Wednesday, 31 August 2016

India confronts epidemic of missing girl children

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


But if we want to empower women, we need men to be allies.

Co-founder of
the Bill and Melinda Gates Foundation

No doubt, in many ways, today is the best time in modern history of India to be a girl. Opportunities for a girl's successes are as unlimited as her dreams. Girls are defying all odds and showing killer Instincts. PV Sindhu, Sakshi Malik and Dipa Karmakar became the unlikely heroines and saved the country's pride from returning empty-handed from the Rio Olympics for the first time since Barcelona 1992. The trio notched a few firsts for India; Sindhu, at 21, became the youngest to win an Olympic medal, a silver which was never achieved in badminton; and Sakshi's bronze was also a first for women's wrestling. India's first female gymnast Dipa went on to miss a bronze by 0.15 points but her clean finish in the high-risk Produnova Vault won the hearts of the nation. Yet an alarm is sounding, revealing a disturbing portrait of millions of girls missing and others struggling.

It is difficult to determine how many girl children are missing due to female infanticide, selective abortion or contraceptive uses. Table 1, however, clearly indicates that in the last three censuses, India has witnessed an alarming increase in the missing girls. It is estimated that around 3 million girls in age group 0-6 have gone missing in 2011 Census. In other words, during 2001-11, on an average, the number of girls that were missing in India was 300,000 per year or 820 per day. The number of missing girls for consecutive census periods 1981-91 and 1991-2001 were 0.5 million and 2 million, respectively.

As a result India is among the countries with the worst child sex ratios in the world. The 2011 census showed that the child sex ratio, number of girls per 1,000 boys between the ages 0-6, has dipped from 945 girls in 1991 to 919 girls in 2011 (Table 1).

Table 1: Trends in population in 0-6 age group, Child Sex Ratio and estimates of missing girls (0-6 years) in India, 1991-2011.

Census Year
India : Population in age group  0-6
(in ‘000)
Child sex ratio
(girls/1000 boys)

Total
Males
Females
1
2
4
5
6
1991
150,421
77,337
73.084
945
2001
163,837
85,022
78,815
927
2011
164,540
85,750
78,790
919
Source: Kothari, Devendra. 2014. “Empowering women in India: Need for a Feminist Agenda”, Journal of Health Management, 16 (2), pp 233-43.

Latest Census numbers also cast a shadow on the adequacy of measures which are helping in educating people to not prefer sons over daughters. As per my estimates, there are fair chances that CSR will decline further and it may be less than even 900 girls per 1000 boys in the Census 2021.1 And this poses new set of challenges to the policy makers, programme managers and civil society organizations.

Now question arises: How to arrest the epidemic of missing girl children? Recently, India's Women and Child Development Minister Maneka Gandhi suggested registering the sex of every child in the womb to ensure the girl child is not killed. In other words, she suggested that child sex determination during pregnancy be made compulsory, the gender of the child registered right from that moment, and the birth be tracked. 2 It appears that she probably did not understand the complex calculus that Indian would-be parents go through - when to have a child, how many, and boy or girl. A glimpse into this intriguing decision-making process undertaken by about 25 million parents every year is provided by the Census 2011 data.

Table 2 reveals that among women who had only one child, the sex ratio was just 782 girls to every 1,000 boys born. This is much lower than the overall sex ratio of the population (943 females for every 1,000 males), and even lower than the sex ratio for children aged up to six years (919). But it is not yet the rock bottom. For women who have two children, the sex ratio plummets to 720 girls for every 1,000 boys. However, with women who have three children, it improves to 814. For women with four children, it improves further to 944 and by five children, it reaches 1,005 girls for 1,000 boys, and the gap has increased between 2001 and 2011.

Table 2: Calculus of choice – lesser the number of children in a family, worse the sex ratio.

Sex ratio 2001
Children in family
Sex ratio 2011
1
2
3
786
1
782
742
2
720
815
3
814
928
4
944
983
5
1005
905
All
890
Source: Census of India 2001 and 2011. Also refer news article by Subodh Varma at: http://timesofindia.indiatimes.com/life-style/health-fitness/health-news/Sex-selective-abortions-go-on/articleshow/50991656.cms.

