chapter iii analysis of health profile of...

CHAPTER III

ANALYSIS OF HEALTH PROFILE OF INDIA

Analysis of Health Profile of India

46

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 post-

natal 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

“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


47

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, psycho-

social 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.


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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


49

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, 2005.

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 0-150. 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.


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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 1700. 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 check-

ups 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.


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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 8.7 67.7 32.3 3119 2113 77/83 3 4 4 4 25 97 40 99 N.A.

Canada 10 70.4 29.6 3673 2587 78/83 3 5 6 7 19 101 34 100 N.A.

Chile 5.3 52.7 47.3 689 363 75/81 5 8 9 16 11 6 23 100 N.A.

France 11 79.7 20.3 3420 2727 77/84 2 3 4 8 34 80 73 N.A. N.A.

Germany 10.6 76.9 23.1 3465 2664 77/82 3 4 4 4 34 80 83 100 N.A.

Japan 8.1 81.3 18.7 2581 2097 79/86 1 3 4 6 21 95 140 100 N.A.

Singapore 3.3 33.1 66.9 1536 509 78/83 1 2 3 14 15 44 32 100 N.A.

Switzerland 10.8 59.1 40.9 4179 2471 79/84 3 4 5 5 40 110 55 100 N.A.

U.K. 8.2 87.3 12.7 2815 2457 77/82 3 5 6 8 23 128 39 N.A. N.A.

U.S.A. 15.3 45.8 54.2 6719 3076 76/81 4 6 8 11 26 94 31 99 N.A.

DEVELOPING COUNTRIES

Bangladesh 3.2 31.8 68.2 37 12 63/64 36 47 61 570 3 3 3 18 51

Brazil 7.5 47.9 52.1 674 323 70/76 13 20 22 110 12 38 24 97 97

China 4.6 40.7 59.3 216 88 72/75 18 19 22 45 14 10 22 98 90

Cuba 7.7 91.6 8.4 674 617 76/81 4 5 6 45 59 74 49 100 100

Ethiopia 3.9 59.3 40.7 26 16 55/59 41 75 119 720 < 1 2 2 6 28

Indonesia 2.5 50.5 49.5 82 42 67/70 17 25 31 420 1 8 6 73 93

Iran 6.8 50.7 49.3 678 344 70/74 19 29 33 140 9 16 17 97 N.A.

Jordan 9.7 43.3 56.7 435 188 70/74 16 18 20 62 24 32 19 99 99

Kenya 4.6 47.8 52.2 67 32 53/56 34 80 121 560 1 12 14 42 88

Nigeria 3.8 29.7 70.3 59 18 48/50 47 97 189 1100 3 17 5 35 58

Sri Lanka 4.2 47.5 52.5 171 81 68/75 8 17 21 58 6 17 29 99 99

Thailand 3.5 64.5 35.3 264 170 66/74 9 6 7 110 4 28 22 97 98

INDIA 3.6 25 75 86 22 63/65 39 54 72 450 6 13 7 47 74

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.


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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


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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.


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Table 3.2:-Life expectancy at Birth in Major States

Source: Family Welfare Statistics 2009, Ministry of Health & Family Welfare.

