India’s agenda for policy reforms must lift the quality of outcomes

Much of the discussion has been on the arithmetic required to get there. Both the post-election Economic Survey and the Union Budget allude to the next generation of reforms required to make this happen but are scant on details. 

For any country to achieve developed country status, it must not only grow significantly for an extended period of time, but the nature of that growth must also evolve from one that is based merely on “quantity" to a broad-spectrum one based on “quality". 

I introduced this idea in my column written prior to the election. In a series of columns, I will expand on the quality reform agenda that is required for India over the next three decades to first get to upper-middle income status and then improve the odds of achieving a fully developed country status.

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The idea of a quantity to quality (QtoQ) transformation is almost fully self-explanatory in its objective. Some have called this the “brawn" to “brains" transition. 

It is easily illustrated with an example in primary education where the goal shifts from the number of children enrolled in schools and coverage of the eligible population to one that is based on outcomes for reading, writing and arithmetic at each grade level. 

Much of the focus for the QtoQ transformation is on developing human talent. In addition, some of the QtoQ elements need to focus on depth, sophistication, availability and pricing for the enabling environment in financial, housing, logistics and other markets.

This first column in the series focusses on the importance of quality public health initiatives to create the population foundation upon which a QtoQ transformation can be built. 

The word “public health" is broad and encompasses vaccination, nutrition, operationalizing the latest scientific advances and wide access to primary care. 

Only a healthy generation can beget an even healthier next generation. Reforms and implementation in this area are a prerequisite for India to make developmental progress.

Take for instance the Under five mortality rate (U5MR), which is the probability that a newborn would not survive until her fifth birthday. Even though it has been coming down steadily over the decades, it is 29.2 per 1,000 live births in India versus an average of less than 5 for OECD countries. Progress into the teens and below for India will become harder and harder to achieve.

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Prior to birth, the age, nutritional status and general well-being of the mother become especially important in determining the birthweight of the baby and the cognitive capacity of the newborn. Low birth weight (LBW) in India (defined by the World Health Organization to be any baby less than 2,500 grams at birth) continues to plague India. 

In India, LBW babies represent about 17.5% versus a global average of 14.6% and an OECD average of about 6%. LBW arises from maternal age, multiple pregnancies, obstetric complications, chronic maternal conditions like hypertension and diabetes, nutritional status of mother (particularly anemia) and substance abuse. 

In addition to a higher risk of early mortality, LBW babies can grow to have limited cognition, have life-long susceptibility to neurological and language impairments and are at greater risk of developing chronic disease.

Vaccination campaigns (Mission Indradhanush) over the last decade have increased full immunization coverage among the 12–23-month-old children to about 76%. 

This means that progress needs to be made for fully a quarter of the population of children to achieve the goal of universal immunization coverage. Vaccine-preventable diseases like pneumonia, diarrhoeal diseases, measles and meningitis still account for over 300,000 annual under-five deaths.

Each of these metrics will become progressively harder to improve upon as India reaches the limits of marginal effectiveness as the law of diminishing returns sets in. 

The QtoQ transformation will need to focus not only on “campaigns" and interventions but on creating an enabling nutrition and education environment for mothers with wide-spread access to primary care. 

A critical element of the QtoQ transformation is a shift from intervention to enablement and self-help. The state must build the capacity to go from acting in “mission mode" to promoting awareness and widening access, particularly for women and children.

There is some debate in academic literature about whether prosperity begets generational health or vice versa. A safe bet is that they move with interdependence and in tandem. 

Particularly because of the significant advances in public health and nutrition science and the experience of other countries, India can benefit by using a “public health"-based stepping stone to prosperity. 

Each healthy working age adult not only can contribute to their full potential, but they can also in aggregate improve upon the envelope of potential for their whole generation. 

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Good health is an end in itself. It is both a moral and real imperative for a developed society. It is also an important contributor to raising income levels for individuals and in aggregate for the whole cohort in the generation.

P.S: “Quality is not an act, it is a habit," said Aristotle.