Notions of development have, thanks to thinkers like Amartya Sen, gone well beyond per capita income as a measure of well-being. Sen articulated the idea of multidimensional human capabilities as a truer measure of welfare and development. Even where the need to collapse welfare to a single dimension led to creations such as the Human Development Index (HDI)—introduced by the United Nations and now used worldwide—the embedding of capabilities in the components of HDI fundamentally changed the measurement of well-being for policy evaluation and design.
Reflecting on various functional capabilities, including the ability to live to old age, freely participate in political activities, or engage in economic transactions, it seems that, while so many of these “substantive freedoms” can contribute to human welfare, basic good health is the foundation of many other capabilities. Even education, which is critical for supporting economic and political freedoms, is driven by good health, to the extent that malnutrition and illness, especially in children, can severely damage the capacity to learn and retain knowledge.
Pushing this reasoning further, one might argue that access to good healthcare, particularly for children, is the most important single function that a government can ensure, beyond the preservation of enough social order to contain violence and reduce the risks of violent death. With this perspective, policies such as India’s National Rural Health Mission (NRHM) seem particularly laudable in their goals (though assessment of outcomes and impacts has just begun —see the Planning Commission’s website for a recent preliminary evaluation). Yet NRHM is a sprawling scheme that seeks to tackle a huge number of deficiencies in India’s public health delivery systems. Healthcare is perhaps the most complex service to deliver, even for the private sector, and seeking to reach those in need through institutions that are themselves in poor health may not always be the best policy approach.
In fact, the poor quality and availability of public healthcare in India has led to such extensive de facto privatization that Indians spend a greater fraction of their healthcare outlays on private providers than is the case even in the wealthy, anti-socialist US (where private providers are often reimbursed or subsidized by taxpayer dollars). Efforts such as NRHM can only do so much in this context, especially when governments at all levels are fiscally constrained. But there is hope, coming from various institutional innovations.
Two of these innovations target precisely the segment of the population that needs it most, children. The targeting is even more precise, in that the first year, first months, even first weeks and days of a child are the most critical for future health. For example, the likelihood of onset of diabetes later in life may be affected by the quality of a child’s first few weeks. Learning capabilities are also influenced strongly by what happens in the child’s initial year. In this sense, one might argue that interventions such as midday school meals and other policies to support education come relatively late for children who are at risk.
Focusing on early child development raises an important complication, however. Development starts nine months earlier than birth. The conditions of birth are themselves important. And most significantly, the health and care of the mother are critical for the child’s pre- and post-natal health and development. This is all so natural that we take it for granted. But it is important to call it out, because it very clearly directs us towards policies that jointly address maternal and child health from conception through the child’s first year (at least).
One institutional innovation, the Chiranjeevi scheme in Gujarat, is a voucher programme that gives poor mothers access to institutionally based deliveries. Private doctors or other qualified medical professionals are empanelled by the state government and increase their incomes by helping poor mothers deliver their babies. The scheme has demonstrably reduced maternal mortality. Other states are copying this model, with the Centre possibly providing needed funds.
Another innovation relies even more on private incentives. LifeSpring Hospitals is a social enterprise, in the sense that its investors are a public sector firm and a social venture fund. It is registered as a company, but its social mission leads it to serve the poor. It now runs seven small maternity hospitals that use tiered pricing and cross-subsidization to provide access to the poor. No frills, focus and standardized processes keep costs down. The hospitals provide pre- and post-natal and paediatric care in addition to deliveries. The public investment came upfront, but there is no continuing demand on public funds.
These new efforts have helped thousands of women and babies. This help has been targeted at the most critical time in their lives, when risks are highest and the potential for good or bad impacts on future capabilities is the greatest. Putting women and children first like this is good economics, and a sign of true development.
Nirvikar Singh is professor of economics at the University of California, Santa Cruz. Your comments are welcome at email@example.com