Table 2 indicates that the sex ratio is poor when women have one or two children, but gets better as they have more children. Two factors are at play here, according to population expert, Prof. PM Kulkarni. One is sex-selective abortions and the other is sex-selective "stopping practices", which is stopping having children based on sex of those born. "Those women who stop childbearing if the first one or two births are sons remain in the category of 1-2 children and those who go on for another child because the first two or three births are daughters get into the category of 3 or more children (that is, there is selectivity). As a result, the sex ratio of children of women with one or two children becomes highly masculine and, for the children of women with 3 or more children, less masculine. 3

A survey, conducted by the Forum for Population Action in a community inhabited by the middle and lower classes in Jaipur, Rajasthan, India in 2010, also revealed a similar pattern (Table 3). The main objective of the survey was to understand the fertility preferences and contraceptive uses. Around 200 couples were selected randomly with the help of local telephone directory who married between 1990 and 1995. Though the sample size is small, findings indicate a strong preference for sons as well as of the small family norms. The survey findings clearly indicate that Indian women with son (s) are more likely to stop having children than those with any daughters; also indicate a strong relationship between family size and the proportion of female children in a family.

Table 3: Distribution of couples by number of children, Jaipur, India 2010.

Couples with:
Number of couples
Percent of total couples
1
2
3
No children
3
1.5
One son
16
8
Two sons
21
10.5
One daughter
5
2.5
Two daughters
14
7
One son and one daughter
39
19.5
One daughter and one son
42
21
More than two children
58
29
Did not answer
2
1
All
200
100
Source: Devendra Kothari. 2010. Fertility preferences in an urban locality, Rajasthan: An analysis of survey data. Forum for Population action, Jaipur, India. FPA Occasional Paper 8.


The foregoing analysis, based on the census and survey findings, clearly indicates that once couples in modern India have desired number of son(s), they do not go for another child. And that is an important intermediate factor contributing in lowering the CSR in India. In other words, the daughter aversion is essentially an outcome of desire of small family coupled with son preference. To achieve the objective, couples adopt various measures including infanticide, selective abortion and contraceptive use. An analysis of National Family Health Survey-3 data indicate that sex ratios of all last births and last births of sterilized women show clearly that couples typically stop having children once they have the desired number of sons. The role of ultrasound, which was widely used for sex selection earlier, has gone down significantly in recent times. According to NFHS-3 data it is more evident among the the wealthiest women than for women in the other wealth quintiles.

So declining child sex ratio is not only the the result of “sex-selective abortions” or “infanticide” but also due to “sex-selective "stopping practices" like sterilizaton. And later could be most important reason b why India is confronting with epidemic of missing girls.

How to gorge ahead?:
Now question arises why couples avoid a birth of a girl child? It is widely observed hat growing up as a girl in India is a challenge in itself. Girl/woman is made to feel like it is all her fault. It is just like that when investigating crimes of passion, the French police are said to use the mantra – 'cherchez la femme' (find the woman) in establishing a motive. This preconceived notion that whatever the ills afflicting us, from crime to unemployment, girls/women must be at the root of them is gaining ground in India's male-oriented society, as noted in the TOI editorial. 4

Much of the discrimination is to do with cultural beliefs and social norms which have become more pronounced in the  deteriorating governance and low and order. There has been a continuous rise in the incidence of crimes committed against women over the years. Girls are raped, beaten, dumped even in the metros like New Dehli. Raising a girl child in such situation is very difficult. Women who live in such environment where they are made miserable through injustice and inequality may not want to raise daughters who will live lives as unhappy as their own. Women have used this excuse as a rationale for killing their girl children in the womb or avoiding them. Frankly and truthfully speaking, in the changed situation, a sizable number of Indians especially females do not want a female child since female children in India continue to get a raw deal in most cases. One can ask questions: Save girl child for what? Eve-teasing? Dowry? Rapes? Domestic violence? This what we have in store for them. This is why we want to save them?

This prevailing view is being supported by Taslima Nasreen - a writer, a feminist, and a secular humanist in her thought provoking article entitled: ”It’s a girl!” ”Kill her”. 5  “The women who support female feticide say: 'It is better that an insufferable life ends before it can begin. It is better to go straight to heaven than stay alive and endure the kicks and blows of the world.' Are they wrong in saying this? This society is not a fit place for girls, so it is better not to allow them to be born”, argues Nasreen. Further, in India irrespective of the caste, creed, religion and social status, the overall status of a woman is lower than men and therefore a male child is preferred over a female child. In such an environment why one should like to have a girl?