S.N. STATES 1997-01 1998-02 1999-03 2000-04 2001-05 2006-10

Male Female Male Female Male Female Male Female Male Female Male Female

1 Andhra Pradesh 61.9 64.4 62 64.6 62.2 64.8 62.4 65 62.7 65.2 65.4 69.4

2 Assam 57.6 57.8 57.7 58.1 57.8 58.3 58 58.6 58.3 69 61.6 62.8

3 Bihar 61.1 59.3 61.4 59.5 61.6 59.7 61.8 59.9 62 60.1 67.1 66.7

4 Gujarat 62.3 64.2 62.4 64.4 62.5 64.6 62.7 64.8 62.8 65 67.2 71

5 Haryana 64.6 65.2 64.7 65.4 65 65.6 65.3 56.8 65.6 66 67.9 69.8

6 Karnataka 62.6 66 62.8 66.2 62.1 66.4 63.1 66.7 63.4 66.9 66.5 71.1

7 Kerala 70.8 76.2 70.8 75.9 70.9 76 71 76.1 71.3 76.3 72 76.8

8 Madhya Pradesh 56.7 56.4 57 56.7 57.2 56.9 57.5 57.2 57.8 57.5 62.5 63.3

9 Maharashtra 64.8 67.3 65 67.4 65.2 67.6 65.5 67.8 65.8 68.1 67.9 71.3

10 Orissa 58 58.2 58.4 58.5 58.6 58.7 58.9 58.9 59.2 59.2 62.3 74.8

11 Punjab 67.2 69.3 67.4 69.5 67.6 69.6 67.8 69.8 68.1 70.1 68.7 71.6

12 Rajasthan 60.3 61.3 60.5 61.6 60.7 61.8 60.9 62 61.2 62.2 66.1 69.2

13 Tamil Nadu 64.1 66.1 64.2 66.3 64.3 66.5 64.6 66.8 64.8 67.1 67.6 70.6

14 Uttar Pradesh 59.2 58.1 59.4 58.5 59.6 58.7 59.9 59 60.1 59.3 64 64.4

15 West Bengal 63.2 64.6 63.3 64.8 63.5 65 63.7 65.2 63.9 65.5 68.2 70.9

INDIA 61.3 63 61.6 63.3 61.8 63.5 62.1 63.7 62.3 63.9 65.8 68.1


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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 1997-2001

to 2006-10 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

(2006-10). 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.

Source: Based on Table 3.2

60

61

62

63

64

65

66

67

68

69

1997-01 1998-02 1999-03 2000-04 2001-05 2006-10

yea

rs

Fig 3.1 : Life-expectancy at Birth in India, 1997-2010

Male Female


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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.

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.

0

10

20

30

40

50

60

70

80

90

A P ASM BR GUJ HAR KAR KER MP MAH ORS PUJ RAJ TN UP WB India

yea

rs

Fig 3.2 : LEB in Major Indian States, 2006-10

Male Female


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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 11th

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 1987 1991 2001 2005 2008 CAGR

Andhra Pradesh 79 73 66 57 52 -1.75

Assam 102 81 74 68 64 -1.73

Bihar 101 69 62 61 56 -2.18

Gujarat 97 69 60 54 50 -2.35

Haryana 87 68 66 60 54 -1.83

Karnataka 75 77 58 50 45 -2.54

Kerala 28 16 11 14 12 -3.03

Madhya Pradesh 120 117 86 76 70 -2.57

Maharashtra 66 60 45 36 33 -3.17

Orissa 126 124 91 75 69 -2.89

Punjab 62 53 52 44 51 -1.50

Rajasthan 102 79 80 68 63 -1.88

Tamil Nadu 76 57 49 37 31 -3.43

Uttar Pradesh 127 97 83 73 67 -2.59

West Bengal 71 71 51 38 35 -3.40

INDIA 95 80 66 58 53 -2.52

Source: SRS (2009) Compendium of India's Fertility and Mortality Indicators 1971-2007,

Family Welfare Statistics 2009 & CAGR is taken from Annexure 3.2


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50

60

70

80

90

100

Fig. 3.3 : IMR in India, 1987-2008

IMR

The rate of fall over the study period from 1987 to 2008 calculated by the

application of CAGR is -2.52 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. -3.40 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).

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


59

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 2006 2008

Male Female Total Male Female Total

Andhra Pradesh 55 58 56 51 54 52

Assam 67 68 67 62 65 64

Bihar 58 63 60 53 58 56

Gujarat 52 54 53 49 51 50

Haryana 57 58 57 51 57 54

Karnataka 46 50 48 44 46 45

Kerala 14 16 15 10 13 12

Madhya Pradesh 72 77 74 68 72 70

Maharashtra 35 36 35 33 33 33

Orissa 73 74 73 68 70 69

Punjab 39 50 44 39 43 41

Rajasthan 65 69 67 60 65 63

Tamil Nadu 36 37 37 30 33 31

Uttar Pradesh 70 73 71 64 70 67

West Bengal 37 40 38 34 37 35

INDIA 56 59 57 52 55 53

Source: SRS (2009): Compendium of India's Fertility and Mortality Indicators 1971-2007.


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Rural and Urban IMR and its Constituents (PMR, NMR, PoMR)

The causal factors of peri-natal deaths are somewhat different from neo-

natal and post-natal deaths. It is a well-established fact that the variations in peri-

natal 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.


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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 60 37 54 44.8 16.2 37.3 40.7 10 32.6 19.8 27 21.7

