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Hunger and Public Action$

Jean Drèze and Amartya Sen

Print publication date: 1991

Print ISBN-13: 9780198283652

Published to Oxford Scholarship Online: November 2003

DOI: 10.1093/0198283652.001.0001

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Experiences of Direct Support

Experiences of Direct Support

Chapter:
(p.226) 12 Experiences of Direct Support
Source:
Hunger and Public Action
Author(s):

Jean Drèze (Contributor Webpage)

Amartya Sen (Contributor Webpage)

Publisher:
Oxford University Press
DOI:10.1093/0198283652.003.0012

Abstract and Keywords

The strategy of support‐led security is examined, reflected in the experiences of some selected countries, in particular, Sri Lanka, Chile, and Costa Rica. This strategy is distinguished by the use of public support (such as public health services, educational facilities, food subsides) to raise the standard of living without waiting for the country in question to achieve prosperity through sustained economic growth.

Keywords:   basic health, Chile, Costa Rica, elementary education, persistent undernutrition, public support, Sri Lanka, standard of living, support‐led growth

12.1 Introduction

In this chapter, we examine the strategy of support‐led security as it is reflected in the experiences of some selected countries, in particular Sri Lanka, Chile, and Costa Rica. The distinction between ‘growth‐mediated security’ and ‘support‐led security’ has already been discussed in some detail in the two preceding chapters. It was explained, in particular, that the distinction between the two does not lie in the use of public support in one case and not in the other. Even the cases of growth‐mediated security (e.g. in South Korea and Kuwait) studied in Chapter 10 involved crucial use of public support provisions utilizing the resources generated by economic growth, and indeed in this respect the contrast between growth‐mediated security and ‘unaimed opulence’ can be both striking and important.

The strategy of support‐led security is distinguished by the use of public support without waiting for the country in question to get rich as a result of sustained economic growth. The rationale of this approach consists of using public support directly for raising the standard of living, rather than waiting for economic growth to do this (by increasing private incomes and providing resources for public support at a later stage). It is the direct use of public support in expanding the capabilities of people, not qualified by achieved growth, that characterizes the distinct nature of this strategy.

The countries that are studied in this chapter are all relatively poor in terms of GNP per head. Even for the two richer ones, viz. Costa Rica and Chile, the levels of GNP per capita (respectively $1,480 and $1,320 in 1986) are substantially lower than that of, say, South Korea ($2,370), in spite of superior achievements in some aspects of quality of life (e.g. expectations of life of 74 and 71 years respectively, as against 69 years for South Korea). The contrast is much sharper in the case of Sri Lanka, with its GNP per capita of only $400 and a life expectancy of 70 years.1 In this respect, Sri Lanka's position is somewhat similar to that of China and Kerala, discussed in the last chapter.

Before we turn to the country experiences, one general point is perhaps worth mentioning. It may be wondered whether a poor country—especially one as poor as, say, Sri Lanka—can at all ‘afford’ to have programmes of public support in any way comparable with those of countries many times richer. That worry is a legitimate one, but in considering feasibilities one must not fall into the trap of assuming exactly similar real costs in different countries. In (p.227) particular, in a poor country not only are the GNP and the public budget quite restricted, the labour costs involved in providing, say, education and health care are also low (because of tinier wages).2 Indeed, even the cost of support of public employment is lower in these economies for the same reason. This does not make the resource problem disappear for the poorer economies (health services in particular tend to have substantial non‐labour costs as well), but the apparent enormity of the gap between what the richer and the poorer countries can afford has to be scaled down considerably to take note of this fact. The ambitious public support programmes in the low income countries to be studied in this chapter would have been probably unaffordable had this not been the case.

12.2 Sri Lanka

The case of Sri Lanka was singled out earlier as one of remarkable achievement despite its low GNP. Judged in terms of life expectancy, child mortality, literacy rates, and similar criteria, Sri Lanka does indeed stand out among the poor countries in the world.3

Sri Lanka's experience is particularly worth studying not only for the exceptional nature of its achievement, but also for its timing. Large‐scale expansion of basic public services began early in Sri Lanka. The active promotion of primary education goes back to the early decades of this century.4 The sharp increase in public health measures took place later, but still as early as the middle 1940s. The radically innovative scheme of providing free or heavily subsidized rice to all was introduced in 1942. The fruits of this expansion were also reaped early, and by the end of the 1950s, Sri Lanka was altogether exceptional in having an astonishingly higher life expectancy at birth than any other country among the low‐income developing countries.5

The issue of timing is of some importance in assessing Sri Lanka's experience. Given the much wider availability of internationally comparable data in later periods, such as 1960 onwards, it is tempting to compare the changes in Sri Lanka's achievement in the post‐1960 world with those of other countries. (p.228) This does not bring out the nature of Sri Lanka's achievement, since it managed a radical transformation in life expectancy earlier than 1960, and the absence of further radical expansion later on was partly due to the high level of longevity accomplished already. The right period for examining Sri Lanka's transformation is the one preceding 1960, rather than following it.

Table 12.1 Sri Lanka: Intervention and Achievement

Year

Public distribution of food

Number of medical personnel

Death rate per thousand

1940

No (introduced 1942)

271

20.6

1950

Yes

357

12.6

1960

Yes

557

8.6

1970

Yes (reduced 1972, 1979)

693

7.5

1980

Yes

664

6.1

Source: Sen (1988d), Table 7.

Indeed, judged in terms of further reduction of under‐5 mortality rate during 1960–85, Sri Lanka is only a moderately good performer—not an exceptional one—even though in terms of absolute levels its current record remains better than that of any other low‐income developing country. The same applies to life expectancy and other related indicators. The neglect of the timing of Sri Lanka's public intervention programme can lead to the spurious conclusion that its achievements are not exceptional, or that public intervention achieved little in that country. This is worth mentioning since that interpretational error has often been made, and since the alleged debunking of the role of public support in Sri Lanka has received wide attention.6

The temporal relation between the expansion of public support and the reduction of mortality rates in Sri Lanka is brought out by Table 12.1. Between 1940 and 1960 the death rate fell from 20.6 per thousand to 8.6 per thousand —a level not far from that of Europe and North America. This occurred along with the radical expansion of health services brought in with great vigour in the middle 1940s and with the bold introduction of free rice distribution in 1942.7

It should also be noted that the vigour of public intervention slackens a good (p.229) deal in the later decades, particularly in the 1970s, with a decrease (rather than an increase) in the number of medical personnel and a sharp reduction in the subsidized distribution of food. Given these disengagements, the slowing down of Sri Lanka's expansion of life expectancy in the later decades would not be any kind of ‘proof’ against the effectiveness of public support as a policy—quite the contrary.8

The temporal connection between the expansion of public support in Sri Lanka and the corresponding achievements is easy to see.9 To move from time‐relations to asserting causal connections is, of course, always problematic, and this can be done only with careful attention being paid to the evidence on the causal links that can explain the observed relations. The causal role of health services and public distribution of food has been the subject of a good deal of empirical analysis recently, and there is much evidence of the causal connections proceeding the way that time‐relations suggest.10

Sri Lanka's experience in support‐led security is particularly interesting not merely because it was one of the first developing countries to go that way (preceding even the spectacular case of China), but also because it was then—and still is—a good deal poorer than many other countries that have traversed the path of security through direct support (e.g. Costa Rica, Chile, or Jamaica). Sri Lanka's strategic experience as a pioneer in overcoming the major penalties of low income remains one of great significance for understanding the prospects for support‐led security in poor countries.

12.3 Chile

Is there a natural affinity between the strategy of support‐led security and particular political regimes? An association of this kind is not implausible, since the attempt to remove hunger through direct public support rather than through the intermediation of growth naturally involves a strong bias in favour of the more deprived sections of the population. Not unexpectedly, regimes where political power is particularly concentrated in the hands of the rich have a tendency to favour development models which give greater prominence to economic growth—whether as an element of a strategy of growth‐mediated security, or in the form of unaimed opulence (or indeed in the form of opulence aimed at the privileged classes!).

An examination of the political systems of the six countries (China, Costa (p.230) Rica, Cuba, Chile, Jamaica, and Sri Lanka) identified earlier as illustrations of the strategy of support‐led security reveals an interesting pattern. The only country in the list which can be described as being ruled by a right‐wing dictatorship is Chile. The others have either communist governments (China and Cuba), or are multi‐party democracies (Costa Rica, Sri Lanka and Jamaica).11 Chile was democratic until 1973 when Allende was overthrown and replaced by General Pinochet.

There is something intriguing in the fact that continued improvements in basic aspects of the quality of life should have taken place in Chile during the grim period of its contemporary history following the coup of 1973—a period marked not only by enormous economic instability but also by the rapid deterioration of many social services, ruthless political repression, and systematic violation of basic human rights. And yet there is, as we shall see, fairly incontrovertible evidence that, in the area of nutrition and particularly child health, the very rapid progress that was already taking place in the 1960s has continued and consolidated throughout the 1970s.12 Since General Pinochet does not have a reputation of being a soft‐hearted do‐gooder, the unusual record of the post‐1973 period stands in need of some explanation.

