|Year : 2014 | Volume
| Issue : 4 | Page : 411-412
The Indian health paradox: Lessons from Bangladesh
Department of Community Medicine, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||25-Jun-2014|
Department of Community Medicine, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Banerjee A. The Indian health paradox: Lessons from Bangladesh. Med J DY Patil Univ 2014;7:411-2
One of the paradoxes in the India growth story is that improvement in the nation's health has not been commensurate with its economic growth. Selected indicators for the World's 16 poorest countries outside of Sub-Saharan Africa show that while India heads the list in gross domestic product (GDP) per capita, it fares poorly in all health indicators such as life expectancy at birth, infant mortality rate, under-five mortality rate, access to sanitation, proportion of under-five children who are malnourished, and child immunization rates. The most embarrassing statistic is the proportion of Indian children below 5 years who are underweight. At 43%, this is higher than even Sub-Saharan Africa. ,
The phenomenon of high rates of child malnutrition in South Asia has been termed the "the South Asian enigma" by Ramalingaswami et al.  They postulated that the low status of women in South Asia leads to poor nutrition and other deprivations during pregnancy causing intrauterine growth retardation and low birth weights, affecting the children's nutritional status right from birth and even conception. This hypothesis is consistent with more recent reports. 
Lessons from Bangladesh, one of our poorer neighbors reinforce this hypothesis. Though being one of the poorest countries in the world, with large sections of the population being deprived of bare essentials, it has made fairly good progress in health indicators, overtaking India. The per capita GDP in Bangladesh is half as in India.  Democratic institutions in Bangladesh are also shakier. There is perpetual political turmoil. In spite of all these factors it is paradoxical that it fares better in most health indicators compared to India.
A comparison of selected public health indicators from Bangladesh Demographic and Health Survey Report 2007  and the National Family Health Survey 2005-2006 (NFHS-3), from India  illustrates some interesting differences. Proportion of households practicing open defecation in India is 55% compared with 8.4% in Bangladesh; proportion of children fully immunized is 44% in India and 82% in Bangladesh; percentage of newborns put to breast within 24 h of birth is 55% in India compared with 89% in Bangladesh; proportion of under-fives who received vitamin A supplementation is 18% in India compared with 88% in Bangladesh, and proportion of children with diarrhea treated with oral rehydration therapy is 39% in India as compared with 81% in Bangladesh. In under-five malnutrition too Bangladesh fares better than India, albeit marginally. The proportion of under-five children who are underweight is 41% in Bangladesh  compared with India where it is 43%.
Some clues to this paradox are provided by the following facts. The most important appears to be sustained positive change in gender relations.  Many gender related indicators are presently much better in Bangladesh compared to India. , For e.g., women's participation rate in the workforce is 57% in Bangladesh compared with 29% in India. Similarly, women literacy and enrolment rates for girls in schools are also higher in Bangladesh. Bangladesh is one of the few countries in the world where girls exceed boys in schools. The proportion of women in parliament is higher in Bangladesh than in India. All these factors are acknowledged across the world as powerful measures of women's empowerment, and Bangladesh has made greater use of this than has India. 
The lessons for India are clear. It needs to empower its women, particularly rural women, if it wants to improve its health status. However, an in-depth, qualitative study supplemented with robust quantitative methods wherever applicable, carried out over a span of three decades among rural women in Satara District of Maharashtra, (from 1975 to 2008), gives mixed signals.  The study has brought out the impact of economic reforms since 1991 on gender roles. There was more school enrolment of girls, higher ages at marriages and smaller family size. Women's employment as wage laborers also declined and they also had more leisure time. However on the downside, traditional gender roles were more refractory to change. In spite of better education, primary role of women was still viewed as homemakers and raising a family with few working in organized labor markets. The author stresses that creating jobs and disposable income for rural women has not received much attention. Millions of rural women need to be brought into the modern economy if India wants to compete in the global economy. Young rural women need to work in the modern labor sector. According to the study by Vlassoff,  employment, specially of rural women, pays off rich dividends in other spheres also. Self-employed and professional rural women were more likely to use contraceptives, and delay having the first child compared to unemployed women, even after adjusting for literacy levels and schooling. Another feature of the study by Vlassoff is that the desire for sons in India has not changed over the years. Although, families are now limiting their total number of children to one or two having a son is still considered necessary. Couples with only daughters continue to have more children than they planned in order to beget a son. According to the study, preference for sons had emotional and cultural roots going beyond economic, inheritance and kinship reasons.  This son preference leads to other associated evils such as prenatal sex determination and selective abortion of girls,  and neglect of the girl child. In adulthood women face violence both outside and inside the home. 
Bangladesh owes much of its success in health despite economic poverty to women empowerment and equity.  It has achieved impressive improvements for the lives of women through access to services and legal protection of human rights. In the export oriented apparel industry, women comprise >85% of the 3 million workers.  In the informal sector, microcredit recipients now number more than 20 million women. Women's participation in economic activities has substantially empowered them within and beyond their own families.
The Bangladesh story of gender equity and empowerment of women as one of the reasons for "…exceptional health achievements despite economic poverty"  offer some lessons for the Indian paradox of "poor health achievement despite economic growth."
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