What do one does then? Avani Bansal, a crusading women's-rights lawyer, suggests a radical prescription: “You (girl) should get up, where ever you are, to show in your own way that society is concerned about the wrong things. The people around you are focusing on the wrong things. ...Tell them to be concerned not about the length of your skirt, but the quality of education that they are providing you. Tell them to be concerned not with how much you mingle with boys, but the equality of opportunity that they can secure for you.” 6

What Avani is suggesting that girls ( or women), you raise your voice against injustice to promote gender equality. Whether this prescription will work in present India where most of the power is primary wielded by men? India ranks 130 out of 155 countries in the Gender Inequality Index (GII) for 2014, way behind Bangladesh and Pakistan that rank 111 and 121 respectively, according to data in the United National Development Programme's latest Human Development Report 2015.


It appears that gender inequality (and discrimination) remains a major barrier to women empowerment. What do we do then? No doubt, expanding education and employment opportunities will help in achieving gender equality but that may take more time. To expedite the process, “we need men to be allies”, as argued by the Co-Chairman of the Bill and Melinda Gates Foundation, Melinda Gates, in her recent article, Women Transform Societies, based on Indian experiences. 7 The Foundation works with partner organizations in India to tackle critical problems in four areas including issues related with women and girls in crisis. Expanding her argument, she writes: “women's empowerment can't be just about women; it also has to be about men - the fathers, brothers, husbands, and sons – with whom they live their lives.” it is because in many cases “..it's men who upholds harmful social norms that stand in women's way”.

So do not exclude men – fathers, husbands, brothers, and sons, they have to be positively engaged to be part of the women empowerment campaign. And such campaign “should drive home the point that girls are to be celebrated.”, noted by Jayashree Dengl, Executive Director of Plan India, a community development NGO focusing on the girl child.

Fortunately, there are many successful examples of public awareness campaigns in India that use male role models to promote gender equality, and such efforts have to be expanded especially in rural areas of north India.

On top of these grassroots strategies, we have to create conducive environment for women empowerment at a larger scale and across economic strata. In my recent paper, Empowering Women in India: Need for a Feminist Agenda, it is argued that there is an urgent need to formulating a feminist agenda to empower women living in highly patriarchal and traditional surroundings with several obstacles.8 The ‘agenda’ must based on the premises that no doubt efficient policing, stringent punishments and legal measures would reduce the incidences of crime against women but these cannot eliminate growing gender inequality in India unless and until the mindset of the society is changed. The article suggests that women-centred reproductive health care along-with enlarged education and employment opportunities for females may alter patriarchal constructs despite strong structural resistance. And this feminist agenda will contribute significantly towards women’s empowerment and reduce gender gap significantly .

India is very lucky that present government under the leadership of Prime Minister Narendra Modi, recognizes that gender equality is part and parcel of the country's future; and campaigns like “Beti Bachao, Beti Padhao (Save the girl child, educate the girl child) will help to arrest the epidemic of missing girls by removing the gender inequality. This campaign has to deal with issues at the larger scale and across the economic strata by involving men.




1 Kothari, Devendra. 2011. Implications of Emerging Demographic Scenario: Based on the Provisional Results of Census of India 2011, A Brief, a publication of Management Institute of Population and Development. Parivar Seva Sanstha, New Delhi.

2 Refer: http://www.firstpost.com/india/compulsory-sex-determination-manekas-idea-is-ingenious-but-hasnt-been-thought-out-2607812.html.

7Refer article by Melinda Gates at: Blogs.timesofindia.indiatimes.com/toi-edit-page/women-transform-societies/

8 Kothari, Devendra. 2014. “Empowering women in India: Need for a Feminist Agenda”, Journal of Health Management, 16 (2), pp 233-43. Also refer articles by the author entitles “Explaining India’s missing girls” (Part I, II and III) athttp://kotharionindia.blogspot.com/2012/10/explaining-indias-missing-girls-part-i.html;otharionindia.blogspot.com/2012/11/explaining-indias-missing-girls-part-ii.html and http://kotharionindia.blogspot.com/2012/12/explaining-indias-missing-girls-part-iii.html.56.cms.   
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Sunday, 10 July 2016

Unwanted childbearing: a huge concern for India

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


Happy World Population Day 2016

From Adam Smith onward, economists have recognized important linkages between population and socio-economic development. Yet, the attention given to these linkages in current development thinking in India is not very clear. This is because one can argue that it is not rapid population growth but rather weak government, corruption and social injustices that are preventing economic and social development. The counter argument is that rapid population growth exacerbates the problems of governance, corruption and social injustice. However, one has to recognize that population is an important factor in development, especially when it is growing seemingly out of control since it leads to a significant diversion of national investable resources to consumption which could otherwise be used for increasing investment and productivity and for improving the quality of public services such as education, health, sanitation, provision of safe drinking water, etc.  