Chile's experience must be seen in historical perspective. Particularly relevant here is the very long tradition of public action for the improvement of living standards, especially in the areas of health care, education, nutrition intervention, and social insurance. This tradition, which goes back to the social reforms of the 1920s, has been intimately linked with the trade union movement and other forms of political activism. Social provisions have been a sensitive political issue, and an area of intense competition among political parties—many pieces of social legislation were indeed enacted in the context of electoral tactics or promises.13

Initially, social services were importantly biased towards the more vocal constituencies of the various parties, and especially towards urban dwellers and the organized sections of the working classes. But the reach of public intervention spread systematically over the years, and by the 1960s Chile had not only the most comprehensive social insurance system in Latin America but also a unified National Health Service (with nearly universal coverage), large‐scale nutrition intervention programmes, and virtually free education at (p.231) all levels.14 Since then, there have been further advances in primary health care (including birth attendance and vaccination), female education, family planning, nutrition intervention, sanitation, and related areas. Today, Chile is probably the only country in the world where public health services ensure not only the monitoring of nearly all young children in the country, but also the provision of food supplements, primary care, and, when identifiably necessary, direct nutritional rehabilitation.15

After the abandonment of Allende's socialist experiment in 1973 following a military coup intended to ‘rescue the country from the clutches of Marxism–Leninism’ (Pinochet 1976), the new government adopted orthodox monetarist policies which put heavy emphasis on ‘liberalizing’ the economy, drastically reducing the scope of government intervention in the economic sphere, and restoring macro‐economic balance through fiscal restraint, greater competition, outward orientation, devaluation, and other tenets of the ‘Chicago school’. This so‐called ‘monetarist experiment’, which lasted until 1982 in its pure form, has been the object of much controversy, but few have claimed it to be a success.16 The failure of the monetarist experiment to lead to a sustained and broad‐based increase in economic prosperity is apparent from the macro‐economic indicators presented in Table 12.2 (see also Figure 12.1). The most conspicuous feature of the post‐1973 period is that of considerable instability, with two sharp recessions (in 1975–6 and again in 1983–5) and no firm and consistent upward trend (to say the least) in the conventional indicators of economic prosperity.

Experiences of Direct Support

Fig 12.1 Chile, 1970–85: selected economic indicators

The question of whether or not the disengagement of the state in the economic sphere during this period has also taken the form of a decline in the provision of social services has been a matter of some disputation. The government has claimed a sustained and in some ways even increased involvement in this area. This claim, however, has been forcefully challenged by a number of critics, who have emphasized the disengagement of the state and the deterioration of many social services since 1973.17

(p.232)

Some relevant indicators (constructed from official statistics) appear in Table 12.3, and they do seem to confirm the latter view. At the same time, it is arguable that the observed reduction of social expenditure since 1973 has perhaps been surprisingly smaller in aggregate terms than one might have expected given the ideological predilections of the Pinochet regime. Though total social expenditure per capita was considerably reduced during the recession of the mid‐70s, it was, on average, only 4% below the 1970 level during the 1981–5 period.18

Table 12.3 Chile, 1970–1985: Social Policies

Year

Public social expenditure per capita (1970 = 100)

Public investment in social sectors (1970 = 100)

Percentage of labour force on emergency programmes

Quantity of milk distributed through PNAC (000 tons)

Total

Education

Health

Social insurance and social assistance

Housing

Other

Total

Health

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

1970

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

0.0

17.1

1971

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

0.0

19.0

1972

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

0.0

19.3

1973

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

0.0

20.3

1974

75.9

79.9

86.6

59.6

129.8

127.3

148.7

124.9

0.0

20.8

1975

63.4

63.2

67.1

60.6

74.1

39.2

80.3

55.4

2.0

23.6

1976

61.9

67.6

62.7

59.9

54.8

101.7

55.0

37.4

5.2

24.5

1977

71.0

78.9

67.8

68.6

61.4

195.4

69.6

18.1

5.6

28.7

1978

79.3

83.0

75.0

82.0

57.4

171.6

46.1

23.1

4.2

29.8

1979

87.6

90.8

73.8

91.6

71.7

209.1

57.2

30.4

3.8

28.7

1980

90.1

88.7

82.4

95.3

71.2

211.4

55.3

20.6

5.3

29.2

1981

97.5

92.1

74.8

110.7

70.5

174.5

39.2

32.1

4.7

29.8

1982

104.4

93.0

78.4

127.6

49.4

135.4

28.3

30.6

6.5

30.3

1983

93.6

78.8

62.4

118.4

40.9

205.6

n/a

n/a

12.6

22.0

1984

93.7

76.2

65.9

117.9

47.8

180.1

n/a

n/a

8.4

27.8

1985

90.0

75.6

63.6

108.0

65.6

172.9

n/a

n/a

7.9

30.3

Note: PNAC stands for the National Programme of Supplementary Feeding. The contributions of different sectors to total public social expenditure in 1970 were as follows: education (25%), health (13%), social insurance and social assistance (51%), housing (10%), other (1%).

Source: (1)–(6): Calculated from Cabezas (1988), Table 11. (7)–(8): Calculated from Foxley and Raczynski (1984), Table V.5. (9): Calculated from Ffrench‐Davis and Raczynski (1988), Table 7. (10): Vial et al (1987), Tables 1 and 2; Ffrench‐Davis and Raczynski (1988), Table A. 19.

More striking, however, is the noticeable shift in the composition of social expenditures since 1973. This point deserves some elaboration. Right through the monetarist experiment, the official policy of the government has been to ‘target’ social expenditures much more sharply than in the past towards the (p.233) poorest groups, and to put greater reliance on the private sector for general provisioning. This strategy is reiterated in a large number of official documents.19 It has been accompanied by an important reorientation in the pattern of public support, including (1) the large‐scale ‘privatization’ of social insurance, (2) the freezing or reduction of mass provisions in the areas of health, housing, and education (in particular a dramatic decline of investment in (p.234) (p.235) these sectors), (3) the maintenance, and in some cases an expansion, of nutrition programmes, along with a reorientation towards the most vulnerable groups, and (4) a very large expansion of emergency employment programmes in years of high unemployment (see Table 12.3).

Table 12.2 Chile, 1960–1985: Selected Economic Indicators

Year

GDP per capita (1970 = 100)

Private consumption per capita (1970 = 100)

Index of real wages and salaries (1970 = 100)

Index of wage earnings per capitaa (1970 = 100)

Unemployment rate (percentage)

(1)

(2)

(3)

(4)

(5)

1960–4

86.4

90.9

1965–70

96.4

97.4

90.9b

1970

100.0

100.0

100.0

100.0

5.9

1971

107.0

111.1

122.7

124.1

5.2

1972

103.8

117.6

96.1

96.5

4.1

1973

96.4

108.0

77.6c

75.2c

4.8

1974

95.8

86.8

65.0

61.9

9.1

1975

82.1

75.7

62.9

54.2

15.6

1976

83.7

74.7

64.7

54.8

16.7

1977

90.6

85.5

71.4

62.8

13.3

1978

96.7

90.6

76.0

69.7

13.8

1979

103.2

95.1

82.2

75.8

13.5

1980

109.5

100.0

89.3

83.8

11.7

1981

113.7

108.9

97.3

94.4

10.4

1982

96.0

94.1

97.6

81.8

19.6

1983

93.7

89.4

86.9

69.5

18.7

1984

98.0

89.0

87.1

76.3

16.3

1985

98.7

86.5

83.2

76.1

14.1

(a) Calculated as the ratio of total wage earnings (real wage index multiplied by employment) to population.

(b) This value refers specifically to 1969.

(c) This value is for the last trimester of the year.

Source: (1)–(3) Arellano (1988), Tables 1 and 3. (4) Calculated from Arellano (1988), Table 3, and Ffrench‐Davis and Raczynski (1988), Tables 7 and A27. (5) Ffrench‐Davis and Raczynski (1988), Table 7.

