CHAPTER III ANALYSIS OF HEALTH PROFILE OF INDIA

Transcription

1 CHAPTER III ANALYSIS OF HEALTH PROFILE OF INDIA

2 The State shall regard raising the level of nutrition and standard of living of its people and improvement in public health among its primary duties. -Article 47 of the Indian Constitution At the close of the second decade of post-reform, India has recorded laudable achievements on the economic front. Its economic structure has undergone significant transformation and we have moved way ahead of the Hindu growth rate, having reached a high of more than 9 percent growth rate. Its GDP is more than one trillion dollars, per capita income and foreign exchange reserves are showing a consistent upward trend. Multinational corporations are all too eager to make investments in the growing Indian economy. But these economic achievements are not being translated into human development in terms of health and education, nutrition and sanitation, water supply and dwelling conditions etc. These basic amenities are essential to enhance entitlements of the people to fulfill their needs by enlarged available choices. India s health scenario expressed in terms of life-expectancy at birth, infant mortality rate, maternal mortality rate, child mortality rate, neo-natal and postnatal mortalities, institutional and safe delivery, malnourished children and women, and persistence of HIV/AIDS, malaria and tuberculosis reflects a poor performance in this area. It is not only lagging far behind the advanced nations but even some of the developing countries, especially of South East Asia. The present chapter is an effort to present the broad spectrum of India's health in international, national and regional perspective in respect of maternal and child health in terms of maternal mortality rate (MMR), life-expectancy at birth (LEB), child mortality rate (CMR), infant mortality rate (IMR) and its components like peri-natal and neo-natal mortality rates, and nutritional status of women and children, ante-natal check-ups, immunization and institutional as well as safe delivery. Disparities at gender level are also analyzed. Health infrastructure in terms of availability of health personnel, midwife/nurses and 46

3 hospital beds and shortfall of Sub-Centres (SCs), Primary Health Centres (PHCs) and Community Health Centres (CHCs) are also discussed. The true picture of an economy is well reflected through the health profile of the people. Generally it is observed that a high level of health profile is associated with highly advanced economies. It is so because health profile is based on a very comprehensive set of factors. It is the product of the interaction of our natural built and physical environment, socio-economic status, psychosocial conditions and cultural norms and beliefs with our physiological selves and our genetic inheritance. At the individual level, a logical interpretation can be established that if a person s health is sound, it means he is taking a balanced diet, doing proper physical exercise and following other norms of good health. Balanced diet and all other related behaviours require income, awareness and true knowledge. Hence, health status itself is a sufficient measure of economic, social, political, cultural and educational attainments that determine truly the entitlements of the people. Several studies support that a high level of health profile is the outcome of a high economic status along with good governance. Health profile of India is very poor. One out of every nineteen children born dies before his first birthday. More than half of women are anemic and maternal mortality is also very high at 212. There are wide gaps in health outcomes at state, region and gender levels. The apparent cause of the deplorable state of health is inadequate funding. Public expenditure on health as percentage of total health expenditure is only 27 percent as against about 80 per cent in advanced countries. Major part of the health expenditure is undertaken by individuals themselves. Total health expenditure as percentage of GDP varies between 8.2 per cent in UK to 15.3 per cent in USA, but in India it is low at 3.6 per cent of a much lower GDP compared to advanced countries (Table 3.1). There are acute shortages of trained personnel and physical as well as technical infrastructure in the health sector. 47

4 The health profile of India gives a very diverse picture as per its cultural diversity. Even broad comparisons between its states bring out enormous variations in basic health indicators. At one end of the scale, states like Kerala and Tamil Nadu shine brighter and their outcomes are comparable to that of middle income countries, and at the other end the large north Indian states find themselves in the same league as the world s least developed countries in terms of the same indicators. In Uttar Pradesh, for instance, the IMR is about six times higher than Kerala. Health Profile of India in International Perspective As mentioned in the introductory part of this chapter India has registered an appreciable level of economic growth in the contemporary globalization era but health outcomes are not commensurate to her giant size and resources. It is apparent from Table 3.1 that India s health outcomes are very poor in the international perspective. Its maternal health condition is deplorable while that of infants too is very poor. Even countries like Thailand and Sri Lanka, riddled with civil war and military coup off and on, have managed to keep their MMR and IMR at much lower levels than India. Jordan also has a low MMR, although its fertility is much higher according to a study. This anomalous finding i.e. high fertility with low maternal mortality is due to high proportion of births attended by trained staff in Jordan as well as a much healthier female population. There is a very strong negative correlation (r = -0.83) between MMR and births attended by skilled health staff. Likewise, IMR in India is also high at 54 per thousand live births against 17 in Sri Lanka and 30 in China. Studies suggest that the income effect are quite slow and weak and other personal and social characteristics especially women education often have a more powerful influence on IMR. Under-five-mortality is very high and it is more than three times compared to Sri Lanka and more than ten times that of Thailand. Maternal health is in a deplorable condition with a high MMR of 450. India is only better than the least developed countries like Kenya, Nigeria and Bangladesh in this respect. Neo-natal mortality rate (NMR), IMR and U5MR of India are 39, 54 48

