Since the declaration of the millennium development goals (MDG) in 2000, there has been constant effort towards equitable progress. With just a year to the 2015 deadline for achieving the eight globally agreed MDGs, the need for monitoring the efforts becomes pertinent.
According to the 2013 World Bank report ‘World Development Indicators’, India stands at 56 (per 1000 live births) in infant mortality rate (IMR) world ranking. Even low-income countries like Nepal, Bangladesh, Peru and the Philippines have a lower IMR, and is comparatively better than India—achieving a higher reduction rate. Similarly, maternal mortality rate (MMR) in India (190 per 100,000 live births) continues to be alarmingly high compared with countries like China (32) and Brazil (69). The World Bank statistics also show that public health expenditure in India has remained unchanged since the 1990s (Fig 1).
According to the Ministry of Statistics and Programme Implementation, Government of India, 2009, the rate of decline is 6 percentage points annually since 2000; India is unlikely to achieve the MDG target of MMR 109 per 100,000 by 2015.
India’s challenge lies not only in meeting the high levels of health status as that of other developed countries, but to address the problems relating to disparities across geographical, social and economic differences.
Inequality in outcome and access
In 2004, the Ministry of Health and Family Welfare integrated focused planning and monitoring of Maternal New born Child Health (MNCH) services for vulnerable groups into the Programme Implementation Plans of each state under the Reproductive and Child Health Programme (RCH). For the purpose of implementation of the RCH programme in India, vulnerable groups are sorted into two categories—underserved groups due to problems of geographical access; and groups that suffer from social and economic disadvantages.
To illustrate the inequity in health outcome indicators, IMR and MMR are analysed. Full immunisation of children in the age group 18 to 23 months and safe delivery during child birth are used as an indicator to illustrate the inequity in health care services.
Infant Mortality Rate: IMR, a long-standing indicator to compute the well-being of children, measures the probability of death before the age of one year. IMR in the rural segment is 46 while in the urban segment it is 28 per thousand live births. However, it is encouraging to note that the gap between rural and urban segment in terms of IMR has narrowed significantly from a difference of 31 per thousand in 2000 to 18 in 2012 (Fig. 2). Since 2000, the reduction of IMR in India has been higher in the rural region at 4 per cent per annum while that in the urban region has been 3 per cent per annum.
As per the Sample Registration System (SRS) survey statistics for 2012 (Vol. 47 No. 2), at one end of the spectrum the IMR, states like Goa (10), Manipur (10) and Kerala (12) are already far below the MDG target of 28. At the other end, northern states like, Madhya Pradesh (56), Uttar Pradesh (53), Odisha (53), Assam (50), Rajasthan (49), Meghalaya (49) and Chhattisgarh (47) are laggards with IMR exceeding far above the MDG target. Andhra Pradesh with IMR of 41 holds the dubious distinction of having the highest IMR in south India. The data also shows that infant deaths in most states are concentrated in the rural areas. While IMR in the urban areas varies from nine in Kerala to 50 in Meghalaya, in the rural areas it ranges from 8 in Goa to 60 in Madhya Pradesh.
Maternal mortality ratio: MMR measures number of women aged 14 to 59 years dying due to any cause related to or aggravated by pregnancy per 100,000 live births. It is encouraging to note the sharp declining trend of MMR from 327 in 1999-2001 to 178 in 2010-12 (Fig. 3). The rural-urban data on MMR is not available for comparison. However, the regional data on MMR throws open stark disparities.
As per the 2012 SRS, highest MMR was recorded in Assam at 328, followed by the undivided state of Uttar Pradesh/Uttarakhand (292), Rajasthan (255) and Odisha (235). At the other end, the top three performers with lowest MMR are Kerala (66), Maharashtra (87) and Tamil Nadu (90).
It is encouraging to note that the decline in MMR in the period 2007-09 to 2010-12 has been most significant in the empowered action group (EAG) states, and Assam. The drop in MMR in the EAG states had been almost 51 points compared to all India average of 34 points.
Access and Utilisation Indicator
Safe Delivery: Newborn and maternal health crucially depends on health care by skilled professionals. While 43.3 per cent of rural women in India had safe deliveries, the proportion is 75.6 per cent in the urban segments of India (District level household and facility survey 2007-08 (DLHS-3); ‘Reproductive and Child Health Project’, International Institute for Population Sciences). Education and social position is also a significant determinant, with 31 per cent of illiterate women and 85 per cent of those with schooling of ten years or more have safe deliveries (ibid).
Besides the regional disparities in health care depicted above through the outcome indicators there also exist disparities amongst social groups. As per the DLHS-3 survey around 38 per cent of scheduled tribes (STs) and 48 per cent of scheduled castes (SCs) accessed safe delivery facilities while the corresponding proportion amongst the general population was higher at 58 per cent. While all groups reported an increase in use of safe delivery facilities over the period 2002-04 to 2007-08, the gap between other groups and the socially disadvantaged ones grew, albeit marginally, indicating that disparity remains a cause for concern.
DLHS-3 data also shows that despite government programmes targeting the socially disadvantaged groups, the situation has not improved appreciably. Thus, while the smaller states and UTs have performed relatively better on this health indicator, majority of Indian women belonging to socially disadvantaged groups continue to lack access to skilled health care.
Immunisation: Immunisation against common childhood diseases has been an integral component of mother and child health services in India since adoption of the primary health care approach in 1978. Despite several efforts taken by the government, India is far from achieving universalisation of immunisation coverage. As per the latest data released by the World Health Organisation report ‘Immunisation surveillance, assessment and monitoring’, 2013, children below 1 year being fully immunised in India is 62 per cent while other south east Asian countries like China, Bangladesh and Pakistan have attained coverage of above 90 per cent.
The disparity across states is a ubiquitous feature of all Indian data. According to the DLHS-3 results, Arunachal Pradesh, Uttar Pradesh, Meghalaya, Madhya Pradesh and Tripura had full immunisation coverage for less than 40 per cent of its children. Meanwhile, it was around 80 percent or more in Goa, Lakshadweep, Daman and Diu, Andaman and Nicobar Islands, Himachal Pradesh, Tamil Nadu, Puducherry, Punjab and Kerala. Accessibility of health services or progressive community health workers is assumed to have a strong impact on immunisation coverage.
Health Inequity and economic development
In view of the wide variations in the health outcome indicators across various levels of geography, it is important to know how inequalities in health vary with the level of economic development of states. Taking a simplistic measure of economic development as per capita gross domestic product (GDP) and health outcome indicator as IMR, we find a significantly high correlation between per capita GDP and IMR (Fig. 4). In general, states with high economic development have lower IMR and vice versa. In case of southern states like Karnataka and Tamil Nadu, despite recording lower per capita GDP as compared to many other states like Gujarat and Haryana have however achieved lower levels of IMR. On the other hand, Gujarat and Haryana, despite high economic development, continue to have high IMR.
Economic development in India is not commensurate with government spending on health (Table 1). Haryana, with a high per capita GDP, spends only 3.1 per cent of the total expenditure on health, which is lower than that of Bihar (3.5 per cent), the lowest state in terms of per capita GDP. On the other hand, government spending on health is high in the states of Rajasthan and Jammu and Kashmir.
A disaggregated study on accessibility to health care services and health outcome indicators reveal that while some parts of the country are close to achieving the MDG targets and their levels are comparable with the developed countries of the world, a large part of northern and central India are far behind achieving the targets. Economic growth along with specific targets of improvement in health status and increase in government expenditure can lead to better health status of the country.