Quality of Life: India vs. China

Quality of Life: India vs. China

MAY 12, 2011,Amartya Sen

Dinodia/Stock Connection/Aurora Photos

Girls in a classroom in the Indian model village of Ralegan Siddhi, northeast of Pune, Maharashtra, 2006

My primary concern is that the illusions generated by those distorted perceptions of prosperity may prevent India from bringing social deprivations into political focus, which is essential for achieving what needs to be done for Indians at large through its democratic system. A fuller understanding of the real conditions of the mass of neglected Indians and what can be done to improve their lives through public policy should be a central issue in the politics of India.

This is exactly where the exclusive concentration on the rate of GNP growth has the most damaging effect. Economic growth can make a very large contribution to improving people’s lives; but single-minded emphasis on growth has limitations that need to be clearly understood.

1.

The steadily rising rate of economic growth in India has recently been around 8 percent per year (it is expected to be 9 percent this year), and there is much speculation about whether and when India may catch up with and surpass China’s over 10 percent growth rate. Despite the evident excitement that this

subject seems to cause in India and abroad, it is surely rather silly to be obsessed about India’s overtaking China in the rate of growth of GNP, while not comparing India with China in other respects, like education, basic health, or life expectancy. Economic growth can, of course, be enormously helpful in

advancing living standards and in battling poverty. But there is little cause for taking the growth of GNP to be an end in itself, rather than seeing it as an important means for achieving things we value.

It could, however, be asked why this distinction should make much difference, since economic growth does enhance our ability to improve living standards. The central point to appreciate here is that while economic growth is important for enhancing living conditions, its reach and impact depend greatly on what we do with the increased income. The relation between economic growth and the advancement of living standards depends

on many factors, including economic and social inequality and, no less importantly, on what the government does with the public revenue that is generated by economic growth.

Some statistics about China and India, drawn mainly from the World Bank and the United Nations, are relevant here. Life expectancy at birth in China is 73.5 years; in India it is 64.4 years. The infant mortality rate is fifty per thousand in India, compared with just seventeen in China; the mortality rate for children under five is sixty-six per thousand for Indians and nineteen for the Chinese; and the maternal mortality rate is 230 per 100,000 live births in India and thirty-eight in China. The mean years of schooling in India were

estimated to be 4.4 years, compared with 7.5 years in China. China’s adult

literacy rate is 94 percent, compared with India’s 74 percent according to the

preliminary tables of the 2011 census.

As a result of India’s effort to improve the schooling of girls, its literacy rate

for women between the ages of fifteen and twenty-four has clearly risen; but

that rate is still not much above 80 percent, whereas in China it is 99 percent.

One of the serious failures of India is that a very substantial proportion of

Indian children are, to varying degrees, undernourished (depending on the

criteria used, the proportion can come close to half of all children), compared

with a very small proportion in China. Only 66 percent of Indian children are

immunized with triple vaccine (diphtheria/pertussis/tetanus), as opposed to

97 percent in China.

Comparing India with China according to such standards can be more useful

for policy discussions in India than confining the comparison to GNP growth

rates only. Those who are fearful that India’s growth performance would

suffer if it paid more attention to “social objectives”such as education and

health care should seriously consider that notwithstanding these “social”

activities and achievements, China’s rate of GNP growth is still clearly

higher than India’s.

2.

Higher GNP has certainly helped China to reduce various indicators of

poverty and deprivation, and to expand different features of the quality of life. There is every reason to want to encourage sustainable economic growth

in India in order to improve living standards today and in the future

(including taking care of the environment in which we live). Sustainable

economic growth is a very good thing in a way that “growth mania”is not.

GNP per capita is, however, not invariably a good predictor of valuable

features of our lives, for those features depend also on other things that we

do— or fail to do. Compare India with Bangladesh. In income, India has a

huge lead over Bangladesh, with a GNP per capita of $1,170, compared with

$590 in Bangladesh, in comparable units of purchasing power. This

difference has expanded rapidly because of India’s faster rate of recent

economic growth, and that, of course, is a point in India’s favor. India’s

substantially higher rank than Bangladesh in the UN Human Development

Index (HDI) is largely due to this particular achievement. But we must ask

how well India’s income advantage is reflected in other things that also

matter. I fear the answer is: not well at all.

Life expectancy in Bangladesh is 66.9 years compared with India’s 64.4. The

proportion of underweight children in Bangladesh (41.3 percent) is lower

than in India (43.5), and its fertility rate (2.3) is also lower than India’s (2.7).

Mean years of schooling amount to 4.8 years in Bangladesh compared with

India’s 4.4 years. While India is ahead of Bangladesh in the male literacy

rate for the age group between fifteen and twenty-four, the female rate in

Bangladesh is higher than in India. Interestingly, the female literacy rate

among young Bangladeshis is actually higher than the male rate, whereas

young women still have substantially lower rates than young males in India.