5 and 72 per thousand live births respectively, while these figures are only 1, 2 and 3 in Singapore and 4, 6 and 8 in Cuba. It proves that these figures are achievable by human effort in both types of countries- developed and developing. The situation of developed countries is far better than India. U5MR is only 4 in Australia and Germany, 6 in Japan and 8 in France and U.K. Health status of the population measured in terms of life expectancy at birth (LEB) is an indicator of how healthy one can expect to be. In comparison to India it is much higher in developed countries and is also high in some developing countries as well. It is evident that there is a gap of 30/35 (male/female) years between best performing country, Japan (79/86 years) and the worst performing country Nigeria (48/50 years) in the data given in Table 3.1. Japanese life expectancy is almost double that of a Nigerian. It means that two generations of Nigerians will pass before one generation of Japanese. This gap is about 15/20 years with respect to India. LEB in India is 63/65 years while it is 77/83 years in Australia, 77/82 years in U.K. and 78/83 years in Singapore. India is lagging behind Sri Lanka (68/75 years) and Thailand (66/74 years). It will be appropriate to mention here that viewed at the global level, the LEB gap between developed and developing economies is narrowing down as per Human Development Report, Between 1960s and today LEB increased by 16 years in developing countries and by 6 years in developed countries. Since 1980s the gap has closed by 2 years. But since early 1990s a long run trend toward convergence in LEB between rich and poor has been slowed by divergence between regions linked to HIV/AIDS and other setbacks (Human Development Report, 2005). Among 11 SEAR (South East Asia Region) Countries HIV/AIDS prevalence is the second highest in India at 910 after Thailand, and it is 500 in Nepal and in other countries of the region the range is between Cases of malaria and tuberculosis are also higher than in many countries of the region (Annexure 3.1 and National Health Profile, 2008). These parameters of health reflect a paradoxical situation in a country which is fast gaining a reputation as an important destination for expert medical care in critical areas of health. 49

6 Medical tourism is an upcoming field in terms of earning foreign exchange. It is also indicative of inequalities in levels of health and living prevalent in low income countries. If we see the availability of health personnel like physicians, nursing and midwifery personnel and hospital beds, it is just 6, 13 and 7 per 10,000 populations respectively. This works out to one doctor for a population of approximately These facilities are much higher even in the small island Caribbean country Cuba (Table 3.1). Neighboring developing countries like Sri Lanka and Thailand perform better than India in this respect. The availability of these facilities is proportionally much higher in advanced countries. The births attended by skilled health personnel is 100 or almost 100 percent in all developed countries and even in some developing countries like China (100%), Cuba (100%), Sri Lanka (99%), Brazil (98%), Iran (97%) and Thailand (97%) while in India it is only 47 percent. The same is also true for ante-natal checkups of at least one visit. India fares better only with respect to the least developed countries like Kenya and Ethiopia. There is a clear-cut linkage of health facilities and health outcomes. Health facilities depend upon health expenditure incurred which is only 3.6 percent of GDP in India. This figure is very low in per capita terms due to a low GDP base and high population in comparison to developed countries. India occupies a place in the league of low income countries like Bangladesh, Ethiopia, Thailand, Kenya and Nigeria. The scenario becomes grimmer because of more than 75 percent of health expenditure being borne by poor people and only 25 percent being supported through the exchequer in India. Though as percentage of GDP health expenditure in India is higher than Indonesia, Singapore, Bangladesh and Thailand but in terms of per capita health expenditure it works out to only $86 PPP per capita the second worst country just above Nigeria ($59 PPP), while developed countries are spending 8 to 15 percent of their much higher GDP for a much lower level of population in comparison to India and China. 50