Assam 68 41 66 37.3 18 35.5 35.9 17.6 34.2 32.3 23.6 31.5

Bihar 59 44 58 29.2 11.9 27.8 32.5 14.6 31.1 26.2 29.9 26.5

Gujarat 60 36 52 38.1 31.6 35.8 41.3 29.5 37.2 19.2 6.3 14.7

Haryana 60 44 55 30.9 22.9 28.7 37.9 25.1 34.4 21.8 18.6 20.9

Karnataka 52 35 47 44.2 14.7 35.1 31.9 13.4 26.1 20.5 21.2 20.7

Kerala 14 10 13 13.5 7.7 12.1 9.1 2.2 7.5 4.5 7.8 5.3

Madhya Pradesh 77 50 72 46.2 44.9 46 52 35.4 49.2 24.6 14.7 22.9

Maharashtra 41 24 34 36.9 25.3 32.2 30.7 17.8 25.5 10.7 5.8 8.7

Orissa 73 52 71 51 35.1 49.3 50.9 30.1 48.7 22.3 21.6 22.3

Punjab 47 35 43 37.6 21.2 31.8 32 23.3 28.9 15.4 11.9 14.2

Rajasthan 72 40 65 47.5 27.3 43.4 49 22.6 43.6 22.6 17.6 21.5

Tamil Nadu 38 31 35 32.7 17.8 26.5 29 15.8 23.5 9.4 15.5 11.9

Uttar Pradesh 72 51 69 49.5 23.9 45.3 50.8 31.1 47.5 21.6 19.8 21.3

West Bengal 39 29 37 32.7 20.7 30.4 29.6 19.3 27.6 8.9 9.9 9.1

INDIA 61 37 55 40.7 23.6 37 40.4 21.8 36.3 20.1 15.6 19.1

Source: SRS (2009): Compendium of India's Fertility and Mortality Indicators 1971-2007

Note: PMR: Peri-natal Mortality Rate; NMR: Neo-natal Mortality Rate; PoMR: Post-natal Mortality Rate.


62

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 1997-

98 to 212 in 2007-09 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.


63

Table 3.6:- CMR by Sex and Residence Since 1991 to 2007

Source: SRS (2009): Compendium of India's Fertility and Mortality Indicators 1971-2007

STATES

1991 2001 2007

Male Female Total

Male Female Total

Male Female Total

Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban

Andhra Pr. 23.9 16.1 22 13.3 21.3 18.1 9.1 18.2 9.3 16 17.3 8.6 16.9 8.8 14.6

Assam 35.6 13.8 31.4 10.8 32.4 24.1 9.1 25.1 13.6 23.6 17.5 10.4 20.8 9.8 18.2

Bihar 21.4 15.4 25.5 17.3 22.8 18.1 14.5 21.7 16.9 19.4 18.3 12.3 20.8 13.3 18.9

Gujarat 26.3 15.7 25.3 19.6 23.3 21.2 11.8 21.4 12 18.5 17.2 8.3 19.9 10.3 15.1

Haryana 24.3 13.5 25.5 16.2 23 16.6 14.6 24.2 17.6 19.2 15.5 11.1 18.3 11.2 15.2

Karnataka 27 12.3 27.1 13.8 23.6 19.7 7.1 18.9 9 16.2 14.9 7.8 14.1 7.5 12.1

Kerala 4.7 3.7 3.9 5 4.3 3.4 3 1.9 1.5 2.6 3.1 2.1 2.7 2.6 2.8

Madhya Pr. 46.5 23.1 51.5 24.1 44.5 27.5 14.8 34.1 14 28.1 24.9 12 27.7 13.4 23.5

Maharashtra 17.6 11.8 19 11.1 16.3 10.9 6.4 13.9 6.9 10.3 10.1 5.5 10.3 6.4 8.4

Orissa 41 16.7 41.3 16.1 39 24.4 15.6 25.8 19.2 24.4 20.8 11.4 21.6 11.9 20

Punjab 16.7 12.7 20.3 13.3 17 13.3 7.2 18.1 12.5 14.1 11.6 8.2 14.1 8.8 11.1

Rajasthan 30.5 17 35.5 24.6 30.9 24.7 14.8 27 17.8 24.3 20.5 9.8 23.7 11.9 19.5

Tamil Nadu 19.4 11.8 17.4 10.9 16.1 12.7 7.5 14.4 8.1 11.8 9.6 7.3 8.8 7.4 8.4

Uttar Pradesh 35.5 21.7 41 25.2 35.6 26.1 18.1 30.1 21.2 26.8 21.1 14.7 26 19.2 22.3

West Bengal 22.2 13 22.4 14.1 20.6 14.4 9.2 14 9.7 13.3 10.2 6.1 9.8 6.8 9.2

INDIA 28.1 15.4 30.2 16.6 26.5 20.3 10.6 22.8 11.8 19.3 17.1 9 19 10.2 16


64

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.


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

0

5

10

15

20

25

30

1990-91 2000-01 2006-07

Fig. 3.4 (a) : CMR- Male

Rural Urban

0

5

10

15

20

25

30

1990-91 2000-01 2006-07

Fig. 3.4 (b) : CMR- Female

Rural Urban


65

achieved today by north Hindi belt ( SRS 2009, Compendium of India‟s Fertility

and Mortality Indicators 1971-2007). 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 1971-2007).

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.


66

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(1992-93). 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.


