Increasing imbalances and rising inequality characterizing the growth process in the South Asian region tend to suggest that sustained improvement in health, future growth, and poverty reduction are threatened by a wide range of factors. These include
Table 14.1 Percentage of urban population to total population in the South Asian countries.
(Source: World Bank 2009)
Countries Urban population as a %
of total population in 2000 Urban population as a %
of total population in 2005 Urban population as a % of total population in 2015
Bangladesh 23.2 25.1 29.9
Bhutan 9.6 11.1 14.8
India 27.7 28.7 32.0
Maldives 27.5 29.6 34.8
Nepal 13.4 15.8 20.9
Pakistan 33.2 34.9 39.6
Sri Lanka 15.7 15.1 15.7
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severe or chronic poverty in the lagging regions, increase in urban poverty particu- larly among slum dwellers and migrants, environmental degradation, infrastructural deficiencies, institutional weaknesses, and governance inefficiencies (Farrington and Robinson 2006). Furthermore, Chaudhury and Devarajan (2006) note systemic failure in the delivery of essential human development services—health, education, water, sanitation, and electricity, especially to the poor in the lagging regions.
These multiple challenges toward improvement in health and sustaining eco- nomic growth and also making those progressively more equitable and inclusive are further intensified by the challenges of globalization at national, regional, and subregional levels. Besides differential impacts on various regions and economic sectors, globalization also leads to short-term fluctuations in trade and investment regimes and distribution of economic and health benefits and risks of growth among geographic regions. In the following, some of these issues and challenges are elabo- rated on by briefly highlighting the current state of growth-poverty-health nexus in the countries of the South Asian region.
Brief Review of Current Growth, Poverty, and Health Nexus in South Asia.
There are strong and pervasive links between poverty and health (Harpham 2009; WHO 2002). Any effort at reducing poverty (i.e., material deprivation and multiple social disadvantaged) implies a commitment to improving health of the poor and the socially disadvantaged. For the majority of the poor people, the health- damaging impacts of economic poverty, such as low living standards, lack of educa- tion, environmental hazards, and poor working conditions are compounded by con- ditions of ill health and exacerbate the vicious circle of poverty-ill health-poverty.
Globally, ill health also can lead to, aggravate, and perpetuate poverty. Thus, efforts that focus exclusively on economic poverty may have limited success in promoting health and breaking the poverty-ill health impasse.
In the following, the discussion on the socioeconomic status of the South Asian region relates to seven out of eight countries (Afghanistan, Bangladesh, Bhutan, India, Pakistan, Maldives, Nepal, and Sri Lanka) excluding Afghanistan because of lack of data. South Asia accommodates 22.8 % of the global population in a land area of only 3.4 % of the world’s total landmass. The seven countries together con- tained 1,469.8 million people with an average density of 321 persons per sq km. as of 2005 (World Bank 2007). However, population density varies widely among the countries, with the highest being 962 in Bangladesh and only 46 in Bhutan (Ahmad 2007). Besides its large absolute size, the population of the region is also growing significantly at an annual average rate of 1.9 % during 1990–2005. Yet another grim feature is that while South Asia is home to over one-fifth of the world’s total popula- tion, its share in global income is a mere 7 % as of 2004. Ironically, side by side with better growth performance, the problem of income inequality is worsening in all countries of the region. For example, in Bangladesh, it increased from 0.318 in 2000 to 0.465 in 2005. In this situation, even if income increases its effects on poverty reduction is compromised to a significant extent. The region is thus noted to have remained a divided one between the hopes of the rich and the despair of the poor.
Besides income poverty, there is widespread human poverty in South Asia which is manifested in various forms of human deprivations (see Table 14.2) and denies millions in the region to live a respectable life. Human poverty encompasses various forms of deprivations (other than income), such as, premature death, poor health,
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illiteracy, poor living conditions, and lack of personal security. As indicated by the data in Table 14.2 on certain aspects of human deprivations, the magnitude of hu- man suffering in South Asia is far greater than revealed by income poverty figures, though all the countries of the region are in the upper range of the medium human development category (with Maldives and Sri Lanka almost reaching the upper- medium category).
