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Inclusive growth: the missing ingredient in Bihar’s success story

4 Feb

Shireen Vakil Miller in THE HINDU FEBRUARY 4, 2010

Despite staggering economic growth, Bihar has one of the highest rates of child mortality in India.

Bihar has been in the news recently for recording an average growth rate of 11.3 per cent for the period between 2004 and 2009. Much has been written about the quality of governance and the improved state of roads. This is indeed commendable, and no mean achievement, for a State that had virtually become a “development outcast”. I was pleasantly surprised to note on a recent trip to Bihar the great improvement made in providing more schools and notably, a huge effort to tackle the complex issue of child labour.

The script for Bihar’s success story is incomplete, however. The State has the dubious distinction of having one of the highest rates of child mortality in India. Out of every 1,000 children born in Bihar, 85 will not live to see their fifth birthday (according to the third National Family Health Survey). The deaths of a third of these children are associated with malnutrition. In fact, the Citizen’s Alliance against Malnutrition states that over 58 per cent of children in Bihar are malnourished. And the State, despite spending crores of rupees on improving the state of the roads, has failed to utilise the funds allotted to it under the Integrated Child Development Services (ICDS) which is mandated with tackling under-nutrition among children under six years of age.



(The anomaly between impressive economic growth and appalling rates of malnourishment is not peculiar to Bihar.The country as a whole records malnourishment rates that do not reflect the economic growth. A scene in Madhya Pradesh.)

The anomaly between impressive economic growth and the appalling rates of child mortality and underweight children is not peculiar to Bihar. The country as a whole has recorded an impressive economic growth (real GDP per capita grew by 3.95 per cent per year between 1980 and 2005). Yet, the percentage of underweight children under 3 went down by just six per cent from 52 per cent in 1992-93 to 46 per cent in 2005-06. Evidence suggests that for every 3-4 per cent increase in per capita income, underweight rate should decline by one per cent. This has not been the case in India.

At the present rate of progress, India will reach the Millennium Development Goal 1 target on eradicating extreme hunger only by 2043.

As we move to greater economic growth rates, the challenge we face is to make this growth more inclusive, ensuring that all of us, especially the most disadvantaged and marginalised groups benefit from this economic growth. Children especially must see the benefits of this growth now if we are to sustain economic growth in the future.

The reality in 2010 is that almost 50 per cent of India’s children are malnourished. In the nation’s capital alone, 42.2 per cent of children under five are stunted and a shocking 26.1 per cent are underweight.

Malnutrition stunts physical, mental and cognitive growth and makes children more susceptible to respiratory and diarrhoeal illnesses. Malnourished children are more likely to die as a result of common and easily preventable childhood diseases than those who are adequately nourished. According to a UNICEF report, 1.95 million children below the age of five die annually in India mainly from preventable causes that are directly or indirectly attributable to malnutrition. The children who survive the ravages of malnutrition are more vulnerable to infection, do not reach their full height potential and experience impaired cognitive development. This means they do less well in school, earn less as adults and contribute less to the economy.

While we have impressive policies and schemes such as the ICDS, these have not made a significant impact. The ICDS needs to reach the poorest and most excluded groups who need it the most, both in rural and urban areas. This is not the case however. Only 28.4 pc of children under six are able to access services provided by an anganwadi centre. Just in Delhi alone, for example, only 8.4 per cent of children under six have accessed an anganwadi centre.

India spends less than five per cent of the annual budget on children. The 2009-10 Union Budget earmarked 4.15 per cent on children! This, in a country where 447 million people are aged 18 and below! Of the total budgetary allocation on children, a mere 11.1 per cent is for child health schemes.

It is the poorest children in the poorest communities who experience much more malnutrition than their better-off counterparts. And yet, existing national nutrition plans barely tackle the socio-economic causes of the problem.

There is an assumption that economic growth will solve the problem of malnutrition but, in fact, economic growth often fails to reduce poverty. The economic causes of malnutrition are set to deepen: food prices remain high and are expected to stay high, the economic downturn is pushing millions more into poverty and climate change is causing an increasing number of extreme climatic events that devastate livelihoods and lead to destitution.