With 1.27 billion or 127 crore people and still growing, India is getting dangerously overcrowded. India is currently the second most populous nation in the world. It will surpass China as the most populous within 3-4 years. Many Indians including policy makers see these emerging demographics as a critical advantage in competition with China. With around 70% of the population under 35, India can afford to dream to become economic power in the world before the middle of this century. However underneath, this rosy outlook for India epitomizing the country’s ability to surpass China on the back of a younger population lays some difficulties, especially deteriorating level of education. It is not enough to have lots of young people — these young people need to be properly educated to fully contribute to the economy. Today, more children are going to school but what they are learning is not clear.

How to mange unwanted fertility? A popularly held belief by India’s policy makers is that as a country becomes economically more prosperous, its fertility declines significantly and leads to a stable population. However, this is a simplistic view of a complex phenomenon.  Since the introduction of market-based economic reforms in 1991, India has become one of the fasted growing major economies in the world. The reforms completed 20 years in July 2011, however, during this period, India’s population increased by 365 million, much more than the population of USA - the third most populous country in the world.  This raises the question: Is Development the Best Contraceptive or Are Contraceptives?  It is argued that there is a need to go beyond the prevailing notion that socio-economic development is an essential precondition for fertility transition, since it provided only a partial explanation for the monumental changes taking place in fertility behavior, especially in low-income economies like Bangladesh.

More than four in ten pregnancies are unintended by the women who experience them, and half or more of these pregnancies result in births that spur continued population growth. In addition, it is estimated that currently there are around 460 million people out of 1270 million in India who are product of unintended/unplanned pregnancies, and most of them are from the lower economic strata. The consequences of unwanted fertility are serious, slowing down the process of socio-economic development. While India’s population continues to grow by 17-18 million people annually, 15 million married women in the reproductive ages, mostly in the Four Large North Indian (FLNI) States of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, seek to postpone childbearing, space births, or stop having children, but are not using a modern method of contraception that is having unmet need for family planning services. Often, these women travel far from their communities to reach a government health facility, only to return home “empty handed” due to shortages, stock outs, lack of choices and/or non availability of doctors and paramedical staff. When women are thus turned away, they are unable to protect themselves from unwanted pregnancies.   Approximately two-thirds of such pregnancies resulted from non-use of contraceptives; clearly indicating the need for easy availability of quality family planning services. The program has largely failed to encourage the use of reversible methods, particularly among young women (15-25) who are in the most fertile years of their reproductive period. In addition, around one-third of unintended pregnancies resulted from the ineffective use of contraceptives, which suggests the need for improved counseling and follow-up of couples that adopt a method. In other words, there is a tremendous need to revamp the family planning program in India to provide services looking to the needs of clients.

Incidence of unintended frequencies can be dramatically reduced, if not eliminated, within a decade by revamping family planning program,   as has been done in Andhra Pradesh.  If Andhra  - with little outside help - can manage its galloping population issue under relatively low literacy and high poverty, there is no reason why FLNI States, with lesser problems and with increasingly generous support from the Centre under National Rural Health Mission (NRHM), should fail so spectacularly in managing unwanted fertility.  It appears that the population and related issues have not been given due importance in the development debate of India. Demography, therefore, in the next 10 years or so will pose serious challenges to economic growth, democracy and national unity by its sheer size. The writing is on 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.

For further details, see: Kothari, Devendra and Sudha Tewari. 2009. Slowing Population Growth in India: Challenges, Opportunities and the Way Forward. MIPD Policy Brief No. 2, Management Institute of Population and Development, (Parivar Seva Sanstha, New Delhi). Also see Blog: kotharionindia.blogspot.com for articles on population and development.


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Thursday, 30 June 2016

India needs efficient healthcare system for overall development

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


Happy Doctors’ Day 2016!

"At the moment, India is on the edge and it can take two routes. It can take a route of investing in health and investing in its people and creating a thriving and flourishing future for India which has a part to play in world affairs or it can do what it is doing now and ignore health in which case it will see epidemics sweep across the country creating an unsustainable future and destroying national security.”

Lancet's editor-in-chief Richard Horton.