Against this background, there is unambiguous evidence of rapid improvement in infant and child mortality as well as in anthropometric measures of the nutritional status of children during the post‐1973 period. Health statistics in Chile have a long history and a reputation of high reliability, and from 1975 annual statistics on the nutritional status of children have been produced on the basis of very large samples. The indications provided by these statistics are striking: between 1973 and 1985, the infant mortality rate plunged from 66 to 19 per thousand live births, while between 1975 and 1985 the assessed percentage of undernourished children below 5 years of age declined from 15.5 to 8.7 (see Table 12.4). It is important to note that critics of government policies have mostly focused on the interpretation of these figures rather than on their validity.20

Table 12.4 Chile, 1960–1985: Child Health and Nutrition

Year

Infant mortality rate (per 1,000)

Prevalence of undernourishment among children aged 0–5 (%)

Percentage of low birthweights

Percentage of under‐5s under nutrition surveillance

Total

Mild

Moderate

Severe

(1)

(2)

(3)

(4)

(5)

(6)

(7)

1960

119.5

1965

97.3

1970

82.2

1971

73.9

1972

72.7

1973

65.8

1974

65.2

1975

57.6

15.5

12.1

2.7

0.7

11.4

72

1976

56.6

15.9

12.1

3.0

0.8

11.4

74

1977

50.1

14.9

11.9

2.5

0.5

10.9

75

1978

40.1

13.0

10.8

1.8

0.3

9.1

72

1979

37.9

12.2

10.4

1.6

0.2

9.0

69

1980

33.0

11.5

10.0

1.4

0.1

8.6

70

1981

27.0

9.9

8.7

1.1

0.1

7.8

70

1982

23.6

8.8

7.8

0.9

0.1

6.9

75

1983

21.9

9.8

8.7

1.0

0.1

6.5

76

1984

19.6

8.4

7.5

0.8

0.1

6.5

77

1985

19.5

8.7

7.8

0.8

0.1

n/a

78

Source: (1) Banco Central de Chile, Boletín Mensual; no. 725 (1988), 2055. (2)–(7) República de Chile, Instituto Naçional de Estadísticas, Anuario de Recursos y Atenciones, various issues (1975 to 1985). The prevalence of undernourishment is based on weight‐for‐age measurements.

Conflicts of interpretation have taken place around the question of whether or not the advances we have just noted can be taken as reflective of broader improvements in living standards. Critics have argued that, on the contrary, the decline in infant and child mortality has taken place against a background of steady deterioration in living standards as a whole, and they have attributed this apparent paradox to the effects of specific intervention in the domains of child health and nutrition.21

The question of whether or not general living standards have indeed deteriorated since 1973 is, again, a controversial one. Some have claimed a sharp reduction in ‘extreme poverty’ as a result of government policies, and even an improvement in income distribution.22 But many others have documented sharp declines in real wages and wage income, rapidly increasing inequality of incomes, rising incidence of certain diseases, deterioration of housing conditions, falling primary school enrolment ratios, and other indications of adverse changes in living standards.23

Given the turbulence of the period, and the opposite directions in which different variables may move, it is not easy to find one's way through these apparently conflicting indications and claims. Among the contrary evidential (p.236) (p.237) directions is the combination of a stagnating life expectancy at age 1 with an increase in life expectancy at birth (reflecting a strong reduction in infant mortality). The relevant figures are given in Table 12.5, and would seem to provide some support for the view that favourable infant mortality trends in Chile since 1973 have not been reflective of a corresponding general improvement in living conditions.24

Table 12.5 Life Expectancy in Chile

Year

Infant mortality rate (per 1,000)

Life expectancy at age 1 (years)

Life expectancy at birth (years)

1960

119.5

64.4

57.6

1965

97.3

66.0

60.5

1970

82.2

68.9

64.2

1971

73.9

68.6

64.5

1972

72.7

68.8

64.8

1973

65.8

68.6

65.1

1974

65.2

68.9

65.4

1975

57.6

68.7

65.6

1976

56.6

68.9

65.9

1977

50.1

68.7

66.2

1978

40.1

68.2

66.5

1979

37.9

68.4

66.7

1980

33.0

68.3

67.0

1981

27.0

68.1

67.3

1982

23.6

68.1

67.5

1983

21.9

68.3

67.8

1984

19.6

68.4

68.0

1985

19.5

68.6

68.3

Source: Banco Central de Chile, Boletín Mensual, no. 725 (1988), 2055 (original source: Instituto Naçional de Estadísticas).

It also seems possible that a distinction would have to be made between the living standards of the poorer sections as a whole (particularly of the working class as a class), and the incidence of extreme poverty among particular groups. (p.238) Given the explicit and consistent policy of concentrating public support on the poorest, the hypothesis of a decline in extreme poverty is not obviously incompatible with the picture of falling living standards for the poorer groups as a whole.25

These methodological issues are not without importance. They bring out, in particular, the limitations involved in concentrating exclusively on health and nutrition indicators for children and infants for the purpose of assessing changes in basic living conditions (even when the primary concern is confined to nutrition and related capabilities). It is certainly sometimes the case that movements in these indicators can be taken as reflective of general trends in health, nutrition and related capabilities. But this is not always true, and the case of Chile illustrates the possible difficulties arising from divergent trends coexisting with each other.

As far as the question of the effectiveness of public support is concerned, however, there is little disagreement as to what caused the observed improvements in the area of child health and nutrition. There have, as discussed earlier, been important debates regarding the relation of these improvements to general trends in the quality of life in Chile since 1973, and also regarding overall changes in the government's commitment to public support. But the role and effectiveness of public support in the specific domain of child health and nutrition is not in dispute.

There is, moreover, nothing really surprising in the fact that targeted intervention programmes (including income support) should have been responsible for a large part of the observed improvements.26 In fact, it would be hard to attribute the impressively steady decline in infant mortality during the last three decades (despite several major economic recessions and political upheavals) to anything else than the maintenance of extensive public support measures, and in particular the remarkable consistency of child health and nutrition programmes. Moreover, the noticeable impact of nutrition and health programmes in Chile has been convincingly brought out in a large number of studies (including several econometric investigations), and it is natural to expect that this impact would continue and be consolidated as these programmes were more vigorously extended to disadvantaged groups.27

(p.239) This account leaves open the intriguing question why a government which had no hesitation in resorting to the most brutal political repression in order to protect the privileges of the dominant classes was so interested in looking after child health and extreme poverty. As far as non‐withdrawal is concerned, an obvious explanation lies in the political difficulties of withdrawing what different sections of the population had come to regard as their legitimate claim to state support in various forms.28 This is perhaps most visible in the domain of health, and in the preservation of the National Health Service along with a dramatic reduction of investment in this sector.29

In some respects, however, there has been an expansion of public support, notably in the area of public works and nutrition programmes. It is tempting to interpret this as a strategy for checking popular discontent at a time of political repression, economic instability, and diminished general social provisions. It has been persuasively argued, for instance, that the expansion of emergency employment programmes was largely a response to the shifting political threats represented respectively by unionized and unemployed workers as a result of mounting unemployment and massive clampdown on trade unions.30 The expansion of targeted nutrition and health programmes also has an obviously populist ring in a country where popular expectations of public provisioning are very high, and the Chilean government has indeed consistently endeavoured to build political capital from its achievements in the area of child nutrition.31

In recognizing Chile's achievements, we have to see the role of public intervention in selected aspects of the quality of life, but also we cannot but observe the part that political pressure and a search for a popular mandate may play even in a country with an authoritarian political atmosphere. Chile does, of course, have a long tradition of democratic and pluralist politics. But the general lesson about the power of adversarial politics even under authoritarian systems may have a wider relevance.

(p.240) 12.4 Costa Rica

If ‘development’ is to be recognized by the expansion of basic capabilities, there is little doubt that Costa Rica is one of the most outstanding success stories of the last few decades. In areas related to health and nutrition, the record of this country is particularly clear from the convergent indications of many direct and indirect pieces of evidence (see Table 12.6 and 12.7). Infant mortality, which had already declined to the respectable level of 76 per thousand live births in 1960, further plunged to 19 over the next 20 years.32 During the same period, life expectancy at birth leapt by an entire decade to reach 73 years, a figure comparable to those of most European countries. The percentage of women (aged 20–34) having completed primary education increased from 27 to 66. Severe undernourishment as a phenomenon virtually disappeared, and nutritional standards attained levels comparable to those of rich countries. The marital fertility rate (which had been rising steadily before 1960) declined from 7.3 to 3.7. The incidence of a wide range of parasitic and infectious diseases retreated dramatically, and morbidity patterns approached those typical of affluent countries. The extent of poverty as measured by conventional income criteria also declined.33 (p.241)

Table 12.6 Costa Rica, 1960–1980: Selected Indicators

Year

GNP per capita (1960 = 100)

Infant mortality rate (per 1,000)

Life expectancy (years)

Percentage of women aged 20–34 with completed primary education

Total marital fertility rate

Percentage of newborns below 2.5 kg.

1960

100

76

62.6

27

7.3

12.5

1965

115

75

62.9

31

6.5

1970

138

63

65.4

43

4.9

9.1

1975

164

38

69.6

55

3.8

1980

185

19

72.6

66

3.7

7.0

Source: Mata (1985), Table 7; Mata and Rosero (1988), Tables 4.1, 2.25, and 2.26.

