India's Disturbing Health Card

COMMENTARY

Pradesh, it is 43 per cent. Thus Andhra

India’s Disturbing Health Card

Pradesh has a bad record of child marriages of girls: 63 per cent in rural areas and 43 per cent in urban areas (both ﬁgures are

Ashish Bose higher than the national average).

The National Family Health Survey-3 data shows disturbing trends for children and women in the reproductive age, especially in the “sick” states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. Signiﬁcantly, Himachal Pradesh is progressive on several indicators and comparable to Kerala, while West Bengal is showing signs of joining the ailing states.

Ashish Bose (ashishb@vsnl.com) is honorary professor at the Institute of Economic Growth, Delhi.

t is not possible to do justice to the 389 tables in the 540-page ﬁnal report of the National Family Health Survey (NFHS-3) 2005-06 (released in October 2007) in this brief article. We shall present some revealing and disturbing facts on the health of women in the reproductive age group and also on children culled from the tables. We have reformatted the tables to make them reader-friendly.

Child Marriage

Women in the age group 18-29 years were asked about their age at marriage. In spite of the Child Marriage Restraint Act, 1929 which prohibits marriage of girls below 18 years, the majority (53.4 per cent) of rural women (in the age group 18-29 years) in India were married before they turned 18. In the following states, the percentages are much higher than the national level: Jharkhand 70 per cent, Bihar 69 per cent, Rajasthan 67 per cent, Andhra Pradesh 63 per cent, West Bengal 62 per cent, Madhya Pradesh 60 per cent and Uttar Pradesh 59 per cent. It is not surprising that in what we call the BIMARU (the demographically sick states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh) states, the ﬁgures are high. What is surprising is that in rural Andhra Pradesh and West Bengal, the ﬁgures are so high.

In contrast, the comparable ﬁgure for rural Kerala is 20 per cent and surprisingly, in Himachal Pradesh, only 14 per cent. In Manipur it is 16 per cent and in Jammu and Kashmir 19 per cent. As we shall see later, Himachal Pradesh is turning out to be a progressive state which can overtake the much publicised state of Kerala in regard to several demographic indicators. Turning to urban areas, we ﬁnd that the overall ﬁgure for women married before they turned 18 is 30 per cent, compared to 38 per cent in Bihar, 36 per cent in Rajasthan, 33 per cent in Jharkhand, 32 per cent in Uttar Pradesh and 31 per cent in West Bengal. In urban Andhra

In contrast, in the urban areas of Jammu and Kashmir, only 9 per cent of the girls were married before they turned 18, in Kerala 12 per cent, in Himachal Pradesh 14 per cent and in Uttaranchal 17 per cent. It seems that in the hilly states of Jammu and Kashmir, Himachal Pradesh and Uttaranchal, urban girls are not married off early though coastal Kerala has the best record.

Teenage Pregnancy

Data were collected from women in the age group 15-19 years who have had a live birth, are pregnant with their ﬁrst child and those who had begun childbearing. In India as a whole, teenage pregnancies were as follows:

Teenage Pregnancies, 2005-06 (in %)

Rural Urban

Have had a live birth	14.5	6.3
Pregnant with first child	4.6	2.4
Have begun childbearing	19.1	8.7

Thus a sizeable proportion of India’s teenagers are involved in reproductive activity, with sharp rural-urban differences. Unfortunately, the relevant table in the NFHS report does not give rural-urban breakdown by state (perhaps available in the data ﬁles but not available in this report) but the statewise tables reveal the following: in Jharkhand 21 per cent of the teenagers have had a live birth, in Bihar 19 per cent, in West Bengal 19 per cent, in Rajasthan 13 per cent, in Assam 13 per cent, in Andhra Pradesh 13 per cent and in Karnataka 13 per cent, compared to the all-India ﬁgure of 12 per cent (combined ﬁgure for rural and urban). In contrast, the ﬁgures are low in some states: 5 per cent in Tamil Nadu, 4 per cent in Uttaranchal, 4 per cent in Punjab, 3 per cent in Kerala, 3 per cent in Jammu and Kashmir, and 2 per cent in Himachal Pradesh.