We have good policies and schemes in place. The time has come to implement these and more importantly, monitor their implementation. A task group on nutrition was set up by the Prime Minister’s Office in October 2008 but it appears that it has not yet met. We know which districts are hardest hit, we need to reach those districts and build the capacities of local health and nutrition workers to deliver effective services. We need to ensure greater convergence between the ministries that have responsibility for tackling malnutrition so that we have integrated plans at the district and panchayat levels to reach the communities that need it the most.

In the third century BC, Patna was the greatest city in India; the seat of the Maurya dynasty with Emperor Ashoka at the helm. Ashoka was arguably one of our greatest and most forward thinking leaders, who believed in inclusive development. If Bihar pays attention to social development ensuring that its economic growth benefits its most excluded groups and minorities, it may yet again lead the way for other States.

(Shireen Vakil Miller is Director of Advocacy with Save the Children)


Death by drought and more

26 Dec


In drought-hit Bundelkhand, corruption is not just a tired cliché from a bad Bollywood movie, it is a life-threatening human rights emergency.

Corruption exacerbates poverty in Bundelkhand…the money earmarked for NREGA is being cleverly pocketed by village council leaders and unscrupulous officials.

Sesame shoots in the fields of Bundelkhand make it seem there is no drought. But the crops are stunted and useless.

Bundelkhand, which comprises six districts in Madhya Pradesh and seven in Uttar Pradesh, has had a drought for seven years except the last one. At the peak of farming season this year, rains were half of normal.

In between Mahoba and Chhattarpur districts lies Khajuraho airport. Swanky roads and five-star hotels dot the tourist destination and belie the silent human catastrophe unfolding just kilometres away. Drought may have ravaged the fields but State apathy and the brazenly corrupt officials are more brutal.

Multitudes throng us in every village we visited. Willing to clutch at straws in their desperation, their voices would go: “Have you written about my mentally challenged son?”… “I applied for old age pension long back.” … “I have been anxiously waiting for my widow pension card.” “They haven’t paid my NREGA wages.”

Inaccessible healthcare

Eighty-five-year old Motiya, slumped on a cot, gives out a heartrending cry as we step into his dingy hut. His wife sleeps nearby. Both have had fever for four days. Motiya has bed sores and can barely move. Villagers say that often worms crawl out of his mouth. “The other day my father defecated in bed. I cleaned him up. Where is the money to get them medicines?” asks Motiya’s son Chaniya, a daily-wage labourer in Seelaun village of Chhattarpur. The government hospital is 25 km away, and rarely stocks medicines.

Cattle, abandoned on highways, and the old are among the causalities of this drought as families flee a disaster. In village after village, elders have in vain applied for pension that provides Rs. 275 a month. Often the local officials demand bribes from penniless petitioners. Also, families who own more than five acres of land are not classified as being Below Poverty Line or BPL. It does not bother the officials that the drought has rendered income from land inadequate.

Dalit woman Jhharokhan Paswan in Chandauli village of Mahoba could not complete the last rites of her husband who died of grinding hunger last year. “My blind husband died a slow painful death,” she says. A tattered sari covers her old body. Had the grain bank supported by ActionAid partner organisation Kriti Shodh Sansthan not given her 40 kg of wheat, she would have had to go on begging. Last month, she threw a dried-up chapatti on the district collector’s table. He promised to mark her as BPL. And she is still waiting.

Against the wall

Despair is all too common in Bundelkhand. Rani’s husband Priti Pal Singh jumped into a well in Chandauli three months back. Their three acre land had stopped yielding, and he couldn’t repay a loan of Rs. 80,000 he took for his daughter’s wedding. Rani has asked for a job but the sarpanch argues over how an upper caste woman can go to work! Though only slightly better-off, villagers have been generous enough to offer food. “I dread to think what will happen if they stop. Sometimes I too feel like jumping into the well,” her voice falters. Nights spent listening to her children crying out of hunger are still fresh in her memory.