Table 12.7 Costa Rica, 1960–1980: Selected Indicators of Public Support

Year

Percentage of the population covered by ‘Social Insurance’ and ‘Social Assistance’

Per capita real public expenditure on education (1970 US $)

Percentage of births taking place in hospital

Percentage of rural population with water supply connection

1960

15.4

19.3

50

n/a

1965

30.6

23.8

34a

1970

38.2

35.4

71

39

1975

54.7

49.3

58a

1980

85.1

63.6

91

62

(a) These figures are in fact for the proximate years, respectively 1966 and 1974.

Source: Mesa‐Lago (1985a), Table 2; Mata (1985), Tables 7 and 8; Mata and Rosero (1988), Table 4.1.

Two factors have accounted for these impressive trends. First, the fairly healthy growth of the economy during these two decades, led by a rapid expansion in the export of ‘cash crops’ (such as coffee), and resulting in this case in a broad‐based improvement of private incomes. Second, the exceptionally rapid expansion of the ‘welfare state’, and in particular extensive public efforts in the domains of health, education, social insurance and income support.

The expansion of the welfare state in Costa Rica must in turn be understood against a unique political background. Located in the heart of a region where social and political repressions are rife, Costa Rica is widely regarded as a leading exception. In fact, since independence in 1821, Costa Rica has had a long history of active democracy, minimal violence and progressive social legislation.34 Slavery was abolished as early as 1813, and capital punishment in 1882. The abolition of the army (sic!) itself took place in 1949. A high value has consistently been placed on education, and secondary schooling has been free and compulsory since 1869. Elections take place every four years under the supervision of the autonomous Supreme Electoral Tribunal, and Costa Rica (p.242) has been said to enjoy ‘the freest and fairest electoral machinery of any country in the world’.35 Turn‐out at the polls is very high (about 80 per cent), and quite often the opposition wins. Most of the police force are replaced at the time of election.36

Costa Rica's achievements have sometimes been seen as a reflection of an egalitarian society and economy. This thesis, while not entirely dismissible, is somewhat misleading. Although inequalities were non‐extreme in the early colonial days, the relatively egalitarian land tenure pattern did not survive the emergence of large coffee and banana estates in the nineteenth century.37 Today the distribution of land in Costa Rica is highly unequal even in comparison with other Latin American countries, and approximately two‐thirds of the agricultural labour force consists of landless wage earners.38 It is true that the distribution of income is much less unequal, and that income inequality in Costa Rica is relatively small by Latin American standards. But these standards are hardly exacting, and it is very hard to see a great contrast between Costa Rica and other developing countries in terms of income distribution.39 The fact is that Costa Rica's economic system is a fundamentally inegalitarian one, and falls far short of guaranteeing adequate entitlements to all—as widespread hunger during the depression of the 1930s had dramatically illustrated. However, cooperative social and political traditions have recently found a new expression in the welfare state, whose far‐reaching activities have provided an increasingly important source of security for the poor.

The foundations of the modern welfare state in Costa Rica were firmly laid down by the social reforms of the 1940s. During the first forty years of this century, the Costa Rican state, dominated by a small and conservative oligarchy, had maintained essentially non‐interventionist policies. However, changes occurred in the early 1940s under the presidency of Calderón Guardia, an enterprising pediatrician turned politician who, among other things, promoted innovative legislation in the area of social insurance, and proposed the introduction of wide‐ranging ‘social guarantees’ to protect the interests of workers. The constitution of 1949 not only consolidated the advances made under Guardia, but also institutionalized the process of social reforms and (p.243) government intervention in economic and social matters by creating a large number of ‘autonomous institutions’ responsible for the pursuit of various forms of supportive government activity—including inter alia educational and health programmes, social insurance, assistance to the needy, land reforms, and public works. These legal foundations, and the pressures generated by the democratic process, have ensured the continued vitality of the welfare state.40

Two closely related and interconnected areas of active intervention deserve special attention here: ‘fiscal social security measures’ and the public health care system.41 The system of fiscal social security measures, which includes contributory and non‐contributory pensions, health insurance, various social welfare programmes and direct financial assistance to needy families, is of a markedly different nature from similar systems in other countries of Latin America. In most of these countries, the fiscal social security system has evolved into a regressive form of large‐scale government support to the more influential groups, especially the urban élites.42 In Costa Rica, this criticism does not seem to apply today. A constitutional amendment was passed in 1961 calling for ‘universalization’ of social security within a decade, and since then the drive in that direction has been very strong. According to Mesa‐Lago, ‘in 1980 practically all the population was covered, between two‐thirds and three‐fourths by social insurance and the rest through social assistance and public health programmes’.43

Fiscal social security measures cover a part of the system of public health44 (e.g. in the form of health insurance). But the latter also includes community health and primary health care programmes implemented directly under the Ministry of Health. These programmes underwent a leap forward in the 1970s with the formulation of a National Health Plan in 1971, and the subsequent (p.244) implementation of vigorous health campaigns, including especially the Rural Health Programme (started in 1973) and the Community Health Programme (started in 1976). There is considerable evidence that these programmes have made a major contribution to rapid health and nutritional improvement in Costa Rica since their inception.45

The links between public support and the improvement of living conditions in Costa Rica are particularly well reflected in the decline of infant and child mortality. The decline of infant mortality over the period 1960–85 in Costa Rica has been overwhelmingly concentrated in the decade of the 1970s. Indeed, the 70 per cent decline in infant mortality over that single decade (from 63 to 19 per thousand live births) may well be an all‐time record—all the more impressive because the base mortality level was itself already quite low. Not surprisingly, many factors seem to have accounted for this achievement. The moderate but broad‐based growth of private incomes must have exercised its influence.46 The expansion of female education, which is known to exercise a strong influence on infant mortality, almost certainly played a role as well. The decline of fertility (itself partly the result of declining infant and child mortality) made a further contribution, which has indeed been quantitatively estimated.47

Interestingly enough, one factor that does not seem to have played a significant role in mortality reduction is the quantitative increase of nutritional intakes. Indeed, nutritional intakes do not seem to have increased much (if at all) over the period under consideration (see Table 12.8). This confirms once again the need to relate nourishment and health not to food entitlements as such but to a broader notion of entitlements including command over crucial non‐food items.48

Table 12.8 Nutritional Status and Nutritional Intake in Costa Rica, 1966–1982

Year

Percentage of stunted children

Percentage of wasted children

Average calorie intake (Kcal./cap.)

Average protein intake (g./cap.)

Rural

Urban

Rural

Urban

1966

16.9

13.5

1,894

2,330

53.6

67.3

1975

7.2

12.5

1978

7.6

8.6

2,020

1,947

54.0

58.2

1982

n/a

4.1

Source: Mata and Rosero (1988), Tables 2.10 and 2.13, summarizing a number of surveys conducted by the Ministry of Health.

The relative unimportance of quantitative increases in nutritional intake in Costa Rica's success contrasts with the crucial role that has been widely ascribed to the vigorous health programmes initiated in the 1970s. Careful statistical studies confirm that, in addition to the positive factors mentioned (p.245) earlier, these programmes have indeed had a strong independent effect on mortality decline. The evidence presented is of two kinds. First, it is observed that while until 1970 the infant mortality rate in Costa Rica could be reasonably accurately ‘predicted’ from its general social and economic indicators on the basis of the relationships (between these indicators and infant mortality) observed elsewhere in Latin America, during the 1970s infant mortality in Costa Rica deviated markedly downward from its predicted value. Second (and more importantly), by utilizing the rich data available at the canton level in Costa Rica, it has been possible to carry out statistical tests to ascertain whether mortality decline was more rapid in regions where the coverage of rural health programmes was more comprehensive, controlling for the effect of regional differences in incomes, education levels, fertility, sanitation, and so on. Detailed investigations of this type have tended to demonstrate that the influence of health care programmes in the 1970s was indeed extremely important.49

Table 12.9 gives a very elementary illustration of the results obtained. It is clear from this table that the rural health programmes of the 1970s were targeted to the cantons with higher initial infant mortality rates (this was indeed a conscious and declared policy). It can be seen that the annual declines of infant mortality, which were relatively slow in these cantons in the 1960s, sharply accelerated in the 1970s. Indeed the ranking of mortality reduction rates in different cantons got largely reversed as a result of these programmes. Basically the same conclusion is retained when the exercise is extended by ‘controlling’ for factors such as education, fertility and economic development.50 (p.246)

Table 12.9 Rural Health Programmes and Morality Reduction in Cantons in Costa Rica, 1968–1980

Ranges of coverage of population in community and rural health programmes in different cantons

Percentage of all births in Costa Rica taking place in the cantons within the respective ranges of coverage

Health indicators in the corresponding cantons

Infant Mortality Rate (per 1,000)

Annual Decline in IMR (%)

1968–9

1979–80

1965–72

1973–80

0–9

(15)

49

21

8

7

10–24

(25)

49

19

8

7

25–49

(13)

64

23

3

14

50–74

(37)

76

22

4

15

75–100

(10)

80

17

5

16

All cantons

(100)

64

21

5

12

Source: Mata and Rosero (1988), Table 4.10. All 79 cantons of Costa Rica are included in the table.