In the category of “currently pregnant” teenage women, we ﬁnd that the highest ﬁgures are in Jharkhand 7 per cent, West Bengal 6 per cent, Bihar 6 per cent, Haryana 5 per cent and Andhra Pradesh 5 per cent, as compared to the all-India ﬁgure of

december 15, 2007 Economic & Political Weekly

COMMENTARY

Table 1: Early Childhood Mortality Rates (Deaths per ‘000 children in age group)	4 per cent. The ﬁg	highest ﬁgures	are:	Jharkhand 28 per
Rank States	Infant Mortality	Neonatal Mortality	Post-neonatal Mortality	Under-Five Mortality	% of Children	% of Children	ures are somewhat	cent, Bihar 25 per cent and West Bengal
(NN)	(PNN)	Who Had All Basic	Who Had No	lower in Kerala	3	25	per cent. The lowest ﬁgures	are:
Vaccinations Vaccinations	per	cent,	Tamil	Himachal Pradesh 3 per cent, Jammu
1	India Uttar Pradesh	57 73	39 48	18 25	74 96	44 23	5 3	Nadu	3 per cent,	and Kashmir 4 per cent, Uttaranchal
2	Chhattisgarh	71	51	20	90	49	3	Uttar Pradesh 3 per	6 per cent, Punjab 6 per cent and Kerala 6
3	Madhya Pradesh	70	45	25	94	40	5	cent,	Madhya	per cent. It is worth noting that Bihar and
45	Jharkhand Assam	69 66	49 46	20 21	93 85	34 31	4 15	Pradesh 3 per cent,	West Bengal are in the same category, at
6	Rajasthan	65	44	21	85	27	6	Rajasthan 3 per cent	least in regard to teenage pregnancy.
7	Orissa	65	45	19	91	52	12	and Uttaranchal 3
8 9	Bihar Arunachal Pradesh	62 61	40 34	22 27	85 88	33 28	7 24	per cent. The lowest	Early Childhood Mortality Rates
10	Andhra Pradesh	54	40	13	63	46	4	ﬁgures are in Jammu	NFHS-3 collected detailed data on children
11	Tripura	52	33	18	59	50	15	and	Kashmir	0.8	(12-23 months) and different types of child
121314	Gujarat West Bengal Jammu and Kashmir	50 48 45	34 38 30	16 10 15	61 60 51	45 64 67	5 6 5	per cent and Himachal Pradesh	mortality: infant mortality rate (IMR), neonatal, post-neonatal, child and under ﬁve
15	Meghalaya	45	24	21	71	33	17	0.9 per cent.	(see notes to Table 1). Table 1 gives the
1617	Karnataka Uttaranchal	43 42	29 28	14 14	55 57	55 60	7 9	For	teenage	details for 29 states (including Delhi
18	Haryana	42	24	18	52	65	8	women who have	national capital territory) but excluding
19	Punjab	42	28	14	52	60	7	begun childbearing,	union territories (UTs).
20 2122	Delhi Nagaland Maharashtra	40 38 38	29 20 32	11 19 6	47 65 47	63 21 59	9 18 3	the all-India ﬁgure is 16 per cent. The	It will be seen that the IMR ranges from the high levels in Uttar Pradesh 73,
23	Himachal Pradesh	36	27	9	42	74	2
24	Mizoram	34	16	18	53	47	7	Table 3: Prevalence of Anaemia in Children 6-59 Months (in %)
2526	Sikkim Tamil Nadu	34 30	19 19	14 11	40 36	70 81	3 0	Rank	States	Any Anaemia (<11.0 g/dl)	Anaemia Status by Haemoglobin Level Mild Moderate (10.0-10.9 g/dl) (7.0-9.9 g/dl)	Severe (>7.0 g/dl)
27	Manipur	30	19	11	42	47	7		India	69.5	26.3	40.2	2.9
28	Goa	15	9	7	20	79	0	1	Bihar	78.0	29.6	46.8	1.6
29 Kerala 15 12 4 16 75 2 (1) The states are in descending order of IMR. (2) Neonatal mortality: The probability of dying in the first month of life. (3) Post-neonatal mortality: The probability of dying after the first month of life but before the first birthday.	2 3	Madhya Pradesh Uttar Pradesh	74.1 73.9	27.1 25.4	43.6 45.0	3.4 3.6
(4) Infant mortality: The probability of dying before the first birthday. (5) Child mortality: The probability of dying	4	Haryana	72.3	25.8	42.2	4.3