Corruption exacerbates poverty in Bundelkhand. The running of the National Rural Employment Guarantee Act or NREGA is an example. The scheme that promises 100 days’ work could have been a lifeline for rural families. But the money earmarked for it is being cleverly pocketed by formidable village council leaders and unscrupulous officials.

NREGA wages have not been paid to 200 people of Akauna village in Chhattarpur for eight months. Officials have yet to answer queries posed in March under the Right to Information Act on how many villagers got jobs in Akauna. Eighty villagers in Seelaun are yet to get remuneration. In village after village, inhabitants underline that those who are close to the panchayat leaders get NREGA work or a BPL tag.

Village council heads often refuse to accept written applications. Hence, little evidence remains of how many rural folk sought jobs and how many got them. The Afforestation Mega Campaign in Uttar Pradesh — a scheme worth Rs. 1582 million — was launched last year to boost the NREGA in drought-prone Bundelkhand. Mahoba was supposed to get 10 million saplings. “Only 40 per cent of the saplings have been sown, the rest are on paper,” reveals Manoj Kumar of Kriti Shodh Samsthan.

Six rivers have gone waterless in Mahoba. So, without food, water and jobs, people have no choice but to migrate to metropolises. Chhattarpur Collector E. Ramesh Kumar was quoted in The Hindudated September 5, “This is not distress migration.” He attributed the movement to seeking better opportunities.

“In Delhi we live in plastic huts next to roads. At times we fall from high rises doing construction work. Does that sound like a better opportunity?” asks Ramlal.

Ramesh Kumar, in a telephonic exchange, says he is only a few months old in Chhattarpur. And that “some shortcomings” perhaps do affect some villages.

Great divide

The distance between Bundelkhand’s poor and their political leaders is huge. Asked whether elected representatives have visited them ever since the polls, there are laughs all around in Chandauli.

Even as Finance Minister Pranab Mukherjee has said the country has enough food stored to prevent high inflation, hunger is widespread in Bundelkhand.

Those who are entitled to subsidised grains in Seelaun assert the full quota of 35 kg hardly ever reaches them. Numerous people across villages wryly confess that their meals consist of chapattis and salt. Bangle seller Ramesh Lakhera says, “I remember the taste of dal.” Lakhera’s earnings have plunged, and lentils cost a steep Rs. 90 per kg.

“Nearly 65 per cent of families are malnourished in 500 villages of Mahoba,” says Manoj Kumar.

In Banda district, 48 per cent of the children aged three or less are underfed. Government records reveal there are 130,000 malnourished children in Chhattarpur and 600 in Tikamgarh district. However grim these statistics may be, there’s more.

“We have discovered 40 undernourished children in Kandva village of Tikamgarh who have not been mentioned in anganwadi registers. Ten are severely malnourished,” says Narendra Sharma of ActionAid. Government-supported anganwadis supposedly provide nutritious food to toddlers and pregnant women.

In Mahoba, 165 anganwadis don’t function at all.

Denied rights

Rural families in Bundelkhand are routinely denied their right to health and life as they are often unable to access lifesaving treatment. The health system is seldom held to account. “Lately we rushed a young man bitten by a snake to the nearest health centre. They sent us away. He died on the way to a bigger hospital,” says Lallu Khan of Mahoba. Last year five children died of diarrhoea in Seelaun. Ramkali Ahirwar from Pratappura says bitterly, “We go to doctors when we are about to collapse. We die at home everyday.”

Asked whether the Uttar Pradesh government headed by a Dalit leader has made any difference to their lives, Phulia Rani, a Dalit woman in Chandauli, says “No.”

Meanwhile, the state website proudly announces “the historic decisions including increase in the budget for the welfare of Dalits and tribals by 41per cent”.

The author is a development journalist based in New Delhi and Hyderabad.

Women’s health need for gender justice

29 Jul

K.S. Jacobin  The Hindu

The poorer health indices for girls and women mandate a social revolution which not only provides equal opportunities but also focusses on achieving equal outcomes.