The world's most revered medical journal - The Lancet - has censured severely Government of India for ignoring health sector and has warned that India is on the “verge of a collapse under the weight of its own ill health”. In an exclusive interview to Times of India, Lancet's editor-in-chief Richard Horton said that failing to combat non communicable diseases like diabetes and heart disease and reduce maternal and child health will cost India's health system and social care "enormously making India collapse”. [1]

Horton’s comments have stirred the ire of Indian health officials, who called them "derogatory" and "not borne out by evidence.  The Ministry of Health and Family Planning   sent a strong worded letter to him and noted that “India has moved from strength to strength and some recent initiatives will ensure improved outcomes for the most vulnerable”. The letter added that the country has made great strides in reducing infant and maternal mortality through its immunization programs as well as increased efforts to control drug-resistant tuberculosis and HIV. [2]

No doubt, in recent years, India has managed to control communicable diseases like malaria, cholera and polio. However, the nation now has to deal with a new breed of lifestyle diseases like diabetes and cardiovascular ailments. Coupled with a sedentary urban lifestyle, increased alcohol consumption and smoking, the urban youth are particularly prone to the aforementioned lifestyle diseases. In addition, large health disparities between states, between rural and urban populations, and across social classes persist. Further, a large proportion of the population is impoverished because of high out-of-pocket health-care expenditures and suffers the adverse consequences of poor quality of care.

Healthcare in India is a big mish mash of great achievements as well as miserable failures. On one hand, we have medical tourism and cutting edge equipment as well as technology and the other we have kids dying of undernourishment and people with treatable conditions. In other words, despite substantial improvements in some health indicators in the past couple of decades, India contributes disproportionately to the global burden of disease, with health indicators that compare unfavorably with other middle-income countries and India's regional neighbors. Known as the diabetes capital of the world, for example, India has about 70 million people with diabetes, which makes a significant proportion of working population. Even its South Asian neighbors like Bangladesh, Nepal, Afghanistan and Sri Lanka have fewer diabetics. Only Pakistan fares worse. One can easily prevent diabetes by effectively controlling its various risk factors such as smoking, obesity and inactive lifestyle.

 

India has neglected its health care, as per the Geneva-based World Economic Forum (WEF).   According to the latest Human Capital Index, released by WEF in June 2016, India ranked low at 105th position globally on the Index, which measures countries' ability to nurture, develop and deploy human capital for economic development. Finland topped the list. India ranks much below China's 71st position while Bangladesh, Bhutan and Sri Lanka are also placed higher on the index. Giving India 105th rank out of the total 130 countries, WEF said the country has optimized just 57 per cent of its human capital endowment - placing it in the top of the bottom quartile of the index. Among BRICS countries, India is ranked lowest as against Russia's 28th, China's 71st, Brazil's 83rd and South Africa's 88th. It is interesting to note that India was ranked 100th last year out of total 124 countries.

The post argues that India needs an effective healthcare system, which addresses both acute and chronic health-care. Also, it must offer choice of care that is rational, accessible, and of good quality. For this, India needs to “adopt an integrated national health-care system built around a strong public-primary care system with a clearly articulated supportive role for the private and indigenous sectors”, as argued by the researchers in their paper published in The Lancet. [3]  In addition, India has to establish effective regulatory mechanisms to monitor the cost and quality of healthcare system.

Despite rapid economic growth over the past two decades, successive union governments have failed to invest generously in health. Most of the challenges facing India’s health system can be attributed to underinvestment and the inefficient use of resources, as argued by Dr. Prabhat Jha of the Centre for Global Health Research, University of Toronto. [4]  Further, the promise of universal health coverage will remain unfulfilled unless health is prioritised, as noted by Dr.  K. Srinath Reddy, President of the Public Health Foundation of India. [5]  In addition, an inadequate number of doctors and a poor network of public hospitals, coupled with bureaucratic bungling, means India often struggles to spend even its allocated budgets.

Asia's third-largest economy spends around 1 per cent of its gross domestic product (GDP) on public health, compared with 3 per cent in China and 8.3 per cent in the United States. (Indian states manage their health budgets separately.) As a result, the per capita spending rates are extremely low at US $ 109 (in Purchase Power Parity terms) as compared to the USA ($7,285) and Brazil ($837). The global figure is US$ 863 (WHO World Health Statistics 2010). As such, there is an urgent need to increase the budgetary allocation for health.