7 Table 3.1:- Health Profile of India in International Perspective COUNTRY HEALTH EXPENDITURE HELATH OUTCOMES HEALTH FACILITIES % GDP %Gov % Pvt PCTot PCGov LEB_M/F NMR IMR U5MR MMR PHYS NURS BEDS BASP ANC DEVELOPED COUNTRIES Australia / N.A. Canada / N.A. Chile / N.A. France / N.A. N.A. Germany / N.A. Japan / N.A. Singapore / N.A. Switzerland / N.A. U.K / N.A. N.A. U.S.A / N.A. DEVELOPING COUNTRIES Bangladesh / Brazil / China / Cuba / Ethiopia / < Indonesia / Iran / N.A. Jordan / Kenya / Nigeria / Sri Lanka / Thailand / INDIA / Source: World Health Statistics 2009, WHO, Geneva. % GSDP:Percentage share of health expenditure in GDP; %Gov: Percentage share of govt. expenditure on health; PCTot: per capita total health expenditure; PCGov: per capita Govt. health expenditure; NMR: Neonatal mortality rate/1000; PHYS: physician per 10,000 population; NURS: nursing and midwifery personnel per 10,000 pop.; BEDS: hospitalbeds per 10,000 pop.; BASP: percentage births attended by skilled health personnel; ANC:ante-natal check-ups at least one visit. 51

8 Percentage share of government in total health expenditure is 87.3 percent in UK, 81.3 percent in Japan, 79.7 percent in France and 76.9 percent in Germany. Cuba, a socialist country is doing far better and its government share is 91.6 percent. The per capita government health expenditure in terms of purchasing power parity in dollar ($ PPP) shows the glaring disparities between developed and developing countries. It is $3076 in USA, $2457 in UK, and $2727 in France while this figure is much lower in developing countries; it is only $88 in China, $81 in Sri Lanka, $22 in India and $18 in Nigeria. According to the National Commission on Macroeconomics and Health India is one of five countries in the world where public spending is lesser than 0.9 percent of GDP and one of the fifteen where households account for more than 80 percent of total health spending. The need to increase spending on health is well recognized that if India like China, is to reap the benefits of a demographic dividend and become an economic powerhouse in 2030, it will have to ensure that people are healthy, live long, produce wealth and shake off the tag of a high risk country. Health Profile in India: State-wise A conspicuous feature of the health scenario in India is absence of uniformity at the level of states. There is wide disparity in the performance of states with respect on the health front. The following indicators of health have been taken account of in the present study: Life Expectancy at Birth (LEB) Infant Mortality Rate (IMR) Child Mortality Rate (CMR) Nutritional Status of Children Maternal Mortality Rate (MMR) Institutional and Safe Delivery Nutritional Status of Women 52

9 Life-expectancy at Birth (LEB) Life expectancy is defined as the number of years a person may expect to live in a socio- economic situation. A healthy life free from morbidity and illness goes to a long way in ensuring the well-being of an individual. People living in a deprived state are more susceptible to morbidity and mortality and, therefore, are likely to have a lower life expectancy. If it is measured since birth then it is termed as life expectancy at birth (LEB). Life-expectancy at birth is one of the most frequently used indicators of health status of people in general. The PQLI, HDI as well as important studies on health have all taken account of LEB as an important health indicator. It is a very comprehensive measure and based on chances of survival at different stages of life and prevailing health situations. If various mortality rates, for instance IMR, CMR, MMR etc. and/or deaths due to HIV/AIDS, malaria, tuberculosis or by any other cause are high, the chances of survival will be low and consequently LEB will also be low. Low LEB is indicative of poor socio-economic conditions prevalent in developing countries. Leading a long and healthy life is a basic indicator of human capabilities. Inequalities in this area have the most fundamental bearing on well-being and opportunities. It is an established fact that developed countries have a much higher life expectancy than developing ones. As a country develops, this is one indicator which shows a positive improvement. It is reflective of higher incomes, better food intake and nutritional status as well as availability of better health facilities in general higher levels of education and awareness. 53

10 Table 3.2:-Life expectancy at Birth in Major States S.N. STATES Male Female Male Female Male Female Male Female Male Female Male Female 1 Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal INDIA Source: Family Welfare Statistics 2009, Ministry of Health & Family Welfare. 54