There has been significant improvement in the health, education and employment status of women in India over time. Yet, health indices for girls and women compare much less favourably with those for boys and men. Successive governments have recognised the inequalities in health indices and have implemented many schemes to improve women’s health. Many programmes, including the National Rural Health Mission, provide care for women, especially during pregnancy and deliv ery and after childbirth. Family planning programmes offer services related to contraception for women, improving their health. Many programmes aimed at the general population also impact women’s health.

Nevertheless, community programmes have contended and shown that economic development results in greater improvement in women’s health than direct medical interventions alone. Consequently, education and employment for women became core features of such programmes. The national campaigns on education (Sarva Shiksha Abhiyan) and employment (National Rural Employment Guarantee Scheme) have a specific focus on girls and women. Self-help groups and micro-credit initiatives also increase skill levels, provide alternative livelihoods and generate income and assets for women.

Indicators of the status of women: A detailed analysis of national data shows some reduction in maternal deaths and an improvement in many indices related to infant health. However, there are gender differentials in many indices, with data disaggregated by gender, showing far greater improvement for males than for females. The perinatal mortality rate, infant mortality rate and under-5 mortality rate are poorer for girls. There is evidence of foeticide and infanticide of girls. They are often malnourished and brought to hospital later in their course of illnesses than boys. The birth of a girl and failure to conceive a boy are significant risk factors for post-partum depression. The suicide rate among young women is about three times that seen for young men. Violence against women and girls is common.

Women and girls have lower adult literacy rates, school enrolment and attendance figures. The long walk to school with its associated fear for physical safety, lack of toilets at schools, the small number of women teachers and the second class status of the girl child contribute to these lower rates.

Socially devalued

Women’s work at home, because of its invisibility, is rarely recognised, although they work for roughly twice as many hours as men. Technological progress in agriculture and the shift from subsistence to a market economy have had a dramatic negative impact on women, cutting them out of employment as many women are unskilled and lack education. Child labour among girls and unequal wages for women for similar work are common. Working women of all segments of society face various forms of discrimination, including sexual harassment. Women’s work is also socially devalued and autonomy in decision-making related to their life rarely exists for the majority of women.

While gender equality and justice are among the United Nations Millennium Development Goals, their implementation in India has been slow and patchy. Issues related to gender equality are not adequately mainstreamed for India. Discussion of gender is usually confined to Goals 3 and 5, which are gender equality and maternal mortality. Women are cast only in the role of victims, rather than as equal partners in development. The social, economic and cultural contexts, the most significant predictors of women’s health, are barely mentioned.

Health justification for gender justice: Gender injustice is often viewed in the socio-cultural context and usually in terms of social outcomes. However, analysis of health data clearly documents the importance of gender and its impact on women’s health. Women are the largest discriminated group in India. This results not just in adverse social outcomes but also unfavourable health outcomes.

Social determinants have a significant impact on the health of girls and women. Viewing the health of women in general as an individual or medical issue and suggesting individual medical interventions reflects a poor understanding of issues. Reducing public health related to women to a biomedical perspective is a major error of the public health movement. Social interventions should form the core of all health and prevention programmes as individual medical interventions have little impact on population indices which require population interventions.

Barriers to scaling up interventions for women: The major barrier to mainstreaming gender justice and to scaling up effective interventions is gender inequality based on socio-cultural issues. The systematic discrimination of girls and women based on culture and tradition needs to be tackled if interventions have to work. Although the short time-lag between the (absence of) medical intervention and the health outcomes stand out as causal, it is the longer latent period and the more hazy but ubiquitous and dominant relationship between gender and culture which have a major impact on the outcome. Failure to recognise this relationship and refusal to tackle these issues result in poorer health standards of women. Tradition and culture maintain their stranglehold on gender inequality. Debates on gender equality are often reduced to talking about culture, tradition and religion. The prevalent patriarchal framework places an ideological bar on the discussion of alternative approaches to achieve gender justice for girls and women.

