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India: Marginal progress in public health short of MDGs

Jul 29, 2011

The marginal improvement in maternal and infant mortality rates are inadequate to achieve the Millennium Development Goals, says the latest sample demographic survey. Health policies have successfully augmented institutional deliveries and immunisations, but failed to arrest the declining sex ratio.

The country's largest demographic sample survey, covering 1.4 million households and a population of 7.01 million, during the period 2007-09, says that there was only a mild improvement in the infant mortality rate (IMR) and the maternal mortality ratio (MMR).


The findings of the latest Sample Registration System (SRS), an exercise which has been on since 1969-70 and happens to be the only source for fertility and mortality data, have not given the government much reason for cheer. Released by the office of the Registrar General of India and Census Commissioner, the SRS findings on the IMR, the MMR and the Under Five Mortality Rate (U5MR) show that the slight progress falls short of even the modest targets set by the Millennium Development Goals (MDG). 

The MDG targets do not aim for a 100% reduction but only a reasonable reduction in mortality levels: reducing maternal deaths to 200 per lakh of live births by 2007 and 109 per lakh live births by 2015. The goals set by the National Rural Health Mission (2005-2012) were more ambitious: reducing the IMR to 30 per thousand live births and the MMR to 100 per one lakh live births and the total fertility rate to 2.1.

The findings in the SRS bulletin for 2007-09 show a slight improvement compared with the data collected for 2004-06. The Maternal Mortality Ratio (this is derived as the proportion of maternal deaths for every 1,00,000 live births reported under the SRS) declined from 254 in 2004-06 to 212 in 2007-09. The decline was most significant in the Empowered Action Group (EAG) States (Bihar, Madhya Pradesh, Rajasthan, Chhattisgarh, Jharkhand, Orissa, Uttar Pradesh and Uttarakhand) and Assam, from 375 to 308. In the southern States as a whole, the decline was from 149 to 127. 

The point to note is that the improvement is measured in terms of the MDG goals set out for India. Tamil Nadu, Maharashtra and Kerala were shown to have reached the MDG target, whereas Kerala was the only State with this distinction in 2004-06. Four other States, Andhra Pradesh, Gujarat, West Bengal and Haryana, had inched closer to the MDG targets, the SRS findings showed.

Poor statistics

However, what is important is that while there was a less than 50 point decline in the national average, it is disconcerting that in the EAG States, which also happen to be the most populous, more than 300 women died each year in every one lakh deliveries. This region also accounted for 61.6% of the total maternal deaths in the country, while the southern States contributed only 11.4%. Kerala remained the only State to have a two-digit figure as far as the MMR was concerned. 

One out of every 20 children died within a year of birth, with more children dying in rural areas (one out of every 18) than in urban areas (one out of every 29)

If Kerala can do it, why is the rest of the country not able to keep maternal mortality figures down? In sheer numbers, around 63,000 women died each year during the period because of delivery-related complications. The SRS bulletin also shows that there was a three-point decline in the IMR (the number of infant deaths per thousand live births), from 53 in 2008 to 50 at present. But the IMR of Madhya Pradesh, which is the highest, remained unchanged, while Kerala stuck to its tradition of recording the lowest IMR. Tamil Nadu achieved the MDG target (28 by 2015), while Kerala actually exceeded it with 12 deaths per thousand live births. Delhi, Maharashtra and West Bengal are shown to be close to the MDG goal.

At the national level, one out of every 20 children died within a year of birth, with more children dying in rural areas (one out of every 18) than in urban areas (one out of every 29). Female infants continued to register a higher mortality rate than male infants, a trend that has been constant since the 1990s. This was the period that saw a boom in private health care facilities as opposed to public health care, which came into focus sometime in 2005 with the advent of the National Rural Health Mission (NRHM).

The U5MR saw a modest decline of five points between 2008 and 2009, and a uniform decline was witnessed for both sexes. Madhya Pradesh, as with its high MMR and IMR, recorded the highest U5MR among the States (89 children in the 0-4 year age group died before reaching their fifth birthday in every 1,000 live births), while Kerala reported the lowest (14). The average national U5MR was 69 in 2008 and 64 in 2009, a decline of just five points.

