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Health outcomes across major States

C. P. CHANDRASEKHAR, JAYATI GHOSH

An examination of the most recent health outcome indicators revealed by the Sample Registration Surveys of the Registrar General of India reveals some surprising results across the major States on infant mortality and maternal mortality rates.

Despite the nod given to “human development” indicators, policy makers and even the general public persist in viewing GDP growth as the primary indicator of progress, whether in India as a whole or in different States.

This is arguably not just inadequate but possibly even misleading, as it is possible for relatively high rates of GDP growth to be combined with stagnant or even worsening conditions of life for a substantial segment of the population, even the majority.

Obviously, therefore, employment conditions (such as access to productive employment, wage rates and conditions of work) should have equal if not greater importance in any assessment of economic progress.

But one obvious set of indicators that is only casually examined by even serious and well-meaning observers relates to health.

There is no doubt that it is hard to assess morbidity, especially when the database for such analysis is poor and much depends upon self-perception.

However, we do have relatively good data on the most basic health outcome indicators of all – infant mortality and maternal mortality – that allow us to assess the differential performance of States across time.

The Sample Registration Surveys (SRS) of the Registrar-General of India provide the most reliable source of such data.

The most recent results of the SRS relate to 2009, and they allow us to look at both the current conditions as well as changes over the previous decade. While in general the infant mortality and maternal mortality indicators track the general level of economic development, the matches are not exact by any means. In fact, these data provide a somewhat different picture of the conditions of life in different States and the progress in the past decade, than is generally perceived.

Infant mortality

Consider infant mortality rates, which are globally considered to be the primary indicator of basic health conditions in a population. Chart 1 shows that these vary widely across States, and that some States with relatively high per capita incomes do not perform well in this regard.

Chart 2 shows that even performance over time is not necessarily related to increases in per capita GDP over the decade.

Thus Maharashtra, which has one of the highest per capita incomes of all major States, is only a moderate performer with respect to IMR, although it has decreased relatively more than the Indian average (Chart 2).

The poor performance Uttar Pradesh, Orissa and Madhya Pradesh is expected, but the relatively rapid decline of IMR in Jharkhand is less expected (though it must be noted that the IMR in Jharkhand is still well above the Indian average).

Two positive examples are Tamil Nadu and West Bengal, both of which have shown relatively rapid declines in IMR over the decade and had IMR very significantly below the Indian averge in 2009.

In the case of West Bengal, a middle income State, this is even more notable. Kerala has long been held as an example in terms of health conditions, and its IMR is many times less than the Indian average, so it is all the more creditable that it managed to reduce the low IMR even further over the period.

Negative example

The negative example comes from Gujarat, a State which for some reason is otherwise being presented as a model of development in various corporate and other quarters.

Not only was the IMR in 2009 close to the Indian average despite the much higher per capita income in that State, but progress over the previous decade was meagre. In 2009, the IMR in Gujarat was only slightly lower than in much poorer and less developed Bihar, and actually higher than in Jharkhand.

Delhi is the richest State in the country, but its performance in terms of IMR has been disappointing, with no improvement and even a slight decline in the decade under consideration. Similarly poor health performance is evident from another rich Northern state, Haryana, which shows higher than average IMR and low rate of reduction. Haryana’s IMR in 2009 was higher than in West Bengal, Andhra Pradesh and Jharkhand.

Urban-rural gap

Chart 3 describes rural and urban IMRs, and here too the results are interesting. Some States show very large gaps, and clearly rural IMRs remain very high even in some relatively rich States such as Gujarat and Haryana. But urban IMRs also do not run along completely expected lines. For example, it is surprising to note that the urban infant mortality rate in Delhi is clearly higher than in Tamil Nadu and West Bengal!

Chart 4 gives an idea of the extent of the location-specific gap in IMRs, by showing the rural IMR as a percentage of the urban IMR.

Predictably, the gap is lowest in Kerala, but Tamil Nadu, West Bengal and Chhattisgarh also perform well in this regard. The largest gaps are in Rajasthan (with a 40 per cent difference!) and Assam. Once again Gujarat is among the States with a very large rural-urban gap in IMRs, along with Maharashtra – both indicating gaps even larger than in poor States such as Madhya Pradesh and Jharkhand.

Maternal mortality

The other critical indicator of health conditions – and of the overall condition of women in society – is the maternal mortality rate.

Data for this also come from the Registrar-General’s office, for periods of three year averages. They are described in Charts 5 and 6.

Once again the north-central belt performs poorly, with Uttar Pradesh, Rajasthan, Madhya Pradesh and Bihar showing the highest rates of maternal mortality as well as relatively low rates of reduction.

The biggest improvement in maternal mortality among the major States appears to be in West Bengal. As a result, by 2009, West Bengal appears more like a southern State with respect to this indicator, as MMRs are relatively low in all the southern States.

Among the richer northern States, Punjab and Haryana show little or no improvement, and Gujarat also underperforms with respect to this indicator.

Such evidence clearly needs to be much more widely publicised and taken seriously by our policy makers, who need to move away from their current obsession with GDP alone.

If sheer survival is seen as at least one valid indication of the overall human condition, then the various States in the country should be ranked quite differently, both in terms of policy direction and public perception.

Source: Health outcomes across major States

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