11 years Analysis of Health Profile of India Data on life expectancy across 15 Indian states is shown in Table 3.2. An improvement of 4.5 years for males and 5.1 years for females during to has taken place as is evident from the given data. LEB of males which was 61.3 years increased to 65.8 years. This figure in the advanced countries is around 80 years eg. Japan (79/86), USA (76/81), Germany (77/82) etc. In some developing countries like China (72/75), Sri Lanka (68/75), Jordan (70/74) life expectancy is higher than India (Table-3.1). There is a gap of 1.7 years to 2.3 years between male and female LEB. Female is biologically the stronger sex and in advanced countries 6 to 7 years of gap generally prevails. But one noticeable fact in the case of Bihar is that its female LEB is below male LEB which points to possible discrimination and neglect of the females. Uttar Pradesh has slightly improved her position and here female LEB is little more than that of male. There are broad inter-state disparities. At the one end of the scale we have Kerala with a high male LEB of 72 years and female LEB of 76.8 years ( ). During this period it was lowest in Assam at 61.6 years for males and 62.8 years for female. The performance of Bihar (67.1/66.7), Assam (61.6/62.8), Madhya Pradesh (62.5/63.3), Orissa (62.3 males only), and Uttar Pradesh (64/64.4), is below the national average Fig 3.1 : Life-expectancy at Birth in India, Male Female Source: Based on Table

12 years Analysis of Health Profile of India The health condition of males in term of LEB is far below in Bihar and Assam than Kerala, Punjab, and West Bengal but conditions of female are shocking. Overall situation of the Hindi belt is unsatisfactory. Inappropriate and inadequate health provision and gender discrimination is responsible for this situation. 90 Fig 3.2 : LEB in Major Indian States, A P ASM BR GUJ HAR KAR KER MP MAH ORS PUJ RAJ TN UP WB India Male Female Based on Table3.2 Infant Mortality Rate (IMR) Infants constitute one of the most sensitive and vulnerable sections of the population. The infant mortality rate is a pointer not only to the health status of the population but also to the social and cultural factors that have an effect on health. The health of newborns is measured in terms of: Peri-natal mortality rate: Deaths of infants within a week after birth. It also includes still-births. Neo-natal mortality rate is calculated by the deaths that occur before 29 days. 56

13 Post-natal mortality rate: Deaths of infants that occur after 29 days upto one year of birth. All these constituents of infant mortality rate (IMR) are estimated at per 1000 live births. The IMR indicates the social and health status of women and children of the nation. It is defined as number of deaths in the first year of a child s life per 1000 live births in a given year. It reflects the availability and affordability of health services at the grassroots level. Though at the all India level IMR has declined by 27 points since the reform year, yet it was as high as 53 in 2008 that is double the targeted figure of 28 of the 11 th Five Year Plan. The condition of BIMARU states is especially very unsatisfactory. From the Table 3.3 based on Annexure 3.2 the highest figure of IMR of 70 in Madhya Pradesh is followed by Orissa (69), Uttar Pradesh (67) and Assam (64). Kerala has the lowest IMR at 12. Performance of Tamil Nadu (31), Karnataka (45), Maharashtra (33) and Punjab (41) is somewhat better. Table 3.3:- IMR in Major Indian States since 1987 to 2008 STATES CAGR Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal INDIA Source: SRS (2009) Compendium of India's Fertility and Mortality Indicators , Family Welfare Statistics 2009 & CAGR is taken from Annexure

14 The rate of fall over the study period from 1987 to 2008 calculated by the application of CAGR is percent at all-india level. Kerala, Tamil Nadu, Maharashtra and West Bengal have registered more than 3 percent of compound rate decline during this period. The highest negative annual compound growth rate was-3.43 percent in Tamil Nadu and actual figure of IMR per thousand declined from 76 to 31; in the case of West Bengal CAGR was near to Tamil Nadu i.e percent and IMR declined from 71 to 35. It is well known that mother s education, higher maternal age at birth, greater interval between successive births, regular ante-natal check-ups, tetanus inoculation, intake of iron and folic acid tablets, breast feeding practices, good hygiene and access to proper medical care are crucial in determining the survival of infants (Bhandari, L.and Dutta, S. 2007) Fig. 3.3 : IMR in India, IMR Source : Based on Table 3.3 Infant Mortality by Sex Infant mortality by sex shows that female babies are less cared for than their male counterpart. This is an effective cause of skewed sex ratio among children in India. Preference for male children persists in both urban and rural 58

15 environments. Boys are seen to be a human resource while they are young and providers of security and livelihood in old-age (Maria del Carmen Elu, WHO, 1995). Table-3.4presents a picture of disparity in infant s deaths at sex level. There is a gap of 3 points at all-india level and it is sustained though the overall ratio has improved by 4 points (57 to 53) in a short time of two years only. Moreover, this gap is more and ranges from 0-5 points at states level. In some states there have been significant changes in sex ratio. While Punjab and West Bengal improved markedly, in Haryana there was a worsening of the sex-ratio as also in Uttar Pradesh. Economically less developed states like Assam, Bihar, Orissa, Madhya Pradesh, Rajasthan and Uttar Pradesh have registered higher IMR than the advanced states. Among the better performing states Kerala leads and is much ahead of the rest of the states and Maharashtra, Tamil Nadu and West Bengal also performed better. The gap between male and female IMR among comparatively developed states is lower (2-3 points) than north Indian BIMARU states (4-5 points). Table 3.4:- IMR by Sex in Major Indian States STATES Male Female Total Male Female Total Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal INDIA Source: SRS (2009): Compendium of India's Fertility and Mortality Indicators