With government expenditure on health as a percentage of GDP stagnant or falling over the years and the rise of unregulated private healthcare sector based on the profit motive, the poor are left with fewer options than before to access health care services. Most healthcare expenses in India are paid out of pocket by patients and their families, rather than through insurance. This has led many households to incur Catastrophic Health Expenditure (CHE) which can be defined as health expenditure that threatens a household's capacity to maintain a basic standard of living. One study found that over 35 per cent of poor Indian households incur CHE and this reflects the detrimental state in which Indian healthcare system is at the moment. [6]  As per Dr. Reddy, Indian health system allows 63 million of its people to sink into poverty each year as a result of unaffordable health care costs. That could be reason, why Lancet's editor-in-chief Richard Horton has warned that India is on the “verge of a collapse under the weight of its own ill health”. 

The healthcare insurance is slowly picking up pace in India. But the pace of increase is very slow.  According to an Indian government study about 17 per cent of India's population had some form of health insurance in 2014.  Government or public healthcare is free for those below the poverty line in many States of India, but there is a question of quality. The NSSO survey (released in April 2016) found  that people rely more on private hospitals, with over 70 per cent spells of ailment (72% in rural areas and 79% in urban areas) being treated in the private sector. As such, government has to expand insurance coverage. Plans are currently being formulated for the development of a universal health care system in India, which would provide health coverage through “national health assurance”, as per the draft National Health Policy (NHP) 2015. Some community health insurance schemes targeting poor families in different states are showing encouraging trends. The governmental agencies need to expedite its role to play a more active role in facilitating and ensuring health insurance coverage for people, particularly the poor.

In addition, there is an urgent need to develop an effective healthcare delivery system, which addresses both communicable and non-communicable healthcare needs. For this, India needs to adopt an integrated national healthcare system built around a strong public primary care system with a clearly articulated supportive role for the private and indigenous sectors, as noted earlier. Now question arises how to achieve this?

A major barrier to service delivery is the severe shortage of qualified health care personnel. Although there are around 400 Indian medical colleges with an annual intake of 52,000 students, there are shortages of both generalist and specialist doctors, which are aggravated by urban concentration and emigration, noted by Dr. Reddy. Shortfalls of properly trained nurses and allied health professionals are even more acute.

Recently, GoI has taken steps to address the problem of shortage of medical professionals.  The Medical Council of India, responsible for medical education, is set to be replaced by a Medical Education Commission as per the Niti Aayog Panel (formerly Planning Commission). The panel has framed the detailed guidelines to ensure a wider talent pool to bridge shortages of skilled health workers and address a major hurdle in meeting growing quality healthcare needs.

How to provide health care services on ground? The draft National Health Policy 2015, which provides a broad roadmap for health system reforms, calls for strengthening primary care services to provide comprehensive care for several health conditions including non-communicable diseases.  Further, continuity of care would be ensured through linkages with secondary and tertiary care facilities. Both public and private sector providers would be engaged to deliver the service package, which would be paid for by the government-funded health insurance schemes, as noted by the draft NHP.  

No doubt, the draft NHP 2015 is an improvement over its predecessors of 1985 and 2002. However, it does not “provide a more concrete road map with doable timetables and practicable end-points”, as argued by the Forum for Medical Ethics Society. [7]  Looking to the ground realities, we suggest the following broad interventions to provide healthcare services (details will be worked out later).

Firstly, there is an urgent need to reevaluate the existing public primary healthcare system.  Presently there are about 23,100 Primary Health Centres (PHCs) in India.  They were established to provide preventive and promotive health care with special reference to maternal and child health as well as family planning services. However, they have gradually become clinical centres. There is an urgent need to concentrate on reproductive health (maternal and child health and family planning). 

Although there has been progress with child and maternal mortality, India has the highest number of child and new born as well as maternal deaths in the world. Two million children still die every year due to preventable causes. The World Bank estimates that the prevalence of underweight children in India is among the highest in the world with dire consequences for productivity and economic growth. [8]  Further, winner of the 2015 Nobel Prize in Economics Prof. Angus Deaton, who spent a considerable amount of time working on ‘stunting’ among Indian children, concluded that widespread growth faltering was a human development disaster  as height reflected early life nutrition which helps brains to grow. [9]  In addition issue of unwanted fertility is very serous one. India’s population has grown from 846 million in 1991 to 1210 million in 2011- that is by 364 million  in the twenty years,  and is still growing by around 17 to 18 million every year. Current population growth is mainly fuelled by unwanted fertility.   More than four in ten pregnancies are unintended/unplanned or simply unwanted by the women who experience them and half or more of these pregnancies result in births that spur continued population growth.   Today 26.5 million babies are born each year and out of this about 6 million births could be classified as unwanted or unplanned. [10]  The consequences of unintended pregnancy are serious, slowing down the process of socio-economic development as well as process of change, and is being reflected in widespread hunger, poor health, poverty, under educated labour force, unemployment,  regressing governance as well as increasing scarcity of basic resources like food, water and space despite concerted developmental efforts since 1991.

