Jayati Ghosh

Transcription

>> It's a great pleasure and honour to be here. I want to talk about this relationship between economic growth and women's health outcomes. And of course you will ask, why women's health? Why not health in general? The reason is because, you know, I do believe this that especially in the developing world, what happens to women's health is in a sense the critical indicator. The health of women and girls is the ultimate indicator of the health of that society. We know that many parts of the developing world, not just South Asia, but a lot of other places that, you know, patriarchy and gender discrimination are quite widespread. And that in turn means that women's health indicators, or those of young girls, are typically the worst. So if you can actually bring those up, you know that the health of the society in general is improving and I think that's why I would like to focus specifically on women's health, and particularly on two critical indicators: the infant mortality rate for girls, that is under the age of one, and the maternal mortality rate. These are reflections not just of the overall status of women in that society but the ability of that society to look after all of its citizens. And that's why it's very useful to look at these very, very fundamental indicators. We know that there is widespread gender discrimination in India. And of course one of the ways in which this is manifest nowadays, it's very clear, is in the child sex ratio, the ratio of girls to boys in the age of zero to six years. This is the -- it's an unbelievable thing for many of us, but this has been progressively worse for the last 30 years. We've been seeing progressively declining child sex ratios, which is a reflection really of technology. And we find that the worst child sex ratios are in fact in the best off communities, and the richest sections of India are precisely those who exercise the greatest, shall we say, discretion in choice of the gender of the child. This is true in China as well. We know this. But it's particularly much in India. So it tells us that yes, we are operating in a world, a set of societies where there's widespread discrimination against women. And it's in this context that I want you to consider specifically women's health outcomes. Now what I wanted to do was to really look at women's health outcomes. The point is that Asia is growing, Asia is dynamic, Asia is emerging and so on and so forth. Right? We all know about this wonderful continent rising up and about to swallow up the rest of the world and all that. [ Laughter ] So here is Asia, here are some of the most successful economies of Asia - I haven't taken China here for a very obvious reason, China has not only sort of rich to middle income status, now, well ahead of all these, but also has had significantly better women's health indicators for 30 years. So I'm leaving China out of this. But these are four countries which have performed rather well in per capita growth terms if you look at it. And Vietnam is by far the best, that is an annual rate of nearly six per cent over 20 years. But India is pretty good too, it's five per cent almost over 20 years, which amounts to a very large increase, a tripling above capital incomes over this period, okay? Sri Lanka, Bangladesh, lower than India but also pretty good. If you look at the second part of this graph, the National Income per capita, this is in terms of US dollars in 2010. It's only Sri Lanka which has achieved what is called middle income status. That is to say, it's now recognised as a country that is above the $2,000 per capita mark. That's sort of the standard definition of middle income. India is still well below but slightly higher than Vietnam, and Bangladesh is still very much a poor country. Okay. Now, let's look at what's happened to female infant mortality rates: as I told you, one of the basic indicators. And this is-- after they've already been weighted out in terms of being able to be get born or not. Okay, this is after they have been born. How many of them survived? And what is remarkable here, I think, it's not just the fact that Vietnam, which is still poorer than India and has had a lower rate of growth, has had significant reduction in infant mortality rates and also began with a much lower base rate. But I think the really striking thing here is what has happened to Bangladesh. As you will see, Bangladesh started out with significantly higher and is now significantly lower. Despite the fact that it is much poorer, still, and its rate of growth has been slower than that of India. So I mean, clearly, India here is a bad performer. If you look at maternal mortality, well yes, Bangladesh is worse than India. The rate of reduction in Bangladesh however is faster than India, okay. If you'll-- they begun much higher and they are still much, they are still higher but the rate of reduction is higher. And of course as you will see, Vietnam and Sri Lanka are way ahead. Sri Lanka has almost developed-country indicators in both infant morality and maternal mortality. So definitely on this front too India, just clearly a poor performer. Well, one obvious explanation for this is in terms of public health spending as a share of GDP and as you can see, India's is abysmal. Okay? So, it turns out, is also Bangladesh but it is definitely abysmal. It was mentioned earlier that India has developed a highly privatised and fragmented system of healthcare, something like nearly three quarters of total health spending in India is out of pocket spending by households. And this has become a very important reason for example, for families falling into poverty or going into debt, this desperation to get private health care to ensure the survival of their family members in a situation where the public sector is completely inadequate. Now this low percent of GDP translates into a laughable amount in terms of the per capita health spending in dollar terms. So, we spend the princely amount of 12 dollars, 78 cents - equivalent in Indian rupees per year in terms of the public health, okay? Now this is really not - even if you take into account that things are cheaper in India - this is really not an amount of money that can be significant in terms of providing minimum facilities, okay? So the unwillingness, not the inability, the unwillingness of the Indian government to spend on public health is a very critical element in the overall poor indicators that we have seen. And of course, we end up having massively lower absolute spending than, say, Vietnam, which is a much poorer country at the current present time. And of course, this translates into what happens in terms of public health delivery as well. So if you're looking at the percent of births that occur with skilled personnel, we have really low, still less than half of our mothers are able to actually give birth to children with access to skilled personnel. In Bangladesh, it's really very low which explains the high maternal mortality still in Bangladesh. But as you can see in Vietnam, it's universal. In Sri Lanka, it's close to universal, 88%. If you take another indicator, I'm taking measles immunisation as the basic indicator here because, you know, the others, you get different results, but it's a kind of, it's a good proxy for the overall immunisation. And Bangladesh does so much better than us. I mean imagine, 71% only of immunisation. There are some states in India, some rather rich states like Gujarat and so on, where immunisation rates have actually been falling for children and you have less than 50% immunised for very obvious - there's a resurgence of polio in the city of Mumbai because of the lack of immunisation. But of course, India is a huge place. It is actually a subcontinent. It's, you know, as you can imagine it's really ridiculous to talk about one India in that sense and this gives you some idea about the very large variation across states. I'd just like to point out a few things for you. Oh, it's shocking me that I can't use this. Yes, Kerala, very low, almost developed-country style indicators, certainly on par with Sri Lanka and has continued to reduce. And Kerala has always been