Public health

Grim picture

Print edition : August 07, 2015

At a anganwadi centre at Syed Murthusha school campus in Tiruchi. Photo: G. GNANAVELMURUGAN

A worker serving breakfast for children at an anganwadi centre, a feeding centre operated by the Integrated Child Development Services, at Semahado village in Maharashtra. Photo: Bloomberg

A survey conducted by the Women and Child Development Ministry and UNICEF in 28 States and Delhi presents a dismal picture of crucial maternal and child health indicators.

ONE OF the success stories that successive governments at the Centre have regularly narrated is the improvement in maternal and child health indicators, including coverage of various facilities and services that directly or indirectly affect the health and well-being of these cohort groups. However, a selective release of a household-cum-facility-based survey conducted by the Women and Child Development Ministry and the United Nations Children’s Fund (UNICEF) in 28 States and the Union Territory of Delhi shows that there is much left to be done. The Rapid Survey on Children (RSOC), which was conducted in 2013-14 to strengthen the existing data system on women and children, focussed on select indicators at the national and State levels. The indicators covered aspects of child development, maternal care, school/college attendance, age of marriage, early childhood care, access to drinking water, toilet facilities, and awareness and utilisation of six Integrated Child Development Services (ICDS) scheme facilities.

The National Democratic Alliance (NDA) government, which was formed in June 2014, kept the survey findings under wraps for almost a year despite queries in Parliament about the status of the report.

In July this year, as murmurs about the secrecy shrouding the report began getting louder, the Ministry put out the national figures on its website. The publication of some of the findings in an international political journal, which said the data indicated an improvement in the indicators, raised suspicions that the survey details had been selectively leaked. For some reason, data relating to the States have not been revealed, but Frontline, among others, was able to gain access to these details. The data obtained from surveys conducted by the Socio-Economic and Caste Census (SECC) and the National Sample Survey Office (NSSO) on the consumption of health services do not speak favourably of the claims made about progress made in recent times on the socio-economic front. So the only plausible reason for not releasing the RSOC data could be the dismal performance indicators they threw up with regard to some Bharatiya Janata Party (BJP)-ruled States, including Gujarat.

The Congress said the NDA was perhaps reluctant to release the State-wise figures as the survey found significant improvement at the national level and in Congress-ruled States. While this may be true for southern States known for their social sector investments, such as Kerala and Tamil Nadu, credit for improvement in the indicators cannot be attributed at random especially when social sector expenditures in the Union Budget continued to be low. The latest country report of the U.N. Millennium Development Goals for India indicates that the national targets are far from being met. Hunger, it says, remains a challenge for India and much needs to be done to reduce maternal mortality and to reach desirable sanitation levels. The RSOC survey is but an affirmation of all this and more.

The respondents included the heads of households and married women in the age group of 15-49 and those who were pregnant at the time of the survey. Some 105,483 households and 5,630 anganwadi centres were covered and 210,000 interviews were conducted to collect information on nutrition status. The height and weight of 90,000 children in the 0-4 age group and 28,000 girls in the 10-18 age group were measured. The survey was modelled on the National Family Health Survey (NFHS) module. The selection of the primary sampling unit, the household and the anganwadi centre, was on the lines of the sample chosen for the NFHS.

The RSOC was commissioned by the United Progressive Alliance (UPA) government towards the end of its second term (2009-14) and was completed in 23 weeks, from the third week of November 2013 to the second week of May 2014.

The survey’s national-level data do not give an encouraging picture. While the rates of registration for pregnancy (84 per cent) and pregnant women who received at least one antenatal check-up were reasonably high, institutional deliveries were below 80 per cent. However, the percentage of fully immunised children, at 65.2 per cent, was not satisfactory. The survey found that only 45.5 per cent of the children enumerated were breastfed within an hour of childbirth. But, breastfeeding rates in the age cohort of zero-five months, at 71.6 per cent, showed a slight improvement.

High rate of stunting

A high rate of stunting was found in the zero-59 months cohort: 38.8 per cent of the children were found stunted; 17.4 per cent were severely stunted (the rates were higher for children belonging to the Scheduled Castes (S.Cs), Scheduled Tribes (S.Ts) and Other Backward Classes (OBCs) compared with the Others category; 15 per cent were wasted and 4.6 per cent severely wasted. Nearly 29.4 per cent of the children were underweight and 9.5 per cent severely underweight. Only 13.3 per cent of the children in the six-59 months age group received iron and folic acid supplements; 45 per cent received vitamin A supplements; and 27.6 per cent were administered dewormers. Only 54.1 per cent of the children who suffered a bout of diarrhoea were given oral rehydration therapy or home available fluids.

The national rates for attendance at preschool at the ICDS centres for ages three to six were 37.6 per cent with 30.8 per cent opting for pre-school education at a private centre and 27.1 per cent not getting any form of preschool education. The registration of births of children below five was 72 per cent but only 37.1 per cent had birth certificates. Some of the shockers thrown up by the survey are that 30.1 per cent of the women were married before 18 years of age, 12.4 per cent of the adolescent girls in the 15-19 age group were married, and 6.2 per cent of the girls in the 10-19 age group were married.