16 Rural and Urban IMR and its Constituents (PMR, NMR, PoMR) The causal factors of peri-natal deaths are somewhat different from neonatal and post-natal deaths. It is a well-established fact that the variations in perinatal mortality are likely to reflect the effectiveness of maternity services. As the World Development Report 2004 finding shows the health services, if delivered well, will improve outcomes for even the poorest groups. In a case study of Gadchiroli district of Maharashtra in India the health program reduced neo-natal mortality rates by 62 percent. Midwifery services and community hospitals are linked to a dramatic reduction in neo-natal and maternal mortality in Sri Lanka and Malaysia. From Table 3.5 it is clear that neo-natal mortality rate (NMR) is almost two times the post-natal mortality rate (PoMR) and in the less developed states both are very high. IMR is the sum of these two- NMR and PoMR. It is also evident from figures in the table that most deaths of neo-natal group occurred within a week of birth. The situation of rural infants is very critical as they constitute majority of peri-natal mortality. They are the most vulnerable and their number of deaths within a week is more than two to three times to urban infants in some states. The major contributor of neo-natal deaths is malnourishment of mothers because of widespread poverty. One important point that needs to be highlighted is that neo-natal mortality rate (NMR) is almost double that of post-natal mortality rate (PoMR). Neo-natal deaths account 45 percent of U5MR alone and this figure is very high in northern states. In the case of Uttar Pradesh it contributes to almost 64 percent of infant mortality in the state. According to the NFHS-2, 74 percent of neonatal deaths occur in the first seven days and more than one-third of this is on the day of birth (Das, L.N. 2008). Hence, it is obvious that the most vulnerable and sensitive group is of rural infants of less than one week. So the government and its agencies should especially target this group to effectively reduce IMR. 60

17 Table 3.5:- IMR and its Constituents by Residence in Major Indian States-2007 STATES IMR PMR NMR PoMR Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal INDIA Source: SRS (2009): Compendium of India's Fertility and Mortality Indicators Note: PMR: Peri-natal Mortality Rate; NMR: Neo-natal Mortality Rate; PoMR: Post-natal Mortality Rate. 61

18 Government is in fact working in this direction under National Rural Health Mission (NRHM) to address real issues and has targeted the affected population to enhance their chances of survival. Certain communities are more vulnerable than others. Disparity is not directly attributable to region, state, caste and community, although certain diseases occur more often in certain states. Rather the disparity can be traced to differences in the socio-economic status between different segments of population. For example, research indicates that low income and limited education correlate very highly with poor health. We can claim some praiseworthy achievements during post- reform period, for example IMR recorded a fall from 95 in 1987 to 53 in 2008, MMR 398 in to 212 in etc. However, these achievements should not complacent. We have miles to go before we sleep. Child Mortality Rate (CMR) Child mortality rate (CMR) is defined as the deaths of children upto 4 years at per thousand child population every year. According to Human Development Report 2005 more than half of the child deaths are reported in four states namely Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. These states are also marked by some of the highest gender inequalities in India. Child mortality is indicative of availability of health facilities like immunization and other preventive health measures. Socio economic conditions, health and literacy level of mother are important determinant factors of CMR. Most deaths in this group occur due to diaherea and malnutrition in deprived and weaker sections of society and in regions of low development. It is estimated that three out of four deaths occurred due to malaria, another important factor was that of children. Most of these deaths could be prevented by simple, low-cost interventions. Vaccine-preventable illnesses- like measles, diphtheria and tetanus- account for another 2-3 million childhood deaths. More than 98 percent of childhood deaths occur in poor countries. 62

19 Table 3.6:- CMR by Sex and Residence Since 1991 to STATES Male Female Male Female Male Female Total Total Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Total Andhra Pr Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pr Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal INDIA Source: SRS (2009): Compendium of India's Fertility and Mortality Indicators