an outlier. In Kerala, it's just a combination of a long history of relatively greater egalitarianism, land reforms from the 1930s onwards, as well as a fairly long tradition of Left governments and Left-oriented policies which have been responsible. But some good news, the biggest decline has occurred in Tamil Nadu, which has gone down very significantly. Another very big decline has occurred in West Bengal and you had a reasonably good decline also in some other states, although it's rather high in many others. Maharashtra is the other one where there's been a decline. It's still high but there's been more action, shall we say, in the last decade in terms of an overall decline. What does this relate to? Well, one of the big reasons for high mortality, for poor health conditions, for the inability to survive is actually poor nutrition. >> And undernutrition helps to explain a lot. As you will see across the states - I don't want to bore you with too many of these details - but you will see how the child mortality rates here. This is the children under five. The mortality rates here work quite strongly in terms of the relationship, in terms of the proportion of underweight children as well. So it's really the fact undernutrition is a very important factor in overall child mortality. Of course, there's also access to health services. There's also a number of other things but nutrition plays a very big role. And that will also tell us why overall health, we are performing so poorly. I mean, this is per capita food grain availability in the country. And what it tells us - by the way, I should, 222 00:10:57,806 --> 00:10:59,336 I want to emphasise this a little bit because there's a widespread perception in the world thanks to George Bush and Condoleezza Rice, who first raised this during the global food crisis of 2008, that food prices are rising because the Indians and the Chinese are eating more. [ Laughter ] And you know, in fact they said, you know, we're happy for them. You know, it's good that they're eating more. You know, they were poor countries but naturally we know that when lots of large populations start eating more then the world's, foods prices will go up. But they're not. Both China and India, average food consumption and total food consumption, food grain consumption, have fallen. They have not gone up, okay? Which is an extraordinary, I mean, I think it's a huge indictment of the growth process but nonetheless, that's what happened. Now this is actually the per capita grain availability per person in the country but it refers to direct and indirect. In other words, this is not just what the households consume as grain because it's looking at the total availability of grain in the country and dividing it by the population. So it includes the grain that therefore gets consumed by animals and food stock and so on and so forth. It's both direct and indirect consumption, just so that people realise. And the extraordinary thing is that, in this period of high growth in the last two decades, there's an overall trend decline in both total food grains and in cereals alone. And this decline has actually - the average in the latest period is significantly lower than the average at the beginning of this period. Well, let's say around here if you take the first half of the 1990s. So it's a very, very significant decline in terms of per capita food grain availability. This is bad news because another thing that has happened, which all of you probably know, is that global food prices have been zooming up again. Now it's not just that they're zooming up now but that they have been extremely volatile in the last four years. This is from January 2007 onwards. And you will see how the food price zoomed up massively, fell again, almost to back where it was in the beginning, rose marginally for another year and then has zoomed up again until early 2011, has been falling slightly right now. This kind of volatility in global food prices is nothing to do with demand and supply, regardless of what anybody may try and tell you. The IMF has come up with an extraordinarily apologetic statement recently saying that yes, there's all this volatility but in fact, you know, that's because of temporary supply shocks and temporary demand shocks. This is nonsense because the world agriculture market is one of those few places that doesn't have seasonality. A harvest somewhere else is a lean period in another part of the world. And so, there's always harvest coming in and therefore, grain in particular, wheat, rice and so on, pretty much you get all year round the supply. There is no seasonality. If you look at these prices, the volatility is largely explained by a growing financialisation of the commodities market, a growing involvement of financial speculators in the global food grain market. And increasingly, these prices are completely correlated with global stock market prices because commodities have become a financial asset like many others. And it is this other aspect of the deregulation of finance, the growing role of the financial class in different aspects of our lives which is inadequately recognised because here we are not just talking about any old market, we're talking about food. A similar thing is also happening in global fuel markets, in the oil market. But this is food, which affects lots of people across the world, which affects, you know, the ability of many, many poor countries to import and certainly the ability of many poor people in moderately well off countries to actually consume food. And this works particularly in India because as you can see, it's very strange in India. When the global wheat price rises, the Indian wheat price rises. The global price comes down, ours doesn't really come down, ours keeps going up. So we have a very strong path through in India of the positive effect. That is when the world price is rising, our prices rise. When the world price falls, ours doesn't fall. When if prices rise again, our price rises. Now, I'd-- one thing I just want to explain to you about this graph, this is dollars per kilogramme, okay? Which means, this is the global trade price, the blue line, in dollars per kilogramme. These are Indian retail prices in Delhi and Mumbai in dollars per kilogramme. The remarkable thing is that we now have our prices higher than world prices, in dollars per kilogramme. We're talking about a country with much lower per capita income. We're talking about a population where 60% have half of the per capita income and yet we have higher than global prices for food. Is it any surprise that they're eating less? Okay, it's not only food. It's also sanitation and that's a very big part of health conditions overall. And here's another major, major failure of the Indian project. As you can see, 70% of our population does not have access to improved sanitation facilities. I don't know if I can bring home to you how significant that is. That means, you're condemning more than 2/3 of your population to the indignity and the lack of minimal health involved in open defecation. In fact for women and girls, that are also safety issues in this kind of thing. I can't begin to describe to you what it means that you're not providing basic sanitation to more than 2/3 of your population. It's an unbelievable thing to have left out, if you like, in terms of the minimum access of citizens to basic services. Okay, now I've given you all these graphs. I'm not gonna keep boring you with more graphs. The question then is, why is this happening? What's going on? What explains this extraordinary dichotomy between economic growth and these disastrous conditions in terms of nutrition, health, sanitation, and so on? There are several reasons for this. There is clearly an unwillingness of the Indian state to put their money where their mouth is, if you like, in terms of these basic things. We talked about that, per capita public spending and so on. So we've seen that there isn't enough in terms of that kind of spending. But, why isn't there enough of that spending? would be the next question, surely. Why is this a government that is still spending around 1% of GDP on all public health despite