Monday, 30 April 2012

India: Policy action for achieving the Millennium Development Goals

Dr. Devendra Kothari
Population and Development Analyst
Forum for Population Action

In the year 2000, the Heads of 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge became the eight Millennium Development Goals to be achieved by 2015. These goals are: 1: Eradicate extreme poverty and hunger, 2: Achieve universal primary education, 3: Promote gender equality and empower women, 4: Reduce child mortality. 5: Improve maternal health, 6: Combat HIV/AIDS, malaria and other diseases, 7: Ensure environmental sustainability, and 8: Develop a global partnership for development. In September 2010, the world recommitted itself to accelerate progress towards these goals[1].

India is one of the signatories which have committed to achieve MDGs. The realization of these goals in India is vital not only for attaining human development and economic growth within the country, but given its enormous size since every fifth person in the world is an Indian,  they are  critical for reaching the MDGs world wide.  To review the progress, the UN Secretary-General Ban Ki-moon visited India during the last week of April 2012.  During his three-day trip, the Secretary-General had discussions with the senior leadership of both public and private sectors including the Prime Minister of India and top business leaders.

With less than four years left to achieve the MDGs, this writing provides a quick snapshot of India’s progress towards the MDGs and highlights a roadmap outlining what is needed to meet the goals. This post is also timely since   India just entered the 12th Five-Year Plan period (1912-17) aiming at “achieving faster, sustainable and inclusive growth”. 

The Government of India claims that the country is on track to meet the MDG targets by 2015. It argues that the number of people living below the poverty line has reduced. It claims that child and maternal mortality rates are reducing at a pace commensurate with its plans. It maintains that during the past one decade, the country launched several new programs capturing the sprit of MDGs. The Mahatma Gandhi National Rural Employment Guarantee Scheme has increased rural employment. The Sarva Shiksha Abhiyan, a national policy to universalize primary education, has increased enrolment in schools. The National Rural Health Mission has resulted in massive inputs in the health sector. It asserts that the Rajiv Gandhi National Drinking Water Mission and the Total Sanitation Campaign address crucial MDGs.
It is, however, difficult to endorse the government's confidence and optimism[2]. Experts argue that the poverty reduction claims are the result of a sleight of hand, which employs debatable measurements and methods for assessment. Further, recent international reports indicate that things are going from bad to worse. India’s rank in the latest UN’s Human Development Report has fallen from 119 in 2010 to 134 out of 187 countries in 2011. In addition, the 2011 Global Hunger Report (GHI) report places India amongst the three countries where the GHI between 1996 and 2011 went up from 22.9 to 23.7, while 78 out of the 81 developing countries studied succeeded in improving hunger conditionThe HUNGaMA (Hunger and Malnutrition) survey carried in 2011 reconfirms that malnutrition among children in India has taken ominous proportions, and the situation in many districts of the country has worsened when compared to what it was about a decade back. India is simply not doing enough for its women either. According to the Gender Gap Index 2011, released by the World Economic Forum, India’s ranking has been falling steadily since 2006 when the Index was launched. In 2006, India was ranked 98th. Between 2007 and 2011, the ranking has swayed between 112 and 114. In addition, recent studies paint a grim picture of school education in India. It appears that progress bypassed those who are lowest on the economic ladder or are otherwise disadvantaged because of their sex or ethnicity. Disparities between urban and rural areas are also pronounced and daunting.
All this is a rather   shameful reflection of the prevailing conditions in a country that is said to be on a growth song, and indicate that India is heading towards an unstable situation of extreme danger or difficulty that could lead to despair, social instability, political strife, policymaking paralysis and capital flight as well as a rapid collapse in growth rates. In this connection, the statement made by  Kaushik Basu,  Chief Economic Advisor of Government of India, should be taken seriously when he acknowledged that “economic reforms in India have slowed down and may remain that way till 2014”[3].