67

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 42.9 34.2 29.8 -20.3 -12.9 -30.5

2 Assam 44.1 35.3 35.8 -20.0 1.4 -18.8

3 Bihar 58.7 52.2 55.0 -11.1 5.4 -6.3

4 Gujarat 42.7 41.6 41.3 -2.6 -0.7 -3.3

5 Haryana 31.0 29.9 38.2 -3.5 27.8 23.2

6 Karnataka 46.4 38.6 33.2 -16.8 -14.0 -28.5

7 Kerala 22.1 21.7 21.2 -1.8 -2.3 -4.1

8 Madhya Pradesh 57.4 50.8 57.9 -11.5 14.0 0.9

9 Maharashtra 47.3 44.8 32.5 -5.3 -27.5 -31.3

10 Orissa 50.0 50.3 39.4 0.6 -21.7 -21.2

11 Punjab 39.9 24.7 23.6 -38.1 -4.5 -40.9

12 Rajasthan 41.8 46.7 36.9 11.7 -21.0 -11.7

13 Tamil Nadu 40.7 31.5 25.9 -22.6 -17.8 -36.4

14 Uttar Pradesh 52.7 48.1 41.5 -8.7 -13.7 -21.3

15 West Bengal 53.2 45.3 37.6 -14.9 -17.0 -29.3

INDIA 47.9 42.7 40.4 -10.9 -5.4 -15.7

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


68

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 1992-93 to 1998-99 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 -5.39 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 1992-93 to 2004-05 the percentage

reduction is only 15.66 percent, varying from 40.85 percent in Punjab, 36.36

percent in Tamil Nadu, 31.28 percent in Maharashtra, and 30.53 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 +23.23

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


69

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 2009. 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


70

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 (2005-2012) and the Reproductive and Child

Health Programme Phase-II (2005-2010), 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 2010.

Table 3.8:- Maternal Mortality Rate in Major Indian States

S.N. STATES 1997-98 1999-01 2001-03 2004-06 2007-09

1 Andhra Pradesh 197 220 195 154 134

2 Assam 568 398 490 480 390

3 Bihar 531 400 371 312 261

4 Gujarat 46 202 172 160 148

5 Haryana 136 176 162 186 153

6 Karnataka 245 266 228 213 178

7 Kerala 150 149 110 95 81

8 Madhya Pradesh 441 407 379 335 269

9 Maharashtra 166 169 149 130 104

10 Andhra Pradesh 346 424 358 303 258

11 Punjab 280 177 178 192 172

12 Rajasthan 508 501 445 388 318

13 Tamil Nadu 131 167 134 111 97

14 Uttar Pradesh 606 539 517 440 359

15 West Bengal 303 218 194 141 145

INDIA 398 327 301 254 212

Source: Family Welfare Statistics 2009 and SRS estimates 2010.


71

Table 3.9 shows that MMR has declined to 254 in 2004-06 and 212 in

2007-09 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 1999-2001 which reduced slightly to 517 in 2001-03. Subsequently a

considerable reduction in maternal mortality to 440 in 2004-06 and 359 in 2007-09

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


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

398

327

301

254

212

200

250

300

350

400

450

1997-98 1999-01 2001-03 2004-06 2007-09

Fig 3.5 : MMR in India

MMR


72

commensurate with its economic situation. It was 177 in 1999-2001 and increased

to 178 in 2001-03, 192 in 2004-06, reducing subsequently to 172 in 2007. Overall

health status of women in BIMA RU states in terms of MMR leaves much to be

desired.


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

134

390

261

148 153 178

81

269

104

258

172

318

97

359

145

212

0

50

100

150

200

250

300

350

400

450Fig 3.6 : MMR in Major Indian States in 2007-09


73

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.


74

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 32.8 49.8 64.4 49.8 65.2 74.9

2 Assam 11.1 17.6 22.4 17.9 21.4 31.0

3 Bihar 12.1 14.6 19.9 19.0 23.4 29.3

4 Gujarat 35.6 46.3 52.7 42.5 53.5 63.0

5 Haryana 16.7 22.4 35.7 30.3 42.0 48.9

6 Karnataka 37.5 51.1 64.7 50.9 59.1 69.7

7 Kerala 87.8 93.0 99.3 89.7 94.0 99.4

8 Madhya

Pradesh 15.9 20.1 26.2 30.0 29.7 32.7

9 Maharashtra 43.9 52.6 64.6 53.2 59.4 68.7

10 Orissa 14.1 22.6 35.6 20.5 33.4 44.0

11 Punjab 24.8 37.5 51.3 48.3 62.6 68.2

12 Rajasthan 11.6 21.5 29.6 21.8 35.8 41.0

13 Tamil Nadu 63.4 79.3 87.8 71.2 83.8 90.6

14 Uttar Pradesh 11.2 15.5 20.6 17.2 22.4 27.2

15 West Bengal 31.5 40.1 42.0 33.0 44.2 47.6

INDIA 25.5 33.6 38.7 34.2 42.3 46.6

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


75

ranges from 37.3 percent in Uttar Pradesh (again the lowest) to 99.4 percent

(highest) in Kerala. Overall performance of states like Andhra Pradesh, Gujarat,

Maharashtra, Punjab, Karnataka, Kerala and Tamil Nadu is above the average,

while BIMARU states are once again below the average. Haryana, however, joins

the league of BIMARU states. There is a gap of more than double between rural

and urban areas in most of the states.