the fact the GDP is growing? Because GDP growth is supposed to allow you spend more. It's supposed -- first of all, your absolute amounts will grow anyway. But secondly, as the GDP grows, your tax revenues grow and you have more what is called fiscal space to actually spend on these essential areas. So why is it not being spent? Well, one explanation which is in a sense, if you like the systemic reason, the structural reason in India, I would argue, is that our history and present of the caste system has given Indian society a deeply unfortunate tolerance of inequality. We are willing to live with inequality in a way and to an extent that is really not acceptable in most other societies. So I think that's, if you like, a broad underlying thing which is certainly a major part of the problem. But that's not the only part of the problem because there is in turn the experience of the last two decades and that's, well, another problem has, if you like, got added to this first one, this inability, this lack of recognition of let's say, 80% of the population as having the same rights as the top 20%. The second very big thing which has become a critical feature in the last 20 years, I would argue, is the overall growth strategy itself. So the point I want to make here, which is possibly a controversial point, is that India's inability to have growth affect and improve the health outcomes of women and girls is the result of that growth strategy itself. It's not that, you know, you have the growth but you didn't spend enough on health. It's just, it's that the pattern of growth you chose prevented you from spending more on health. So the two are very closely linked. They are not separate, it's not that you have the growth thing here but, you know, you just spend a bit more and come on, be good now and so on. No. You really have to actually think of that growth strategy in terms of what it's based on and what it is able to deliver. What is it based on? It's based on two ideas. The first is that growth must be delivered by the private corporate sector and that's the basic agent of growth, that's the basic factor. And therefore to promote growth, you have to promote private corporate activity which basically means you have to provide incentives, you have to create, investor confidence, you have to provide them subsidies, very large subsidies. One major form of subsidy in India is in terms of effective tax reductions. The government's own estimate of tax reduction, tax benefits to the large corporate sector -- the government's own not some crazy woman from New Delhi but the government's own estimate of the tax benefits it has given to large private corporates in the last five years is three and a half per cent of GDP every year on average. That is more than our public health spending and our spending on primary education put together. Okay, so we are talking about a very, very dramatic reorientation of priorities here. So growth has to be delivered by the private corporate sector. That in turn means you must do everything you can to promote that private corporate sector: deregulation, tax subsidies, et cetera, et cetera, the entire range of things and it also means that you cannot enter into areas where the private sector may also have an interest. Because how does the private corporate sector grow? By entering activities and making everything marketable by commercialising activities. So you have to stay away from things where they might want to get in too. So if you create good public hospitals, there will be less candidates for all those private hospitals. If you create good public schooling, there will be less candidates for all the private schools and so on and so forth. So it's part of that overall strategy which is fundamentally based on promoting private activity. The other aspect of Indian growth which is often not recognised, everyone thinks that's, you know, how should I put it? There's a perception in India that Indian growth is based on real factors, whereas, you know, in the US, it was financially -- it was the whole property bubble led by sub-prime housing. In the UK also, there was a property bubble. In Spain and Greece as we now know there was a property bubble. Well, guess what everybody. In India also, we have a credit driven property bubble. We've had-- we got discovered, if you like, by the international investors around 2003. And from about 2009, we've been flavour of the month. You know, India is a very hot destination for international capital and so we've received very large inflows of some foreign direct investment but mostly financial flows: of credit flows and portfolio in capital flows. This has created a boom - did create, right now we're going to recession like all of you. It created a boom in the Indian property market, in Indian stock markets and of course, it led to the enrichment of a significant middle class. Remember that 20% of the Indian population is already more than 200 million people. So it would amount to a pretty large economy on its own. So this large, new, growing middle class is a minority of the Indian population but it constitutes a huge market in itself. There has been a significant increase in credit driven consumption, a massive increase in credit cards, in what is called retail credit, borrowing for houses, for cars, for consumer durables in general and all of that kind of thing. And the middle class, which as I said is a very large number in absolute terms, has dramatically increased its spending as a result. We do know what happens to credit driven bubbles in the end, okay? When the end comes exactly, of course we don't know. Because that-- we'd all be very rich if we could predict exactly when it comes. But we do know that they do eventually come to an end. So it's not in that sense a particularly sustainable pattern of growth. But the Indian growth story, the success in the last decade has been dominantly based on a credit driven bubble, on exports which are driven by Chinese manufacturing. China is our biggest market now. We are exporting raw materials and intermediate goods to China, we are importing finished products from China. China is our biggest trading partner, it's our biggest export market and the biggest source of our imports. But we are caught therefore in the Chinese export to the north because then we are part of that system. And the domestic growth is based on, as I said, this credit driven bubble. That's why we are able to have a significant expansion of growth even though we have all these dreadful and deteriorating nutrition indicators. Even though employment has not grown, we now have the worst employment growth in post-independence history, ever since we started collecting the data. The last five years has given us the worst employment growth, where more than half of all our workers are self-employed in petty production, which mean they can't find employers. It's not because people like to be self-employed, it's because you don't get a job or you lose your job so you take some bananas and shove them on the cart and go out and sell them, okay? So it's this extraordinary combination of very, very high growth with displacement of traditional livelihoods and activities and reduction in wages that has -- in a sense is the story of the Indian boom. The other thing which is often not -- well I suppose it follows, you know, because you are basing all your hopes on corporate activity for growth, you tend to promote profits as a share of income. So we now have one of the lowest shares of wages to national income in the world. In manufacturing, production, the wage share of the value added of output is now eight per cent. And if I give you some idea, in England you're all jumping up and down and getting very excited because yours has fallen to 20%. It's bad. I'm with you. [ Laughter ] I agree with you that it's bad and you know, it should not fall, et cetera. But eight percent, okay? We are really now-- we have in a sense, we have squeezed the working class for pretty much as much as they can be squeezed. And of course, those are the sections of the working class or the middle class, whose real incomes may be squeezed in real wage terms, are