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Begging Questions

Mohan Rao

By Margaret Jones
Orient Longman, New Delhi, 2004, pp. 305, Rs. 595.00

VOLUME XXIX NUMBER 12 December 2005

Sri Lanka’s health and demographic transitions, much like Kerala’s, has spawned something of a public health cottage industry. They turned the understanding of these transitions, derived from the experience of the nineteenth century European experience, upside down. In the West – England and Wales being the quintessential case – as living standards improved, as per capita incomes rose increasing food intake, and as these countries initiated public health revolutions, death rates declined despite little contribution from medical care technologies (McKeown 1976).1 After a period, with increasing urbanization and industrialization, with a continuing decline of death rates, in particular infant and child mortality rates, the birth rates declined in the face of opposition from both the Church and state. How, then, did Sri Lanka and Kerala, with none of these determinants of health and population transition, in the face of widespread poverty, hunger, unemployment, manage to undergo health and demographic transitions?   While the literature is rich, the jury is still out, for clearly there were historical reasons for these remarkable changes. The volume under review is therefore welcome to not just historians, but to public health practitioners as well. Unlike India, Sri Lanka – despite structural adjustment programmes -- has maintained substantial public spending on health. This is of the order of five per cent of GDP, compared to less than one per cent in India. As a consequence, about 95 per cent of in-patient care and more than 85 per cent of out-patient care is within the public sector. In India, on the other hand, merely about 44 per cent of in-patient care and 19 per cent of out-patient care is in the public sector, the rest in the largest least regulated private health industry in the world. Is it then any surprise that health care expenditure is emerging as one of the leading causes of indebtedness in the country? What are the historical roots of this?   Margaret Jones shows us that expenditure on medical and sanitary services in Ceylon, as a proportion of government expenditure, was high, and increased during the twentieth century: from 5.8 per cent in 1901 to 10.8 per cent in 1939 – considerably above that in India in the corresponding period. Again, unlike India, expenditure on defence and internal security was considerably less. The author notes that the data reveals “ a government which is increasingly prepared to spend more on social welfare than on security” (p.61). This is to say, could it be true that the ...

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