Health Status of the country
- The health of a nation is an essential component of development, vital to the
nation‟s economic growth and internal stability. Assuming the minimum level of health
- care to the population is a critical constituent of the development process.
- First, India has to complete its unfinished agenda of reducing maternal and
infant mortality as well as communicable diseases such as TB, Vector-borne disease of
malaria, Kala-azar and Filaria, water borne diseases such as
cholera, diarrhoeal diseases, leptospirosis, and vaccine-preventable measles
and tetanus.
- Second, India has to contend with the rising epidemic of non communicable
diseases including cancers, diabetes, cardiovascular diseases, chronic
obstructive pulmonary diseases and injuries.
- Third, developing systems to cope with the new and re-emerging infectious
diseases like HIV, Avian influenza, SARS and very recent H1N1 influenza.
Since independence, India has built up a vast health infrastructure and health personnel
and considerable achievements have been made over the last six decades to improve key
health indicators such as life expectancy, child mortality and infant mortality and
maternal mortality.
In 2005, India launched in a big way the National Health Mission (NRHM), an
extraordinary effort to strengthen the rural health care delivery systems. However, coverage
of priority interventions remains insufficient, and the content and the quality of existing
interventions are sub optimum.
India in the International Scenario in terms of key health indicators
The comparative picture with regard to key health indicators such as Life Expectancy,
Maternal Mortality Rate, Infant Mortality Rate and Total Fertility Rate points that
countries placed in almost same situations such as Indonesia, Sri Lanka and China have
performed much better than India.
Life expectancy in India has more than doubled in years the last sixty years. It increased
from around 30 years at the time of independence to over 63.5 years in 2002-2006.
India‟s life expectancy is lower than the global average of 67.5 years and the average of
most of countries that won their independence from colonial rule at about the same time
like China, Vietnam, Srilanka and so on.
India‟s Infant Mortality Rate too has shown a steady decline from 129 deaths per 1000
live births in 1971 t o 47 in 2010. The rate of decline has been slowing from 9
points in the 1970s to 16 points in the current decade. Currently, the urban IMR is 31 as
compared to the rural IMR of 51.
India is not in an appreciable situation when compared with the countries of the same
region.The problem of estimating MMR has been the fixing of a reliable denominator due to
the comparative rarity of the event, necessitating a large sample size. However, given
this constraint, data suggests that India had a MMR of 400 in 1997-98 to 301 in 2001-03
declining to 254 deaths per 100000 live births in 2004-2006 and 212 in 2007-09.
On the maternal mortality front, South Asian nations except Sri Lanka do worse than India,
and South Asia as a region has poor record of maternal mortality in the world, very
significantly affecting the global effect to achieve the MDG set for 2015.
The population stabilization is indicated through TFR, which is the average number of
children that a woman would bear over her lifetime if she were to experience the current
age-specific fertility rates. Total Fertility Rate has reduced from 5.2 in 1971 to 2.6 in
2008. India‟s record compares poorly with that of Japan, China and United States which
have TFR of 1.3, 1.7 and 2.1 respectively.
Variation of health indicators across the states
The special concern and challenge is the wide variance in health indication across the
states. Life expectancy is 74 years in Kerala whereas the life expectancy of states like
Assam, Bihar, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh is in the range of
58-62 years, a level achieved during the period of 190-75 in Kerala. Similarly, Kerala and
Tamil Nadu reporting an MMR of 95 and 111 respectively lower than Assam (480),
Bihar/Jharkhand (312), Madhya Pradesh/ Chattisgarh (335), Orissa (303), Rajastan (388)
and Uttar Pradesh/Uttar khand (440).
Further, TFR of Uttar Pradesh, Bihar, Jharkhand, Rajasthan, Madhya Pradesh, and
Chhattisgarh that account for over 40% of India‟ population and have a TFR in the range
of 3.0 to 3.9 – a level that Kerala and Tamil Nadu had in the early 1970s.
The nine states Assam, Bihar/ Jharkhand, Madhya Pradesh / Chhattisgarh, Orissa,
Rajasthan, Uttar Pradesh / Uttar khand account for 47% of India‟s population represent the
core of our poor performance on all four indicators that is Life expectancy, IMR,
MMR and TFR.
Maternal Health – Antenatal Care
Maternal care involves three stages antenatal care (period of pregnancy), delivery care
and post natal care (care after the delivery of the baby) Even though every stage is
significant for the health of mother as well as child, antenatal care takes more emphasis
as it assures a safe delivery, less chances of neonatal deaths / infant deaths or maternal
deaths. Ante natal care involves timely appropriate checkups, taking Iron and Folic Acid
supplements and Tetanus toxin vaccines and delivery at hospital.
According to NFHS-3, less than half of the women received antenatal care during the
first trimester of pregnancy, 22% had their first visit during the fourth or fifth month
of pregnancy and 51% of mothers had three or more antenatal visits. Rural women are less
likely to receive three or more visits than urban women. 65% of the mothers received IFA
supplements, but only 23% consumed them for the recommended 90 days or more.