able to access credit. So they can buy more through credit. Very similar story to what was happening in the United States when real wages were falling but they had more and more access to credit and so they borrowed to consume. So that's the Indian growth story. I think it's fairly clear that this is not sustainable, okay? It's not sustainable economically. As we've seen, credit driven bubbles don't last. Secondly, it's not sustainable because the entire export driven model is under threat today. I mean, we know that the Eurozone is, euphemistically putting it, is facing problems. [ Laughter ] We know that the United States is in such a mess that the politics is not going to allow much traction there in terms of any real attempt to get over the recession. There's not going to be any fiscal stimulus coming from the US. So these are the two largest markets for developing Asia. The United States and Europe are more than 50% of Asian exports. Yes, we have diversifying, China in particular is diversifying. But even so the shift of weight of these two markets is going drag down this dynamic region. So the export -- and of course, it's not just that the absolute market is shrinking but also that as that market shrinks and as more jobs are lost here and in the United States, there will be more protectionism, there will be more attempts to set barriers that prevent cheaper imports from coming in and to save jobs. These are all inevitables. So that particular export led model is also no longer really feasible. It's not sustainable environmentally, this particular project, because we really in this short period have already done such massive damage to our environment, such major strains on our ecology, that we're already facing these limits. There are parts of India where the soil quality has actually fallen by 40% in 20 years. There are parts of India where the rivers are no longer usable by humans and so on. So we have already destroyed our environment to such an extent that it's become a constraint on production, on human activity. So for all of these reasons, this is not sustainable. And of course finally, it's also bad news because, as I said, it delivers bad news in terms of health outcomes, okay? It's therefore not particularly desirable, quite apart from not being sustainable. The good news, finally [laughs], you could say, the good news is that there is an alternative, that there is another way of doing things, there is another set of economic policies and an overall macroeconomic strategy that can give you better results and is feasible. Okay? I would call this broadly speaking a kind of wage and employment based strategy where your focus is not on the private corporate sector for delivering growth but on expanding the consumption and the conditions of life of the mass of the population because that will create the market that will create incentives for private activity. >> Now this requires a set of things. The things -- for example, one of the things it requires most of all is to improve the viability of small producers. I've already mentioned that, you know, that the dominant form of production in India, in the whole of South Asia, in most of developing Asia, small producers are dominating in terms of the numbers. Most people are employed in small scale production. Let's improve the viability of that. There's lot of ways of doing that. I won't go into the details now. But also, we really have to have a massive increase in social spending. Spending on health, nutrition, sanitation, education, okay? And that's not because it's a good thing to do. Not because it will even improve your, you know, long term growth prospects, that's what often people say, that you invest in humans now and they will give you a more productive workforce 20 years from now. Not because of that but as a growth strategy. The reason is because if you spend, if you actually provide more public employment in these areas, this creates what we call multiplier effects. That is the incomes that these people get from this employment, they go out there and spend in their local area. That generates more economic activity and a local market, which creates more jobs and so on and so forth. So you actually can create not just a counter-cyclical buffer, not just something that prevents you from suffering in a period of recession, but an aggregate growth strategy which is based on improved incomes and consumption of the people as a whole. This I believe is not just the desirable and the, you know, the preferable way of approaching macro-economic and growth strategy in developing countries and, dare I say it, even in some developed countries today. I believe it's going to be the only way because the other way is not working, we know that. And it's going to be working less and less and less. So I really do believe that focusing on women's and girls' health, among other things, and putting public money into that, putting more employment, better conditions, better facilities into that, is part of an overall growth strategy. It's not just part of a welfare strategy. And if we look at it that way, then we see that economic growth and women's health outcomes need not be a very sharp division. And to be sustainable, they really have to be growing together. Thank you very much. [ Applause ] [ Inaudible Remark ] >> Well, that was wonderful. Thank you very much indeed for a superb lecture. And it shows how those of us in the health community, sadly, because we take a very narrow health approach to many of these problems, why we often fail to get our messages through to politicians because we don't look at these broader socio-economic strategies. So we have an opportunity to-- we have good time for discussion actually and so why don't we start off with some questions from the audience and see where we go. Who'd like to start first? We have microphones in the aisles. >> I wanted to ask you if you are aware of the EU-India free trade agreement that is being rushed through right now with the deadline in February 10th. It's going to devastate workers here because the single thing that India is asking for their side is for companies to be able to send in cheap Indian labour into this country. On the other side and from what you're talking about, really devastating because of the access of the transnational finance to public procurement. Like you say, once that is the situation then the public cannot be-- the public side cannot be promoted and the tightening of intellectual property on generic medicines that has been forced on India, liberalisation of banking, insurance, financial services, access for all the dodgy financial services that we had here. You obviously do know what I'm talking about. >> Yes. >> Yes. >> Unfortunately speaking, it's been completely secret here, I know it's been quite secret in India but it has burst out, yeah. >> Yes, well I completely agree with you. It's absolutely disastrous. And in fact the problem with many of these free trade -- so called free trade agreements is that they're entirely corporate driven. So what is being defined as the interests of India are really the interests of Indian corporates, which is why we have allowed a lot of openness in all of these areas of investment activity because the private corporates are interested in that too, reciprocally. The implications on the people are horrific. And there has been some noise about it in India but as -- I don't know what your rules are but in India, unfortunately, the government doesn't have to take this to parliament or do anything. They can negotiate it secretly. They can sign it secretly. And they can present the results to the people. >> It's worse here because it's done in Brussels. >> Oh, yes. That's true. [Laughter] >> Oh God, Europe. Europe's raised its head. Okay, so down here and then up-- back there. >> Yeah. >> Thank you. I'm Michael Anderson from the British Department for International Development. I wanted to ask you a question about-- you said you weren't going to compare with China because they're very different. India became a middle income country in 2008, China much, much earlier. But 30 years ago, China was way ahead. And I wondered