The way forward

While the Constitution guarantees equality for women, legal protection has little effect in the face of the prevailing culture. Many researchers and activists are no longer convinced that we can succeed in improving women’s health or status unless society attempts to confront its gender bias openly. For too long we have been refusing to discuss women’s issues explicitly with society. It would appear that nothing short of a social revolution would bring about an improvement in the health of Indian women.

Many approaches have been suggested. They will all need to include approaches which examine, understand and confront gender discrimination in social, cultural and religious spheres. Legal solutions enforcing gender justice are equally necessary, and monitoring the implementation of legislation is mandatory.

The right to health is a fundamental right and the poorer health indices of half the population is a cause for concern. There is an urgent need for a detailed re-examination of public health statistics for India, disaggregated by gender and region. There is an equally vital need to set up policies and programmes to counter adverse trends. The evidence from such disaggregated data should be used to set targets for action. Progress has to be visible and benchmarks have to be set high.

The magnitude of the inequality related to health is often downplayed even within medical circles. The second-class status of women in Indian society persists and women’s perspectives continue to be missing, marginalised or ignored. There is a definite need to engage communities and the population as a whole in a debate to challenge traditional stereotypes and accepted social norms. Programmes to achieve gender equality should not only focus on the provision of equal or greater opportunities for women. They should also concentrate on achieving equality in gender outcomes within a reasonable time frame. Outcomes in general, and health outcomes in particular, are measurable with a much greater degree of accuracy than opportunities.

All plans and projects within community programmes should be assessed using the “gender lens” in order to achieve gender justice for women. These programmes will have to cover the social context of home, school, workplace, law and politics in order to improve women’s health. There is a need to challenge the normalisation of gender discrimination in India. The focus should be on public health approaches to change social and cultural perspectives with the aim of primary prevention of discrimination while continuing medical interventions for early diagnosis and management of the medical consequences. There is a need for aggressive gender justice in order that women in India achieve equal health and social status in the foreseeable future.

(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)

Miles to go

6 Nov

The third National Family Health Survey has immense significance for policymaking in health, nutrition and gender issues.


The report of the third National Family Health Survey (NFHS-3), released in the second week of October, has immense significance for policymakers in health, nutrition, education and gender issues. The NFHS-3 (2005-06) is significant in that it has gone beyond the parameters set by the two preceding surveys, in 1998-99 and 1992-93. And for the first time, the survey interviewed all women (ever-married and never-married) in the 15-49 age group and all men in the 15-54 age group. In earlier surveys, only ever-married women were chosen for individual interviews. The NFHS-3 sample covered 109,041 households, 124,385 women and 74,369 men in the 29 States. According to G.C. Chaturvedi, Director of the National Rural Health Mission (NRHM), the findings of the NFHS-3 are an important benchmark for the NRHM.

The NFHS-3 included testing of the adult population in a community-based survey, the first of its kind, to estimate HIV (human immunodeficiency virus) prevalence in the general population. Surprisingly, the figures dipped sharply, forcing the government to revise its national figures.

The NFHS-3 essentially throws light on the state of India’s health, behavioural attitudes, fertility and mortality. In another first, it provides information on perinatal mortality (stillbirths and early infant deaths), male involvement in the use of health and family welfare services, adolescent reproductive health, family life, education, high-risk sexual behaviour and awareness of tuberculosis.

The shocking parts of the report contain implications for the girl child. India continues to be in the stranglehold of a very strong son preference; the presence or absence of a male child in the family dictates family planning. “Many women prefer not to use contraception and to continue childbearing until they have at least one son,” says the report.

The survey drew out responses of women to domestic violence. More than one-third of the women in the 15-49 age group had undergone physical violence; and 9 per cent of the women in the same age group, some form of sexual violence. Only 6 per cent of women were subjected to domestic violence in Himachal Pradesh, but the figure was 40 per cent or more in Rajasthan and Madhya Pradesh and 56 per cent in Bihar.

As much as 37 per cent of ever-married women had experienced violence at the hands of their spouses and 16 per cent, emotional violence. The survey found that 1 per cent of the women had initiated violence against their husbands; evidently, that was in reaction to violence perpetrated on them earlier.