Inter-state differences

Three States apart from Kerala achieved the MDG target for 2015 of 42 deaths per thousand live births. Tamil Nadu, Kerala, West Bengal and Maharashtra showed a declining U5MR. There was a clear pattern here. States that showed a high MMR are also those where the IMR and the U5MR were high. The U5MR for urban areas was closer to the MDG target, while the U5MR for rural areas was still very high at 71 deaths per thousand live births, perhaps indicating the greater availability of health care in urban areas.

"Low fertility rates coupled with sex-selective abortions have played havoc with the numbers of girl children"

Even though the male-female differential had narrowed, the female U5MR was much higher than the national average and had remained so since 1990. The total fertility rate (the total number of children born to a woman in her entire reproductive period) remained constant at 2.6 during 2008-09, with Bihar recording the highest at 3.9 and Kerala and Tamil Nadu recording the lowest at 1.7.

While the low fertility rate may be a welcome sign for policymakers, it is apparent that low fertility rates coupled with sex-selective abortions have played havoc with the numbers of girl children. Even though the Central government and a few State governments retain their conservative approach to population stabilisation, the efforts of women's organisations have ensured that coercive measures of population control have been abandoned.

The decline of the IMR, the MMR and the U5MR, even if low, is not surprising. According to the Rural Health Statistics for last year, there was a 44% increase in the number of auxiliary nurse midwives at the primary health centres (PHCs) and their sub-centres. The percentage of PHCs functioning in government buildings went up from 78% to 88.6% in 2010 and the number of doctors at PHCs went up from 20,308 in 2005 to 25,870 in 2010. 

The number of specialist doctors increased from 3,550 in 2005, the year in which the NRHM was launched, to 6,781 in 2010. But there was still a shortfall of 62.8% in the number of surgeons, 55.2% in that of obstetricians and gynaecologists (responsible for safe deliveries, gynaecological issues and overall reproductive and maternal well-being), 72% in the case of physicians and 69.5% in the number of paediatricians.

Not a story of well-being

The average rural population covered by sub-centres, PHCs and community health centres (CHCs) exceeded the norm in every category. The nominal reduction in the IMR, the MMR and the U5MR does not really tell a story of the well-being achieved through the NRHM. The Delivery Monitoring Report of the NRHM for the period ending March 31, 2011, shows that though the mission has been in place for six years, there are still deep shortfalls even by the NRHM's own norms. 

For example, the number of sub-centres required under the NRHM is 1,75,000, while what has been made available was 1,47,069, a shortall of nearly 30,000 sub-centres. The report also gives information about the number and percentage (total reported deliveries) of institutional deliveries, the number of children fully immunised and the number of female and male sterilisations. It says that there was an increase in the number of institutional deliveries (78%) – perhaps primarily because of the incentive-driven Janani Suraksha Yojana – and 86.9% of children had been immunised and 3.9% of couples sterilised.

Close on the heels of the SRS data, the Census office released the provisional population totals in the second week of July, giving the break-up of the rural-urban distribution. Rural India comprised 68.84% of the total population, while urban India constituted 31.16%, which was an increase of 3.35 % over the last decade.

In fact, the State-wise break-up of the rural-urban population totals showed an increase in the urban population in almost every State as a percentage of the total population and a doubling of urban growth rates in some Union Territories. In some States, the increase was marginal, in others it was by several percentage points. Delhi showed the highest proportion of urban population by residence, followed by Chandigarh.

On a more worrying note, while the overall child sex ratio reached an all-time low from 1961, with a fall of 13 points over the last decade, in rural areas, the latest Census showed, the fall was steeper, at 15 points. From 934 children in the 0-6 category for every 1,000 male children in 2001, the rural sex ratio fell to 919 in 2011. Delhi surprisingly recorded the lowest, 809, in its rural areas, while Andaman and Nicobar Islands recorded the highest, 975. In urban areas, Haryana recorded the lowest and Nagaland recorded the highest child sex ratio. Peculiarly, while Nagaland showed a dip in its rural child sex ratio by almost 30 points, its urban child sex ratio shot up, ranking it the best in the country in urban areas.

These and other data form the basis for an appropriate direction in policymaking. Unfortunately, the low rate of decline in the IMR, the MMR, and the U5MR and the latest data on population showing the rural-urban distribution of the child sex ratio, among other things, have not attracted the kind of attention they should have.

Source : Frontline
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