Reproductive & Child Health of the Poor in India (original) (raw)

In recent years there has been a growing concern for women’s health in developing countries. This is evident from the adoption of women’s health perspectives in strategies addressing child survival, family planning and women’s development issues. This concern necessitates authentic information that can provide a diagnosis of women’s health status and needs in a developing country as ours. This part of the report studies various aspects of reproductive health by (i) conducting a literature survey, (ii) analyzing secondary data on that indicator to see the trend and current status using data sources such as the National Family Health Survey and Reproductive Child Health Survey, and (iii) studying the factors that affect some of the key outcome indicators with the help of econometric analysis. The indicators of Reproductive and Child Health that we have analyzed in this section are as follows: • Demographic rates • Fertility and Family Planning • Safe Motherhood • Post-natal Care and Child Survival • Reproductive Health Morbidity • Broader Issues Related to Women’s Reproductive Health In compiling and analysing data for the above-mentioned RCH outcomes, our focus has been to see how these variables impact on the poor and marginalized sections of the society. The analysis has been done separately for: • Rural and urban areas. • Social groups and religions (SC, ST, Muslim, Christian, Hindus Others) • Economic classes (Quintiles calculated on basis of index derived from asset ownership and use) • Across time There are significant inter-state differences, therefore state-level studies are very important.. All India estimates should be crosschecked with those of the focus states, as the conditions in states might be very different. • The so-called north-south India differences are a gross aggregation. States in southern India also require making great improvements even though they might be somewhat better off economically. • The fact that there are significant inter-state differences also points to the possibility of significant intra-state differences. • The most ‘RH deprived’ districts are identified as those where RH indicators are the poorest. This is done for all the states of India, and the data is hi-lighted for the identified four states. The poorest 20 percent economic sections might not be highly different from the not so poor (poorest 40 or even 60 percent) in many indicators of RH. The low sex ratio shows that focusing policy on women could have a large impact on the overall demographic and social sustainability of progress The relatively high death rates for those in the 0 to 4 age group also reveals the great improvements that are possible by focusing on children The above two point to the importance of gender sensitivity of policy in the social sector. Both child and mother are the basic building blocks of any society and economy. Poor RH indicators imply poor conditions being faced by mothers and children. That only underscores the importance of studies and policy action focused on reproductive health. In almost all the cases the most under-privileged are quite apparent – economically the poorest, lower social groups, and those in rural areas are worse off. On the whole we find that those indicators that are related to the mother or the child receiving or availing of some health related service the measures are much lower than those where their own inherent health is being measured. However this is less true for Ante-natal care. That is one measure that shows that about two thirds of the women are covered. As a result IFT supplementation and tetanus injections also show relatively better performance across the board. Assistance during delivery and in locations with better medical facilities is a significantly weak area where coverage of RH services in considered. Less than a third of the births occur in hospital whereas as many as two thirds of the births have some pre-delivery complications. The results strongly show that the conventional approach to fertility and family planning has not been able to cover the most underprivileged sections. The privileged – better educated, higher economic and social classes and those living in urban areas are better – but even these sections are not fully ‘covered’. Poor design of government programs, lack of public-private partnership, lack of sensitivity to women’s requirements, etc. may have contributed to this, but why they have failed or not succeeded as much as they should have is a necessary precondition before policy measures can be designed to improve upon them. Education is by the far the most important factor in better fertility and family planning indicators, on safe motherhood as well as all RH related indicators studied. Mother’s education has a greater marginal impact than economic class (quintiles) on most marriage, fertility, and family planning variables. The household head’s education is also found to significantly improve the likelihood of achieving better RH outcomes in many if not most cases. An understanding of the actual difference between educated and less educated women is also important from another perspective. Issues such as use of contraceptives have to a large extent been driven by the way they have been ‘sold’ by government and allied forces. Perhaps as a result non-permanent contraception has not really taken off both for highly and for less educated women. It is also clear that contraceptive use by younger couples will have to be primarily temporary (non-sterilization) if it is to expand. And a better understanding of the thought process as well as decision taking process will enable a better design of family planning measures. Though significant differences are found between Muslim, Christian and Hindu women, the econometric analysis shows that many if not most of these differences can be explained due to differing socio-economic conditions faced by the different religious groups. Better economic profile tends to have some impact on a woman’s inherent health and so does better education. • However, the impact of better economic status appears to be relatively more of anemia and weight. • In the case of receiving ANC (or IFT or tetanus injection) however a better economic profile appears to matter less than better education. Further work in this area will be essential if a policy measures that are more ‘accessible’ to underprivileged women are to be put in place. It is found that purely greater education does not necessarily improve a woman’s ability to have a safer mother-hood; it also needs to be supported by a better economic profile. At the same time, purely having a better economic profile does not necessarily imply that better ANC will be received. The trends show that assistance during birth has improved significantly in the six-year gap between 1992-93 and 1998-99. Both for rural and urban areas the improvement has been of the order of 10 percentage points. Significantly however, in rural areas, the improvement has been predominantly for the higher economic classes and less so for the lowest quintiles. In the case of the urban areas however, the improvement has been predominantly for the lowest three quintiles. The results suggest that suggest the following for policy to incorporate: • A well functioning and well-spread PHC network can have a significant impact. However the critical issue is well functioning public services. The data also shows that purely spending greater amounts does not ensure better RH outcomes in terms of RH indicators. • Private health care providers presence does not matter significantly – local governments should consider how locally based private practitioners could be ‘incorporated’ into providing RH services as well • Education of the mother matters in all likelihood because of better awareness levels, is it feasible to increase awareness without having to educate the mother. Educating adults tends to be a very difficult task and has large time-gaps. • The links between education–mass media access-autonomy and economic power are important factors in a woman awareness levels and her ability to decide for herself. Micro-level studies would be essential to find the routes through which these links work. • In other words, higher awareness, greater ability to make choices, better accessibility are the important links throughout the different issues studied. • Pure economic or accessibility issues, are not necessarily the only constraints – it is the various links that are missing for the bulk of the women in the country and putting these links in place would enable the rapid improvement in RH indicators. • Purely putting in more funds or improving village level infrastructure, or providing greater services will not necessarily lead to the reaching or crossing of the MDG goals. • Appropriate RH policy would be one that is able to decipher the links between awareness and decision-making and remove those constraints. However, in a society where it will be difficult to change both the critical factor rapidly (education level of the mother and economic profile of households), the key policy question is how can better awareness levels be created in uneducated women so that they demand better and more services. At the same time, how can services be provided such that they are within the economic reach of the poor and the under-privileged? These are the key RH policy questions. It then follows whether it is feasible or desirable to enhance private delivery of reproductive services? Can some basic minimum quality be ensured? Do such services need to be subsidized? And who should subsidize them? The answers to these questions will be essential for a better delineation of what RH policy should aim at and how.