ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846

A+| A| A-

India's Disturbing Health Card

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.

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.

I
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

    To read the full text Login

    Get instant access

    New 3 Month Subscription
    to Digital Archives at

    ₹826for India

    $50for overseas users

    Comments

    (-) Hide

    EPW looks forward to your comments. Please note that comments are moderated as per our comments policy. They may take some time to appear. A comment, if suitable, may be selected for publication in the Letters pages of EPW.

    Back to Top