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Women's health is more than an economic issue by Jayati Ghosh

While higher income levels mean countries have more money to improve women's health, ultimately it comes down to how governments decide to spend the money

We know that economic growth and human development do not always go hand in hand, as evidenced by the very different position of countries in per capita GDP rankings compared with human development rankings. But the link between health conditions and economic growth is usually thought to be stronger.

Rising per capita incomes typically involve an improvement in food and nutrition levels among the poor, which is obviously an essential precondition for better health. Increasing national income also puts more absolute resources in the hands of governments to spend on essential public health. Even if the proportion of public health spending to GDP remains unchanged, rising per capita GDP means rising per capita public spending on health. Governments may even increase their health expenditure as a share of GDP.

All this can mean greater spread and better quality of basic public health services. It can also allow governments to spend on infrastructure that has a direct bearing on health, such as better housing, transport, safe drinking water and sanitation.

Such public spending has the most critical effect on the health of women and girls, who are less likely to access healthcare if it is paid for out of the household budget.

So it is reasonable to expect a positive association between economic growth and female health. In particular, infant and maternal mortality rates should improve more quickly in countries where per capita incomes are growing faster.

So why, then, does this not always happen?

Let's consider the most dynamic region of the world, Asia, where many countries have experienced significant increases in per capita incomes.

China has been the most successful, growing at an annual rate of more than 9.5%, amounting to a six-fold increase in per capita incomes in the two decades up to 2010. The infant mortality rate (IMR – number of deaths below the age of one per 1,000 live births) for girls declined by 53%, reaching 20 per thousand in 2009, and the maternal mortality rate (MMR – the number of women dying because of childbirth-related complications per 100,000 live births) declined by 65% to 38 per 100,000 in 2008. Vietnam was also impressive in this period – per capita income grew at 6% per annum, though it is still just one quarter of the Chinese level. In Vietnam, the girls' IMR fell by 50% to 20 and the MMR fell by 6% to 56.

Then there are countries like Sri Lanka and (to a lesser extent) Thailand, which have delivered even better women's health outcomes but with lower per capita growth rates. They have both achieved indicators that are close to those of developed countries (female IMRs of 11 and 10 respectively in 2009, and MMRs of 39 and 48 in 2008).

These examples suggest that it may be possible to improve women's health without higher income levels.

But there are unfortunate counter-examples in two of the region's largest and most populous economies: India and Indonesia. India has had the third-fastest growing economy in the region, and its per capita income in US$ terms is now well above that of Vietnam. Yet the female IMR is more than double, at 51 per 1,000, and it declined by only 40% over the two decades – one of the slowest rates of improvement in the region. The MMR at 230 per 100,000 in 2008 was nearly five times that in Vietnam and nearly six times that in Sri Lanka. Similarly, Indonesia is clearly a middle-income country, but the MMR of 240 in 2008 was much worse than in poorer countries such as Thailand, Sri Lanka and Vietnam.

Of course, India is also very regionally diverse, with some states such as Kerala showing excellent health outcomes for women, similar to those in Vietnam. And three states have also shown much improved health indicators in the past two decades: Tamil Nadu, West Bengal and Maharashtra. But the bulk of the country still shows generally appalling levels of IMR and MMR, which have declined very slowly even in comparison with other less dynamic economies in the region.

One important reason for this is undernutrition, which has actually worsened in recent times according to indicators such as calorie consumption. Rising prices of food are making this problem worse as women and girls in poor households take the brunt of food scarcity. Related to this is the distributional issue: income growth has been concentrated among the top 10% of the population, whose health indicators were already more like those in rich countries, and there is little improvement of consumption patterns in the bottom half. Another reason is poor sanitation, reflecting low governmental priority to critical concerns such as clean drinking water and toilets. A third cause is lack of good and affordable reproductive-health services. Nearly three-quarters of all health spending is by households out of their own pockets, which contributes to many families falling into debt and poverty.

All of these factors are crucially determined by government policy. Despite much publicly expressed concern on these issues, the government of India has simply not put its money where its mouth is. Public spending as a share of GDP has not increased, and per capita spending on some essential activities such as immunisation and primary health centres has actually gone down. Instead, the government has sought to provide essential health services on the cheap, using the underpaid labour of local women working for much less than the minimum wage.

So the apparently growing divide between economic growth and women's health outcomes in countries like India is really the result of the poor public policy. This is not inevitable: the experience of other Asian countries shows that a more positive synergy can be created, with health spending not just valued for its own sake, but as an essential element in an overall macroeconomic and growth framework oriented to better conditions of human life rather than just GDP expansion.

• Jayati Ghosh will be delivering the Lancet Lecture 2011 on 28 November on the subject of Economic growth and women's health outcomes: A deepening divide?