There is, of course, nothing contrary in these results. Many of the studies mentioned earlier have noted that the decline of infant mortality in Costa Rica over the last few decades has been associated with an impressive retreat of infectious and parasitic diseases. It would be rather odd if carefully managed programmes of primary health care concentrating on enterprises such as immunization, deworming, environmental improvements, oral rehydration and prenatal care did not succeed in substantially accelerating this process and making a dent in the undernutrition‐infection complex. Costa Rica went directly at the problem and has reaped as it sowed.

12.5 Concluding Remarks

In this chapter and the previous one, we have examined selected country experiences of direct support. We have paid special attention to China, Costa Rica, Chile, Sri Lanka and the Indian state of Kerala. All these experiences suggest a close connection between the expansion of public support measures and the improvement of living conditions. Public support can take various forms, such as public health services, educational facilities, food subsidies, employment programmes, land redistribution, income supplementation, and social assistance, and the country experiences that were examined have involved various combinations of these measures.

While there are significant contrasts in the relative importance of these different forms of public support in the different country experiences, the (p.247) basic commonality of instruments is quite striking (especially in view of the great diversity of the political and economic regimes). Underlying all this is something of a shared approach, involving a public commitment to provide direct support to raise the quality of life, especially of the deprived sections of the respective populations.

The causal links between public efforts and social achievements in these as well as other countries have received a good deal of attention in the recent development literature. The investigations have taken different forms. One group of studies have been concerned with examining similarities in the nature of public support efforts in different countries (each with good records in mortality reduction and other achievements), and the commonalities involved in their respective efforts have been assessed, especially in contrast with the experience of other countries.51 A second group of studies have been concerned with interregional comparisons within single countries, comparing the achievements of regions with greater or lesser involvement in public support.52 A third set of studies have presented intertemporal comparisons within single countries of public efforts and social achievements.53 A fourth set of studies have examined the direct impact of public support measures, such as health and nutrition programmes, at the micro level.54 The causal links between public support provisions and social achievements have been clearly brought out in different ways in these diverse empirical investigations.

In this chapter and the preceding one, our focus has been concentrated on five specific ‘case‐studies’. Three of the five cases studied (viz. China, Chile and Costa Rica) were among the five countries identified in Chapter 10 as being the top performers in the ‘support‐led’ category in reducing child mortality during the period 1960–85.55 The other two countries in this identified list were Jamaica and Cuba. These countries are harder to study for a variety of reasons, including data limitation. Nevertheless, we may make a few brief remarks on particular aspects of the experiences of these two countries.

Regarding Jamaica, the data on infant and child mortality rates, already examined in Chapter 10, suggest a rapid improvement in basic living (p.248) conditions during the last few decades. This is indeed confirmed by other relevant indicators. By 1985, the expectation of life at birth in Jamaica was 74 years, a level as high as that of Britain or West Germany. Adult literacy was virtually universal for both men and women. And morbidity patterns had undergone a radical transformation, including a considerable retreat of infectious and parasitic diseases.56

As far as programmes of public support are concerned, Jamaica has an impressively activist record. This includes ‘a distinguished history of accomplishments in public health care since early in the twentieth century’.57 The record of public involvement in the provision of basic education is equally strong, with the bulk of Jamaica's outstanding literacy record being attributable to public, rather than private, educational institutions. The supportive role of the state, kept alive by a highly assertive electorate, has extended to many other fields of action including those of housing, sanitation, public employment, food subsidies, nutritional intervention, social insurance and social assistance.58

It is plausible enough that, as with the other countries studied in this chapter, a strong link exists between public support and social achievements in this case. This view is all the more convincing given that, during the period under consideration (1960–85), the rate of economic growth in Jamaica has been dismally low—in fact negative (see Table 10.3 in Chapter 10).

There is a further and rather striking aspect of Jamaica's experience which deserves mention here. The negative growth rate of GNP per capita for the 1960–85 period is mainly due to the record of the economy between 1973 and 1980, when Jamaica had the unique distinction of a negative growth rate every year.59 This was also a period of socialist government, when the People's National Party (PNP, elected in 1972 and re‐elected in 1976) was in office. It is possible that the PNP's policy of retaining an essentially capitalistic economy, while simultaneously cracking down in many ways on private initiative, reinforced the negative external factors to produce the economic morass of this period. But the socialist programme of the PNP government also included many positive and ambitious initiatives in domains such as health care, education, housing, food subsidies and public employment. Under the circumstances, if it were to turn out that the 1970s were also a decade of particularly rapid improvements in health and nutrition, Jamaica's experience (p.249) would provide strong confirmation of the powerful influence that public support measures can have in removing hunger and deprivation even in the face of highly adverse macroeconomic circumstances.60

The available demographic evidence supports this hypothesis, with, inter alia, a decline of infant mortality of the order of 50 per cent during the decade of the 1970s.61 Nutrition surveys provide some further evidence in the same direction. For instance, the incidence of rural undernutrition among children aged 5 and below appears to have declined from 12.1 per cent to 8.3 per cent between 1970 and 1978.62 There is, thus, a strong possibility that indicators of economic opulence and nutritional well‐being were moving in sharply contrasting directions during the 1970s.

This interpretation of Jamaica's experience calls for fuller investigation. The potential adverse effects of rapidly declining incomes on living conditions, with a decline in average real incomes of as much as 25 per cent or so between 1973 and 1980, should not be taken lightly. The combined evidence from independent nutrition surveys must be handled with some caution. Even mortality data are much less reliable for Jamaica than for the other countries studied in this chapter.63 A closer examination of the available evidence (from anthropometric data, morbidity surveys, demographics statistics, etc.) would be needed to confirm the apparent achievements of the 1970s. As things stand, however, the period of socialist government in Jamaica does appear to be one of substantial success in support‐led security.

In the case of Cuba, there is—as with Jamaica—a clear temporal association between expansion of public support on the one hand and improvements in health and nutrition on the other. Indeed, the sharp decline in infant and child mortality since 1960 (observed in Chapter 10) coincides with the post‐revolutionary (p.250) revolutionary period, which has witnessed not only a radical land reform and a great deal of income redistribution, but also ambitious initiatives in the domains of health care, fiscal social security measures, nutrition programmes, basic education and food rationing. To cite only a few relevant facts, between the years immediately preceding the revolution of 1959 and the mid‐1970s, the share of the poorest 20 per cent of the population in national income appears to have roughly quadrupled, secondary school enrolment ratios increased more than eightfold, the rate of open unemployment dropped by around 75 per cent, and the number of nurses per inhabitant more than tripled.64

The successes of China and Cuba in removing endemic undernutrition and deprivation are of some relevance in assessing the development experience of post‐revolutionary socialist countries. The economic performances of these countries have been the object of a good deal of criticism—both internal and external—in recent years. The reprimands have often been well deserved, and the inefficiencies of bureaucratic planning have emerged powerfully enough. But the criteria of appraisal have often been rather limited, e.g. focusing on the size of commodity production rather than on the achievements in nutrition, health, education, morbidity, longevity and other basic aspects of the quality of life. As was discussed earlier (Chapter 1) and illustrated with empirical experiences (Chapters 10 and 11), aggregate economic opulence can be a very misleading indicator of achievements in developing basic human capabilities. The growth of GNP is no more than one important means to deeper ends, and as the variations in the intertemporal experiences of China show, the growth of commodity production can have quite a contrary pattern to that of life expectancy and related indicators (see Chapter 11).

The impressive records of Cuba and pre‐reform China in the fields of health, education, nutrition and life expectancy have to be incorporated in a fuller and fairer assessment of the performance of these socialist economies. Of course, in this broader assessment other aspects of the quality of life must also be brought in, including the political freedoms enjoyed or denied. Sometimes the lack of these freedoms may not only vitiate the quality of life directly, it could indirectly also affect adversely health and longevity themselves. We have discussed, for example, the role of political suppression in the genesis of the Chinese famines of 1958–61 (see Chapter 11). But these complex considerations contribute to (rather than detract from) the need to broaden the criteria of success from the narrow concentration—currently fashionable—on the growth of commodity production and GNP. In that broadened evaluation, the successes of the socialist economies of China and Cuba in nutrition and health (p.251) must figure prominently, along with other relevant assessments (many of which would be much less favourable). A proper reassessment of the experiences of socialist countries cannot be carried out in the narrow format that has come to be used so widely.

Before concluding the empirical investigations of this part of the book, something should be said about the resource requirements (and affordability) of the kind of public support measures that we have found crucial to the strategy of support‐led security. Scepticism regarding the feasibility of largescale public provisioning in a poor country often arises precisely from the belief that these measures are inordinately ‘expensive’. The experiences studied in this chapter and the previous one (particularly those that have succeeded in spite of a low GNP per capita, e.g. China, Sri Lanka and Kerala) suggest that this diagnosis is, at least to some extent, misleading.