between the first and fifth birthdays. (6) Under-five mortality: The probability of dying before the fifth birthday.	5	Chhattisgarh	71.2	24.0	45.2	2.0
	6	Andhra Pradesh	70.8	23.7	43.5	3.6
	7	Karnataka	70.4	28.6	38.6	3.2
Table 2: Percentage of Women (15-49) with Anaemia (Haemoglobin in g/dl = grams per	8	Jharkhand	70.3	29.3	39.1	1.9
declilitre) States	Any Anaemia (<11.0 g/dl)	Mild (10.0-10.9 g/dl)	Moderate (7.0-9.9 g/dl)	Severe (>7.0 g/dl)	910	Rajasthan Gujarat	69.7 69.7	22.8 25.0	40.2 41.1	6.7 3.6
India	55.3	38.6	15	1.8	11	Assam	69.6	28.7	38.7	2.2
1	Jharkhand	69.5	49.6	18.6	1.3	12	Punjab	66.4	21.7	38.1	6.6
2	Assam	69.5	44.8	21.2	3.4	13	Orissa	65.0	28.9	34.5	1.6
3	Bihar	67.4	50.5	15.9	1	14	Meghalaya	64.4	31.7	31.7	1.0
456	Tripura West Bengal Andhra Pradesh	65.1 63.2 62.9	49 45.8 39	14.8 16.4 20.6	1.3 1 3.3	151617	Tamil Nadu Maharashtra Tripura	64.2 63.4 62.9	27.1 21.9 27.5	34.6 39.6 34.6	2.6 1.8 0.7
7	Orissa	61.2	44.9	14.9	1.5	18	Uttaranchal	61.4	28.5	30.6	2.3
8	Sikkim	60	42.1	16.2	1.7	19	West Bengal	61.0	30.0	29.4	1.5
9 10111213	Chhattisgarh Haryana Madhya Pradesh Gujarat Uttaranchal	57.5 56.1 56 55.3 55.2	39.9 37.6 40.8 36.2 40.4	15.7 16.7 14.1 16.5 13.3	1.9 1.7 1 2.6 1.5	2021 222324	Sikkim Jammu and Kashmir Delhi Arunachal Pradesh Himachal Pradesh	59.2 58.6 57.0 56.9 54.7	28.9 25.8 26.3 27.1 25.7	29.5 30.4 30.0 29.1 26.8	0.8 2.4 0.7 0.8 2.2
14	Tamil Nadu	53.2	37.4	13.6	2.2	25	Kerala	44.5	23.5	20.5	0.5
1516	Rajasthan Jammu and Kashmir	53.1 52.1	35.2 37.3	15.4 13.1	2.5 1.6	2627	Mizoram Manipur	44.2 41.1	23.5 25.6	20.2 15.2	0.6 0.3
17	Karnataka	51.5	34.4	15.1	2	28	Goa	38.2	19.5	17.1	1.5
18	Arunachal Pradesh	50.6	36.6	12.5	1.6	(1) The states are arranged in descending order of “any anemia”. (2) This is based on children who stayed in the household the night before the interview. Prevalence of anaemia, based
19	Uttar Pradesh	49.9	35.1	13.2	1.6	on haemoglobin levels, is adjusted for altitude using formula in CDC (1998). Haemoglobin in g/dl= grams per declilitre.
20	Maharashtra	48.4	32.8	13.9	1.7	Excludes Nagaland
21	Meghalaya	47.2	32.8	12.6	1.8	Table 3a: Trends in Children’s Anaemia (in %)
22	Delhi	44.3	35.2	8.8	0.2	Anaemia Status by		NFHS-3 (2005-06)			NFHS-2 (1998-99)
23	Himachal Pradesh	43.3	31.6	10.5	1.2	Haemoglobin Level	Rural	Urban	Total	Rural	Urban	Total
24	Mizoram	38.6	29.1	8.8	0.7	Any anaemia (<11.0 g/dl)	80.9	72.2	78.9	75.3	70.8	74.3
25	Goa	38	29.6	7.8	0.6	Mild (10.0-10.9 g/dl)	25.7	25.8	25.7	22.7	23.7	22.9
26	Punjab	38	26.2	10.4	1.4	Moderate (7.0-9.9 g/dl)	51.7	42.0	49.4	47.1	42.0	45.9
27	Manipur	35.7	30.1	5.1	0.5	Severe (7.0 g/dl)	3.5	4.4	3.7	5.5	5.1	5.4
28	Kerala	32.8	25.8	6.5	0.5	(1) This table includes only the last two children of 6-35 months of ever-married women who were interviewed.
(1) The states are in descending order of “any anaemia” and exclude Nagaland.	(2) Prevalence of anaemia, based on haemoglobin levels, is adjusted for altitude using formulate in CDC (1998).
(2) Prevalence of anaemia, based on haemoglobin levels, is adjusted for altitude using formula in CDC (1998).	(3) Haemoglobin in g/dl=grams per decilitre. NFHS-3 estimates of anaemia. Excludes Nagaland.
Economic & Political Weekly	december 15, 2007	11