Table 3.10:- Institutional and Safe Delivery in Rural/Urban Areas in

Major Indian States

S.N STATES Institution Delivery Safe Delivery

Rural Urban Rural Urban

1 Andhra Pradesh 40.4 78.6 58.5 85

2 Assam 15 59.9 18.9 64.6

3 Bihar 12.4 39.9 20.8 52.3

4 Gujarat 33.2 69.4 41.8 74.2

5 Haryana 14.9 47.1 34.8 66.1

6 Karnataka 38.7 78.8 47 86.4

7 Kerala 91.5 99.4 92.8 99.4

8 Madhya Pradesh 12.3 49.8 21.2 62.3

9 Maharashtra 34.6 80.9 43.8 84.1

10 Orissa 19.3 54.7 30.5 61.4

11 Punjab 32 56 58.1 78.2

12 Rajasthan 15 47.9 29.3 63

13 Tamil Nadu 73.1 92.6 78.4 95.1

14 Uttar Pradesh 11.7 37.3 17.5 52.3

15 West Bengal 31.5 80.1 36.2 81.7

INDIA 24.6 65.1 33.5 73.3

Source: NFHS-2

Likewise in the case of safe-delivery rural/urban disparity is again more

than double. Kerala maintains her first rank and Uttar Pradesh is relegated to the

last among the group of fifteen major states. Andhra Pradesh, Punjab, Gujarat,


76

Maharashtra, Tamil Nadu, Kerala and Karnataka have done well and their figures

are above the average.

The result of these institutional and safe deliveries is observed directly in

maternal and infant health. It is evident that low institutional and safe delivery

areas are pockets of high MMR and IMR. The present UPA government and other

state governments have expressed serious concern and taken initiatives towards

improvement. Janani Suraksha Yojana (JSY) for instance emphasizes „the high

focus‟ states under National Rural Health Mission documents to increase

institutional delivery but by cash assistance only. The number of deliveries in

government health facilities shot up by 36 percent in Rajasthan and 53 percent in

Madhya Pradesh according to a recent study by the government for the period

between late 2007 and early 2009. The study revealed that conditional cash

payment led to a reduction of above four peri-natal deaths per 1000 pregnancies,

and two neo-natal deaths per 1000 live births.


0

20

40

60

80

100

120Fig 3.7 : Institutional Delivery in Major States(Rura/Urban)

Rural Urban


77

Nutritional Status of Women

Women‟s nutrition is important because they bear children, breast feed the

infant and look after their various needs. Poor health of women leads to underfed

and undernourished infants and children who are susceptible to life threating

infections and diseases. Low per capita income and its unequal distribution leads

to poor nutrition and underweight children and adults especially women who in

many Indian families are the last to partake of meals. Two measures of women‟s

nutritional status are Body Mass Index (BMI) and anemia. Body Mass Index

(BMI) below 18.5 is termed as under nutrition and underweight which is widely

prevalent in under developed and developing economies due to poor nutritional

intake on account of low per capita income and unequal distribution of it.

Malnutrition among women is the outcome of low dietary intake, poverty,

illiteracy and lack of awareness on account of economic and social backwardness,

and their high energy output for work and child-bearing. In rural and remote areas

women work more than men when economic and domestic labors are combined.

With their inescapable reproductive responsibilities they bear triple burden of

market production, home production and reproduction. Generally very high

association is found between low BMI and Anemia among women (r = +0.81).

Data in Table 3.11 depict that more than one-third women are under-nourished

and in case of anemia more than half of the women are facing this scourge.

Underweight women‟s lot has improved marginally to 35.6 percent from 35.8

percent i.e. -0.6 percent changed during NFHS-2 and NFHS-3, the period of high

economic growth. As per the data NFHS-3, 45.1 percent women are underweight

in Bihar, 41.7 percent in Madhya Pradesh, 41.4 percent in Orissa.

Health status of women in terms of BMI below normal is appalling in states

like Assam, Haryana and Bihar as percentage of these women has increased by

34.7 in Assam, 20.9 in Haryana, 14.8 in Bihar and 11.8 in Punjab. Punjab and


78

Haryana, both economically better performing states have shown increase in

number of women with low BMI. Hence it can be very safely inferred that

economic advancement is no guarantee of improvement in health status especially

of women. Government has to take affirmative action towards provision of

nutrition and maternity care for women.