Indeed, the costs of many of the social security programmes in the countries we have studied have been in general astonishingly small. This applies, in particular, to public provisioning of health care and education. It has been estimated, for instance, that in China the percentage of GDP allocated to public expenditures on health has been only around 2 per cent. Moreover, only about 5 per cent of total health expenditure has tended to go to preventive health care, which has been one of the major influences behind the fast retreat of infectious and parasitic diseases.65 There are similarly striking figures for the other experiences of support‐led success we have studied.66

As was discussed in the first section of this chapter, the relatively inexpensive nature of public provisions in the domains of health and education is not, in fact, so surprising given the low level of wages in many developing countries.67 The distinction of China or Kerala or Sri Lanka does not lie in the size of financial allocations to particular public provisions. Their real success (p.252) seems to be based on creating the political, social and economic conditions under which ambitious programmes of public support are undertaken with determination and effectiveness, and can be oriented towards the deprived sections of the population.

We should close this part of the book with a few general remarks about the empirical experiences of ‘support‐led security’ examined in this chapter and the preceding one. The connection between programmes of public support and achievements in the quality of life has obvious relevance for policy making, and that is why we have attempted to study various aspects of these experiences in some detail. But the existence of such a connection is not in itself particularly remarkable. It is, in fact, not enormously surprising that efforts in providing extensive public support are rewarded by sustained results, and that public sowing facilitates social reaping.68

Perhaps what is more remarkable is the fact that the connections studied here are so frequently overlooked in drawing up blueprints for economic development. The temptation to see the improvement of the quality of life simply as a consequence of the increase in GNP per head is evidently quite strong, and the influence of that point of view has been quite pervasive in policy making and policy advising in recent years. It is in the specific context of that simple growth‐centred view that the empirical connections between public support measures and the quality of life deserve particular emphasis.

Indeed, the simple growth‐centred view is misleading not only because of the importance of public support in the successful implementation of ‘support‐led security’ (with which this chapter and the last one have been concerned), but also because of the role that public support clearly plays even in the successful experiences of what we have been calling ‘growth‐mediated security’. As was discussed earlier (in Chapter 10), the contrast between a strategy of ‘growth‐mediated security’ and the tactics of ‘unaimed opulence’ can be very significant indeed, and there are plenty of examples of countries with high growth rates of GNP, real incomes, food output, etc., with extremely sluggish improvement of the quality of life. A shared feature of support‐led security and growth‐mediated security is that they both involve crucial use of public support. Neither strategy hands over the job of raising life expectancy, reducing undernutrition, morbidity, illiteracy, etc. to an unaimed process of GNP growth.

What the particular studies of support‐led security—on which we have concentrated in this chapter and the last—bring out is the force with which public support programmes can work even when a country is quite poor in (p.253) terms of GNP per head. This makes it possible to do something immediately about conquering deprivation and raising the quality of life without having to wait quite some time before ploughing back the fruits of economic growth into improved health and longevity. That immediacy is an important aspect of the promise of support‐led security, and it can substitute for a good deal of fast economic growth (on which see section 10.7 of Chapter 10). Given that most countries are in situations such that they cannot hope to grow as fast as Kuwait or South Korea or Hong Kong have done over the last few decades, immediacy is a distinct advantage of the strategy of support‐led security over that of growth‐mediated security.

This recognition should not, however, be seen as establishing any general superiority of ‘support‐led security’ over ‘growth‐mediated security’. Indeed, it is arguable that the latter strategy has its own advantages too. In particular, it makes it possible to establish the material basis of further progress in the future—even in the fields of health and longevity—going well beyond the elementary task of eradication of undernutrition and acute deprivation on which we have concentrated in this book.

Moreover, an assessment of the respective advantages of each strategy ultimately has to go beyond the concerns that have been the focus of this book. High incomes and extensive public support are both important to many other basic capabilities than those of being well nourished and healthy. High incomes provide individual access to commodities (such as better housing and more elaborate forms of entertainment) which can be used to lead a more varied life. Public support, on the other hand, can be an effective route to enhancing capabilities in domains where social interdependences are particularly strong, e.g. higher education.

Both growth‐mediated security and support‐led security have much to offer. Their advantages are partly congruent and partly divergent. In this chapter and the preceding one, the empirical analyses have pointed inter alia to the merits of support‐led security and the process through which these merits are realized. The possibility of immediacy in encountering hunger and acute deprivation is certainly a serious virtue in that context. But this and related virtues of support‐led security have to be assessed in the light of more comprehensive considerations relevant to this evaluation, including those brought out by the empirical and evaluative analyses in the earlier chapters of this book. (p.254)

Notes:

(1) These figures are taken from World Development Report 1988, Table 1.

(2) This applies even in terms of market wages, but the contrast may be sharper in terms of social cost of labour, because of underemployment and surplus labour. On this issue, see Dobb (1960), Sen (1960, 1984a), Chakravarty (1969), Marglin (1976), and Drèze and Stern (1987).

(3) In view of the domestic problems that Sri Lanka has had in recent years, involving political violence and social strife, it is easy to think of Sri Lanka as a much troubled country. That it certainly is, even though it is also the country with the highest life expectancy among all the low income countries of the world. There are, inter alia, considerable disparities between the different communities, and the appreciation of Sri Lanka's achievements has to be qualified by an adequate recognition of these—and other—inequalities.

(4) There is a similarity in this respect with the expansion of literacy in the Indian state of Kerala. Kerala too, as was discussed in Chapter 11, reaped the rewards of early expansion in literacy.

(5) Nutrition indicators based on anthropometric measurements as well as on dietary intakes confirm that the post‐war period in Sri Lanka was one of rapid improvements in living conditions. On this see Gray (1974) and the literature cited there.

(6) On this see Bhalla and Glewwe (1986) and Bhalla (1988), and also Bhagwati (1987). On some technical problems in the Bhalla–Glewwe analysis, in addition to the issue of the misleading choice of time period, see Anand and Kanbur (1987), Glewwe and Bhalla (1987), Isenman (1987), Pyatt (1987), and Ravallion (1987c). See also Sen (1988f).

(7) The eradication of malaria was one of the first targets of public health care measures, and this campaign was remarkably successful. However, this success only accounts for a part of total mortality reduction during this period. For an excellent discussion of this question, and a review of earlier contributions, see Gray (1974). The author concludes on the basis of careful statistical analysis that the control of malaria altogether accounted for 23 per cent of the decline in average crude death rates in Sri Lanka in the post‐war period. Somewhat higher estimates, with a ‘preferred value’ of 44 per cent, were obtained by Peter Newman (1970, 1977).

(8) This is quite aside from the fact that by 1960 Sri Lanka's achievements in longevity and low mortality were already high. This made further improvements in absolute terms that much harder to achieve compared with countries having still a long distance to go.

(9) There is also some indication of a possible temporal relation between the reduction of public support from the late 1970s and the increase in morbidity and mortality of the affected groups. On this see Edirisinghe (1987), Jayawardena et al. (1987), Sahn (1987), UNICEF (1987b), Sahn and Edirisinghe (forthcoming). See also Anand and Kanbur (1987).

(10) See Newman (1970, 1977), Jayawardena (1974), Gwatkin (1979), Fields (1980), Isenman (1980), Alailima (1985), Basu (1986), Anand and Kanbur (1987), Samarasinghe (1988), among others.

(11) The state of Kerala in India was also separated out as having a distinguished record of support‐led security (see Chapter 11). Kerala has, of course, a multi‐party system, as in the rest of India. It has also had substantial periods of communist government within that system.

(12) During the early 1980s, progress continued but apparently at a slower pace.

(13) This applies, right from the start, to the Social Security Act of 1924, which inscribed itself in a broad range of social and constitutional reforms, represented Chile's pioneering introduction of social insurance in the American continent and also marked the beginning of supplementary feeding in Chile (Mesa‐Lago 1985b, Vial et al. 1987). On the history of social services in Chile, and its intimate connection with adversarial politics until 1973, see Arellano (1985a, 1985b). See also Hakim and Solimano (1978), who provide a particularly instructive account of the development and politics of milk distribution programmes.

(14) On these and other aspects of social services in contemporary Chile, see e.g. Hakim and Solimano (1978), Foxley et al. (1979), Harbert and Scandizzo (1982), Gonzalez et al. (1983), Monckeberg (1983), Wallich (1983), Arellano (1985a, 1985b), Mesa‐Lago (1985b, 1985d), Valiente et al. (1985), Ffrench‐Davis and Raczynski (1988), and Vial et al. (1987). The redistributive effects of social services in Chile, and particularly of public health and nutrition programmes, have been clearly brought out in a number of studies—see e.g. Foxley et al. (1979), Grossi (1985), and Torche (1985).