COMMENTARY

Table 4 : Education, Exposure to TV, Use of Contraception by Women and TFR the NFHS-3 report does not give the

States Education Use of TFR No Education (%) 12 or More Years Watch TV (%) Contraception (per Woman)

rural-urban breakdown. The overall pic-

Complete by Women (%)

ture is shown in Tables 3 and 3a (p 11).

W M W M W M Rural Urban Rural Urban

India 40.6 18.0 12.0 19.7 55.0 63.2 45.3 55.8 3.0 2.1 Bihar 62.1 27.7 4.9 20.8 23.1 33.4 26.8 41.3 4.2 2.9 Educational Level, Exposure to TV, Use

Rajasthan 61.1 24.3 7.3 15.7 40.4 55.0 38.0 62.0 3.6 2.2 of Contraception and Fertility Level: Jharkhand 58.5 27.1 7.8 17.0 31.8 36.8 25.2 49.9 3.7 2.3

Table 4 presents data on education of

Uttar Pradesh 53.5 21.4 10.7 19.8 40.1 50.1 25.3 42.4 4.1 3.0 Madhya Pradesh 50.1 22.9 8.8 18.1 43.0 49.8 51.5 56.3 3.3 2.6 women (and men), TV viewing, use of

Chhattisgarh 49.9 21.0 7.4 15.4 44.8 55.6 46.4 58.9 2.9 1.8 contraception by women (any modern Andhra Pradesh 45.4 23.2 8.8 18.4 74.3 78.4 67.0 67.2 1.8 1.7

method) and total fertility rate (TFR). The

Arunachal Pradesh 41.9 22.4 9.6 14.8 54.5 56.7 36.4 39.4 3.2 2.5 Jammu and Kashmir 41.0 15.3 14.2 19.3 64.5 62.6 40.4 55.8 2.7 1.6 TFR is a measure of fertility that summa-