Table 3.11:- Nutritional Status of Women (BMI and Anaemia) in Major

Indian States

S.N STATES BMI Anaemia

2*3 2'*3' NFHS-2 NFHS-3 NFHS-2 NFHS-3

1 Andhra Pradesh 37.4 35.5 49.8 62.9 -5.08 26.31

2 Assam 27.1 36.5 69.7 69.5 34.69 -0.29

3 Bihar 39.3 45.1 63.4 67.4 14.76 6.309

4 Gujarat 37 36.3 46.3 55.3 -1.892 19.44

5 Haryana 25.9 31.3 47 56.1 20.85 19.36

6 Karnataka 38.8 35.5 42.4 51.5 -8.505 21.46

7 Kerala 18.7 18 22.7 32.2 -3.743 41.85

8 Madhya Pradesh 38.2 41.7 54.3 56 9.162 3.131

9 Maharashtra 39.7 36.2 48.5 48.4 -8.816 -0.21

10 Orissa 48 41.4 63 61.2 -13.75 -2.86

11 Punjab 16.9 18.9 41.4 38 11.83 -8.21

12 Rajasthan 36.1 36.7 48.5 53.1 1.662 9.485

13 Tamil Nadu 29 28.4 56.5 53.2 -2.069 -5.84

14 Uttar Pradesh 35.8 36 48.7 49.9 0.559 2.464

15 West Bengal 43.7 39.1 62.7 63.2 -10.53 0.797

INDIA 35.8 35.6 51.8 55.3 -0.559 6.757

Source: NFHS-2&3

2*3: percentage change in BMI below normal among women during NFHS-2 &3;

2'*3': percentage change in Anaemia in ever married women (15-49) during NFHS-2

&3;

In terms of prevalence of anemia in ever married women (15-49 years), the

situation has become more pathetic. This figure has shot up from 51.8 percent to


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55.3 percent i.e. 6.8 percent of increase (column-2‟*3‟) during NFHS-2 and

NFHS-3. Kerala in this crucial measure failed to maintain its respectable position

and registered the highest percentage increase. Punjab, Tamil Nadu, and even

Orissa and Assam have registered an improvement in this lot. On the other side,

Karnataka, Andhra Pradesh, Gujarat, Haryana and Rajasthan are the states

showing an upward trend. It is anomalous that in the fast growing economies like

Gujarat and Haryana anaemia increased substantially.Theyhave failed on this

front.

Status of Health Facilities in Major Indian States

Poor performance on the health aspect of human development is traced out

due to poor health facilities and infrastructure. The National Health Policy (NHP-

2002) has suggested addressing infrastructural deficits in health sector especially

in rural and remote areas. In accordance with the Policy central government has

launched National Rural Health Mission (NRHM, 2005-12) to achieve the target

of „Health for All‟ through people‟s participation with the approach of „Health by

people‟. The NRHM seeks to provide effective healthcare to rural population

throughout the country with special focus on 18 states (Assam, Arunachal

Pradesh, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir,

Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan,

Sikkim, Tripura, Uttarakhand and Uttar Pradesh). The strengthening and

effectiveness of health institutions like SCs/PHCs/CHCs/Taluk/District Hospitals

have positive consequences for all health programs.

Since initiation of the Community Development Program in 1951, India has

gradually developed a vast health infrastructure. But the present status of health

infrastructure reflected through Table 3.12 derived from Annexure 3.3 shows that

availability of basic health facilities in terms of Sub Centers (SCs), Primary Health


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Centers (PHCs) and Community Health Centers (CHCs) are inadequate in India.

Larger north Indian states of high and dense population like Uttar Pradesh, Bihar,

West Bengal, etc. show higher percentage of shortfall, above the national average

of 12.3 percent, 16.3 percent and 32.6 percent for SCs, PHCs and CHCs

respectively. On the other hand the case is just reverse in the southern states of

Kerala, Karnataka and Tamil Nadu etc. where these facilities are in surplus.

The shortfall is depicted through the population load per center. In the case

of CHCs highest shortfall of 88.7 percent was recorded in Bihar with a load of

more than one million populations per center. Other shortfall states, Uttar Pradesh,

West Bengal, Andhra Pradesh, and Madhya Pradesh etc. have registered above the

norm load of 5000 population in case of SC, 30000 population at per PHC and

100000 at per CHC. There are only two states namely Kerala and Karnataka that

have registered a surplus situation of CHCs. Economically more developed states-

Haryana, Gujarat, Punjab and Maharashtra etc. are also facing inadequacy of these

facilities, with population per centre being above the norm.