if you could speculate on why those differences existed back then when there's a very different model of growth. I wonder if it's connected to-- Bangladesh is able to achieve even better results than India in many indicators, including a number you didn't put up, with less money. And I wondered if there's something there to probe and I'm gonna offer a hypothesis: the National Rural Health Mission in India, every year money is returned from the states back to the centre because the states are unable to spend the money that the centre allocates. So there's a lack of ability to deliver which at the moment is not very well explained. >> Yes. Okay, 3 sort of-- shall I? >> Please. >> -- 3 very big questions. China-- look, I mean, public provision I do believe has a very, very large role to play in China and, particularly by the 1980s well before the reform process started, it was a largely egalitarian society with very extensive public provision of health and education services. I do believe universal public provision is a key. I don't think any society has done it without universal public provision and I think it was essential in China. If anything, in the growth phase in China health conditions deteriorated slightly, because they actually allowed a lot of privatising and they started charging higher user fees and all that kind of thing. It's only very recently that they've realised what they've done and they're putting more money into that big health package. So I'd-- I believe, I mean if you have to ask me for one answer for China, I would say public provision-- universal public provision. Bangladesh is a more interesting and more complicated story because, of course, it's also one of those more aid dependent societies in the sense where a large part of the aid has also gone into health. So in addition to the public, you also have the role of international aid in providing some health services. Nonetheless, I'm not-- also by the way, Bangladesh nutrition indicators are much better and that's a big thing for infants. Infant mortality, as we saw both nutrition and immunisation are better in Bangladesh than in India on the whole and both of those play a role. Maternal mortality is still very high. It's come down but it's still very high. And I think, part of that is related to the relative absence of public provision. I think that does play a big role. I think the National Rural Health Mission is a bit of a disaster. I do believe that it is part of the overall strategy of the central government to try and provide health on the cheap. Because it is based on a model that uses ASHAs, Accredited Social Heath Activists, who are basically village women, who earlier weren't supposed to be paid at all, now they are paid the princely sum of 500 rupees a month, in some cases, it's a thousand rupees a month, to take the burden of public health care. I think that's obscene. I think -- I don't see why Indian citizens can't get public heath care through a proper public service with public employees and facilities and all of that. So I don't think the National Rural Health Mission was well conceived. I also do not think that health services should be seen as a scheme or a mission. I think that they are part of what, you know, societies have to provide to people. The states not being able to spend has also to do a significant amount with this bureaucratic issue of centre to state transfer. These have come up in all of these large schemes like the employment guarantee and a number of others where there are such stringent rules put on utilisation certificates and so on that states are not able to fulfil them in time. But in any case even if they did spend them all, I mean it's peanuts. The money is so little. And it's based as I said on the underpaid labour of local women that it's really not likely to deliver that much. >> Thank you very much. >> The argument you put forward this evening was compelling. But really, it's not new and you'll be the first to say that it's not new, it's fairly fundamental economics. And so I wonder if I could ask the million rupee question and ask you, how do we get governments to listen? If a major banking crisis only puts the Conservative government in power and has us cutting deficits to grow our way out of recession, if we have these 'stupid', to use your technical phrase. [ Laughter ] >> Stupid economic policies that we are all throwing all of our weight behind when all of the evidence is telling us >> Yeah. >> to do just the opposite. So how, when your arguments have been around for decades, if not centuries, do we get them to listen in spite of it all? >> [Laughs] It's the million rupee and the million renminbi and the million euro and the million dollar and the million pound question. Yes. You know, I used to also be quite despairing especially when after -- in the aftermath of the big financial crash of 2008, when we thought that financial markets had so thoroughly exposed themselves, you end up with this great resurgence of finance and they're back, they're dancing on our graves. If you see what I mean. [ Laughter ] >> Yes. But I-- you know, the last few months have been a little bit less gloomy, I do believe. I think that there was a phase when the immediate aftermath of crisis, job loss, panic, et cetera was used by finance which had basically taken and which was-- which is the cause of all of these large deficits today, by the way, in the government. It was used by finance and the media, which plays a really bad role, to impose a set of policies and persuade everyone that there's no alternative. But when you look at the history of past crises, this is not the first time this has happened. This goes through these phases, it goes through a period of about four or five years before people get it. And they say, no enough, okay. And I think we're getting there because you know, now history is telescoped always. It's much faster now. I think it's beginning to happen. I mean whether it is in terms of you know, various Occupy movements or it is in terms of the wider protests in southern Europe, whether the indignados and so on, or it's the protests in Chile against the privatisation of education or it's the protests in Thailand which, you know, is demanding more worker rights and so on. I think -- I think there's a change. You know, I think, I mean okay, we -- all we can do is hope. But it doesn't happen easily. Governments don't do it because they think it's the right thing. They do it because they're forced to do it. And maybe we're getting to that point. Fingers crossed [laughs]. >> Okay, I'm trying to go to left and right but there's-- oh, yes, I think we've got somebody here on the fourth row. >> Yeah, this is Devet Vari and I have just submitted my PhD with Jawaharlal University in July. >> Wow, very good. [ Laughter ] >> It's nice to meet you here. [ Laughter ] >> My question is like if National Rural Health Mission is a disaster in India, then Janani Suraksha Yojana - it's a part of National Rural Health Mission which is to provide cash incentives to the pregnant women for delivering in health institutions - and according to the RCH and DLHS round three, institutional delivery has actually increased, like doubled or tripled, in most of the low performing states in India, and that credit has been given to Janani Suraksha Yojana. So it -- like the Janani Suraksha Yojana part of National Rural Health Mission is actually performing good. >> You know, I, okay, this is the trouble with anything that happens is that there can always be two interpretations of why it happened. But let me put it this way. If you do not have a good public institution, what's the point of a woman being able to go to it, right? So -- and 500 rupees is really too trivial an amount for that woman to be able to access a good private institution. So what you are really saying is that, that 500 rupees will enable the woman to provide herself nutrition or do something or the other and so on. I actually resisted this Janani Suraksha Yojana very strongly because it was actually presented as a choice. Do we give 500 rupees to every pregnant woman? Or do we provide more in terms of the Anganwadi, you know the women