As such, existing Primary Health Centre should be the cornerstone of reproductive health services. Effective reproductive health practice requires skillfully combining a number of theoretical models and frameworks to support systems addressing the health needs of women, children, and families. Future improvements in RH should be built on this legacy but it will come only from a 'paradigm shift' in primary health practice, as noted by Dr. Starfield  in her recent paper entitled “ Politics, primary healthcare and health: was Virchow right?” . She writes  further,  “primary healthcare provides a considerable contribution in reducing the adverse impact of social inequalities in health”. [11]

Secondly, the general medical/clinical care will be provided in a given jurisdiction by the General practitioners (GPs) both in rural and urban areas.  In the medical profession, a general practitioner is a trained medical doctor who treats all common medical conditions both acute and chronic illnesses and refer patients to hospitals and other medical services for urgent and specialist treatment. They focus on the health of the whole person combining physical, psychological and social aspects of care. Also, GPs may be routinely involved in pre-hospital emergency care, community hospital care and performing low-complexity surgical procedures. The government may provide some basic facilities like space, essential equipments, etc.   to run the services. The contract is (re)negotiated every 5 years. The units will be fully computerized, that is, with computer-based patient records. GPs will be the corner stone of Indian healthcare system at the bottom in the proposed framework.

The secondary healthcare will be provided by a specialist or facility at the District/Tehsil level hospitals or Community Health Centers upon referral by a primary care physician including GP and that requires more specialized knowledge, skill, or equipment.

There has been mention of public-private partnerships for tertiary care in the NHP 2015, but this has yet to take concrete shape by imposing pubic duties on private professionals and hospitals. In our proposed model, most of the tertiary care will be taken care by the private sector, and referred cases will be paid by the public exchequer or through insurance. Recently, GOI has decided to invest to the tune of Rs 30,000 crore in 10 institutes of medical sciences (Like AIIMS). According to Ministry of Health and Family Planning setting up of these “institutes would address regional imbalances in availability of affordable and reliable tertiary health care services”. In addition, GoI would spend a very large amount as recurring expenses to run these institutes.  I think such amount could be spent as subsidy to help poor and middle class patients to avail tertiary care at the private hospitals

Lastly, the disease profile is changing rapidly in India. Modern science through improved sanitation, vaccination, and antibiotics, and medical attention has eliminated the threat of death from most infectious diseases. However, the World health organization has identified India as one of the nations that is going to have most of the lifestyle disorders in the near future. Nowadays, not only are lifestyle disorders becoming more common, but they are also affecting younger population. The population at risk shifts from 40+ to may be 30+ or even younger. Already considered the diabetes capital of the world, India now appears headed towards gaining another dubious distinction of becoming the lifestyle-related disease capital as well. A study conducted jointly by the All India Institute of Medical Sciences and Max Hospital shows the incidence of hypertension, obesity and heart disease is increasing at an alarming rate, especially in the young, urban population. As such, effective public health measures are urgently needed to promote physical activity.

In addition to sports, yoga needs to be promoted as a non-sectarian wellness initiative. On the occasion of the second International Yoga Day, Prime Minister Narendra Modi has done well to highlight the non-sectarian character of yoga. Emphasizing that yoga was not religious in nature; he asserted that the traditional practice was even meant for atheists. Moreover, he described yoga as an instrument that provided health assurance with zero spending. A mass movement that promotes yoga can be one way of following the dictum that prevention of ill health is better than cure.

The National Cadet Corps is the Indian Military cadet corps and it is open to school and college students on voluntary basis. Now few schools and colleges are continuing with this activity. The cadets have no liability for active military service once they complete their course but it helps in grooming the youth of the country into disciplined and healthy citizens. The Government of India must rethink about reintroducing it in all the   schools and colleges on the voluntary basis.