20 Table 3.6 shows the glaring disparity in child mortality at regional (rural/urban) and sex levels in major Indian sates. The rural/urban gap is nearly double and in some cases more than double in manystates, even some of the relatively more developed states of Maharashtra, Gujarat and Karnataka. Only in the States of Kerala and Tamil Nadu rural/urban gap is low, of one and two years only. This is so because rural areas are historically neglected. Their infrastructure and facilities are meager compared to that in urban areas. Sex level disparity shows that female children are less cared for and their deaths are more than their male counterpart though they are the biologically advantaged sex. This situation reflects the deficits as well as disparities in health infrastructure and facilities. Generally economically more developed states do better and their figures of CMR are less than the national average. Their ranks are higher than the less developed states. 30 Fig. 3.4 (a) : CMR- Male 30 Fig. 3.4 (b) : CMR- Female Rural Urban Rural Urban Source: Based on Table 3.6 Figures in Table 3.6 show that among the major Indian states Kerala was at the top of the list during whole period. The lowest CMR was achieved by Kerala and the level achieved by this state three decades ago (12.2 in 1981) is not still 64

21 achieved today by north Hindi belt ( SRS 2009, Compendium of India s Fertility and Mortality Indicators ). Even as late as 2007 figures of BIMARU states, namely Bihar (18.9), Madhya Pradesh (23.5), Rajasthan (19.5), Uttar Pradesh (22.3) and that of Orissa (20) and Assam (18.2) are much above the all India average (Table 3.6). In 1981 CMR of Gujarat a relatively more developed state (40.6) was very high, close to that of Bihar (42.5), Orissa (42.2) and Assam (39.5) (Compendium of India s Fertility and Mortality Indicators ). Even in 1991 performance of Gujarat remained below that of Andhra Pradesh and West Bengal (even Bihar s CMR was lower) (Table 3.6). But during last three decades this economically advanced state improved its position. It does mean that provision of health care is more important than economic advancement as is proved by Kerala s performance, a moderately developed state, way ahead of Maharashtra, Gujarat and Haryana. Nutritional Status of Children An important factor that needs mention when studying CMR is the nutritional status of children. Nutritional status of children is an important of their health and their capability to resist diseases. Nutrition can be considered as the availability of a complete diet with macro and micro nutrients to lead a healthy life. Lack of macro nutrients (calories and proteins) is termed as raw hunger while micro nutrients (vitamins, iron, iodine, zinc, calcium etc.) is known as hidden hunger. Our concern here is with raw hunger. Three anthropometric measurements are generally used in this perspective. These are height-for-age, weight-for-age and weight-for-height. An important measure of nutritional levels obtained is the percentage of underweight children. It is also included in measures of poverty such as the Human Poverty Index- a deprivation index developed by UNDP. 65

22 Poor and inadequate nutrition manifests itself in low weight of children and is a reflection of the existence of poverty. As per the Human Development Report 2005 income poverty is closely related to hunger and malnutrition. Malnutrition weakens the immune system, increasing the risk of ill health, which in turn aggravates malnutrition. Moderately underweight children register four times more than the well-nourished children in the death toll from infectious diseases. National Family Health Survey (NFHS) in its several rounds has estimated the percentage of underweight children in India on a state - wise basis. Just after commencement of economic reforms, nearly half of the children (47.9%) were underweight according to data of NFHS-1( ). This has come down during two successive surveys to 42.7 and 40.4 in NFHS-2 and NFHS-3 respectively at all-india level. But there are broad inter-states disparities. The percentages obtained in Bihar, Madhya Pradesh, Uttar Pradesh and Orissa are significantly higher than elsewhere. 66

23 Table 3.7:- Underweight Children in Major Indian States (Figures are in percentage) S.N STATES NFHS-1 NFHS-2 NFHS-3 1*2 2*3 3*1 1 Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal INDIA Source: NFHS-1, 2&3. 1*2: percentage change between NFHS-1 & 2; 2*3: percentage change between NFHS-2 & 3; 3*1: percentage change between NFHS 3 &1. After fifteen years of reform, the data of NFHS-3 show that the highest percentage of underweight children is in Madhya Pradesh at 57.9 percent followed by Bihar (55%), Uttar Pradesh (41.5%), Gujarat (41.3%), Orissa (39.4%) and Haryana (38.2%). The situation in Gujarat and Haryana is surprising as their economic status is far better than the BIMARU states. This is so because factors responsible for malnutrition are other than poverty and include the age of marriage, age of women at first child birth, prevalence of early breast feeding of children and awareness among women about health (K. R. G. Nair, 2007). Around one third of children born in India are underweight at the time of birth, and an important reason for this is early teenage pregnancies. Measures to increase age of women at the time of their first child birth would help in lessening this 67