As many as 53 per cent of the girls in the 15-18 age group had a low body mass index (BMI) and only 4.3 per cent were overweight. Another worrying feature pertaining to rural India found by the survey was that the level of awareness of and access to ICDS facilities was low although knowledge about the availability of supplementary nutrition at ICDS centres and immunisation services was high.

The level of sanitation continued to be poor. Some 44.8 per cent of the respondents still practised open defecation and only 42.7 per cent had access to improved sanitation facilities. The only silver lining appeared to be access to some source of drinking water, which was as high as 92 per cent but far below universal standards. Consumption of iodised salt was confined to 67 per cent. While 52.4 per cent of the children in the age group six to 35 months received supplementary food at the ICDS centres, only 45.2 per cent of those in the 36-71 months age group did so. Only 42.1 per cent of pregnant women and 44 per cent of lactating mothers got the benefit of supplementary food from the ICDS centres.

The ICDS centres were found to be ill-equipped—only 40.5 per cent of them had their own buildings, 52.7 per cent had a separate kitchen, 43.4 per cent had toilet facilities, and 44.7 per cent had drinking water facilities. Only 32.4 per cent of the centres had electricity connections and only 29.3 per cent of the centres were found providing all the six services: supplementary nutrition, preschool education, immunisation, nutrition and health education, health check-ups and referrals. Anganwadi workers, on the other hand, showed a high level of knowledge with regard to intake of food required by pregnant women, the acceptable normal birth-weight of children and the need to initiate breastfeeding in the first one hour after delivery.

Had the survey sought to find out if the burden of work was high on ICDS workers, it would have got a high percentage of answers in the affirmative. ICDS centres continue to play a crucial role in providing supplementary nutrition to pregnant women, lactating mothers and children in the zero-six cohort but workers and helpers engaged in these centres seldom get their due in the entire structure.

Another aspect of the report that needs to be highlighted is the stark contrast in the indicators among the States, which is not yet in the public domain. States with a high per capita income and that have been cited as examples of exemplary governance have poor indicators. States with a low per capita income, such as Tripura, a Left Front-run State, show lower rates of stunting among children compared with Gujarat.

In the National Capital Territory of Delhi, which can be considered a demographic microcosm of the country, some 29.2 per cent of the children were reported to be stunted, with 14.1 per cent severely stunted. While registration of births was 85.9 per cent, only 43.3 per cent had birth certificates. As many as 18.8 per cent of the women had married before the age of 18; 47 per cent of the girls were categorised as low weight; and 7.7 per cent as overweight. The percentage of open defecation was low at 2.5 and 90 per cent had access to some source of clean drinking water.

A look at some of the BJP-ruled States did not provide a good picture despite the claims of excellent governance and delivery systems.

Percentage of pregnancies

The percentage of pregnancies registered in Gujarat was 88.2 per cent, 4 percentage points more than the national average but 5 percentage points less than Tamil Nadu (93.6 per cent). Similarly, institutional deliveries in Gujarat were at 87.9 per cent while the corresponding figure for Tamil Nadu was 99.3 per cent. Only 56.2 per cent of the children in the 12-23 months group were fully immunised in Gujarat, whereas it was 59.2 per cent in Tripura, 53.5 per cent in Madhya Pradesh and 67.3 per cent in Chhattisgarh.

The figures of stunted children in the zero-five years age group were alarming in the BJP-ruled States: it was 41.8 per cent in Gujarat, 41.6 per cent (with higher stunting rates for the S.C. and S.T. populations at 49.8 and 44.4 per cent respectively) in Madhya Pradesh and 43 per cent in Chhattisgarh with 44.6, 46.2 and 41.7 per cent for the S.Ts, S.Cs and OBCs respectively. In Tripura, the percentage of stunting was 31, in Delhi 29.2, in Tamil Nadu 23.3, in Uttar Pradesh 50.6, and in Kerala 19.5 per cent.

As for the BMI for girls in the 15-18 age group, nearly 56.9 per cent of the girls in Gujarat were low weight (much higher than the national average of 53 per cent), 54.3 per cent in Chhattisgarh and 36.1 per cent in Madhya Pradesh. The corresponding figure for Tripura was 37.6 per cent, Uttar Pradesh 45.5 per cent, Kerala 44.4 per cent, Delhi 47 per cent and Tamil Nadu 41.9 per cent. The fact remains that not every citizen is covered under universal access to basic services. The ICDS centres are ill-equipped and understaffed, and therefore their staff are overworked. However, there was a high degree of awareness among the respondents and the service providers about the need for the centres. The shortfalls, if any, were in the supply from the top. The data pertaining to the States have to be placed in the public domain for a better understanding of why certain States, despite their limited budgets, are able to spend more on health and maternal services while others, despite having better economic indicators, lag behind. The Budget cuts will only make matters worse for those who need it the most.

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