Development as Freedom (9 page)

It is interesting, in this context, to refer to some statistical analyses that have recently been presented by Sudhir Anand and Martin Ravallion.
⁷
On the basis of intercountry comparisons, they find that life expectancy does indeed have a significantly positive correlation with 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 connection between GNP per head and life expectancy appears (in the Anand-Ravallion analysis) to vanish altogether.

It is important to emphasize that this result, if vindicated by other empirical studies as well, would not show that life expectancy is not enhanced by the growth of GNP per head, but it would indicate that the connection tends to work particularly
through
public expenditure on health care, and
through
the success of poverty removal. The basic point is that the impact of economic growth depends much on how the
fruits
of economic growth are used. This also helps to explain why some economies, such as South Korea and Taiwan, have been able to raise life expectancy so rapidly through economic growth.

The achievements of the East Asian economies have come under critical scrutiny—and some fire—in recent years, partly because of the nature and severity of what is called “the Asian economic crisis.” That crisis is indeed serious, and points to particular failures of economies that were earlier seen—mistakenly—as being comprehensively successful. I shall have the opportunity of considering the special problems and specific failures involved in the Asian economic crisis (particularly in
chapters 6
and
7
). But it would be an error not to see the great achievements of the East Asian and Southeast Asian economies over several decades, which have transformed the lives
and longevities of people in the countries involved. The problems that these countries now face (and have potentially harbored for a long time), which demand attention (including the overall need for political freedoms and open participation as well as for protective security), should not induce us to ignore these countries’ achievements in the fields in which they have done remarkably well.

For a variety of historical reasons, including a focus on basic education and basic health care, and early completion of effective land reforms, widespread economic participation was easier to achieve in many of the East Asian and Southeast Asian 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 that slowness has acted as a barrier to economic development.
⁸
The expansion of social opportunities has served to facilitate high-employment economic development and has also created favorable 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. The longevity achievements of these other high-growth economies have moved more slowly.

There are two interesting—and interrelated—contrasts here:

I have already commented on the first contrast (between, say, South Korea and Brazil), but the second contrast too deserves policy
attention. In our book
Hunger and Public Action
, Jean Drèze and I have distinguished between two types of success in the rapid reduction of mortality, which we called respectively “growth-mediated” and “support-led” processes.
⁹
The former process works
through
fast economic growth, and its success depends on the growth process being wide-based and economically broad (strong employment orientation has much to do with this), and also on utilization of the enhanced economic prosperity to expand the relevant social services, including health care, education and social security. In contrast with the growth-mediated mechanism, the support-led process does not operate through fast economic growth, but works through a program of skillful social support of health care, education and other relevant social arrangements. This process is well exemplified by the experiences of economies such as Sri Lanka, pre-reform China, Costa Rica or Kerala, which have had very rapid reductions in mortality rates and enhancement of living conditions, without much economic growth.

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 (particularly health care and basic education) that reduce mortality and enhance the quality of life. Some examples of this relationship are shown in
figure 2.1
, which presents the GNP per head and life expectancy at birth of six countries (China, Sri Lanka, Namibia, Brazil, South Africa and Gabon) and one sizable state (Kerala) with thirty million people, within a country (India).
¹⁰
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 much richer populations of Brazil, South Africa and Namibia, not to mention Gabon. Even the
direction
of the inequality points opposite 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 (including epidemiological policies, health care, educational facilities and so on), an income-centered view is in serious need of supplementation, in order to have a fuller understanding of the process of development.
¹¹
These contrasts are of considerable policy relevance, and bring out the importance of the support-led process.
¹²

FIGURE
2.1:
GNP per Capita (U.S. Dollars) and Life Expectancy at Birth, 1994

Sources:
Country data, 1994, World Bank,
World Development Report 1996;
Kerala data, Life expectancy, 1989–1993, Sample Registration System cited in Government of India (1997), Department of Education,
Women in India: A Statistical Profile;
Domestic product per capita, 1992–1993, Government of India (1997), Ministry of Finance,
Economic Survey 1996–1997
.

