Health care hopes

An overcrowded maternity ward at the Government Sultania Zanana (Lady) Hospital in Bhopal. This photograph was taken in June 2009 when six women patients and a newborn died within 24 hours in the hospital. Complications during childbirth, internal bleeding, disseminated intra-vascular coagulation and other post-natal complications were cited as reasons.-A.M. FARUQUI An overcrowded maternity ward at the Government Sultania Zanana (Lady) Hospital in Bhopal. This photograph was taken in June 2009 when six women patients and a newborn died within 24 hours in the hospital. Complications during childbirth, internal bleeding, disseminated intra-vascular coagulation and other post-natal complications were cited as reasons.

The abject lack of focus on womens health has been one of the complaints of the womens movement against successive governments. By and large, elected representatives and policymakers have looked at issues concerning womens health from the point of view of controlling fertility and thereby the countrys population. Womens organisations have been wary of the emphasis on reproductive health as governments tried to push through invasive technologies presented as innovations that widened the choices before the Indian woman the standard euphemism being widening the contraceptive basket and meeting the unmet need.

Almost all governments at the Centre have shied away from addressing the main determinants of health. For example, even the much touted inter-sectoral convergence approach of the National Rural Health Mission has not taken off.

More women members in the legislative bodies will hopefully bring the issues of womens health to the forefront, especially those concerning the determinants of maternal and infant health. The Economic Survey 2009-10 made an important observation in its chapter Human Development, Poverty and Public Programmes, listed towards its very end. Quoting a report by the committee constituted by the Ministry of Rural Development, it said that at any given point of time, the calorie intake of the poorest quartile continued to be 30 to 50 per cent less than the calorie intake of the top quartile of the population though the former needed more calories because of the harder manual work it did.

The report also said that the calorie consumption of the bottom 50 per cent of the population had been consistently decreasing since 1987. Apart from the differential levels of calorie consumption within the population, within families, too, the distribution is skewed as women and girl children consume less than what they require.

The Economic Survey says that health indicators are uneven with large-scale State variations and gender variations apart from the rural-urban differences. While there has been a considerable decline in the infant mortality rate (IMR - deaths per 1,000 live births), the maternal mortality ratio (MMR) has not shown a comparable fall over time. The current MMR is 254 deaths per one lakh live births while the goal of the NRHM is to bring it to 100 and the IMR to 30 per thousand live births.

This was the same year that the National Rural Health Mission was launched to provide accessible, affordable and accountable quality health services to rural areas with an emphasis on poor persons and remote areas. According to a 2003 pilot study by the Indian Council of Medical Research (ICMR) on the estimates of maternal mortality ratios in India, the steady MMR indicates an urgent public health concern. It said: The complications of pregnancies and the births are found to be the leading cause of deaths and disability among women of reproductive age. The health problems of mothers and newborns arise as a result of synergistic effects of malnutrition, poverty, illiteracy, unhygienic living conditions, infections and unregulated fertility. At the same time, poor infrastructure and ineffective public health services are also responsible for low inadequate obstetric care.

The pilot study, conducted in Uttar Pradesh, Karnataka, Uttarakhand, Maharashtra and Delhi, came up with some interesting facts on the socio-economic profiles of maternal mortality victims. Around 50 per cent of those who died lived in semi-pucca houses, 21 per cent were from kutcha dwellings, while the rest lived in pucca houses. More than 90 per cent of those who died had used open fields for defecation; one third had no electricity in their homes and used hand pumps as a source of drinking water. About 60 per cent were illiterate. More than one fourth of those who died belonged to the Scheduled Castes, while 12 per cent belonged to the Scheduled Tribes.

The study concluded that the victims of maternal deaths had a low socio-economic standard, were illiterate, and lived in unhygienic conditions.

More than 50 per cent of the respondents in the households where maternal deaths had taken place reported that the nearest health facility was four to five kilometres away; there were no transport facilities in about 14 per cent of the cases. More than 55 per cent reported that inadequate transport facilities came in the way of treatment. The main cause of death was post-partum haemorrhage, septicaemia and anaemia..

Most of the deaths (59 per cent) had taken place at the institution (not at home) and were post-natal. The bulk of those who died were from the S.Cs (26.6 per cent), the S.Ts (11.7 per cent) and Other Backward Classes (24.47 per cent), while other caste groups accounted for 37.23 per cent of the deaths. Some 16 per cent died on the way to hospital. Shockingly, half of those who died were under 25.

In 2005, the NRHM was launched to provide accessible, affordable and accountable quality health services in rural areas, with an emphasis on poor persons and remote areas. In 2010, the MMR remains the same and affects the same kind of people.

In response to a question in the Rajya Sabha on March 16 on whether the government was planning to formulate a national policy on health with a special focus on providing quality health care to the economically weaker sections and whether it planned to make it mandatory for specialist doctors to serve in rural areas for a specified period, Minister for Health and Family Welfare Ghulam Nabi Azad replied in the negative. He said that the National Health Policy 2002 aimed to achieve an acceptable standard of good health for the general population and that the NRHM would provide accessible, affordable, accountable and effective primary health care facilities to all sections of society. He added that there was no proposal to make it mandatory for specialist doctors to serve in rural areas. In response to another question in the Upper House, the government admitted that there was a shortage of doctors.

A report by the Comptroller and Auditor General of India on the functioning of the NRHM revealed several shortcomings. Village-level health and sanitation committees have not been set up and there has been no inter-sectoral convergence on health care as envisaged by the NRHM.

The targeted new health centres have not been established and many of the existing health centres have no proper buildings, electricity and water supply, and hygienic environment. Many public health centres (PHCs) and community health centres (CHCs) offer no in-patient services and have no operation theatres, labour rooms and equipment for pathological tests, X-ray screening and emergency care. The norms require PHCs and CHCs to maintain stocks of essential drugs, contraceptives and vaccines that should be adequate for two months, but in at least nine States the PHCs and CHCs that were checked did not have them.

There was also a serious shortage of staff and service providers, and contract employees were engaged to fill in for them. There were shortages of specialist doctors at CHCs, staff nurses at CHCs and PHCs and auxiliary nurse midwives (ANMs) and multi-purpose workers at the subcentres, which are the first point of contact between people in remote areas and the primary health care system. It must be pointed out here that the ANMs play a crucial role in maternal health and deliveries.

When the NRHM was launched, the public expenditure on health amounted to only 1.23 per cent of the gross domestic product (GDP). It has not gone up substantially since, despite the multiple challenges on this front; the revised estimates for 2009-10 now account for a mere 1.45 per cent of the GDP.

The 2005-06 National Family Health Survey, or NFHS-3, revealed that 16 per cent of the women in the age bracket of 15-19 were mothers or were pregnant at the time of the survey and that 45 per cent of the women aged 20-24 years were married before the age of 18. The percentage was much higher in rural areas. Even though NFHS-3 did not compile data on girls who were married before they turned 15, the 2001 Census showed that nearly three lakh girls under 15 had given birth to at least one child.

Besides, NFHS-3 found that while female sterilisation accounted for 37 per cent of the total family planning methods used, male sterilisation, which is considered a far safer procedure, accounted for only 1 per cent.

Only 36.8 per cent of mothers had received post-natal care from a doctor/nurse or ANM within two days of their last delivery. Nearly 33 per cent of women had a body mass index (BMI) that was below normal and only a mere 14.8 per cent were found to be overweight or obese. Shockingly, 57.9 per cent of the pregnant women in the age group 15-49 were found to be anaemic, while 78.9 per cent of children in the age group 6-35 months were found anaemic.