workers and helpers in the ICDS, the Integrated Child Development Scheme. You know, if you don't provide good public services then there is no incentive and there's no advantage in forcing women to go to them. So I would say the first job is to make public health services for, you known, delivery and child care et cetera, good, which means you have to spend money on them. When you look at where cash transfers have worked, Brazil and Mexico for example, they were accompanied by increasing public spending on these child care facilities, health facilities and so on, education facilities. So you have to spend more money on that, make them good. And I don't know, I mean, wherever I have gone in rural areas, women are happy to go to institutional delivery if it's good. But you look at the conditions, they're three to a bed in some of these hospitals. Why force women to go through that? You know. [ Inaudible Question ] >> Yes, yes. To me, it is not self evident that 500 rupees in a private sector shop is going to necessarily give you better, you know -- Let me put it this way, I wouldn't want my -- I wouldn't want to go though it myself. I certainly will not put my daughter through that. To me, that's the bar [laughs]. >> Now I was going to say the gentlemen in the orange t-shirt, but half the audience is wearing orange t-shirts [laughter] so whoever is the guy who's got the microphone can speak. >> Hi there. >> Hi. >> I'm William Birch, I'm a Third year medical student studying International Health. as my BSc. What strategies do you know that are effective in tackling the deep social issues which are causing gender selection of newborn social in India? >> Yeah. This is a really big one. I wish I knew. I tell you what doesn't seem to work much are these cash incentives. You know, many state governments have done this. You get a thousand rupees when the child is born and then you get, I think 5,000 if she survives 'til age 5 and then you get 21,000 when she gets to 21. No, when she marries or some such thing, I forget. These do not work. In all the states that have done them, the child sex ratio has fallen farther, okay? So these don't work. What works, oh God I wish I knew, you know this a really tough one [laughs]. How do you get societies to value women more and how do you reduce son preference? It's a really tough one. I don't know. I do know what doesn't work. It's the cash incentives that doesn't work. >> Thank you very much for the very interesting lecture. There is usually a very close correlation between infant and maternal mortality and morbidity, and female education but you haven't mentioned it. I just wondered if you could say whether that's an intermediary in some of these things or not in India and whether we know. >> You know, it's true that a number of studies have found, well, they haven't looked at education so much as just literacy and they found a strong correlation. But the really strong correlation is with nutrition. And I think, that's one of the problems is that we have - it's basically an undernourished population and it's undernourished in critical years, you know, in the reproductive years and that affects the child and the mother's mortality and all of that. Yes, education does make a difference. At the district level, it's been found that there is some degree of, you know, that women now are more able. This is what the ASHAs are supposed to do in the National Health Rural Mission. They're supposed to go and give women effectively what they would have got if they had been literate in terms of, you know, knowledge about healthy practices and sanitation and so on and so forth. And yes, it does play a role but as I said, the dominant role is nutrition. >> There was -- over here. A lot of hands going up. I will get to you all if we keep the questions running. >> Yes. >> Suzanne Gallagher. So I'm just wondering about whether or not you can be guaranteed that spending more money will definitely ensure better services because, I don't know, you cited Brazil there and Mexico that there had been improvement. I'm not an expert myself but I known in the UK with the doctors, the NHS managers. I've discussed this with, increase in spending in the NHS does not mean increase in services and there has been doubling in last 10-15 years but has the service improved? The general consensus in rooms I've been in is no. So, I'm more interested on the implementation side like how do you ensure that there will actually be an impact on women's health, infant mortality, all the issues you have cited tonight? >> No you're absolutely right. That's a very important question and certainly that's the case, that there is no one to one relationship. The US has the most expensive health system in the world and not very good, you know, health indicators relative to a number of other countries. So its not only the amount of money but it is -- at this level of spending, it's a necessary condition. I mean, yes, in addition to spending more money, you have to make sure that that money is spent in a way that is effective. But you can't do it without spending. You can't do it on $12 a year per citizen, which is what we're trying to do. So I think at this level, we are really talking about money being a necessary condition, certainly not sufficient, I completely take your point, lots of other things to be doing with that. But you know, the government basically says, Oh, well, you know, we will reorganise and restructure and reform the health system while spending this tiny amount. That's not good enough. >> Okay, Anthony then Sarah. And so you say it [laughs]. >> I think I'm right that >> during the 2008-- >> Yeah >>-- food crisis that the Indian finance ministry did suspend the ability of hedge funds to speculate on food commodities and futures and then later rescinded that for reasons that are not altogether clear. And alone amongst all the Western leaders, Nicolas Sarkozy has been the only one who is really given a voice to doing this. I'm just wondering why there isn't more upward pressure in India through the media and through the electorate for this kind of action, given the effects of food inflation on their spending power. >> Well, you know the Indian government banned forward trading in six important commodities, essential food items in 2006 before the financial crisis. And they did this because of pressure from the left parties who at that point were supporting that UPA government. So they did it and they rescinded it when they were no longer-- not for all of them, it's only wheat. They have kept the ban on the others but they have allowed it for wheat, which is the price which has been going up the fastest. Just when they won, they came back the second time around without the left support in 2009. So there is still very strong feeling about this because, you know, it's absurd that it would benefit farmers. Most Indian farmers do not access commodity futures markets and so on [laughs]. And it really-- as we have seen it does the opposite of benefit consumers. In India there is a fairly strong opinion against it, including among the bureaucracy. There's also a very strong financial lobby which is pushing for it as you can imagine and it is one of the things, part of the EU FTA as well which the European Union has decided to demand. I wish there was more of an outcry also publicly here. In fact a year ago, I actually came to London and lobbied with a whole lot of MPs with the World Development Movement to make this more of a public issue. It doesn't seem to have become one but I'm told that there is now-- I saw a report on this in the Independent that there is now a set of little TV, not TV, online programmes, parodying George Osborne with sort of a caricature of him playing various roles but highlighting the fact that he's not doing the right thing about commodity speculation. Maybe something will work. >> Hello my name is Sarah Hawkes from the Institute of Global Health here at UCL. I just want to ask you a little bit about the right hand side of your title, the Women's Health Outcome side and link it to the question previously about how do you get people-- policy makers to pay attention? And just kind