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Stumbling from the start

The Achievements of Babies and Children (ABC) Index measures four very basic aspects of child wellbeing - survival, immunisation, nutrition and schooling. India scores no more than 66% overall. But states such as Tamil Nadu and Himachal Pradesh, and even Sri Lanka and Bangladesh, have made rapid strides in child development. What is the key? The rights-based approach and outstanding records of active state involvement in the provision of health, nutrition and education services.

It has been suggested that the first question the Indian prime minister should ask his ministers is not “How is the economy growing,” but “How are children growing”. The ministers, however, would probably rather answer the former, for the state of Indian children is nothing short of a humanitarian emergency. Few countries, in fact, have worse indicators of child development. Progress in this field has been very slow, with countries like Bangladesh ‘overtaking’ India during the last few years. This crisis casts a deep shadow on India’s progress in other fields.

The average Indian child gets a rather poor start in life. Even before birth, he or she is heading for disaster due to poor antenatal care and maternal undernutrition. About one-third of expectant mothers in India are deprived of tetanus vaccinations, an important defence against infection at birth. Similarly, about one-fourth of pregnant women do not have a single antenatal checkup, and a majority of deliveries take place without the assistance of a health professional (Table 1). Worse, the average Indian mother is frail and anaemic. This is likely to result in low birth weight, a major cause of child undernutrition.

After birth, life continues to be precarious. About one-third of all newborn babies in India weigh less than the acceptable minimum of 2.5 kg. Undernutrition levels continue to increase during the first two years of life, largely due to poor breastfeeding and faulty weaning. About half of all children below 3 are undernourished, more than half are deprived of full immunisation, and a large majority suffer from anaemia (Table 2). Illness is also widespread, with a fifth of all children suffering from diarrhoea and almost a third suffering from fever. A substantial proportion of Indian children (about one-tenth) never reach the age of 5.

India: Maternal health and related indicators 

 

1998-99 (NFHS-2)

2005-06 (NFHS-3)

Proportion (%) of mothers who had*:

No tetanus immunisation during pregnancy

33

NA

No antenatal checkup

34

*

No iron or folic supplement

42

NA

No assistance from a health professional during delivery

58

*

Proportion (%) of adult women with:

 

 

Anaemia

52

*

Body Mass Index (BMI) below 18.5

36

*

* Data pertains to births during three years preceding the survey
Source: National Family Health Survey 1998-99 (NFHS-2) and National Family Health Survey 2005-06 (NFHS-3) data presented in the International Institute for Population Sciences (2000, 2006); also available at www.nfhsindia.org. The figures apply to ever-married women in the age-group 15-49 years

As children grow up, poor nutrition and ill health affects their learning abilities and preparedness for schooling. In 1998-99, almost one-third of all children in the 15-19 age-group failed to complete Class 5, and half did not complete Class 8. So much for the ‘fundamental right to education’! By the time Indian children are supposed to complete upper primary school, many of them have actually been pushed into the labour force, further ruining their health by working long hours in harsh conditions.

In short, millions of Indian children are condemned to stumble right from the start. During the first six years of life, and especially the first two, they sink into a dreadful trap of undernutrition, ill health and poor learning abilities. This burden is extremely difficult to overcome in later years.

Slow progress

Another disturbing aspect of this situation is that the rate of improvement over time is also very slow. Extreme forms of hunger and undernutrition, such as marasmus and kwashiorkor, have sharply declined over the years. But the general progress of nutrition indicators (such as the height and weight of Indian children) is sluggish.

The findings of the third National Family Health Survey (NFHS-3), released just a few days before the completion of this abridged report, are quite alarming in this regard. For instance, the proportion of undernourished children, based on standard weight-for-age criteria, was virtually the same in 2005-06 as in 1998-99: in both years, nearly half of all Indian children were underweight. Even the decline of stunting in that period, from 45% to 38%, is far from impressive -- about one percentage point per year. If the incidence of stunting continues to decline at this rate, it will take another 25 years or so to reach levels similar to those in China today.