Three in Four mothers have received the prescribe dose of TT vaccination.
Delivery Care
Delivery at health facility in the presence of health professionals with the required
medical facility is recommended for safe delivery. Three out of every five delivery in
India take place at home. Only two births out of five takes place in a Health facility.
However, the percentage of birth in health facility has increased steadily since NHFS-1.
According to NHFS-3, Deliveries at home are more common in among women who
received no antenatal checkups, older women, women with no education, women in the
lowest quintile and women with more than three previous births.
Postnatal Care
Early postnatal care for a mother helps safeguard her health and can reduce maternal
mortality. Only 37% of mothers had a postnatal checkup within 2 days of birth, as is
recommended. Most women receive no postnatal care at all. Postnatal care is common
following births in a medical facility, however, about one in five births in medical
facilities were not followed by a postnatal checkup of the mother. Only 15% of home
deliveries were followed by a postnatal checkup.
Maternal Mortality Rate
Maternal death is an important indicator of the reach of effective clinical health services
to the poor, and is regarded as one of the composite measure to assess the country‟s
progress. Reliable estimation of levels and trends of maternal mortality is thus extremely
essential. Deaths due to pregnancy and child birth are common among women in the
reproductive age groups. Reduction of mortality of women has thus been an area of
concern and governments across the globe have set time bound targets to achieve it. The
Millennium Development Goals (MDG) have set the target of achieving 109 per lakh of
live births by 2015.
- The MMR during 2001–03 has been 301 per 100000 live births.
And 254 in 2006, 212 in 2009 . Levels of maternal mortality vary greatly across the
regions due to variation in access to emergency obstetric care (EmOC), prenatal care, and
anemia rates among women, education level of women, and other factors. There has been
a substantial decline during the seven year period of 1997–2003. However, the pace of
decline is insufficient. At the present rate of decline, it will be difficult to achieve the goal
of 109 by 2015. The major causes of these deaths have been identified as Hemorrhage
(both ante and post partum) (37%), toxemia (hypertension during pregnancy) (5%),
obstructed labour (5%), puerperal sepsis (infections after delivery and unsafe condition)
(11%), abortions (8%), anemia and other conditions (34%).
- It is very clear that delivery care remains an important determinant of maternal health
outcomes. This reinforces that rapid expansion of skilled birth attendance and EmOC is
needed to further reduce maternal mortality in India. The trend for undertaking an
institutional delivery is on increase as desired in India but differentials exist in different
parts.
Infant Mortality Rate
One of the most sensitive indicators of the health status of a population is Infant
Mortality Rate. The IMR in India is steadily decreasing, which is 50 per 1000 live births.
It is 34 in urban areas far lower than 55 of the rural area during 2009.
Further, it also varies across states with Kerala has the lowest IMR with 12 and the highest is
in Madhya Pradesh with IMR of 67.
- It is observed from the National Family Household Survey-3 and District Level
Household Survey -3 that the higher rates of antenatal, institutional deliveries and
postnatal are associated with lower IMR.
- Infant mortality in rural areas is 50% higher than in the urban areas. Children
whose mothers have no education are more than twice as likely to die before their first
birthday as children whose mothers have completed at least 10 years of school. In
addition, children from scheduled castes and scheduled tribes are at greater risk of dying
than other children.
Maternal and Child Health Programmes in India
- India has a long history of Maternal and Child Health Programmes since independence, which have undergone significant shifts in their emphasis over time. The 5-year phase of RCH II was launched in 2005 with a vision to bring about outcomes as envisioned in the MDGs, the National Population Policy 2000, the National Health Policy 2002 and The Tenth Five Year Plan, minimizing the regional variations in the areas of RCH and population stabilization through an integrated, focused, participatory programmes meeting the provisions of assured, equitable, responsive quality services.
Major initiatives in Child Health under RCH II:
- The strategy for child health care aim to reduce under 5 child mortality through
interventions at every level of service delivery and through improved child care practices
and child nutrition. One major component of the strategy was training to the AWWs and
ANMs for early diagnosis and referral to facilities. It focuses on preventive, promotive, a curative service i.e. it gives a holistic outlook to the programme. Major components of the strategy are:
(a) Strengthening the skills of the health care workers
(b) Strengthening the health care infrastructure
(c) Involvement of the community
The first two components are facility based IMNCI and the third one is community based
IMNCI. The major features of the IMNCI are:
- Focus on the newborn care and young infant- since a significant proportion of child mortality is centered in the first few months of life
- Development of protocol and algorithm for home visits by field functionaries like ANMs and AWWs for all newborns in the first week of life.
- Ensuring harmonization between existing health interventions and programmes like ICDS and anti Malaria programmes implemented by agencies other than the Department of Family Welfare that impact child health.