It would be appropriate to cite here the recent National Rural Health

Mission report that nearly 8 percent the country‟s 22,669 PHCs do not have a

doctor while nearly 39 percent were running without a laboratory technician and

17.7 percent without a pharmacist. The condition of the 3,910 CHCs, supposed to

provide specialized medical care, is equally appalling. Out of the sanctioned

strength, posts of 59.4 percent surgeons, 45 percent obstetricians and

gynecologists, 61.1 percent physicians and 53.8 percent pediatricians are vacant

(Hazra, A. 2010).


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Table 3.12:- Status of Health Facilities in Major Indian States

STATES Shortfall (%) Population Load / Centre

SC PHC CHC SC PHC CHC

Andhra Pradesh 7.0* 18.4 65.3 4424 35287 331743

Assam 9.1 3.6* 47.6 5043 27122 214966

Bihar 35.2 25.2 88.7 7665 39891 1061667

Gujarat 0.2* 6.5 1.0 4364 28961 109451

Haryana 17.3 11.8 14.4 6050 34080 140460

Karnataka 10.5* 81.1* 7.6* 4285 15909 107351

Kerala 3.9 2.8* 18.3* 5153 28997 101178

Madhya Pradesh 14.7 30.8 20.1 5004 38425 133276

Maharashtra 12.9 8.5 26.4 5272 30715 152815

Orissa 8.2 9.2* 20.9 4678 24462 135443

Punjab 8.4 16.8 3.7 5456 36091 124779

Rajasthan 20.2* 3.3 5.2 3769 28785 117644

Tamil Nadu 23.4* 9.4* 12.6 4011 27219 136413

Uttar Pradesh 22.1 15.9 53.1 6416 35660 255647

West Bengal 14.4 54.4 30.1 5576 63530 165945

INDIA 12.3 16.3 32.6 5049 31364 163725

Source: Rural Health Statistics in India, 2010.

* shows surplus situation

Senior research officers of Planning Commission highlight the fact that

India churns out 29,500 medical graduates annually, but most of them are reluctant

to serve in villages and would rather join the private sector for better salaries and

urban posting (Gupta & Gupta, 2008). In effect, 67 percent of doctors enrolled for

rural posting remain absent from duty. Also, there is only one allopathic doctor for

1,634 people. According to Medical Council of India, the total number of

registered allopathic doctors in the country is 6,83,582 (Hazra, A. 2010).


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Goals to Be Achieved

Ever since Bhore Committee (1946) recommendations to the latest National

Health Policy 2002 blueprint, all major upcoming committees and Plans after

independence have recommended as well as tried to implement the establishment

and upgradation of a well-structured and comprehensive health infrastructure. In

Alma Ata Declaration (1978), India, as a signatory country, solemnly resolved to

achieve “Health for All by 2000”. Agreeing with this declaration, various

successive Plans took into account not only the high risk vulnerable groups, i.e.,

mother and child but also focused sharply on underprivileged segments within the

vulnerable groups. First National Health Policy (NHP-1983) recommended to

take noteworthy initiatives to set up a well-dispersed network of primary health

care services, intermediation through „Health Volunteers‟ having appropriate

knowledge, simple skills and requisite technologies; establishment of a well-

worked referral system and overall to develop an integrated network of evenly

spread specialty and super specialty services. Government initiatives have

recorded some noteworthy successes over time. The success of the initiatives is

reflected in the progressive improvement of many demographic/epidemiological/

infrastructural indicators.

Table 3.13:-Achievements Through The Years : 1951-2000

INDICATOR 1951 1981 2000

IMR 146 110 70

LEB 36.7 54 64.6

Malaria per million 75 2.7 2.2

Leprosy per 10000 38.1 57.3 3.74

Small Pox >44887 eradicated

Polio

29792 265

SC/PHC/CHC 725 57363 163181

Doctors 61800 268700 503900

Nurses 18054 143887 737000

Source: National Health Policy, India. 2002.


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Table 3.13 gives data on some of the achievements on the health front, both

in terms of indices like IMR and LEB as well as in terms of health infrastructure,

with a resultant reduction in cases of malaria, leprosy and polio and eradication of

small pox. However, these achievements are not impressive enough in the

international perspective and on the basis of performance our country is grouped

with underdeveloped countries like Nigeria and Bangladesh. Health centres and

personnel have increased many-fold. India as a welfare state and aspiring for a

millennium superpower status has to fulfill Millennium Development Goals

(MDGs) within the stipulated period. In line with this commitment to eradicate

extreme huger by at least half, to reduce child and maternal deaths by two-thirds

and three-quarters respectively during 1990 to 2015, India has emphasized these

targets in various forthcoming Plans (Xth

and XIth

), programs (NRHM) and policy

announcements (NHP-2002) as evident from Table 3.14 below. Sample

Registration Survey (SRS-2011) has also fixed targets to reduce IMR, U5MR and

MMR upto 28, 42 and 109 respectively by the stipulated year of MDGs i.e. 2015.