State of India’s children

 

1998-99 2005-06 (NFHS-2) (NFHS-3)

Proportion (%) of young children with the following characteristics:

Low birth weight (about 30)

Not breastfed within an hour after birth

84

*

Undernourished*

47

46

Stunted*

45

*

Wasted*

16

*

Not fully vaccinated+

58

56

Not vaccinated at all+

14

NA

Birth was not preceded by any antenatal checkup

34

*

Suffer from anaemia

74

79

Proportion (%) of young children who suffered from the following, during the last two weeks:

Fever

30

NA

Diarrhoea

19

NA

Acute respiratory infection

19

NA

* Based on standard anthropometric indicators: weight-for-age for ‘undernourished’, height-for-age for ‘stunted’, weight-for-height for ‘wasted’
+ Age: 12-23 months
Source: National Family Health Survey (see Table 2.1). Unless stated otherwise, the reference group consists of children aged below 3 years (excluding children aged below 6 months, if appropriate). For ‘low birth weight’, the estimate is from Human Development Report 2006

Health-related indicators from the third National Family Health Survey are no less disturbing. For instance, they suggest that child immunisation rates were much the same in 2005-06 as in 1998-99 (Table 2). The incidence of anaemia among children was also similar in both years; in fact, it was a little higher in 2005-06, according to the available NFHS-3 data. While some indicators have improved, the general pace of change is excruciatingly slow -- much slower, for instance, than in neighbouring Bangladesh.

Similar concerns arise if we look at mortality indicators. In India, as in most other countries, the infant mortality rate has steadily declined during the last 50 years or so: from about 150 per 1,000 live births in the late-1950s, to 60 or so per 1,000 today. However, the decline in infant mortality slowed down significantly in the ’90s, compared with earlier decades. Although the rate of decline seems to have picked up again during the last few years, the overall progress made since 1990 is limited compared to many other countries.

This slow progress in the field of child health and nutrition is all the more striking as the Indian economy is one of the fastest-growing economies in the world. In the last 15 years, India’s GDP has been growing at around 6% per year, on average, and per-capita income has more than doubled. Few countries have had it so good as far as economic growth is concerned. Yet, progress on child development indicators has been much slower in India than in many countries with comparable or even much lower rates of economic growth.

India and South Asia

When India is compared with other countries, the comparison is usually made with ‘big’ countries -- say China or the United States. Yet there is a great deal to learn from looking around us within South Asia, especially in matters of nutrition and health. Far from being ‘backward’ in comparison with India, other South Asian countries are generally doing better than India in this field (see Table 3). It may come as a shock to learn that India has the lowest child immunisation rate in South Asia. For instance, the proportion of children who have not had a BCG vaccine in India is twice as high as in Nepal, more than five times as high as in Bangladesh, and almost 30 times as high as in Sri Lanka! Turning to child undernutrition, India emerges in a poor light again, with only Nepal doing worse. And despite its sophisticated medical system and vast army of doctors, India has not been able to achieve higher rates of child survival than any of its neighbours except Pakistan. Almost any ‘summary index’ of these child development indicators would place India at the bottom of this list of countries.

Some aspects of this picture are relatively well-known. For instance, Sri Lanka’s outstanding achievements in the field of child health have been widely noted. In spite of being almost as poor as India, in terms of per-capita income, Sri Lanka has an infant mortality rate of only 12 per 1,000 -- less than one-fifth of India’s (about 62 per 1,000). Similarly, child immunisation is virtually universal in Sri Lanka, in sharp contrast with India where this is still a distant goal (Table 3). What is less well known is that Sri Lanka’s success in this field is largely based on public intervention. Free and universal provision of essential services, especially in health and education, became an important feature of social policy in Sri Lanka at an early stage of development. For instance, most children in Sri Lanka have been integrated in a common schooling system of reasonable quality, under government auspices. In fact, private schools have been banned since the 1960s, up to the secondary level. Indian readers may also be surprised to hear that in Sri Lanka “few people live more than 1.4 km away from the nearest health centre” (Oxfam International, 2006). The fact that Sri Lankan children are doing so well in comparison with their Indian siblings is no accident -– it reflects highly divergent levels of public commitment to the wellbeing of children in these two countries.