of as an outside the box thought: WHO figures clearly show that the biggest burden of disease globally, and the South Asian regions is no exception, is in men. The only figure where that is different in South Asia is in injuries related to domestic fires, for all the reasons that you know better than I. And I just wonder whether you think that you might have more success in lobbying for additional funds to be spent on health outcomes if they were people's health outcomes rather just women's health outcomes. Partly because you will get civil society more on board, you'll get men supporting the idea that it's worth investing in health. But also because I think conceptually, people find it easier to see that it's important to preserve men's health, to promote men's health if you want an economically sustainable workforce. >> Yeah, okay. Well, you know one is I don't think this was intended as a sort of lobbying slogan because what I was doing was using women's health as a proxy for the overall health, on the grounds that if the women's health is improving, you know everybody's health is improving. The burden of disease issue is a little bit more complicated, isn't it? Because, you know, if a lot of women's health issues arise because of the child bearing thing and that's not, you know, disease as such. So it's-- I really am not familiar sufficiently with, you know, how these statistics are collected to capture this but I'm not so sure that that would capture the actual health positions, especially in a number of relatively poor developing countries, in Sub-Saharan Africa, in South Asia, and so on, with high maternal mortality rates that would adequately capture the health challenges faced by men and women. But I completely take your point that obviously what we're caring about is the health of everybody. Do we see it only because it's the health of the work force? I would say, no. I would say that the way to pitch it politically would be to say listen, this is not about improving your workforce health so that they become more efficient workers but it's a means of creating demand to allow your economies to get out of the mess they're in. So currently I would picture it in terms of an economic strategy, as a macro-economic solution to economic recession and stagnation. >> Okay, lady over there. And then the gentleman over there. >> Hello, hello. >> Hello, I'm Ruth Bell from the Department of Epidemiology and Public Health from UCL. So you've discussed the dominant role of nutrition in infant mortality and maternal mortality. And I wondered how optimistic you are that the current food security bill that's going through the Indian parliament will help in that situation to improve food security in India? >> [Laughs] You know, this is one of those bills that we spent many years lobbying for and then the version which is up in parliament is so bad that it's better that-- it's better not to have a law than to have the version that is being proposed. But fortunately, the fight goes on and I don't believe that the eventual bill that we get is going to be the terrible version which is currently in play. You know, the Indian parliament has actually been quite progressive on a number of issues in terms of the Employment Guarantee Act, for example. The government wanted to put a very watered down version and intense lobbying with the MPs was able to actually produce a much better act. And I'm hopeful also with the food security bill. Also because, you know, the recent rise in prices in India has been very, very-- in 2 years prices -- food prices have gone up 45%. It's the biggest issue; parliament was stalled for three days last week, just because of food prices. So I think there is now a general political outcry to a degree which might create a better act. If it is an act that actually provides a near universal, minimum amount of grain to every household which is what is proposed, then it's a step forward, shall I say. It doesn't solve the problems of course but it's definitely a big step forward. >> I'm intrigued by the sex ratio and the very disturbing data that the more developed or economically developed a state in India is, the worse the situation is and the presumption being that it's access to antenatal ultrasound and selective termination. And I'm interested in Kerala and the question as to matriarchal society and women's education on the one hand versus economic development on the other, and the fact that Kerala's economics has rather declined recently and more and more people are going to the Middle East and presumably, therefore coming back with overseas money and all of that pressure that the non-resident Indian when returning has for gated communities and separate -- So one suspicion is that Kerala may well go the way of all these states where selected abortion is common. What's happening in Kerala with the sex ratio? What's happening with the GD coefficient? What's happening with health as Kerala is changing its economics? >> Okay, another big question. You know, Kerala is not really a matriarchal society. One caste in Kerala is matrilineal which is to say that you get from the main line but it's really the mother's brother who controls everything. And in fact, if you talk to any women from Kerala, they will tell you that patriarchy is alive and well and flourishing in Kerala. You know, so it's not in that sense. However it has been a more egalitarian society and it has been a society which has educated girls for a fairly long time, there's been universal primary education now for about three decades really. The sex ratio in India has improved in only two states. It's Kerala and West Bengal. And it's also two state that happen to have a very large presence of the Left movement, have been run by Left governments for-- well in Bengal until this April for 35 years and Kerala, on and off over the last three decades. So I mean, you know, perhaps it is also the over all, you know, culture of-- broader egalitarian culture which has promoted the slightly better attitude. But you're absolutely right, that yes, Kerala is also a very migrant society at the moment but it's interesting, a large part of this migration is female. And it's females going abroad to work in the service sector. You know, migration is highly gendered in Asia. The men go for construction and manufacturing, the women go for services. The care sector dominantly from Kerala but, you know, from poorer families they will go and work in domestic service and otherwise they go into what is broadly called entertainment. But in Kerala, they go dominantly into nursing. And it doesn't necessarily therefore reinforce, you know, regressive social trends. It actually perhaps, you know, because the women then get different exposure, they come back with the different -- in that sense it's not such bad news. [Laughs] Yeah. >> Question right at the back there, please. >> Hi there. I'm Kelly Clarke. I'm a PhD student at the Institute for Global Health. >> I was just wondering-- >> Just wave so we can-- >> Oh, thank you. Okay-- >> I'm not sure I want everyone to turn around and look but-- [ Laughter ] >> I was just wondering, in what way you felt the International Community, the INGO or the non-governmental organisations, international aid, can engage with and support the alternative macro-economic strategy that you put forward. >> Well, I mean there's no question we need all the help we can get, right? [Laughs] From whichever direction. It's no longer the case that the-- well, this is the other problem, you see, that in India because it is so-called emerging and the government feels very rich right now, it pushes everybody, aid donors and so on are basically, treated like-- you know -- a word which I will not mention. So it's difficult I would say. It is difficult for international NGOs to get into a campaign unless they are very-- are working very closely with local partners because there is a growing distrust across the region of voices from abroad. And there's a growing perception that we can do it ourselves better. To actually influence governments, it may not be a good idea to speak directly to governments. It may be a much better idea to support