24 intergenerational transfer of malnourishment from mother to child (K. R. G. Nair, 2007 and Gragnolati, et.al, 2006). There is a continuous decline in the percentage change of underweight children in almost all the states as evident from Table 3.7 but the rate of decline varies from one state to another. Maximum reduction in underweight children has taken place in Punjab (-38.09%), followed by Tamil Nadu (-22.6%), Andhra Pradesh (-20.27%) and Assam (-19.95%) during the early reform period spread over to covering two surveys NFHS-1 and NFHS-2. Orissa and Rajasthan have registered an upward trend. Later on during the period of last two surveys NFHS-2 and NFHS-3, performance of Maharashtra (-27.46%) is the best followed by Tamil Nadu (-17.78%), West Bengal (-17%), Karnataka (-13.99), Uttar Pradesh (-13.72) and Andhra Pradesh (-12.87%). Percentage reduction of underweight children in these states is above the national average of percent. It is distressing that in some states percentage of underweight children actually increased between NFHS-2 and NFHS-3, such as in Haryana (+27.76%), Madhya Pradesh (+13.98%) and Bihar (+5.36%). If we look at the overall post reform period from to the percentage reduction is only percent, varying from percent in Punjab, percent in Tamil Nadu, percent in Maharashtra, and percent in Andhra Pradesh, to 6.30 percent in Bihar, and 3.27 percent in Gujarat. There are two states namely Madhya Pradesh and Haryana where percentage of underweight children actually increased, by +0.9 percent in Madhya Pradesh and much higher at percent in Haryana which is not commensurate with the overall economic performance in the latter state during post reform era. To meet the challenges posed by malnutrition ICDS (Integrated Child Development Service) a popular flagship Programme is run by the Ministry of Women and Child Development. In case of malnourished children Rs. 4 per child and in the case of severely malnourished children Rs. 6 per child is sanctioned as 68

25 weighted cost. It is one of the world s largest programs providing for an integrated package of services for the holistic development of the child. Besides this nutritional support and referral medical services are available to pregnant and lactating mothers and adolescent girls at Anganwadis. The services provided under the ICDS schemes are: supplementary nutrition, non-formal pre-school education, immunization, health checkup, referral services and nutrition and health education (V. Mohan Rao 2010). Maternal Mortality Rate (MMR) Reproductive health indicators reflect gross neglect of women s health. Women s health in terms of maternal mortality continues to be a serious public health problem in developing countries and its reduction has been emphasized as one of the major Millennium Development Goals. WHO estimates that more than 5,00,000 women die every year due to pregnancy related causes worldwide (leaving over a million motherless children) and almost all of these deaths occur in the developing countries. As mentioned in the very beginning of this chapter MMR in India is remarkably high accounting for almost 20 percent of global maternal deaths (Table 3.1). It is only four in Australia and Germany, five in Switzerland but more than hundred times in India (450) as per World Health Statistics The principal risk factors for dying from pregnancy-related causes are: no attendance at ante-natal care, too great a distance between the home and the nearest hospital facility, home delivery, belonging to specific ethnic/religious group, and delivery assistance from family members and traditional birth attendance (Margreet M. Oosterbaan, WHO, 1995.). Moreover, it has also been observed that simply improving access to trained health attendant during delivery cannot ensure reduction in maternal mortality. This has to be backed up by the provision of emergency obstetric care (EmOC) facility to save the lives of women 69

26 who develop complications during pregnancy and delivery (Ramesh Bhat, et.al, IIM, Ahmedabad, 2007). As per Annual Health Report 2010, Ministry of Health and Family Welfare, Government of India, promotion of maternal and child health has been one of the most important objectives of the Family Welfare Programme in India. Under the National Rural Health Mission ( ) and the Reproductive and Child Health Programme Phase-II ( ), Government of India is actively pursuing the goals of reduction in maternal mortality by focusing on four major strategies of (a) essential obstetric and new born care for all, (b) skilled attendance at every birth, (c) emergency obstetric care (EmOC) for those having complications and (d) referral services. The National Population Policy-2000 and National Health Policy-2002 have set the goal of reducing MMR to less than 100 per 100,000 live births by the year Table 3.8:- Maternal Mortality Rate in Major Indian States S.N. STATES Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Andhra Pradesh Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal INDIA Source: Family Welfare Statistics 2009 and SRS estimates

