1. The Contribution of Social and Political Factors to Good Health GOOD HEALTH AT LOW COST (The Rockefeller Foundation) Patrica L.Rosenfield, WHO-Special Programme for Research and Training in Tropical Diseases By: R Muralikrishnan & Keerti Pradhan keerti@aravind.org

2. Introduction There is no general agreement to what constitutes ‘good health’ There is a pre-conceived notion that higher the national average income(GNP & GDP), better the health status But some countries like China, Costa Rica, Srilanka and Kerala(a small state in a big country) have health status on par with developed countries. Their experiences have shown that good health is more than the two statistics:Long Life Expectancy and Low Infant Mortality Rate. Mortality and Morbidity reductions are only a part of the process of achieving good health which includes psychological, social and economic well-being also

3. Methods In the mid 80’s, the Rockefeller Foundation tried to study and document the social and political contribution to good health in these countries People who are active participants in the health development policies of their own countries (Eg.Dr.P.G.K.Panikar, Ex-Director,CDS) Followed by a conference where they consolidated the experiences and commonalities

4. CHINA KERALA SRILANKA COSTA RICA CUBA

5. Economic and Political Status All the four countries had shown dramatic improvements in mortality-related statistics of Low IMR and High Life Expectancy, under severe Economic Constraints Population ranged from 2.3 million(Costa Rica) to 1008.2 million(China)-1980-82 GNP Per capita US$ 1430(Costa Rica) to US$150(Kerala) Monarchy, colonization and subsequent democracy of government were features of their political development China, Kerala and Sri Lanka-British Rule Three of them had Western style democracies Kerala & Sri Lanka-Democracy since independence Costa Rica was a republic for 150 years

6. Comparison of Kerala & All India KeralaAll-India Death Rate/1000 (1998)6.49.0 Rural Birth Rate(1998)18.328.0 IMR(1998)1672 Life Expectancy (1993)66.561.5 Literacy Rate (1991)90.5952.11 Female Literacy Rate(1991)86.1719.43 Mean age at marriage(F)22.319.3 Per capita Income(1995-96)832411649 Doctor-Population Ratio1:72131:2148

7. Political and Economic Orientations Political economic orientations vary between countries and over time within the same country Kerala- Communist government since 1956, although a coalition government was in the centre Sri Lanka- Socialism and Capitalism have prevailed at various times over the past 35 years Costa Rica- Power shared by “the Social Democracy, Christian Democracy and coalition of left parties China- Marxist-Leninist economic system since 1949 but now moving on to new economic orientations Hence, no single political or economic approach can claim credits

8. Common Social and Political Factors Historical commitment to health as a social goal Social welfare orientation to development Wide spread political participation Equality of health services coverage for all social groups(equity) Intersectoral linkages for health

9. Historical Commitment Legislation Organized government policy for access to health care Implemented at early stages of policy development Establishment of hospitals and health centres Kerala-Immunization, Sanitary Reforms and Modern Style Hospitals from 1860. Ayurveda (Historical Importance) Srilanka- Ayurveda. Western Medicine China-Chinese Medicine mainstay till 1949. Western Medicine(1917) Costa Rica- Health actions( mid 19 th cent) & ‘village doctors’ Missionary Influences Spanish colonists in 16 th century- Roman Catholic Missionaries in 19 th Century-Kerala, Srilanka & China

10. Social Welfare Orientation Continuity in government expenditure for Social Sector Preventive health measures(Hygiene & Sanitation) Food subsidies Educational programs-Historic formal programs Land Reforms-ensuring redistribution of income Srilanka and Costa Rica have the lowest defense expenditures India's defense budget around 20-25% but is not reflected in Kerala state budget In China, the large military sector has played an important role in health and health-related improvements

11. Wide Spread Political Participation Participation in the electoral process Combined with education Awareness about the need for health programs Extent of Decentralization NGO involvement in Planning Community Involvement

12. Equality of Health Services Coverage Measured as health, educational and nutritional status of the underserved (women,children,ethnic and minorities, etc) The Nayar society of Kerala was interested in women’s education and the first girl’s school was established in 1819 In addition accessibility, utilization and urban-rural distribution were also considered Rural co-operative medical centres in China. Tea planters health programmes in Srilanka Reorganization of ministry of health on reaching underserved areas

13. Inter Sectoral Linkages Health, Education and Agriculture Mechanisms to finance health Inter agency committee Incorporation of economics into health training programmes Closer ties between social security and health systems Srilanka had established a “national health development network” Costa Rica drew social security and health together through legal mechanisms Kerala is using District Councils to develop inter sectoral systems for health China has closely linked political, administrative and economic organizations

14. Conclusion Four studies reveal important common factors influencing good health The highest level of political commitment has been complemented by local conditions and flexibility at policy making and implementation levels

15. Discussion Is there any other factor(s)?For.eg.Prof.Abel Smith demonstrates ‘health seeking behaviour’ as another reason for good health in Kerala Do these commonalities constitute a basis for universal health policy application? Does more work need to be done to develop a conceptual framework for assessment?

16. Thank You…