local movements that are making the same demands and I think this is a mistake a number of aid agencies have made. You know, because you can't anymore have - anywhere in the developing world - you can't anymore have these fellows, you know, whether it is a World Bank sticker or an Oxfam sticker, it doesn't matter anymore. You know, really there is a general resentment of the outside opinion unless it is very strongly merged with the local, you know, local mobilisation, shall I say. Okay? >> We're coming to a close now and we have three people who have been very patient down here. Man in the greenish jumper, in white shirt and then gentlemen, seated here. So first, yes. Yeah. >> Nicholas Maxwell at 1353 01:03:29,356 --> 01:03:29,466 Science and Technology Studies, UCL. I want to make a suggestion about the one billion dollar question. Perhaps academia has some responsibility for the situation. We've inherited from the past this idea that the basic proper aim of academic inquiry is knowledge. First of all, you acquire knowledge and then you apply it to help solve social problems. But if we took seriously the idea that academia is all about helping us, helping to promote human welfare, helping us to achieve what is of value to us in life. The basic problems we have to solve are not really problems of knowledge but problems of living, problems of action. And if academia was rationally organised, it would give intellectual priority surely to articulating our problems of living and proposing and critically assessing possible solutions. And out of this would kind of emerge such a technology and feedback into it. And if it were organised in that way, then maybe academics will be able to shout from the rooftops, when governments and other big powerful institutions in the world start pursuing very harmful policies, that they are pursuing harmful policies and that they should mend their ways and they might also get through to the public better. But if the basic aim is-- the basic idea is that we're acquiring knowledge. Then this doesn't really equip us to do that. And if you look at the academia, you'll see it's terribly sort of broken up into specialties without any idea of what the coherent enterprise is, so it seems to me, possibly we academics, have some responsibility for the situation. >> Yes. >> Do you agree? >> Here, here. [ Laughter ] [ Pause ] >> I'm Patrick Carol. I'm a actuary. And I know you're using measures of maternal mortality, measures of infant mortality but you don't refer to expectations of life as a measure of mortality across the ages. Is there some reason for cautioning India for using it-- about using that measure? >> Actually, no. It's just that I've-- I chose this-- these as very basic indicators. I mean, I could have also taken life expectancy but there is a lot of debate about our life expectancy figures and so-- [ Inaudible Remark ] >> Yeah. Because it's all questiondc, I mean, I don't really know the details but how you smooth the curve and stuff like that. So there's a lot of-- there's a big fight going on. And I didn't want to get into that one. >> Ah, very interesting. [ Laughter ] >> Okay. Just two rows in front you. >> Hello. Andrew Follmer from the World Bank, we've been mentioned a couple of times. So-- [ Laughter ] >> You're a brave man to disclose yourself. >> No, I'm-- [ Laughter ] >>-- happy to take it on. The WDR, the World Development Report was released in September, as you're probably aware, on gender. And the UK launch was last week. And it tackles and looks at women at the centre of development very much through a parity around economic opportunity. Now that is if you're convinced by that argument and you take it forward - you may not be convinced by it - but that's what convinced the Ministry of Finance to change their policy choices and their spending decisions. That's one of things they answer to. I welcome your views on that and how that place out in the Indian context. So providing economic opportunity to women can change the situation in which they find themselves. If you put that opportunity with women they normally make much better decisions for their family and their children than if you put that money in the hands of the man. Secondly, just I think the-- one of the issues that came when you were answering earlier on was about the paucity of data that's disaggregated for gender. And I think that's one of the key things that the World Bank team struggled with, with preparing this report. It just isn't out there. So the academic opportunity-- community rather, the NGO community, the World Bank community need to change the way they capture data so we can actually measure this issue and then tackle it with the policies that we implement. >> Yeah. You know, to take the second one first, I couldn't agree with you more. You know, I have been on International Commissions of the Department of Advancement of Women and ILO and UNIFEM and et cetera for 20 years we have been asking for this gender disaggregated data. Maybe now that you've asked for it, maybe we'll get it, I don't know. I mean, I hope so because yes, absolutely. But you know, despite the fact that we've been asking for it, it haven't come for a quite a while now. But there's always hope. On the issue of employment of women, yes, of course. I mean, definitely, you know, economic opportunities for women are desirable in themselves and give various other outcomes. I don't think there's any dispute about that. There is of course the other question though that economic opportunities for women should not come at the expense of, you know, the lack of provision of the care work that women end up doing, the significant amount of unpaid housework that women are involved in because of the whole double burden issue which I'm sure you're aware of. And so, yes, we know that economic opportunities improve the conditions of women. We also know that they have-- there are other issues associated with that because it depends not just on the very factor of paid work but the conditions of that work, the remuneration of that work and you know, whether that work is taking place with minimum safety and other conditions. So it's not a straightforward thing. It is definitely a positive thing but it has to be seen in context. So just the fact that there are more women in paid employment is not a cause of unqualified celebration. You would first have to look at the entire range of conditions of that work and then decide, I think. >> Last question. Right on the front row here. [ Laughter ] >> Thank you. My name is Amina. I'm doing a PhD in the Department of Epidemiology and Public Health where Ruth is. And I'm looking at nutritional outcomes in women in India and China amongst other countries, and looking at how they vary by wealth and eduction. But my question is completely unrelated and I wanted to push you a little bit and ask you if you'd be able to give a-- which single recommendation would you support if the 99% was to speak up and make a single request from all governments to try and tip the balance a little bit? What would it be? I don't know, you must know in Europe the Tobin tax proposal has been put forward. And Ha-Joon Chang who's an economist-- development economist in Cambridge has stated that the financial sector needs to be less efficient, not more efficient. Would you support a proposal for taxation of financial transactions? >> Oh, sure, yes. But you know, that's a tiny little thing. I mean it's good and I'm all for it. But it's not going to change, you know, this power balance that you talk about. One proposal you want, one little proposal or a broad strategy? If you want a slogan, I don't know how you would put it. But you know, there was that film, "Honey, I Shrunk the Kids", or something. We have to shrink finance. [ Laughter ] >> So slogan: shrink finance. It's too large. It is too large for the good of the economy. It's too large for the good of the people. And there are many ways to shrink finance but it has to be shrunk. >> Thank you. [ Laughter ] >> Thank you very much. Now, I'd like to thank the-- [ Background Applause ] >> -- Jayati for a splendid lecture. Thank you. [ Inaudible Discussion ]