Many more such initiatives need to be facilitated. All these    can and should be used to tackle lifestyle diseases especially obesity and diabetes. This in turn can help the country save millions of rupees that are lost to early onset of illnesses among people. But such initiatives cannot become a mass movement if any of it is made mandatory and forcibly pushed down the throats of people, schools or colleges. The challenge of promoting physical activity is as much the responsibility of government, as of the people. And India must take it seriously. 

In conclusion, most Indians, who pride themselves on being part of the world’s fasted growing economy, “miss a heartbeat when they read about India’s grossly inadequate healthcare infrastructure”. [12]  Not enough hospital beds (less than nine for 10,000 patients). Not enough doctors (just seven per 10,000 patients). Not enough medicines. Not enough preventive healthcares.  Despite some impressive gains, India’s health continues to lag behind that of many of its Asian neighbors. Basic services like water, sanitation and sewage systems at best remained patchy barring some larger towns, and that may be the main cause of communicable diseases.

No doubt, Indians deserves better healthcare. For this, India needs to re-define its vision for healthcare. The above discussions provides broad picture to revamp the existing healthcare system to make it pro people especially pro poor.  However, this needs a bigger mindshare of the healthcare planners. The plan must also focus on fixing issues of providing clean safe water. In our zest to build toilets as part of Swacchh Bharat campaign it is essential not to forget that we also need a robust sewage system that works and is built to last. In addition, any plan to revamp the healthcare must rely on appropriate induction of technology. Today, digital technology, electronic health records, wearable sensors make it possible to remotely deliver healthcare and these must be part of the healthcare plan.

As per WHO report, India is fast turning as the world capital of lifestyle diseases, as noted earlier.  Just to give a number, there are some 70 million diabetics currently and another 70-80 million who will get it in the next 5 years in India and plenty will not get diagnosed. The abnormal thyroid prevalence in India is over 8 per cent. These are significant numbers that burden human productivity and have an impact on the national economy.

Prime Minister Modi is leading from the front. He is a leader with immense energy and commitments to the people. He must take concrete steps that “create an entitlement for all citizens to equitable, high quality services”. Otherwise it will defeat his development agenda.

In an interview to Times Now on June 27, 2016, PM Modi said: My development parameter is simple: how the poorest of the poor benefit from development. The poor is the central focus”.  In this agenda, we think, health and education are intrinsically important, as argued earlier. [13]  A society that does not provide quality universal healthcare and universal primary education is “morally repugnant in this day and age”.   



[1]. Refer at: http://timesofindia.indiatimes.com/india/Brtish-medical-journal-Lancet-to-take-Modi-to-task-for-ignoring-health-sector/articleshow/49484703.cms. 

[2]. Refer at: http://www.fiercepharma.com/regulatory/indian-health-officials-slam-lancet-editor-s-comments.

[3]. Refer article:  Patel, et al. 2015. Assuring health coverage for all in India, The Lancet, vol. 386 (10011), p. 2422-2435.

[4]. Jha and Laxminarayan. 2009. Choosing Health: An entitlement for all Indians, Centre for Global Health Research, Toronto.

[5] . Reddy. 2015.  India's Aspirations for Universal Health Coverage, N Engl J Med (373), pp.1-5.

[6] Refer article: “Catastrophic Health Expenditure and Poor in India: Health Insurance is the Answer?”  by T V Sekher at: http://iussp.org/sites/default/files/event_call_for_papers/T.V%20Sekher-IUSSP%20pdf.pdf

[7]  Refer article: “National Health Policy 2015”, Economic & Political Weekly, Vol. 50, Issue No. 36, 05 Sept, 2015.

[8] Refer:  World Bank, India Malnutrition Report, 2009 at: http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/223546-

[9] Angus Deaton. 1913. The Great Escape: Health, Wealth, and the Origin of Inequality, Princeton University Press

[10] Kothari, Devendra. 2014. “Managing Unwanted Fertility in India: Way Forward”, Institute of Economic Growth (ed.):   National Rural Health Mission: An Unfinished Agenda, New Delhi: Book Well, pp.25-36. 

[11] Starfield, Barbara. 2011. Politics, primary healthcare and health: was Virchow right? Journal of Epidemiology & Community Health; Vol. 65 (8), p 653-55. 

[12] Refer article:  Healthcare system in India at http://omanobserver.om/healthcare-system-in-india/ 

[13] Refer, author’s article: Two-Year in power, the Modi Government needs greater clarity of purpose, at http://kotharionindia.blogspot.in/2016/05/india-needs-to-be-as-wary-of-unlocking.html


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