Surprise may well be expressed about the possibility of financing support-led processes in poor countries, since resources are surely needed to expand public services, including health care and education. In fact, the need for resources is frequently presented as an argument for
postponing
socially important investments until a country is already richer. Where (as the famous rhetorical question goes) are the poor countries going to find the means for “supporting” these services? This is indeed a good question, but it also has a good answer, which lies very considerably in the economics of relative costs. 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
labor 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. Relative prices and costs are important parameters in determining what a country can afford. Given an appropriate social commitment, the need to take note of the variability of relative costs is particularly important for social services in health and education.
¹³

It is obvious that the growth-mediated process has an advantage over its support-led alternative; it may, ultimately, offer more, since there are more deprivations—
other than
premature mortality, or high morbidity, or illiteracy—that are very directly connected with the lowness of incomes (such as being inadequately clothed and sheltered). It is clearly better to have high income
as well as
high longevity (and other standard indicators of quality of life), rather than only the latter. This is a point worth emphasizing, since there is some danger of being “overconvinced” by the statistics of life expectancy and other such basic indicators of quality of life.

For example, the fact that the Indian state of Kerala has achieved impressively high life expectancy, low fertility, high literacy and so on despite its low income level per head is certainly an achievement worth celebrating and learning from. And yet the question remains as to why Kerala has not been able to build on its successes in human development to raise its income levels as well, which would have made its success more complete; it can scarcely serve as a “model” case, as some have tried to claim. From a policy point of view, this requires a critical scrutiny of Kerala’s economic policies regarding incentives and investments (“economic facilities,” in general), despite its unusual success in raising life expectancy and the quality of life.
¹⁴
Support-led success does, in this sense, remain shorter in achievement than growth-mediated success, where the increase in economic opulence and the enhancement of quality of life tend to move together.

On the other hand, the success of the support-led process as a route does indicate that a country need not wait until it is much richer (through what may be a long period of economic growth)
before embarking on rapid expansion of basic education and health care. The quality of life can be vastly raised, despite low incomes, through an adequate program of social services. The fact that education and health care are also productive in raising economic growth adds to the argument for putting major emphasis on these social arrangements in poor economies,
without
having to wait for “getting rich”
first
.
¹⁵
The support-led process is a recipe for rapid achievement of higher quality of life, and this has great policy importance, but there remains an excellent case for moving on from there to broader achievements that include economic growth as well as the raising of the standard features of quality of life.

In this context, it is also instructive to reexamine the time pattern of mortality reduction and of the increase in life expectancy in the advanced industrial economies. The role of public provision of health care and nutrition, and generally of social arrangements, in mortality reduction in Europe and the United States over the last few centuries has been well analyzed by Robert Fogel, Samuel Preston and others.
¹⁶
The time pattern of the expansion of life expectancy in this century itself is of particular interest, bearing in mind that at the turn of the last century, even Britain—then the leading capitalist market economy—still had a life expectancy at birth that was lower than the average life expectancy for low-income countries today. However, longevity in Britain did rise rapidly over the century, influenced partly by strategies of social programs, and the time pattern of this increase is of some interest.

The expansion of programs of support for nutrition, health care and so on in Britain was not uniformly fast over the decades. There were two periods of remarkably fast expansion of support-oriented policies in this century; they occurred during the two world wars. Each war situation produced much greater sharing of means of survival, including sharing of health care and the limited food supply (through rationing and subsidized nutrition). During the First World War, there were remarkable developments in social attitudes about “sharing” and public policies aimed at achieving that sharing, as has been well analyzed by Jay Winter.
¹⁷
During the Second World War also, unusually supportive and shared social arrangements developed, related to the psychology of sharing in beleaguered Britain, which made these radical public arrangements for the distribution of food and health care acceptable and effective.
¹⁸
Even the National Health Service was born during those war years.