(15) It is important to note that while the National Health Service (through which the most important nutrition and health programmes are implemented) does not quite provide universal coverage of infants and young children, there is no indication that the excluded population consists primarily of disadvantaged groups. In fact, the reverse may often be nearer the truth. On this see Torche (1985), Valiente et al. (1985), and Vial et al. (1987).

(16) For various evaluations of this experiment, see Harberger (1982), Ffrench‐Davis (1983), Foxley (1983), Sigmund (1984), Corbo (1985), Edwards (1985), and Moran (1989), among others.

(17) See e.g. Ruiz (1980), Foxley and Raczynski (1984), Solimano and Haignere (1984), Scarpaci (1985), Raczynski (1987), Scheetz (1987), Arellano (1988), and Ffrench‐Davis and Raczynski (1988), among others.

(18) As shown in Cabezas (1988), alternative studies and sources lead to very similar conclusions regarding broad post‐1973 trends in aggregate ‘public social expenditure’ (shown in the second column of Table 12.3). The concept of public social expenditure has to be distinguished from the narrower notion of ‘fiscal social expenditure’, which has been used as a basis of the official claim that social expenditures have risen in per‐capita terms under the Pinochet regime (see Scheetz 1987, and Arellano 1988).

(19) For statements of the official view of social policy in Chile since 1973, and of the general philosophy of the government in economic and social matters, see Government of Chile (1974), Pinochet (1976), Mendez (1979, 1980), Banco Central de Chile (1984), and particularly Government of Chile (1988). The last document describes the ‘new objectives’ of the ‘social reforms in Chile since 1973’ as (1) the eradication of extreme poverty, and (2) the promotion of true equality of opportunities (p. 6). The former objective is explicitly distinguished from, and contrasted with, a policy of income redistribution. The second objective alludes essentially to the virtues of privatization.

(20) See in particular Ruiz (1980), Foxley and Raczynski (1984), Solimano and Haignere (1984), Ffrench‐Davis and Raczynski (1988), Raczynski (1987), and Arellano (1988). Solimano and Haignere, for instance, acknowledge in spite of their severe criticisms of recent government policies that ‘Chile, fortunately, has had a highly competent system for collecting health statistics since the early 1950s, and there is evidence that the reliability of mortality data has not deteriorated significantly’ (p. 5), and note in connection with trends in the incidence of child malnutrition that ‘there is no reason to believe that the overall decline is unreal’ (p. 9).

(21) This view has been expressed by a large number of authors, including those cited in the preceding footnote.

(22) See e.g. Haindl and Weber (1986), Mujica and Rojas (1986), Rojas (1986), and Government of Chile (1988). For rejoinders see Arellano (1988) and Ffrench‐Davis and Raczynski (1988).

(23) See the critiques of government policies cited earlier.

(24) After pointing out that infant mortality and life expectancy in Chile are strongly correlated, and stating the ‘life expectancy is a very general indicator of quality of life’ (p. 9), Hojman (1988) argues against the ‘widely held preconception that infant mortality has been artificially reduced with purposes of propaganda, by means which have no relation whatsoever to wider quality of life indicators’ (p. 19). Note, however, that by construction life expectancy at birth is very sensitively related to infant mortality. This does not apply to the expectation of life at age one, and when this indicator is compared with infant mortality, the strong (inverse) correlation on which Hojman's claim is based seems to disappear (see Table 12.5).

(25) The role of public works programmes in this context is particularly noteworthy. At their peak in 1983, emergency employment programmes employed as much as 13% of the labour force, and their importance for poor households is easily seen (e.g. Cheyre and Ogrodnik 1982, Raczynski and Serrano 1985, and Raczynski 1987).

(26) Of course, other factors have also played a role, notably the continued expansion of female education and the reduction in fertility (according to Valiente et al. 1985, the contribution of the latter to the decline of infant mortality has been estimated at about 20% by two different studies). These factors are themselves closely linked with various forms of public action, e.g. in the domains of education and family planning.

(27) For studies and discussions of the impact of health and nutrition intervention in Chile, both before and after 1973, see Hakim and Solimano (1978), Harbert and Scandizzo (1982), Medina and Kaempffer (1982), Castaneda (1984, 1985), Torche (1985), Valiente et al. (1985), and various contributions in Underwood (1983) as well as the review by Vial et al. (1987).

(28) An official document on social policy states that Chile's ‘long history of State intervention in social matters’ has ‘both positive and negative aspects . . . On the negative side, it is difficult to modify already existing social programs and to adapt them to the ever changing reality of poverty’ (Government of Chile 1988: 33).

(29) This ‘concealed disengagement’, and a number of other aspects of social policy under Pinochet (e.g. the emphasis on ‘targeting’ and ‘privatisation’), bear interesting analogies with recent experiences of liberalization in a number of other countries, including Sri Lanka since 1977 (Sahn and Edirisinghe, forthcoming) and Britain in the 1980s (Atkinson et al. 1987 and Welfare State Programme, forthcoming).

(30) On this, see particularly Arellano et al. (1987, 1988). The authors claim, inter alia, that ‘whereas in 1973 there were almost 10 times more unionized than unemployed workers or “pobladores”, by 1983 the number of unemployed (“pobladores”) was more than three times that of unionized workers’ (Arellano et al. 1987: 16).

(31) Official documents and public speeches since 1973 are full of self‐congratulatory references to the rapid progress achieved in the area of child health and nutrition, and to this day ‘the pro‐Pinochet press regularly runs stories noting that Chilean newborns are among the fattest in the hemisphere’ (Contrera 1988: 24).

(32) As in the case of Chile, the pace of improvement in living conditions seems to have decelerated in the 1980s under the impact of world recession—see Peek and Raabe (1984), Mesa‐Lago (1985a) and Mata and Rosero (1988). The general issues of world recession, adjustment policies and human well‐being are discussed in Jolly and Cornia (1984), Cornia et al. (1987), Taylor (1988a), Jayawardena (forthcoming). It must be stressed that the economic difficulties of Costa Rica in the 1980s are overwhelmingly attributable to world‐wide fluctuations in economic activity as well as commodity prices, and in this respect Costa Rica shares the common predicament of most Latin American countries.

(33) These trends have been established and discussed in a large number of studies, and the statistical evidence establishing them is robust enough. See e.g. Haines and Avery (1982), Saenz (1982, 1985), Jaramillo (1983), Mohs (1983a, 1983b), Rosero (1984, 1985a, 1985b), Peek and Raabe (1984), Halstead et al. (1985), Mata (1985), and the meticulous review by Mata and Rosero (1988). The last authors present, inter alia, clear evidence of nutritional improvement as indicated by anthropometric measurements.

(34) For an excellent account of the nature of Costa Rican democracy, see Ameringer (1982). For background details on the economy and society of Costa Rica we have also drawn on Rosemberg (1979, 1983), Seligson (1980), Castillo et al. (1983), Mesa‐Lago and Diaz‐Briquets (1988), Peek and Raabe (1984), Wesson (1984a), Gonzalez‐Vega (1985), Mesa‐Lago (1985a), Fields (1988), and Mata and Rosero (1988).

(35) Ameringer (1982: 33).

(36) It would be an exaggeration, of course, to describe Costa Ricans as ‘non‐violent’, as has often been done. The homicide rate in Costa Rica, for instance, is much smaller than in neighbouring Latin American countries, but it is not negligible, and some concern has recently been expressed at the fact that homicides increasingly take more violent forms than ‘the traditional straight killing’, partly as a result of rising alcoholism (Mata and Rosero 1988). Another important social problem in Costa Rica is the disadvantaged position of ethnic minorities.

(37) See Seligson (1980), who discusses the importance of Costa Rica's colonial history, including the evolution of land tenure and the relatively homogeneous ethnic composition of the population.

(38) Peek and Raabe (1984: 12).

(39) See e.g. the tables on income distribution in recent issues of World Development Report. For a careful study of land and income distribution in Costa Rica, see Peek and Raabe (1984).

(40) On the role of democratic politics in shaping social policy in Costa Rica, see e.g. Ameringer (1982), Rosemberg (1983), and Mesa‐Lago (1985c).

(41) By ‘fiscal social security measures’ we understand social security in the narrower and more conventional sense than the broader idea of ‘social security’ used in this book (discussed in section 1.3). This conventional notion is perhaps best reflected by the legislative concerns of the ILO covering ‘social insurance’ and ‘social assistance’. On fiscal social security measures in Costa Rica, see e.g. Green (1977), Rosemberg (1979, 1983), Briceño and Méndez (1982), Mesa‐Lago (1985a, 1985c), and Rodriguez (1986).

(42) This verdict is extensively defended and documented in numerous writings by Carmelo Mesa‐Lago—see e.g. Mesa‐Lago (1978, 1985b, 1985c, 1986, 1988b). It is worth noting that the three countries which Mesa‐Lago singles out as departing from this pattern happen to be Chile, Costa Rica, and Cuba (see Mesa‐Lago 1985d). These three countries distinguish themselves by having unified fiscal social security systems with universal (or nearly universal) coverage.

