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Health in China and India: a Cross-Country Comparison in a Context of Rapid Globalisation

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Health in China and India: a Cross-Country Comparison in a Context of Rapid Globalisation Social Science & Medicine 67 (2008) 590–605 Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed Health in China and India: A cross-country comparison in a context of rapid globalisation Trevor J.B. Dummer a,*, Ian G. Cook b a Canadian Centre for Vaccinology, IWK Health Centre & Dalhousie University, Goldbloom RCC Pavilion, 5850/5980 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada b Liverpool John Moores University, Liverpool, United Kingdom article info abstract Article history: China and India are similarly huge nations currently experiencing rapid economic growth, Available online 12 June 2008 urbanisation and widening inequalities between rich and poor. They are dissimilar in terms of their political regimes, policies for population growth and ethnic composition and heterogeneity. This review compares health and health care in China and India within Keywords: the framework of the epidemiological transition model and against the backdrop of global- India isation. We identify similarities and differences in health situation. In general, for both Globalisation countries, infectious diseases of the past sit alongside emerging infectious diseases and Health care Health inequalities chronic illnesses associated with ageing societies, although the burden of infectious dis- China eases is much higher in India. Whilst globalisation contributes to widening inequalities Review in health and health care in both countries – particularly with respect to increasing dispar- Epidemiological transition ities between urban and rural areas and between rich and poor – there is evidence that local circumstances are important, especially with respect to the structure and financing of health care and the implementation of health policy. For example, India has huge prob- lems providing even rudimentary health care to its large population of urban slum dwellers whilst China is struggling to re-establish universal rural health insurance. In terms of funding access to health care, the Chinese state has traditionally supported most costs, whereas private insurance has always played a major role in India, although recent changes in China have seen the burgeoning of private health care payments. China has, arguably, had more success than India in improving population health, although recent reforms have severely impacted upon the ability of the Chinese health care system to operate effectively. Both countries are experiencing a decline in the amount of govern- ment funding for health care and this is a major issue that must be addressed. Ó 2008 Elsevier Ltd. All rights reserved. Introduction run via the Chinese Communist Party (CCP), compared to the democratic political system in India, the former has China and India present intriguing comparative exam- introduced stringent restrictions on population growth ples to the health researcher. Both countries are similarly compared to the latter, while India is more ethnically huge in terms of population size, are currently subject to heterogeneous for example, and contains a complex and rapid economic growth and are struggling to overcome divisive caste system. negative legacies of the past, including marked inequalities In the context of cross-country health comparisons, the between rich and poor. They are dissimilar in that China is epidemiological transition model provides a useful frame- work to interlink a nation’s changing mortality and morbidity profile with population and socio-economic * Corresponding author. Tel.: þ1 902 494 8059. E-mail addresses: [email protected] (T.J.B. Dummer), changes associated with development (Omran, 1971). In [email protected] (I.G. Cook). undeveloped societies, mortality is commonly from famine 0277-9536/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2008.04.019 T.J.B. Dummer, I.G. Cook / Social Science & Medicine 67 (2008) 590–605 591 and infectious disease epidemics (diseases of poverty). As geographical extent. In the modern era of Western expan- society develops, infectious diseases decline and there is in- sion around the globe, China remained largely uncolonised creasing mortality and morbidity caused by lifestyle factors but nevertheless subject to Western imperialism by a range and chronic illnesses, linked to increasing life expectancy of countries, while most of India was directly colonised by (diseases of affluence). The classical epidemiological transi- the British, except for the ‘Native States’ that were largely tion model has three phases: the age of pestilence and fam- subjugated to the rule of the Raj. For both countries, the ine, the age of receding pandemics, the age of degenerative 20th Century was largely a struggle for independence and human induced diseases (Phillips, 1994; Smallman- from foreign control, but whereas this led in China to the Raynor & Phillips, 1999). Olshansky and Ault (1986) outline one-party rule of the Chinese Communist Party (CCP) a fourth phase, the age of delayed degenerative diseases, from the founding of the People’s Republic of China in where the age distribution of deaths (primarily from de- 1949, the outcome in India was a democratic multi-party generative diseases) shifts markedly towards older ages. A system, albeit often dominated by the Congress Party since late-stage epidemiological transition phase has been de- Partition in 1947. While the CCP has been criticised by ex- fined recently to characterise the health changes associated ternal observers for excesses such as the Cultural Revolu- with the current era of rapid development and globalisa- tion or the Single Child Family Programme, India’s tion; in this new phase, improvements in health occur as democracy has often seemed weak and fragile, marred by a result of medical developments and socio-economic assassinations of leading politicians such as Indira Gandhi changes, but uneven development results in many health or her son Rajiv for example, and continual tensions over problems associated with diseases of poverty (Omran, Jammu and Kashmir. Despite their differences, both coun- 1983; Smallman-Raynor & Phillips, 1999). tries today are being increasingly lauded for their economic China and India are both rapidly developing countries fac- expansion, and in the 21st Century both seem set to be- ing a range of health problems, including polarisation of come the economic powerhouses commensurate with their health care provision and health outcomes in relation to so- vast populations. cial, economic and geographical marginalisation. As both Table 1 summarises key demographic, health and eco- countries continue to develop economically and socially nomic statistics for each country. China emerges better in and move through the epidemiological transition – from most of the comparisons shown: birth, death and total fer- a predominance of infectious diseases to the emergence of tility rates are lower than for India, while life expectancy chronic diseases – their health care systems are experiencing for both males and females is considerably higher in China. immense pressures from both increasing and changing de- The number of physicians and hospital beds are greater per mands. Previous research has shown that health in China is head of population in China. Infant mortality is higher in In- characterised by the late-stage epidemiological transition dia, while the main cause of death overall is ‘infectious and phase, as defined above, inwhich the transition from diseases parasitic diseases’ in India, contrasting with cancers in of poverty to diseases of affluence has not reflected smoothly China. Foreign direct investment (FDI) in China is markedly the country’s social and economic development pathway higher than FDI in India, while its GNP per capita is just over (Cook & Dummer, 2004). In particular, diseases of poverty double India’s and economic growth remains greater in have not been eradicated but are re-emerging and interact China than in India, by around two percentage points. with new infectious diseases (including HIV/AIDS and The adult literacy rate is also much higher in China than SARS), an increasing prevalence of chronic diseases, rapid in India, especially amongst women. The percentage of population growth, social, economic and geographical polar- population urban is nearly 10% higher in China. Ethnically, isation and widening inequalities in health and health care. China is not a particularly diverse country, with Han Chi- Our aims in this present study are to explore the similar- nese being by far the largest ethnic group (92% of the pop- ities and differences between health outcomes within China ulation). By contrast, using linguistic group as an indicator and India. We build upon previous work on China (Cook & of ethnic variation shows that in India there is not one spe- Dummer, 2004, 2007; Dummer & Cook, 2007)todiscover cific linguistic group dominating to the same extent as Han whether the health problems currently affecting China are Chinese dominates in China, although we acknowledge replicated in India. We explore the applicability of the late- that we are not quite comparing like with like in terms of stage epidemiological transition model to the health situa- ethnic contrast. The United Nations Development Pro- tion in India. Globalisation arguably homogenises societies gramme (UNDP) Human Development Index (HDI) – a com- and economies around the world; if this is so, then we would posite indicator of a nation’s
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