There is much evidence to suggest that Bangladesh’s current progress has a

great deal to do with the role that liberated Bangladeshi women are beginning to play in the country.

What about health? The mortality rate of children under five is sixty-six per

thousand in India compared with fifty-two in Bangladesh. In infant mortality, Bangladesh has a similar advantage: it is fifty per thousand in India and forty-one in Bangladesh. While 94 percent of Bangladeshi children are immunized with DPT vaccine, only 66 percent of Indian children are. In each of these respects, Bangladesh does better than India, despite having only half of India’s per capita income.

Of course, Bangladesh’s living conditions will benefit greatly from higher

economic growth, particularly if the country uses it as a means of doing good

things, rather than treating economic growth and high per capita income as

ends in themselves. It is to the huge credit of Bangladesh that despite the

adversity of low income it has been able to do so much so quickly; the

imaginative activism of Bangladeshi NGOs (such as the Grameen Bank, the

pioneering microcredit institution, and BRAC, a large-scale initiative aimed

at removing poverty) as well as the committed public policies of the

government have both contributed to the results. But higher income,

including larger public resources, will obviously enhance Bangladesh’s

ability to achieve better lives for its people.

3.

One of the positive things about economic growth is that it generates public

resources that the government can devote to its priorities. In fact, public

resources very often grow faster than the GNP. The gross tax revenue, for

example, of the government of India (corrected for price rise) is now more

than four times what it was just twenty years ago, in 1990–1991. This is a

substantially bigger jump than the price-corrected GNP.

Expenditure on what is somewhat misleadingly called the “social sector”—

health, education, nutrition, etc.— has certainly gone up in India. And yet

India is still well behind China in many of these fields. For example,

government expenditure on health care in China is nearly five times that in

India. China does, of course, have a larger population and a higher per capita

income than India, but even in relative terms, while the Chinese government

spends nearly 2 percent of GDP (1.9 percent) on health care, the proportion

is only a little above one percent (1.1 percent) in India.

One result of the relatively low allocation of funds to public health care in

India is that large numbers of poor people across the country rely on private

doctors, many of whom have little medical training. Since health is also a

typical example of “asymmetric information,”in which the patients may know very little about what the doctors (or “supposed doctors”) are giving

them, even the possibility of fraud and deceit is very large. In a study

conducted by the Pratichi Trust— a public interest trust I set up in 1999— we

found cases in which the ignorance of poor patients about their condition

was exploited so as to make them pay for treatment they didn’t get. This is

the result not only of shameful exploitation, but ultimately of the sheer

unavailability of public health care in many parts of India. The benefit that

we can expect to get from economic growth depends very much on how the

public revenue generated by economic growth is expended.

4.

When we consider the impact of economic growth on people’s lives,

comparisons favor China over India. However, there are many fields in

which a comparison between China and India is not related to economic

growth in any obvious way. Most Indians are strongly appreciative of the

democratic structure of the country, including its many political parties,

systematic free elections, uncensored media, free speech, and the independent standing of the judiciary, among other characteristics of a lively

democracy. Those Indians who are critical of serious flaws in these

arrangements (and I am certainly one of them) can also take account of what

India has already achieved in sustaining democracy, in contrast to many

other countries, including China.

Not only is access to the Internet and world opinion uncensored and

unrestricted in India, a multitude of media present widely different points of

view, often very critical of the government in office. India has a larger

circulation of newspapers each day than any other country in the world. And

the newspapers reflect contrasting political perspectives. Economic growth

has helped— and this has certainly been a substantial gain— to expand the

availability of radios and televisions across the country, including in rural

areas, which very often are shared among many users. There are at least 360

independent television stations (and many are being established right now,

judging from the licenses already issued) and their broadcasts reflect a

remarkable variety of points of view. More than two hundred of these TV

stations concentrate substantially or mainly on news, many of them around

the clock. There is a sharp contrast here with the monolithic system of

newscasting permitted by the state in China, with little variation of political

perspectives on different channels.

Freedom of expression has its own value as a potentially important

instrument for democratic politics, but also as something that people enjoy

and treasure. Even the poorest parts of the population want to participate in

social and political life, and in India they can do so. There is a contrast as

well in the use of trial and punishment, including capital punishment. China

often executes more people in a week than India has executed since

independence in 1947. If our focus is on a comprehensive comparison of the

quality of life in India and China, we have to look well beyond the

traditional social indicators, and many of these comparisons are not to

China’s advantage.

Could it be that India’s democratic system is somehow a barrier to using the

benefits of economic growth in order to enhance health, education, and other

social conditions? Clearly not, as I shall presently discuss. It is worth recalling that when India had a very low rate of economic growth, as was the case until the 1980s, a common argument was that democracy was hostile to fast economic growth. It was hard to convince those opposed to democracy that fast economic growth depends on an economic climate congenial to development rather than on fierce political control, and that a political system that protects democratic rights need not impede economic growth.