Orissa 40.3 21.6 8.0 16.4 52.1 60.8 43.6 50.1 2.5 1.9 rises the rate of childbearing in a given Haryana 37.6 14.4 14.3 20.0 62.1 63.1 57.7 59.7 2.9 2.2

period of time, often a year, and is derived

West Bengal 36.3 22.9 8.6 16.0 51.6 56.9 49.9 49.9 2.5 1.6 Karnataka 33.6 17.2 13.5 21.1 69.5 80.4 64.7 59.2 2.2 1.9 by summing the age-speciﬁc birth rates

Uttaranchal 32.6 11.6 22.0 29.9 66.3 70.4 54.2 59.2 2.7 2.2 for a population of women in a given Gujarat 32.4 13.2 13.2 17.3 62.0 69.5 55.5 57.7 2.8 1.9

period. This table also brings out the rela-

Assam 30.2 14.4 10.2 15.3 44.4 56.6 24.8 37.2 2.7 1.4 Meghalaya 29.5 24.4 13.4 14.0 49.3 56.4 13.0 36.7 4.4 2.3 tionship between education, exposure to

Punjab 28.5 14.0 19.1 17.2 80.4 84.8 58.6 51.8 2.1 1.9 TV, use of contraception and fertility level Sikkim 26.7 11.5 12.5 18.2 67.0 66.0 48.0 51.7 2.2 1.3

without doing elaborate statistical exercis-

Maharashtra 23.5 7.3 16.4 24.1 69.4 76.3 65.8 64.0 2.3 1.9 Tripura 22.4 11.1 6.7 11.7 67.2 73.3 45.0 44.4 2.3 1.7 es. For example, Bihar which has the high-

Manipur 21.8 5.6 20.9 31.5 71.6 73.2 23.0 24.8 3.1 2.4 est rural TFR (4.2) (barring Meghalaya Tamil Nadu 21.7 9.3 19.2 23.2 81.4 83.9 60.7 59.2 1.9 1.7

where it is 4.4), only 27 per cent of the rural

Nagaland 21.7 15.3 10.9 16.3 53.3 61.9 18.8 31.8 4.2 2.7 Delhi 21.4 9.6 37.2 38.0 89.5 87.8 55.9 56.5 2.5 2.1 women practise contraception, only 23 per

Himachal Pradesh 18.5 5.3 21.4 30.1 72.4 79.9 71.0 71.2 2.0 1.6 cent of women watch TV (compared to 80 Goa 12.7 6.0 28.1 25.1 87.3 85.9 35.2 38.6 1.8 1.8

per cent in rural Punjab), and only 5 per

Mizoram 5.6 5.5 14.3 16.0 79.1 83.3 54.6 64.0 3.3 2.5 Kerala 3.9 1.3 25.7 24.8 73.0 80.7 57.6 58.5 2.0 1.7 cent of the rural women completed 12 or

(1) The data for women relate to the reproductive age group (15-49 years).

(2) The states are arranged in order of women (15-49) with no education.

Chhattisgarh 71 and Madhya Pradesh 70, to low levels in Kerala 15 and Goa 15. Andhra Pradesh has a fairly high IMR of 54 per 1,000 live births compared to Himachal Pradesh’s 36.

Sadly, Uttar Pradesh, the most populous state in India, has the highest infant mortality rate. It is shocking to note that in spite of the much trumpeted immunisation programme of the government, in India as a whole, only 43.5 per cent of the children had all basic vaccinations. The ﬁgures vary from 23 per cent in Uttar Pradesh to 81 per cent in Tamil Nadu. It is also shocking to note that in Assam 15 per cent of the children had no immunisation at all while in Orissa, 12 per cent of the children had no immunisation at all. In the smaller states of Arunachal Pradesh, Tripura and Nagaland, the situation was worse in regard to immunisation.

Prevalence of Anaemia in Women (15-49 Years): One of the dismal ﬁndings of NFHS-3 is the high level of prevalence of anaemia (too few red blood cells in the bloodstream resulting in insufﬁcient oxygen to tissues and organs) among women in the reproductive age group. Table 2 (p 11) gives the details. It will be seen that in a majority of the states in India, women suffer from anaemia.

