India’s progress towards the healthcare MDGs
As we discussed in our first blog post, Model Districts aim to serve as a roadmap for accelerated progress towards MDGs 1, 4, and 5.
First, let’s quickly review the most relevant targets in these Millennium Development Goals:
GOAL 1 – Eradicate extreme poverty and hunger
Target 1C: Halve the proportion of people who suffer from hunger
- Prevalence of underweight children under five years of age
GOAL 4 – Reduce child mortality rate
Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate
- Under-five mortality rate (per 1,000 children)
- Infant (under 12 months) mortality rate (per 1,000 live births)
- Increase proportion of 1-year-old children immunized against measles to 75%
GOAL 5 – Improve maternal health
Target 5A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
- Maternal mortality ratio (per 100,000 live births)
- Proportion of births attended by skilled health personnel
Target 5B: Achieve, by 2015, universal access to reproductive health
- Contraceptive prevalence rate
- Adolescent birth rate
- Antenatal care coverage
- Unmet need for family planning
How is India progressing towards the MDGs?
In reports in 2003 and 2004, Drs. Sachs and Bajpai from the Earth Institute emphasized that while India has strong economic growth and had made some progress towards the MDGs (poverty, education), the healthcare goals lagged significantly, with unacceptably high rates of maternal mortality, infant mortality, and undernutrition. India’s sheer size impacts the entire South Asia region’s performance and gives the country particular importance. Development strides vary; while there were over 670 million mobile phone connections in India in late 2010, 665 million people did not have access to a private toilet or latrine, and over 75% of households’ per capita calorie consumption is less than daily minimum requirements (10,11).
Since Sachs and Bajpai’s call for more serious action towards the health MDGs, the pace of improvement remains slow, and falls short of national and MDG targets (see FIGURES 1 and 2). Why? Coverage of high-priority interventions remains inadequate, programming quality is insufficient, efficient management and governance is lagging, and deplorable inequities further complicate delivery and uptake. Corrective action is required immediately to accelerate progress towards national and MDG health goals.
What is the current maternal and child health status in India?
Maternal health: Goals 1 and 5. India has the highest number of maternal deaths in the world. The national maternal mortality rate (MMR) is 254 per 100,000 live births, an absolute number of 68,000 per year. Comparatively, China’s MMR is 45 (1). There is disparity between states, and some states far exceed national MMR, including Assam (480) and Uttar Pradesh (440) (2). The majority of deaths are preventable through safe deliveries and adequate maternal care.
However, only 52.7% of women have a safe delivery (defined as one in an institution or at home attended by skilled health professional). Less than 20% had full antenatal care, which includes at least three antenatal care visits, one tetanus toxoid shot, and the recommended dose of iron supplementation (3). Over half of married women are anaemic, and one third of women are underweight (4). India is also marked by particularly high unmet need for contraception, rampant unsafe abortion, young pregnancies (30% of women deliver before the age of 20), and minimal reproductive health support for younger women (5).
Child health: Goals 1 and 4. One in every 15 children in India die before they reach their fifth birthday (6). This is a total of 1.8 million children a year. Eight states contribute to 75% of infant mortality; our five Model Districts are within these states (1). Over half (54%) of all childhood deaths in India are related to malnutrition; about 30% of children are born low birthweight, and rates of undernutrition peak before two years of age.
There are 52 million undernourished children in India. 44% of Indian children under five are underweight and 48% stunted due to chronic malnutrition; this means India is home to 46% of the world’s underweight children and 32% of the world’s stunted children (4,7). The country does not have an active strategy for managing the prevention or treatment of acute malnutrition. Nearly 30% of the global childhood deaths attributed to stunting, severe wasting, and low birthweight occur in India—a total of 24.6 million DALYs (8).
Despite these health challenges, as we’ve talked about in our previous post (and we’ll keep hammering this), India’s public health expenditures are less than 1.5% of its GDP (prior to launching NRHM, expenditures were 0.9% GDP), and the WHO ranks India 171st out of 175 nations on public health spending (9). The 2011-12 Budget issued two weeks ago did not allocate the health expenditure increases required to get India where it needs to be in health spending (more about this from Dr. Bajpai).
While these statistics are grim taken at one go, Model Districts and others believe very strongly that health systems strengthening is the way forward. By targeting governance, financing, performance management, data collection and use, supply systems, financing, and planning at district, block, facility, and community levels, we’ll aim to accelerate progress towards MDGs and serve as a badly-needed centre of excellence for health and nutrition.
Additionally, we’ll add here that the Lancet recently released a comprehensive series called ‘India: Towards Universal Health Coverage’ on primary care in the country, and where India is at on health goals. We’d strongly recommend it for further, more detailed reading.
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1. UNICEF 2008
2. Sample Registration System 2004-2006
3. District Level Houshold Survey-III (2007-2008)
4. National Family Health Survey-III (2005-2006)
5. Paul et al, 2011. Reproductive health, and child health and nutrition in India: meeting the challenge. Lancet, 377(9762): 332-349.
6. World Bank 2009, World Development Indicators.
7. UNICEF 2009
8. Black et al. 2010. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet, 375: 1969-1987.
9. WHO 2008.
10. UNICEF 2009
11. Deaton, Angus S. and Dreze, Jean, Nutrition in India: Facts and Interpretations (April 2008). Available at SSRN: http://ssrn.com/abstract=1135253