India could have done much better in achieving MDGs if the government as policy making body and officials as implementing agency had serious but focused concern, commitment, good governance, transparency and accountability. Government in its unwarranted enthusiasm to achieve double digit growth has completely neglected to accord high priority  for MGDs. China has done much better in this by  focusing initially on core areas like improving the quality of reproductive health  and education.
Is India on track to meet the MDGs in 2015? There is evidence that while some States are on track, many others lag behind and will lower the country's overall achievement.  For example, in 2007-09, on average 212 women died giving birth to a child for every 100,000 live births  (maternal mortality ratio) down from 327 in 1999-01. The Four Large North Indian (FLNI) States of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh had the highest numbers ranging from 359 to 261. Kerala at 81, Tamil Nadu at 97 and Andhra Pradesh at 134 have the best figures. This calls for an areas specific strategy/approach  to achieve MGDs. Further, India must also take more determined and focused steps to achieve goals. The people of the world are watching.

Among eight goals, improving maternal health (Goal 5) and  promoting  gender equality and empower women (Goal 3), are  most crucial in achieving sustainable development as well as MDGs. Maternal ill health and death impact families, communities and societies and has far reaching effects across socio-economic strata. Further, decreasing the rates of maternal mortality and morbidity is important because poor maternal health is both an indicator and a cause of extreme poverty. Available data indicate that   the lack of education, poor health conditions and discrimination in opportunities for work and income still haunt women. It appears that India is simply not doing enough for its women to improve access to resources and freedom of movement.  There is an urgent need to rethink as how to expedite the process of women empowerment in a patriarchal and traditional society like India with innumerable obstacles.

Here, the provision of client centred maternal health care could be an answer. It refers to the health of women during pregnancy, child birth and the postpartum period. It encompasses the healthcare dimensions of preconception, prenatal and post natal   care in order to reduce maternal and child morbidity and mortality as well as fertility. The preconception care includes education, family planning, health promotion, screening and other interventions among women of reproductive age to reduce risk factors that might affect future pregnancies. The goal of prenatal care is to detect any postnatal complications of pregnancy early, to prevent them if possible, and to direct the woman to appropriate specialist medical services as appropriate. The postnatal care issues include recovery from childbirth, concerns about newborn care, nutrition, breastfeeding, infant immunization and family planning.

It is interesting to note that maternal mortality, child survival, and fertility are not independent factors, but rather involve a series of biological and social mechanisms in close interaction with one another. Impact of the use of reproductive health services is reflected on the level of maternal and child mortality, as well as on unwanted/unplanned fertility. Higher use of reproductive health services, leading to good maternal health, is making positive effect on health indicators like Infant Mortality Rate (IMR) and Maternal Mortality ratio (MMR) and Total Fertility Rate (TFR). Data from some high and low performing States of India supports this observation, as shown in Table 1.  Since Uttar Pradesh and Bihar, two lowest  performing and most populous  States located in North India, recoded very low utilization of antenatal (col. 2) and family planning (col.3) services in India, their MMR (col. 4) and TFR (col. 5) are very high -  in fact highest in the country. They also recorded the highest unwanted fertility per woman (col. 6) and low level of women empowerment, measured in terms of decision-making power (Col. 7).  On the other hand, by simply improving the availability and accessibility of quality antenatal care (col. 2)[4] and family planning services, the States of Andhra Pradesh and Tamil Nadu, located in South India, achieved a significant improvement in maternal health indicators as well as in the status of women (Col. 7), as shown in Table 1.

