 1980s
  • growth in private incomes
  • Transition from
    • collective which received economic gains
    • to
        • one in which local public services had to be financed by taxing private incomes
  • Poorer regions had less income for services, e.g.
    • Education expenses were harder for poor
  • RESULT: decreased public sector, many more people marginalized


post reform changes in china
Post-Reform Changes in China
  • Village health services comprehensively privatized
  • Economic growth at cost to social services, which have become relatively under-funded
  • Huge increases in inequality between urban and rural, between coastal and inland, and within regions
  • IMR improvement overall flattened, rural worsened
  • Stunting seen increasing in rural populations
  • SUICIDE rates very high, and rural > urban, pesticide
urban social security post reform
Urban Social Security Post-Reform
  • State owned enterprises face market competition with higher labor costs because required to provide social support
    • if leave one’s work lose all benefits
  • Growing labor force in private sector
  • Aging population
  • Flexible labor market
    • 1/5 to 1/3 of labor force is redundant
  • Increasing unemployment, urban poor


rural social security post reform
Rural Social Security Post-Reform
  • New land distribution system
  • Rural factories declining
  • Rural labor force is older
  • Increasing work-related disabilities
  • Must rely on family but family size is small
  • Many men will remain unmarried with no family to support them in old age
  • Migration (from poorer west to east) (M>F):
    • Long-term migrants formally gained urban status
    • floating population (informal) 80-120 million in 1995

fill jobs in low end of earnings ladder

social security china post reform
Social Security China Post-Reform
  • Remittances from floating population to migrants’ home communities a significant economic help, and may have slowed the urban-rural income gap
    • Returning migrants to rural villages devote more attention to children’s education
  • 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
medical care china post reform
Medical Care China Post-Reform
  • Medical expenditures increased 7 fold 1978-92
  • Increasing private medical costs
  • Health Insurance schemes,
  • Speculate considerable medical harm from unnecessary care provided for profit
  • Doctors less trusted now


china s coercive one child policy
China’s coercive one-child policy
  • India Crude Birth Rate dropped to 29/1000 in 1992
  • China Crude Birth Rate dropped to 19/1000 in 1992
    • loss of individual freedoms
    • increased neglect of girl children
      • 1981-1990 MALE IMR dropped from 38.4 to 28.4
      • 1981-1990 FEMALE IMR dropped from 36.3 to 32.8
      • if female IMR had dropped proportionately as much as male, would avert 78,000 deaths a year
kerala has similar birth rate as china cbr 18 lower than china 19
Kerala has similar birth rate as China (CBR 18 lower than China 19),
  • Kerala has lower TFR’s, higher adult female literacy, and slightly higher life expectancies
    • women played important role in Kerala’s economic and political life, property relations and educational movements
    • don’t need coercion to bring down fertility in poor countries
      • don’t have selective infanticide
    • Kerala’s IMR is lower than China’s
      • both were about the same when China introduced its one-child policy
    • China’s IMR is lower for males than females, while opposite true in Kerala
kerala model
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
Kerala's Health

Political economy

Socialist government

Strong trade unions

Five year economic plans

Vibrant public discourse

Subsistence economy

Government distribution shops

Anti-big business

Religious Diversity (Hindu, Muslim, Christian)

Primary Health Care

Basic education

Various Parameters

DROP OUT RATE Class 1-X: 24% 1998-9 (India's 67%) and in 2002-3 Kerala reduced it while in India it increased

kerala s health54
Kerala's Health


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


kerala india gender comparisons
Kerala / India gender comparisons


india euphoria overtake china
India euphoria "Overtake China?"

Child malnourishment

53% cf 20-25 % Sub Sha Af

Food spending ~60% of income for

9/10 rural families

7/10 urban families

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 May 6, 2004: "Jobs scarce in India's boom"

Public sector work has gone ("reforms since 1991")

India ranks 4th in Billionaire Olympics SUBSIDIZE RICH

India Shining GOI

1/3 of world's 840 million hungry in India

Food grain consump/cap 185 kg in 1997 but 152 kg in 2001 (cf levels in 1943 at time of Bengal famine when there was plenty of food but not made available)

Food grain stocks at record highs (public distribution system being dismantled because of IMF/WB Rx)

Rats consume Rs 3 billion

Sdhanva Deshapande LeftWord Bks

Foreign Policy article

china today
China Today

ballooning beggars (NYT 040407) migrate from rural to urban areas

Organized begging rings fronted by children

Debate: intellectuals push for greaterindividual 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




Zhao 2006


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

china india comparisons today
China/India Comparisons Today


Businesses like

Totalitarian governments

  • 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