Major Aspects of Human Deprivation in South Asia
Among the magnitude of human deprivations in South Asia, short span of life, in- fant and child mortality, illiteracy, lack of health services, lack of access to safe
Bangla-
desh Bhutan India Maldi-
ves Nepal Pakis- tan Sri
Lanka Average:
deve- loping countries
Ave-rage:
South Asia Human develop-
ment index, 2004a
0.530 0.538 0.611 0.739 0.524 0.539 0.755 0.679 0.599
Life expectancy at birth (years), 2004
63.3 63.4 63.6 67.0 62.1 64.4 74.3 64.7 63.7
Infant mortality rate (per 1,000 live births), 2004
56 67 62 35 59 80 14 57 62
Undernouris- hed people (% of total population), 2001–2003b
30 – 20 11 17 23 22 17 20
Adult literacy rate
% (ages 15 and above), 2004
– – 61.0 96.3 48.6 49.9 90.7 78.9 60.9
Population with sustainable access to impro- ved sanitation (%), 2004
39 70 33 59 35 59 91 49 37
Population with sustainable access to an improved water resource (%), 2004
74 62 86 83 90 91 79 79 85
a Low human development index countries: below 0.500; medium human development index countries: 0.500–0.799; and high human development index countries: 0.800 and above
b Data refer to the most recent year during the period, for which data are available
Table 14.2 Human development index and other social deprivation indicators of the SAARC countries. (Source: UNDP 2006)
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water, poor living conditions, and environmental degradation, put increasing strains on the health and well-being of the urban population, especially the urban poor.
Short Span of Life Short span of life is considered one of the severe forms of human deprivation as it manifests the risks of premature death. Though life expec- tancy at birth has improved over the years in South Asia, ranging from 62 years in Nepal to 74 years in Sri Lanka in 2004, the region continues to have one of the lowest life expectancies in the world, second only to Sub-Saharan Africa (UNDP 2006).
Infant and Child Mortality Infant and child mortality, which also represents a severe form of deprivation, is also one of the highest (62 per 1,000 live births in 2004) in the region. South Asia still accounts for one-third of the burden of the glo- bal under-five deaths (UNDP 2006).
Adult Literacy More than 400 million adults (aged 15 years and above) in South Asia, representing half of the developing world’s illiterate population, are unable to read or write. While 39 % of the adult population is illiterate, a major part of the remaining 61 % considered literate is only functionally literate. However, notable progress in adult literacy has been made in Maldives and Sri Lanka where the cur- rent rates are 96 % and 91 %, respectively, which compare favorably with the adult literacy rates in the high-income countries (UNDP 2006).
Undernourished People There is high incidence of undernourishment among both adult and children in South Asia which is due to both poverty and nonavailability or inadequate availability of basic health services to people in general. The primary health care services are both limited and expensive. Except for Sri Lanka and Mal- dives, the per capita public expenditure on health in the region is also very meager, varying between PPP US$ 48 for Pakistan and PPP US$ 82 for India as of 2003 (UNDP 2006).
Access to Water and Sanitation In respect of sustainable access to an improved source of water, South Asia has made commendable progress. But the region’s per- formance in respect of improved sanitation is worse than that of the average of all developing countries. There are still 867 million people in the region without ade- quate sanitation facilities and 198 million without access to safe water. These are indications of poor living conditions which are another form of human deprivation resulting from poverty (UNDP 2006).
Environmental Degradation In fact, economic and social development in the South Asian region is being currently threatened by ever increasing environmental degradation and continuing climate change. Deforestation, overuse, and unplanned use of land and other natural resources are creating unabated environmental degra- dation in all the South Asian countries. Ever increasing air and water pollution in the region is considered a major threat to natural environment and hazardous to human health (Ahmad 2007).
It thus transpires from the above that poverty, inequality, and social exclusion in South Asia are enormous and exhibit signs of continued accentuation, espe- cially because of many challenges brought by globalization and liberal market paradigm. The poor in South Asia are disproportionately made up of women and
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children, ethnic minorities, casual and migrant workers, the youth, and the unem- ployed. Moreover, many of the urban poor dwell in slums and/or backward and remote areas characterized by lack of proper housing, water, sanitation, security, access to healthcare services, education, employment and income-earning oppor- tunities, and environmental degradation. As a result, these vulnerable and social- ly disadvantaged urban poor people face a higher burden of diseases. Therefore, specific subpopulations experience poorer health with limited or no access to health care compared with other populations in South Asia. Although rapid de- velopment increases life expectancy, unhealthy lifestyle behaviors contribute to certain disease incidence (i.e., cancer). Appropriate policy changes and desirable institutional realignment are thus required to achieve faster and broader pro-poor