That debate has now ended, not least because of the high economic growth

rates of democratic India. We can now ask: How should we assess the

alleged conflict between democracy and the use of the fruits of economic

growth for social advancement?

5.

What a democratic system achieves depends greatly on which social

conditions become political issues. Some conditions become politically

important issues quickly, such as the calamity of a famine (thus famines tend

not to occur at all when there is a functioning democracy), while other

problems— less spectacular and less immediate— provide a much harder

challenge. It is much more difficult to use democratic politics to remedy

undernourishment that is not extreme, or persistent gender inequality, or the

absence of regular medical care for all. Success or failure here depends on

the range and vigor of democratic practice. 1 In recent years Indian

democracy has made considerable progress in dealing with some of these

conditions, such as gender inequality, lack of schools, and widespread

undernourishment. Public protests, court decisions, and the use of the

recently passed “Right to Information”. Act have had telling effects. But

India still has a long way to go in remedying these conditions.

In China, by contrast, the process of decision-making depends largely on

decisions made by the top Party leaders, with relatively little democratic

pressure from below. The Chinese leaders, despite their skepticism about the

values of multiparty democracy and personal and political liberty, are

strongly committed to eliminating poverty, undernourishment, illiteracy, and

lack of health care; and this has greatly helped in China’s advancement.

There is, however, a serious fragility in any authoritarian system of

governance, since there is little recourse or remedy when the government

leaders alter their goals or suppress their failures.

The reality of that danger revealed itself in a catastrophic form in the

Chinese famine of 1959–1962, which killed more than 30 million people,

when there was no public pressure against the regime’s policies, as would

have arisen in a functioning democracy. Mistakes in policy continued for

three years while tens of millions died. To take another example, the

economic reforms of 1979 greatly improved the working and efficiency of

Chinese agriculture and industry; but the Chinese government also

eliminated, at the same time, the entitlement of all to public medical care

(which was often administered through the communes). Most people were

then required to buy their own health insurance, drastically reducing the

proportion of the population with guaranteed health care.

In a functioning democracy an established right to social assistance could not

have been so easily— and so swiftly— dropped. The change sharply reduced

the progress of longevity in China. Its large lead over India in life

expectancy dwindled during the following two decades— falling from a

fourteen-year lead to one of just seven years.

The Chinese authorities, however, eventually realized what had been lost,

and from 2004 they rapidly started reintroducing the right to medical care.

China now has a considerably higher proportion of people with guaranteed

health care than does India. The gap in life expectancy in China’s favor has

been rising again, and it is now around nine years; and the degree of

coverage is clearly central to the difference. 2 Whether India’s democratic

political system can effectively remedy neglected public services such as

health care is one of the most urgent questions facing the country. 3

6.

For a minority of the Indian population— but still very large in actual

numbers— economic growth alone has been very advantageous, since they

are already comparatively privileged and need no social assistance to benefit

from economic growth. The limited prosperity of recent years has helped to

support a remarkable variety of lifestyles as well as globally acclaimed

developments of Indian literature, music, cinema, theater, painting, and the

culinary arts, among other cultural activities.

Yet an exaggerated concentration on the lives of the relatively prosperous,

exacerbated by the Indian media, gives an unrealistically rosy picture of the

lives of Indians in general. Since the fortunate group includes not only

business leaders and the professional classes but also many of the country’s

intellectuals, the story of unusual national advancement is widely and

persistently heard. More worryingly, relatively privileged Indians can easily

fall for the temptation to focus just on economic growth as a grand social

benefactor for all.

Some critics of the huge social inequalities in India find something callous

and uncouth in the self-centered lives and inward-looking preoccupations of

a relatively prosperous minority. My primary concern, however, is that the

illusions generated by those distorted perceptions of prosperity may prevent

India from bringing social deprivations into political focus, which is

essential for achieving what needs to be done for Indians at large through its

democratic system. A fuller understanding of the real conditions of the mass

of neglected Indians and what can be done to improve their lives through

public policy should be a central issue in the politics of India.

This is exactly where the exclusive concentration on the rate of GNP growth

has the most damaging effect. Economic growth can make a very large

contribution to improving people’s lives; but single-minded emphasis on

growth has limitations that need to be clearly understood.

1. 1 I have discussed this issue more fully in " How Is India Doing? ," The New York Review , December 16, 1982; in (jointly with Jean Drèze) Hunger and Public Action (Clarendon Press/Oxford University Press, 1989); and in

Development as Freedom (Knopf, 1999). ↩

2. 2 I discuss this in "The Art of Medicine: Learning from Others," The Lancet , January 15, 2011. ↩

3. 3 I am grateful to Lincoln Chen, Jean Drèze, and A.K. Shiva Kumar for

helpful discussion of this and related issues. ↩

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