   Table 1:  Interaction among maternal mortality, child survival and fertility, evidence from India
Selected States of India (Population in million, 2011)
% mothers received
3+ Ante natal care
% of Couples using
modern contraceptive
Maternal deaths/ 100,000  live births
of children/
women (2010)
Number of unwanted births/ woman
Level  of women
empower-ment (%)
Uttar Pradesh
(200 million)
(104  million)
(1210 million)
Andhra Pradesh
(85 million)
Tamil Nadu
(72 million)
Source: Registrar General of India and National Family Health Survey-3 (2005-06)

While the India’s population continues to grow by around 16-17 million annually, more than 15 million women, mainly from the lower classes, lack access to basic reproductive health services. Often, these women must travel far from their communities to reach a health facility, only to return home “empty handed”, due to shortages and stock-outs, as well as non availability of staff. When women seeking reproductive health, including family planning services are turned away, they are unable to protect themselves from unintended pregnancies and sexually-transmitted infections, including HIV/AIDS.  Further, by all accounts, population growth in India has been rapid; however, relatively high population growth mainly due to unwanted fertility makes it more difficult to lift large numbers of people out of poverty. Around 26 million children are born in India every year and out of this about 5.5 million births have been classified as unplanned/unintended. Further, based on the National Family Health Survey[5], it is estimated that   about 30 per cent or around 224 million people in the age group 0-35 years in India in the year 2005-06 was the product of unwanted childbearing. The level of unwanted fertility in this age group has increased from 23 per cent in 1992-93 to 30 percent in 2005-06.  Based on findings of the National Family Health Surveys 1, 2 and 3, it is estimated that currently there are around 450 million people out of 1200 million in India who are product of unintended/unplanned pregnancies, and most of them are from the lower economic strata.

The consequences of unintended pregnancy are serious, slowing down the process of socio-economic development. It is because unwanted childbearing results in poor physical growth, reduced school performance, diminished   concentration in daily tasks thus impacting work capacity and work output resulting in diminished earning capacity. The impact of unwanted childbearing is reflected in widespread hunger, poverty, unemployment as well as increasing scarcity of basic resources like food, water and space in several parts of India despite concerted developmental efforts since 1991. India’s large unwanted fertility, a threat to sustainable development as well as in achieving MDGs, demands immediate attention.

Here, the maternal-healthcare-centred approach or intervention  is a positive option that has been largely unrecognized by policymakers, as well as by many bilateral and philanthropic organizations. The need of the hour, thus, is to create confidence among policy makers and programme managers that a breakthrough is possible. The 12th Five Year Plan must re-emphasize its commitment to maternal health and provide essential leadership in promoting reproductive health and increase awareness of the social, economic, and environmental consequences of poor maternal health. Although simply provision of maternal health alone is not going to solve all the problems faced by poor women, it will help in giving   them a level playing field and it will provide a boost to their confidence. And that will lead to accelerated progress towards achieving MDGs.

Another issue which needs equal attention is quality of education. Unless education is rescued from quagmire of mediocrity, all talk about developing a skilled human resource pool and realizing the country`s demographic dividend will be without substance; and the country would be inching closer to demographic disaster. As such, investment in education has to be increased to improve the quality of education especially at the government schools and colleges where most of the students are from poor and rural families.

The writing is on the wall. The question is not whether we act or not, but whether we act now or later and deal with much more dire and expensive consequences. What we do in the next few years especially during the period of Twelve Five Year Plan (2012-17) will determine India’s future as well as its capacity to achieve MDGs.

[1]  For details, see: The Millennium Development Goals Report, 2011, United Nations. 


[2] For more information on these points: see wirings of the author in blog:, especially refer “What the poverty debate in India misses?” dated 31.10.2011, and “To beat the gloom, India needs to focus on real issues”. Also see: news paper article by KS Jacob, Millennium Development Goals & India, The Hindu, dated 20. 10. 2010.

[3] In Washington to attend the Annual Spring meeting of the International Monetary Fund (IMF) and the World Bank (April 20, 2012), Dr Basu was addressing the concerns expressed by the US corporate on some recent decisions of the Indian government and its reluctance to initiate the series of next phase of reforms.

[4] Antenatal care covers at least five basic services - pregnancy monitoring, tetanus toxoid vaccine, iron and folic acid tablets (IFA) and nutrition/ safe delivery counseling. These can help women go through the pregnancy safely and ensure that the new born is in good health.

[5]India: National Family Health Survey (NFHS-3), 2005-06, IIPS, Mumbai, 2007.

No comments:

Post a Comment