27 Table 3.9 shows that MMR has declined to 254 in and 212 in but this figure is also very high. If we go by past experience the target of 100 by 2010 seems doubtful and unlikely to be achieved. Over 67,000 women in India continue to die of pregnancy related causes every year. Condition of maternal health is worst in Uttar Pradesh where the highest MMR (539) was recorded in which reduced slightly to 517 in Subsequently a considerable reduction in maternal mortality to 440 in and 359 in took place in Uttar Pradesh. It was replaced by Assam as the state with the highest MMR. Kerala maintained its first rank in terms of maternal health and its figure remained lowest during all four surveys. There can be seen a great divide between northern and southern states; it is almost five times between the best performing state, Kerala (81) and the worst performer, Assam (390). Kerala is followed by Tamil Nadu (97), Maharashtra (104) and Andhra Pradesh (134). On the other 450 Fig 3.5 : MMR in India MMR Source: Based on Table 3.8 end northern states figures are above the national average 390 in Assam, 359 in Uttar Pradesh, 318 in Rajasthan and 269 in Madhya Pradesh. But the performance of Punjab, economically one of the better performing states is not in 71

28 commensurate with its economic situation. It was 177 in and increased to 178 in , 192 in , reducing subsequently to 172 in Overall health status of women in BIMA RU states in terms of MMR leaves much to be desired Fig 3.6 : MMR in Major Indian States in Source: Based on Table 3.8 Institutional and Safe Delivery In India prevalence of high percentage of illiteracy, and more importantly a society bound by traditions and customs, almost half of the delivery takes place at home at the hands of the local Dai (not always well trained) or female members of the family, in most unhygienic conditions. With no antenatal check-ups by trained medical personnel, problems like hypertension and high blood sugar, anaemia etc. go undetected. Diagnostic tools like ultrasound which can detect abnormalities are also not availed of. Monitoring of pregnancy does not take place. This leads to various complications at the time of child-birth putting both the mother and the new-born at risk, often leading to death of either or both; consequently poor birth outcomes, resulting in low-weight and premature babies. Delivery in hospitals/clinics can eliminate or at least reduce these risks. A recent survey 72

29 conducted in three districts of West Bengal shows that low access to health facilities was a major deterrent in increasing institutional deliveries in the state. District hospitals and sub-divisional/ sub-general hospitals alone accounted for more than 60 percent of deliveries. This indicates that rural women have to travel large distances (14 to 24 km.) to access an institution for delivery (Tapas Sen and Amarnath, H.K. et.al; 2009). Data presented in Table 3.9 shows that cases of institutional deliveries increased during three successive National Family Health Surveys covering a period of fifteen years, yet it was low at less than 50 percent at the national level. There is again a big gap in the performance of northern and southern Indian states. Southern states like Kerala, Tamil Nadu, Karnataka, Goa, Andhra Pradesh, union territory of Pondicherry etc. are states which historically have been under western influence for a long time. Hence, there is less resistance to modern influences, techniques and culture while states like Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh and Orissa are more tradition bound and resistant to modern influence and change. Performance of southern states is far better than the northern BIMARU states in this regard. Figures in the table show that as per NFHS-3 data institutional delivery in the less developed states of Assam, Bihar, Uttar Pradesh, Madhya Pradesh and Orissa varies between 20 to 35 percent only while in the more developed states it is 64.7 percent in Karnataka and Maharashtra, 87.8 percent in Tamil Nadu, and the highest 99.3 percent in Kerala. Kerala maintained its first rank in all three surveys, with institutional delivery almost hundred percent (NFHS-3). Unlike other aspects of development, institutional delivery in Haryana, Punjab and Gujarat is low. Almost same situation is found in the case of safe delivery as presented in the Table. Percentage of safe delivery is higher than institutional delivery in all states. Kerala once again with other southern states leads over Assam and the northern BIMARU states. 73

30 Table 3.9:- Percentage of Institutional and Safe Delivery in Major Indian States S.N. STATES Institutional Delivery Safe Delivery NFHS1 NFHS2 NFHS3 NFHS1 NFHS2 NFHS3 1 Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal INDIA Source: NFHS-1, 2 & 3 The problem of safe and institutional deliveries is much more in rural areas than in urban ones. In rural areas there are no hospitals where deliveries can take place. Health centres are ill equipped with resources, personnel as well as infrastructure (equipment, drugs, power supply). The problem is compounded with inadequate transport, kutcha roads etc. Deliveries, by and large take place at home in unhygienic conditions. The dais- trained and untrained, are ill equipped to deal with emergencies. As per Table 3.10, institutional delivery in rural areas varies from 11.7 percent (the lowest) in Uttar Pradesh to 91.5 percent (the highest) in Kerala. On the other hand percentage of institutional delivery in urban areas 74