Child deprivation in India and South Asia, 2004

 

Bangladesh

Bhutan

India

Nepal

Pakistan

Sri Lanka

Immunisation
(% of children under 3 years who have not received the stated vaccine)

BCG

5

8

27

15

20

1

DTP3

15

11

36

20

35

3

MCV

23

13

44

27

33

4

Pol3

15

10

30

20

35

3

Child undernutrition
(% of children with
the stated condition)

 

 

 

 

 

 

Underweight

48

19

47

48

38

29

Stunting

43

40

46

51

37

14

Wasting

13

3

16

10

13

14

Infant and child
mortality
(per 1,000 live births)

 

 

 

 

 

 

Infant mortality rate

56

67

62

59

80

12

Under-5 mortality
Rate

77

80

85

76

101

14

Source: UNICEF (2006), ‘State of the World’s Children’. In each row, the ‘worst’ figure is highlighted

No less interesting is the contrast between Bangladesh and India. In spite of being poorer (much poorer) than India, Bangladesh has better indicators of child development in many respects, as Tables 3 and 4 illustrate. The contrast in immunisation rates is particularly sharp: the proportion of children who have not been vaccinated is two to five times as high in India as in Bangladesh, depending on which vaccine one looks at. Similarly, infant and child mortality rates are significantly lower in Bangladesh than in India.

It is worth noting that this pattern is a relatively recent development: it is during the last 15 years or so that Bangladesh has ‘overtaken’ India in this field. While Bangladesh had a much higher infant mortality rate than India in 1990 (91 and 80 per 1,000 live births, respectively), today the positions are reversed: 56 per 1,000 in Bangladesh compared with 62 per 1,000 in India. India has been neatly leapfrogged, that too during a period when economic growth was much faster in India than in Bangladesh.

India and Bangladesh: Children’s wellbeing and related indicators, 2004 

 

India

Bangladesh

Infant mortality rate
(per 1,000 live births)

62

56

Proportion (%) of 1-year-olds immunised

 

 

BCG

73

95

Measles

56

77

Proportion (%) of undernourished children, 1995-2003*

 

 

Based on weight-for-age

49

48

Based on height-for-age

45

43

Estimated maternal mortality rate, 2000
(per 100,000 live births)

540

380

Net primary enrolment ratio (female) (%)

87

95

GDP per capita
(PPP US $)

3,139

1,870

* Data refers to the most recent year for which estimates are available during this period

Source: Human Development Report 2006. Unless stated otherwise, the reference year is 2004

It is also worth noting that the contrast between India and other South Asian countries would be even sharper if we were to focus on deprived regions or communities in each country, instead of national averages. This is because internal inequalities are typically larger in India. Other South Asian countries tend to be less ‘heterogeneous’, not only in terms of regional differences but also in terms of socio-economic inequalities. It is doubtful whether any country in South Asia (other than India) has substantial pockets where children live in such dreadful conditions as, say, among the Musahars of Bihar or the Sahariyas of Madhya Pradesh. And it is worth remembering that the Musahars alone represent a population of about 2.5 million -- more than the entire population of Bhutan, or for that matter of 45 of the 177 countries listed in the latest Human Development Report.

Childhood among the Sahariyas

In May 2006 Dilli Dakha lost her first child, a girl aged one-and-a-half years. After that she had a boy, Sugreev, who is now two. The couple then lost their twin daughters Ganga and Jamuna. According to Dakha, she was unable to feed them as there was no milk. She says she eats one roti with onion, once a day. Her family’s diet does not include any pulses or vegetables because they cannot afford it. Her husband earns around Rs 20 per day, on the few days he goes out to work. Subsequent to her third delivery she has started losing her sight, largely due to Vitamin A deficiency.