Table 3.14:- Goals to Be Achieved

Indicator MDG

X-

FYP

XI-

FYP

NHP by

’10 NRHM SRS-2015

IMR … 45 28 30 30 28

U5MR reduce2/3 … … … … 42

MMR reduce3/4 200 100 100 100 109

These goals are to be achieved at the national level. For individual states,

different targets for different parameters have been set, depending on their existing

achievement, the intention being to realize the targets set at the national level by

the end of the Eleventh Five Year Plan. It remains to be seen how much the states

can actually achieve. Economically affluent and socially advanced states with

better health outcomes have had to achieve more during this plan. Table 3.15


84

shows that MMR, IMR, percentage of malnourished children (CMN) and

percentage of anemic women (WAn) have been targeted to reduce at 100, 28, 23

and 28.1 respectively at national level.

Table 3.15:-Targets for Eleventh Five Year Plan

Relation of Maternal and Child Health

In this chapter maternal and child health in terms of their mortality ratios

and nutritional status have been discussed in detail earlier. Some important

indicators are taken to make an analysis of their relationships. Three indicators of

mortality – IMR, CMR and MMR, and two-two indicators of nutrition and health

facility at the time of delivery the most critical situation for both mother and child

STATES MMR IMR CMN Wan

Andhra Pradesh 65 28 18.3 31

Assam 163 33 20.2 34.5

Bihar 123 29 29.2 34.2

Gujarat 57 26 23.7 27.8

Haryana 54 29 21 28.3

Karnataka 76 24 20.6 25.2

Kerala 37 7 14.4 16.2

Madhya Pradesh 126 37 30.2 28.8

Maharashtra 50 17 19.9 24.5

Orissa 119 36 22 31.4

Punjab 59 21 13.5 19.2

Rajasthan 148 33 22 26.6

Tamil Nadu 45 18 16.6 26.7

Uttar Pradesh 172 35 23.7 25.4

West Bengal 64 18 21.8 31.9

INDIA 100 28 23 28.1

Source: www.planing commission.nic.in/plans/planrel/fiveyr/11th

CMN: Malnourished Children, WAn :Anemia in Women


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are selected for the purpose. It is expected that child‟s health is highly influenced

by mother‟s health. The results of the following Table 3.16 are on expected lines.

Correlation matrix based on Annexure 3.4 shows some very important

findings pertaining to maternal and child health. There is a high positive

correlation between IMR and underweight children[r = 0.693]. A very high

negative correlation is worked out between IMR and institutional and safe

deliveries [r = -0.866 & r = - 0.864]. Similarly, maternal deaths at the time of

delivery in terms of MMR are strongly related in negative way to births attended

by skilled health personnel at hospital or at home [r = -.811 & r = -.832]. Children

are underweight because of the legacy transferred from their underweight mothers.

Underweight children show a strong positive correlation to underweight mothers

[r= 0.83]. Moreover, health of jacha and bacha (mother and baby) in terms of

IMR and MMR is highly related to the government‟s provision at the time of

delivery.

Table 3.16:- Correlation Matrix of Maternal and Child Health

Variables IMR CMR MMR UWC UWW IND SFD

IMR 1.000

CMR 0.933 1.000

MMR 0.821 0.841 1.000

UWC 0.693 0.726 0.517 1.000

UWW 0.725 0.659 0.480 0.830 1.000

IND -0.866 -0.851 -0.811 -0.757 -0.675 1.000

SFD -0.864 -0.846 -0.832 -0.796 -0.729 0.987 1.000 Based on Annexure 3.4

IMR – Infant Mortality Rate, CMR – Child Mortality Rate, MMR – Maternal Mortality Rate,

UWC – Underweight Children, UWW – Underweight Women, IND – Institutional Delivery,

SFD – Safe Delivery


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Generally untrained dai who cannot address complications attend to

deliveries in rural and urban-slum areas resulting in high IMR and MMR. It is well

accepted that overall health profile of a nation revolves around prevailing health

conditions of the mother and the new-born. Nutritional status and institutional

delivery emerge as important aspects of a nation‟s health status. The crux of this

correlation table is that the mother‟s health is the basis of child health. Hence,

policy makers must pay due attention to this crucial issue.

Conclusion:

It is apparent from the above discussion that health status of India is poor

by international standard and there are wide disparities prevalent at all levels.

Government has done too much over the long period after Independence, but it is

not adequate keeping in mind the increasing population of the country. Maternal

and child health is in deplorable situation and overall health status of population is

not in tune with the development in the economy.

chapter iii analysis of health profile of...

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