(43) Mesa‐Lago (1985b: 45; our translation).

(44) The literature on public health in Costa Rica is enormous. Some useful references include Mata (1978, 1985), Haines and Avery (1982), Jaramillo (1983), Mohs (1983a, 1983b), Tomic (1983), Asociación Demográfica Costarricense (1984), Mesa‐Lago (1985a), Rosero (1985a, 1985b), Caldwell (1986), and various contributions in Halstead et al. (1985). For a particularly useful and up‐to‐date account, which also summarizes neatly the existing evidence on the relation between health intervention and health and nutritional improvement, see Mata and Rosero (1988).

(45) The evidence on this point is discussed in many of the contributions cited in the preceding footnote.

(46) The rate of decline of infant mortality in Costa Rica since 1911 seems to have been more rapid during periods of economic prosperity than through recessions. See Rosero (1985b) and Mata and Rosero (1988). Note, however, that the growth of income per capita in Costa Rica does not seem to have been more rapid in the 1970s than in the 1960s. According to the World Development Report 1984, the growth rate of GDP per capita in Costa Rica was 3.2% over the 1960–70 period, and only 2.0% between 1970 and 1982 (calculated from Tables 2 and 19).

(47) According to Rosero, the decline of fertility is estimated to have been responsible for 24% of the observed reduction in infant mortality in Costa Rica between 1960 and 1977 (Rosero 1985a: 131). Note that the decline of fertility is itself closely related to social policy, including education and family planning programmes—see Stycos (1982) for a detailed analysis. In 1981, two‐thirds of those using contraception utilized state‐provided services—the proportion rising to 90% among agricultural labourers (Rosero 1985a: 131).

(48) Of course, it must be remembered that Costa Rica is more prosperous than most countries of Africa or South Asia, and it is not clear that substantial improvements in nutritional status could be easily achieved in much poorer countries without inter alia an increase in calorie intake.

(49) On both types of evidence, see the detailed review of evidence in Mata and Rosero (1988). Rosero (1985a) estimates that 41% of the infant mortality decline between 1972 and 1980 is attributable to the expansion of primary health care, and another 32% to secondary health care (mainly out‐patient consultations at hospitals). See also Haines and Avery (1982) on the importance of maternal and child health programmes during the period 1968–73.

(50) See Mata and Rosero (1988) for details.

(51) See e.g. Sen (1981b), Flegg (1982), Halstead et al. (1985), Stewart (1985), Caldwell (1986).

(52) See e.g. Patel (1980), Castaneda (1984, 1985), Jain (1985), Nag (1985), Prescott and Jamison (1985), Morrison and Waxler (1986), Kumar (1987), Mata and Rosero (1988).

(53) See e.g. Castaneda (1984, 1985) on Chile, Anand and Kanbur (1987) on Sri Lanka, and Mata and Rosero (1988) on Costa Rica.

(54) See e.g. Gwatkin et al. (1980), Harbert and Scandizzo (1982), Garcia and Pinstrup‐Andersen (1987), Berg (1987a), Mata and Rosero (1988), and the studies of health and nutrition programmes cited earlier in this chapter in connection with specific country studies.

(55) The two other cases studied did not qualify in the ‘top performer’ list in Chapter 10 for rather special reasons. In the case of Sri Lanka the programme of support‐led security began substantially earlier (and gathered particular momentum in the 1940s) and by 1960 Sri Lanka already had a very low level of child mortality, leaving less scope for exceptional performance in the period 1960–85 on which the international comparison in Chapter 10 concentrated (see section 12.2). In the case of Kerala as well, the interventionist history pre‐dates 1960, but, more importantly, it did not even ‘qualify’ to be included in the international comparisons in Chapter 10 since Kerala is not a country but only a state within India.

(56) See UNICEF (1987a), Cumper (1983) and Moran et al. (1988).

(57) Moran et al. (1988: 13). For a detailed investigation of these accomplishments, and of their economic and political basis, see Cumper (1983).

(58) On various aspects of public support in Jamaica today, see Gloria Cumper (1972), Gobin (1977), Girling and Keith (1977, 1980), Jameson (1981), G. E. Cumper (1983), Gunatilleke (1984), Samuels (1987), Mesa‐Lago (1988a, 1988c), and Moran et al. (1988). The prominent role of public assertiveness and participatory politics in Jamaica's experience of support‐led security is evident from several of these contributions. On this see also Duncan (1984).

(59) See e.g. the data presented in Boyd (1987), Table 5.1. In the 1960s, the economy had enjoyed a period of positive and fairly substantial economic growth.

(60) The People's National Party was beaten in the 1980 election by the rival Jamaica Labour Party, which immediately adopted extensive measures of economic liberalization and ‘adjustment’, including very severe cuts in social programmes and public support. In spite of some economic recovery, the 1980–5 period seems to have been one of stagnation and possibly even deterioration in living standards. On this, see Boyd (1987), Melville et al. (1988a, 1988b), Mesa‐Lago (1988c) and Moran et al. (1988).

(61) See Government of Jamaica (1985), Annex 6, Table A3, Moran et al. (1988), Table A1, and FAO (1988), Table 2.6. The precise magnitude of the decline is hard to ascertain, and substantially different estimates are provided by different studies.

(62) Samuels (1987), Table 4.11, based on weight‐for‐age measurements (the incidence of stunting also decreased considerably). Striking improvements during the 1970s have also been observed in the studies of Alderman et al. (1978) and Marchione (1977, 1984), which cover specific ‘Parishes’. The data presented by Marchione (1984) apparently indicate some setback between 1975 and 1978–80 in the parish studied, but the 1978–80 figures—as Marchione explains—are not comparable with the earlier ones. Comparable figures for 1973 and 1975 indicate a decline of about 40% in the incidence of undernutrition for children below age 3 (calculated from his Table 3 first column). For evaluations of recent nutrition surveys in Jamaica, see Omawale and McLeod (1984), Davis and Witter (1986), Landman and Walker (1987), and Melville et al. (1988a, 1988b).

(63) There is, in fact, a possibility that the UNICEF estimates used in Chapter 10 give a slightly exaggerated picture of Jamaica's recent achievements, due to some decline in the quality of death reporting (George E. Cumper, London School of Hygiene and Tropical Medicine, personal communication).

(64) The figures are based on Brundenius (1982), Tables 8.1, 8.4, 8.5, 8.6. On the transformation of living conditions in Cuba since 1959, and the role of public support in bringing about this transformation, see Brundenius (1981, 1982, 1984), Eckstein (1980, 1982, 1986), Aldereguia (1983), Diaz‐Briquets (1983), Muniz et al. (1984), Halebsky and Kirk (1985), Santana (1987), Ghai et al. (1988), among others. For interesting comparisons of the experience of Cuba with those of Costa Rica, Jamaica, Sri Lanka, and Chile, see Jameson (1981), Monckeberg (1983), Meegama (1985), Mesa‐Lago and Diaz‐Briquets (1988).

(65) Baumgartner (1989). On this general question, see also World Bank (1984a) and Jamison (1985).

(66) The percentage of GDP allocated to public expenditures on health in Sri Lanka in 1981 was barely 1% (Perera 1985: Table 8). The corresponding figure for Cuba was around 2.7% (Muniz et al. 1984: Tables VI.1 and VI.6). In Kerala, per‐capita government expenditure on health is not much greater than in the rest of India (Nag 1985: Table 16). In Costa Rica, overall government expenditure on health is relatively high, but the public health programmes described in the preceding section accounted for only 2% of the total (Saenz 1985: 143). For further evidence and discussion of the scope for low‐cost public provisions in the domain of health, with special reference to China, Costa Rica, Kerala and Sri Lanka, see various contributions in Halstead et al. (1985), and also Caldwell (1986).

(67) There are also other considerations that would lead to a reduction of the real resource burden of public support in developing countries. First, financial costs are not always a good reflection of social costs, and in particular a good case can often be made for regarding the social cost of labour in labour‐surplus economies as being lower than the market wage. Second, the opportunities for raising revenue are not independent of the existence of a social security system. For instance, the scope for resorting to exacting indirect taxation may be much larger when vulnerable groups are protected from possibly severe deprivation. Third, there is an element of investment in public provisioning (e.g. through the relation between health, nutrition, education and productivity). This reduces the diversion from investment opportunities that is apparently involved in a programme of public support.

(68) Hunger and deprivation are, to a large extent, social conditions that cannot be seen only in isolated individual terms. There are strong interdependences and so‐called ‘externalities’ involved in health (e.g. through the spread of diseases), education (e.g. through influencing each other), and nutrition (e.g. through food habits being dependent on social customs). The importance of social intervention in ensuring adequate entitlements to ‘public goods’, and in dealing with externalities generally, has been well recognized for a long time in economics (see Samuelson 1955, and Arrow 1963).