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 condition. The 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
(2005-06)
|
% of Couples using
modern contraceptive
(2005-06)
|
Maternal deaths/ 100,000 live births
(2007-09)
|
Number
of children/
women (2010)
|
Number of unwanted births/ woman
(2005-06)
|
Level
of women
empower-ment (%)
(2005-06)
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
Uttar Pradesh
(200 million)
|
27
|
29
|
359
|
3.8
|
1.5
|
34
|
Bihar
(104 million)
|
17
|
29
|
261
|
4.0
|
1.6
|
33
|
India
(1210 million)
|
44
|
48
|
212
|
2.7
|
0.8
|
37
|
Andhra Pradesh
(85 million)
|
85
|
67
|
134
|
1.8
|
0.3
|
41
|
Tamil Nadu
(72 million)
|
96
|
60
|
97
|
1.8
|
0.4
|
47
|
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.
[2] For more information on these points: see wirings of the author in blog:
kotharionindia.blogspot.com, 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.