The deaths of children like Ganga and Jamuna are, unfortunately, not new to the district. Dilli Dakha and her husband are Sahariya tribals.

It is claimed that the Sahariyas were the first tribals in the country. For generations they depended on the forests for their survival, living a subsistence life with limited needs. Agriculture, gathering forest produce and hunting were traditional ways of earning a livelihood.

Life has not been easy for the Sahariyas after their eviction from the forests. Sahariya children are the worst affected due to poverty, lack of livelihood resources and an indifferent government policy. According to the regional medical research centre for tribals in Jabalpur, the Infant Mortality Rate (IMR) among Sahariyas is 88 per 1,000 live births, and 93.5% of Sahariya children are severely malnourished. According to the same sources, the average lifespan of a Sahariya is only 45 years; 74.3% of Sahariya children are underweight, and 75.4% stunted. Data from the state government’s Bal Sanjeevani Abhiyan (8th Report) indicates that 58% of children in the age-group 0-6 years, in the district, suffer from malnutrition. Nearly 86.5% of Sahariya women are anaemic because of the non-availability of nutritious food. These indicators show that the Sahariyas are one of the poorest and most deprived communities in the country.

-- Rolly Shivhare

Regional contrasts

National averages often hide major disparities between regions and socio-economic groups. This is particularly the case in a country like India, which is so large and so diverse. To illustrate, consider the immunisation rates as reported in the second National Family Health Survey (1998-99). For a child born in Tamil Nadu, the chance of being fully immunised by age one is around 90% (even higher among privileged Tamil families). But, chances of being fully immunised are only 42% for the average Indian child, dropping further to 26% for the average ‘scheduled tribe’ child, and a shocking 11% for the average Bihari child. When different sources of disadvantage (relating, for instance, to class, caste and gender) are combined, immunisation rates dip to abysmally low levels. For instance, among ‘scheduled tribe’ children in Bihar, only 4% are fully immunised and 38% have not been immunised at all. Startling disparities can also be observed in other aspects of child development.

Regional disparities are further explored in Table 5, based on NFHS-2 data. The table focuses on four crucial aspects of the wellbeing of children: survival, immunisation, nutrition and schooling (their SINS, if you like). For each of these, a standard indicator has been chosen (other indicators could have been used, but the choice does not matter much for our purpose). Each indicator is measured in percentage terms, and can be roughly interpreted as the ‘probability’ that an average child in the relevant state achieves a particular goal: survival until age 5, full immunisation, adequate nourishment, and school participation, respectively. In the last column, we present a simple ‘summary index’ of child development, based on these four indicators. This index is an average of the four indicators. To stress the vital importance of the achievements reflected in this index, we call it the ‘Achievements of Babies and Children’ (ABC) index.

In interpreting the index, it is useful to remember that we are focusing here on very basic achievements of Indian children, as the acronym indicates. Ideally, we would like every child (or almost every child -– nothing is perfect!) to survive until the age of 5, be fully immunised, well nourished, and go to school. In that case, the ABC index would be close to 100% -- full marks. As Table 5 shows, however, this ideal situation is nowhere near being realised in any Indian state, even Kerala, the trailblazer in this field. At the bottom of the scale, the ABC index is barely 50% for the states formerly known (somewhat unkindly) as BIMARU states -- Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. Roughly speaking, this corresponds to a situation where the average child in these states achieves only half of the four elementary goals examined in Table 5.

One will perhaps not be surprised to see Kerala at the top of this ranking, since Kerala is well known for its achievements in the fields of health and education, which have a long history. However, it is interesting to note that Kerala is no longer “way ahead” of all the other states, as it once used to be. Further, the states that are “catching up” with Kerala do not seem to be doing it on the basis of economic growth alone. If the achievements of babies and children were driven by economic success, we would expect Punjab and Haryana (India’s most prosperous states) to be ahead of the other states. But, in fact, Punjab and Haryana rank fourth and sixth, respectively, in terms of the ABC index. Both have been overtaken by Tamil Nadu and Himachal Pradesh, which are now quite close to Kerala as far as child development is concerned.