Slapping was the most common form of violence from husbands; 62 per cent of the women reported physical or sexual violence in the first two years of their marriage. Only one out of four abused women sought help to end the violence. A large majority of them chose to bear it in silence. Alarmingly, the report said that more than half the women in India believed that it was justifiable for a husband to beat his wife. The acceptance of wife-beating was found to be high in Manipur and low in Himachal Pradesh and Uttarakhand.

The good news in the survey is that women waited longer to marry and fertility was on the decline. As a telling example, a domestic worker based in Delhi said she was married off at 15 in her village in Allahabad, conceived at the age of 16 and bore seven children in 14 years. But she was determined that none of her daughters were going to be married before 22. She got her eldest daughter married at 24 and ensured that at least one of her daughters completed college. Such instances are common in urban centres, particularly the metros.

But the bad news is that more than half the women were getting married off before the minimum age of 18. Urban women waited two years longer than their rural counterparts for marriage; the median age at marriage among urban women aged between 20 and 29 was 18.8 years while that of rural women in the same age group was 16.4 years. This, in turn, had an impact on maternal mortality as well as infant and perinatal mortality.

The survey has other revealing facts. For instance, the fertility rate has come down from 2.9 per woman in the NFHS-2 to 2.7 per woman. However, this is seldom appreciated by policymakers, who often speak of a population boom in the country.

Recently, the Supreme Court suggested that women with more than two children should be excluded from the Janani Suraksha Yojana (JSY), or scheme for safe motherhood, which now covers all Below Poverty Line (BPL) mothers. Health Ministry sources told Frontline that they were yet to respond to the suggestion. Initially, the JSY was confined to families with only two children; but when sections among the Left and other health activists pointed out the inherent injustice in the scheme, it was made accessible to all BPL mothers.

Though the fertility rate has come down, replacement levels (two children for two parents) are yet to be reached. The NFHS-3 brings out the fact that the desire to stop childbearing has increased rapidly with the number of living children. Only 3 per cent of women with no living children said they did not want any more children, compared with 83 per cent of women with two children and 90 per cent of women with three children.

The desire to stop childbearing increased with education. The fertility rate decreased sharply by the household’s wealth index as well, from 3.9 children for women living in households in the lowest wealth quintile to 1.8 children for those living in households in the highest wealth quintile. Ninety per cent of women, the survey found, wanted to stop childbearing if both their children were sons, 87 per cent wanted to stop if they had one son and one daughter.

The proportion of women with two daughters and no sons and who wanted no additional children increased from 37 per cent in the NFHS-2 to 61 per cent in the NFHS-3. But this does not indicate that son preference has gone down or that the women themselves are in a position to decide the ideal family size or the number of sons or daughters they would like to have. The motivating reason for wanting a daughter is more religious – fulfilling of the obligation of kanyadaan (giving a daughter away in marriage), which is supposed to enable parents to acquire the highest level of merit or punya.

Knowledge of contraception was found to be almost universal, but more women and men knew about female sterilisation than male sterilisation though the latter is considered to be safer among the terminal methods of contraception. Ninety-three per cent of the men knew about condoms as opposed to 74 per cent of women.

Significantly, even the choice of contraception was influenced by son preference. At 67 per cent, the adoption rate of female sterilisation was the highest among women with two sons. Also, women who had more sons were found to be more likely to be persuaded to go in for contraception. Wealth also influenced contraceptive prevalence; it was almost 68 per cent among women in the highest wealth quintile and 42 per cent in the lowest wealth quintile.

For health activists and women’s organisations who have been crying hoarse regarding informed choices, the survey has dismal news. Only one-third of the women contraceptive users said they were aware of the side effects while only one quarter were informed about what to do in case of any side effects. It was only in Tamil Nadu and Delhi that more than half the women knew what to do in case of side effects.

The survey has also confirmed the worst suspicions of health activists regarding the safety of injectable contraceptives. The NFHS-3 found that among the spacing methods, the discontinuation rates were the highest for injectables (53 per cent), followed by pills and male condoms. For pills, intrauterine devices (IUDs) and injectables, the most common reason for discontinuation were concerns about side effects or health problems.