West Bengal does not fare well at all in regard to anaemia in women. In fact, it is comparable to the BIMARU states when one considers health indicators.

Prevalence of Anaemia in Children (6-59 Months): Table 3 (p 11) shows a very depressing picture. In India as a whole, 70 per cent of the children have some anaemia. It is surprising to note that even in the demographically progressive states like Andhra Pradesh, Karnataka and Tamil Nadu the prevalence rate is as high as in the states of Bihar, Jharkhand, Uttar Pradesh, Madhya Pradesh and Rajasthan.

A shocking revelation is that the prevalence of anaemia has increased from 74 per cent as per NFHS-2 (1998-99) to 79 per cent according to NFHS-3 (2005-06).

As the report points out: “The increase is seen primarily in rural areas where anaemia rose from 75 per cent to 81 per cent” (NFHS-3:290). As mentioned earlier more years of education.

Conclusions

It may be noticed that in Kerala, Goa and Punjab, the percentage of women with 12 or more years of education is higher than that of males. It is interesting to note that in Jammu and Kashmir, Delhi and Sikkim,

Open Review

Several international journals are moving away from closed "Peer Review" of research papers, towards an "Open Review" process. In open reviews anyone can comment on a paper submitted for publication. This will increase transparency in reviews as well as enhance participation and involvement of the research community.

EPW occasionally posts a submission on its web site and invites comments. Visitors to the EPW web site and readers of the journal are encouraged to offer detailed comments. EPW will discuss the comments with the author and a revised version will be processed for publication.

Please visit the Open Review section on our web site (www.epw.org.in) to read and comment on the paper currently submitted for Open Review.

december 15, 2007 Economic & Political Weekly

CLIMATE CHANGE

women watch TV more than men. It is worth noting that Himachal Pradesh has the highest use of contraception both in rural and urban areas (71 per cent).

Finally, we note that the TFR in rural areas is the lowest in Andhra Pradesh 1.8, Goa 1.8, Tamil Nadu 1.9 and Kerala 2.0. The highest rural TFR is in Meghalaya 4.4, Bihar 4.2, Nagaland 4.2 and Uttar Pradesh

4.1. The urban TFR is lowest in Sikkim 1.3, Assam 1.4, Jammu and Kashmir 1.6 and West Bengal 1.6. The highest urban TFR is in Uttar Pradesh 3.0, Bihar 2.9 and Madhya Pradesh 2.6, excluding the smaller states.

The report of NFHS-3 has massive data on fertility, family planning, infant and child mortality, maternal health, child health, nutrition, anaemia, HIV prevalence, morbidity, healthcare, women’s empowerment, domestic violence and so on. We have highlighted only some signiﬁcant ﬁndings of the survey. There is enough scope for taking up detailed studies to fully utilise the data.

This should include evaluation of the quality of data also. For example, we do not think that NFHS type of survey can collect reliable data on domestic violence which is a favourite topic of some western lobbies.

To sum up, my thesis (ﬁrst propounded in 1985 to brief the then prime minister) that to understand India’s population problem, one must focus on the BIMARU states is relevant even in 2005-06 according to the NFHS-3 data. Taking both population size and area into consideration, there is no doubt that these four states are indeed the most vulnerable states in India. Of course there are smaller states like Orissa, Assam and the northeastern states which are equally vulnerable. The National Rural Health Mission has rightly included all these states in the list of “high focus” states (earlier called empowered action group states). NRHM also includes the hilly states of Jammu and Kashmir and Himachal Pradesh in the high focus states. Our analysis, however, shows that Himachal Pradesh is a demographically progressive state, comparable with Kerala. On the other hand, West Bengal, especially rural West Bengal is emerging as a BIMARU state. There are however many imponderables which only detailed analyses will clarify.

Economic & Political Weekly december 15, 2007