There is an important pointer here to the role of public action in this field. Indeed, both Tamil Nadu and Himachal Pradesh have made serious efforts to ensure that all citizens have access to basic health, nutrition and education services. In Himachal Pradesh, for instance, a “schooling revolution” of sorts has taken place in the last few decades. Widely considered as an educationally “backward” state not so long ago, Himachal Pradesh has rapidly caught up with Kerala, based on active state promotion of elementary education. In 1998-99, school attendance rates in the 6-14 age-group were as high as 99% and 97% for boys and girls respectively, compared with 97% for both, in Kerala.

This schooling revolution, together with related social initiatives, has not only led to a dramatic increase in education levels, it has also (more recently) paved the way for rapid advances in other fields including health and nutrition. Himachal Pradesh’s high ABC index is one manifestation of this general pattern of accelerated social progress based on public intervention.

Regional contrasts in child development, 1998-99

 

State

Selected
child development indicators*

‘Achievements of Babies and
Children’ (ABC) index

Survival
(% of children who
survive to age 5)

Immunisation           Nutrition
(% of children who     (% of children who are not              who are are fully immunised)   underweight)

Schooling
(% of children who
attend school)

Kerala

98.1

80

73

97

87.0

Tamil Nadu

93.7

89

63

92

84.4

Himachal Pradesh

95.8

83

56

98

83.2

Punjab

92.8

72

71

91

81.7

Maharashtra

94.2

78

50

93

78.8

Haryana

92.3

63

65

89

77.3

Jammu and Kashmir

92.0

57

66

84

74.8

Karnataka

93.0

60

56

80

72.3

Andhra Pradesh

91.6

59

62

76

72.2

Gujarat

91.5

53

55

78

69.4

West Bengal

93.2

44

51

87

68.8

INDIA

90.5

42

53

79

66.1

Orissa

89.6

44

46

79

64.7

Assam

91.1

17

64

77

62.3

Uttar Pradesh+

87.8

21

48

77

58.5

Rajasthan

88.5

17

49

76

57.6

Madhya Pradesh+

86.2

22

45

76

57.3

Bihar+

89.5

11

46

63

52.4

*Age-groups: 12-23 months for immunisation; below 3 years for nutrition; 6-14 years for schooling
+ Undivided (for example, including Jharkhand in the case of Bihar)
Note: The ABC Index is an unweighted average of the four indicators (for further discussion, see text). States are ranked in descending order of the index

Though Tamil Nadu has not been as successful as Himachal Pradesh in the field of elementary education, it has an outstanding record of active state involvement in the provision of health and nutrition services. For instance, Tamil Nadu was the first state to introduce cooked midday meals in primary schools, way back in 1982 -- almost 20 years before the Supreme Court nudged other states in the same direction. Tamil Nadu also has an outstanding network of anganwadis. Here again it is not an accident that Tamil children are doing relatively well; nor is it due primarily to economic growth. Rather, it reflects concerted efforts to provide children with the ‘opportunities and facilities’ that are due to them under the Constitution.

At the other end of the scale, the dismal levels of child development in Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh reflect a long history of public apathy towards the wellbeing of children in these states. In some of these states, or their ‘offspring’ (Chhattisgarh, Jharkhand and Uttaranchal), there have been positive signs of change in recent years. For instance, Chhattisgarh launched an innovative community health programme (the Mitanin programme) in 2001-02 and recent evidence suggests that this programme may be having a significant impact on child health. However, the general level of attention to children’s rights and wellbeing in these states remains abysmally low.

(Excerpted from Focus on Children Under Six (FOCUS), published by Citizens’ Initiative for the Rights of Children Under Six)

InfoChange News & Features, June 2007