Another important aspect of the survey relates to child sex ratio, which has dipped since Census 2001. Though the NFHS does not do a head count unlike the Registrar General’s office, its findings regarding the child sex ratio from the sample population are not likely to be very different from the child sex ratio figures that will emerge in the Census 2011.

In the NFHS-3, the sex ratio of the population in the 0-6 age group is 918 girls for every 1,000 boys; this was 927 girls per 1,000 boys according to Census 2001. The under-seven sex ratio in urban areas is the same as in Census 2001, but a decline was seen in rural areas.

On nutritional, maternal and child health indicators, there has not been much improvement. Perinatal mortality, which was explored for the first time, turned out to be rather high at 49 deaths for every 1,000 pregnancies. Such mortality was very high for young mothers and in first pregnancies. It is highest for the rural poor uneducated mother.

While the infant mortality rate (IMR) has gone down from 68 deaths to 57 per 1,000 live births, it is still very high. It is estimated that one in 18 children dies within the first year of birth and more than one in 13 dies before the age of five.

Children of the Scheduled Castes and the Scheduled Tribes are at a greater risk. Even here, there is a gender bias: 79 girls under five die before the fifth birthday compared with 70 boys per 1,000 births. Uttar Pradesh has the highest IMR in the country while Kerala and Goa fall in the category of States with the lowest IMR.

As for maternal health, only 44 per cent of women started antenatal care in the first trimester of pregnancy. The percentage of women getting more than three antenatal visits by the auxiliary nurse midwife (ANM) ranged from 17 per cent in Bihar and Uttar Pradesh to 90 per cent in Kerala, Goa and Tamil Nadu.

The quality of antenatal care is also a major issue. The iron and folic acid coverage for expectant mothers was lower than the national average in Nagaland, Bihar, Arunachal Pradesh, Jharkhand, Uttar Pradesh and Meghalaya. The percentage of women who received two or more tetanus toxoid injections ranged from 40 per cent in these States to 90 per cent or higher in Delhi, West Bengal and Tamil Nadu.

“The thrust of the NRHM is on the mother and child. The southern States are almost on the threshold of replacement level fertility while the northern States have still a long way to go. Our attempt is to get the IMR levels to 30 per 1,000 live births. There is a lot of demand for institutional deliveries but the supply side is weak,” said Chaturvedi. Of the 22,000 sub-centres in Uttar Pradesh, he said, only 7,000 had buildings.

Manpower is another concern. Between 1947 and 1997, there were only 47,000 doctors in Uttar Pradesh, in the private and public sectors taken together. The number of nurses was 30,000 less than what was recommended by the Bhore Committee. Chaturvedi felt that more than money, the motivating factor for the efficient functioning of the accredited social health activist (ASHA) was “recognition”. On the other hand, health activists argue that accredited social health activists need to be given a decent remuneration as most of them hail from poor families, and that there is need for more than just social appreciation.

The findings of the NFHS-3 underscore the need for more convergence among Ministries as it cannot be left to the Health Ministry alone to deal with what is primarily an economic issue. The survey brings out clearly which section of the population is desperately in need of health care. Health issues are not maternal health issues alone. The most commonly reported problem faced by women in terms of accessing health care was the distance to the health facility; 44 per cent of the Scheduled Tribe women reported “distance” to be a major problem.

The percentage of women who have at least one big problem in gaining access to health care declined rapidly with increasing wealth. On the other hand, the dependence on the private health sector continues to be quite high. According to the survey: “The private medical sector remains the primary source of health care for the majority of households in both urban areas (70 per cent) and rural areas (63 per cent) … overall, the private medical sector dominates health care delivery in the country and the use of private doctors and private clinics is the primary source of health care among the rich and poor alike.”

If the “Health for All” declaration, to which India was a signatory nearly 30 years ago at Alma Ata, must have any meaning, it cannot be with the majority of the population depending on the private sector, where health care is affordable to only a few. It cannot also be realisable in a situation of a declining child sex ratio, high IMR and rampant son preference.

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