Amartya Sen, 1999 WHA keynote address

* Professor Amartya Sen was the 1998 Nobel Laureate in economics.

Professor Sen

I must take on the question - the very difficult question - as to how health relates to development. At one level, the question admits of a simple answer: surely the enhancement of the health of the people must be accepted more or less universally to be a major objective of the process of development. But this elementary recognition does not take us very far. We have to ask many other questions as well. How important is health among the objectives of development? Is health best promoted through the general process of economic growth which involves a rising real national income per capita, or is the advancement of health as a goal to be separated out from the process of economic growth seen on its own? Do all good things go together in the process of development, or are there choices to be made on the priorities to be chosen? How does our concern for equity reflect itself in the field of health and health care?

While there is a connection between opulence, on the one hand, and our health, longevity and other achievements, on the other, the linkage may or may not be very strong and may well be extremely contingent on other circumstances. The issue is not the ability to live forever... but the capability to live really long (without being cut off in one’s prime) and to have a good life while alive (rather than a life of misery and unfreedom).

The usefulness of wealth lies in the things that it allows us to do (the substantive freedoms it helps us to achieve, including the freedom to live long and to live well. But this relation is neither exclusive (since there are significant other influences on our lives other than wealth), nor uniform (since the impact of wealth on our lives varies with other influences). It is as important to recognise the crucial role of wealth on living conditions and the quality of life, as it is to understand the qualified and contingent nature of this relationship. An adequate conception of development must go much beyond the accumulation of wealth and the growth of gross national product and other income-related variables.

Relative and absolute deprivation of African Americans

It is quite remarkable that the extent of deprivation for particular groups in very rich countries can be comparable to that in the so-called “third world”. For example, in the United States of America, African Americans as a group have no higher - indeed have a lower - chance of reaching advanced ages than do people born in the immensely poorer economies of China or the Indian State of Kerala (or in Sri Lanka, Jamaica or Costa Rica).

Even though the income per capita of African Americans in the United States of America is considerably lower than that of the American white population, they are, of course, very many times richer in income terms than the people of China or Kerala (even after correcting for cost-of-living differences). In this context, the comparison of survival prospects of African Americans with those of the very much poorer Chinese, or Indians in Kerala, is of particular interest. African Americans do tend to do better in terms of survival at low age groups (especially in terms of infant mortality) vis-à-vis the Chinese or the Indians, but the picture changes over the years.

Chinese men and those in Kerala decisively outlive American black men in terms of surviving to older age groups. Even African American women end up having a similar survival pattern for the higher ages as the much poorer Chinese, and decidedly lower survival rates than the even poorer Indians in Kerala. So it is not only the case that American blacks suffer from relative deprivation in terms of income per head vis-à-vis American whites, they also are absolutely more deprived than the low-income Indians in Kerala (for both women and men), and the Chinese (in the case of men), in terms of living to ripe, old ages. The causal influences on these contrasts (that is, between living standards judged by income per head and those judged by the ability to survive to higher ages) include social arrangements and community relations such as medical coverage, public health care, elementary education, law and order, prevalence of violence, and so on.

[This] contrast...takes the African American population as a whole, and this is a very large group. If instead we consider African Americans in particularly deprived sections of the community, we get a much sharper contrast. If we take the African American male population in, say, the District of Columbia, St. Louis City, New York, or San Francisco, we find that they fall behind the Chinese or the Keralan at a remarkably early age. And this despite the fact that in terms of income per head, which is the focus of attention for standard studies of growth and development, the African Americans are much richer than the poor population with whom they are being compared in terms of survival patterns.

These are striking examples, but it would be right also to note that, in general, longevity tends to go up with income per head. Indeed, this is the case, even within particular counties. Is there something of a contradiction here?

There is really none. Given other factors, higher income does make an individual or community more able to avoid premature mortality and escapable morbidity. But other factors are not, in general, the same. So income is a positive influence, and yet - because of the variation of other factors (including medical facilities, public health care, educational arrangements, etc.) - there are a great many cases in which much richer people live much shorter lives and are overtaken by poorer people in terms of survival proportions. It would be just as silly to claim that higher income is not a contributory factor to better health and longer survival as it would be to assert that it is the only contributory factor. Also, on the other side, better health and survival do contribute, to some extent, to the ability to earn a higher income (given other things), but then again, other things are not given.

Growth-mediated health development

The point is often made that while the rankings of longevity and per-capita income are not congruent, nevertheless if we take the rough with the smooth, then there is plenty of evidence in intercountry comparisons to indicate that by and large income and life expectancy move together. From that generalisation, some commentators have been tempted to take the quick step of arguing that economic progress is the real key to enhancing health and longevity.

The point about intercountry statistical connections, seen in isolation, is indeed correct, but we need further scrutiny of this statistical relation before it can be seen as a convincing ground for taking income to be the basic determinant of health and longevity and for dismissing the relevance of social arrangements (going beyond income-based opulence).

It is interesting, in this context, to refer to some statistical analyses that have recently been presented by Sudhir Anand and Martin Ravallion¹. On the basis of intercountry comparisons, they find that life expectancy does indeed have a significantly positive correlation with gross national product (GNP) per head, but that this relationship works mainly through the impact of GNP on (1) the incomes specifically of the poor, and (2) public expenditure particularly in health care. In fact, once these two variables are included on their own in the statistical exercise, little extra explanation can be obtained from including GNP per head as an additional causal influence. Indeed, with poverty and public expenditure on health as explanatory variables on their own, the statistical connection between GNP per head and life expectancy appears to vanish altogether.

This does not show that life expectancy is not enhanced by the growth of GNP per head, but it does indicate that the connection tends to work particularly through public expenditure on health care, and through the success of poverty removal. Much depends on how the fruits of economic growth are used.

For a variety of historical reasons, including a focus on basic education and basic health, and early completion of effective land reforms, widespread economic participation was easier to achieve in many of the East and South-East economies in a way it has not been possible in, say, Brazil or India or Pakistan, where the creation of social opportunities has been much slower and acted as a barrier for economic development. The expansion of social opportunities has served as facilitator of high-employment economic development and has also created favourable circumstances for reduction of mortality rates and for expansion of life expectancy. The contrast is sharp with some other high-growth countries such as Brazil - which have had almost comparable growth of GNP per head, but also have quite a history of severe social inequality, unemployment and neglect of public health care. Gains in population longevity of these other high-growth economies have moved more slowly.

The growth-mediated process works through fast economic growth, and its success depends on the growth process being wide-based and economically broad, and also on the utilisation of the enhanced economic prosperity to expand the relevant social services.

Public provisioning, low incomes and relative costs

The “support-led” process does not wait for dramatic increases in per-capita levels of real income, and it works through priority being given to providing social services that reduce mortality and enhance quality of life. For example, we can look at the GNP per head and life expectancy at birth of six countries (China, Sri Lanka, Namibia, Brazil, South Africa and Gabon) and one sizeable state (Kerala), with 30 million people, within a country (India). Despite their very low levels of income, the people of Kerala, or China, or Sri Lanka enjoy enormously higher levels of life expectancy than do the much richer populations of Brazil, South Africa and Namibia, not to mention Gabon. Even the direction of the inequality points oppositely when we compare Kerala, China and Sri Lanka, on one side, with Brazil, South Africa, Namibia and Gabon, on the other. Since life expectancy variations relate to a variety of social opportunities that are central to development, an income-centred view is in serious need of supplementation, in order to have a fuller understanding of the process of development.

People in poor countries are, of course, persistently disadvantaged by many handicaps; the picture is one of diverse adversities. And yet, when it comes to health and survival, perhaps nothing is as immediately important in many poor countries as the lack of medical services and provisions of health care.

The economics and politics of health care

Financial prudence is not the real enemy here. Indeed, what really should be threatened by financial conservatism is the use of public resources where the social benefits are very far from clear, such as the massive expenses that now go into the military in one poor country after another. It is an indication of the topsy-turvy world in which we live that the doctor, the schoolteacher or the nurse feels more threatened by financial conservatism than does the general and the air marshal. The rectification of this anomaly calls not for the chastising of financial prudence, but for a fuller accounting of the costs and benefits of the rival claims.

This important issue also relates to two central aspects of social living: the recognition of the role of participatory politics, and the need to examine economic arguments with open-minded scrutiny. If the allocation of resources is systematically biased in the direction of arms and armaments rather than in the direction of health and education, the remedy of that has to lie ultimately in informed public debate on these issues, and ultimately on the role of the public in seeking a better deal for the basic requirements of good living, rather than efficient killing. Nothing perhaps is as important for resource allocation in health care as the development of informed public discussion, and the availability of democratic means, for incorporating the lessons of a fuller understanding of the choices that people in every country face.

The second issue is that of economic scrutiny. It is, in particular, important to see the false economics involved in an argument often presented against early concentration on health care. Lack of resources is frequently articulated as an argument for postponing socially important investments until a country is already richer. The viability of this “support-led” process is dependent on the fact that the relevant social services (such as health care and basic education) are very labour intensive, and thus are relatively inexpensive in poor - and low-wage - economies. A poor economy may have less money to spend on health care and education, but it also needs less money to spend to provide the same services, which would cost much more in the richer countries.

A concluding remark

Those who ask the question whether better health is a good “instrument” for development may be overlooking the most basic diagnostic point that good health is an integral part of good development; the case for health care does not have to be established “instrumentally” by trying to show that good health may also help to contribute to the increase in economic growth.

Given other good things, good health and economic prosperity tend to support each other. Healthy people can more easily earn an income, and people with a higher income can more easily seek medical care, have better nutrition, and have the freedom to lead healthier lives.

“Other things” are not given, and the enhancement of good health can be helped by a variety of actions, including public policies (such as the provision of medical care). While there seems to be a good general connection between economic progress and health achievement, the connection is weakened by several policy factors. Much depends on how the extra income generated by economic growth is used, in particular whether it is used to expand public services adequately and to reduce the burden of poverty. Growth-mediated enhancement of health achievement goes well beyond mere expansion of the rate of economic growth.

Even when an economy is poor, major health improvements can be achieved through using the available resources in a socially productive way. It is extremely important...to pay attention to the economic considerations involving the relative costs of medical treatment and the delivery of health care. Since health care is a very labour-intensive process, low-wage economies have a relative advantage in putting more - not less - focus on health care.

Finally, the issue of social allocation of economic resources cannot be separated from the role of participatory politics and the reach of informed public discussion. Financial conservatism should be the nightmare of the militarist, not of the doctor, or the schoolteacher, or the hospital nurse. If it is the doctor or the schoolteacher or the nurse who feels more threatened by resource considerations than the military leaders, then the blame must at least partly lie on us, the public, for letting the militarist get away with these odd priorities.

Ultimately, there is nothing as important as informed public discussion and the participation of the people in pressing for changes that can protect our lives and liberties. The public has to see itself not merely as a patient, but also as an agent of change. The penalty of inaction and apathy can be illness and death.

Reference

1. Anand S, Ravallion M. Human development in poor countries: on the role of private incomes and public services. Journal of economic perspectives 1993;(7).