Basic health care and maternal mortality are the most pressing concerns for India now, UNDP India senior advisor, Dr K Seeta Prabhu, tells Sreelatha Menon.
Would it be right to say India’s human development is at a standstill for the past few years, as the annual growth recorded is less than a per cent? Is it because we are not able to record this growth annually? Given the lack of data, what is its objective?
India has made steady progress in human development and registered a 1.51 per cent growth rate, which is above the average of 1.40 per cent for south Asia and 0.65 per cent at the global level. It is true that changes in human development indicators such as literacy, average number of years of schooling and life expectancy take a longer time to show than changes in income. However, this precisely makes it necessary to monitor the direction of change annually.
What is the most worrying aspect in India — poverty, education gaps, unsustainable development, lack of electricity, digital divide, migration, agrarian crisis or health care crisis?
It is difficult to single out one factor for all these aspects are interlinked and together result in multiple deprivations that go beyond income poverty. Income poverty can result in lack of opportunities for children to pursue education, leading to perpetuation of inter-generational transmission of poverty. Lack of electricity and access to health facilities as well as the digital divide are stark manifestations of deprivations. Unsustainable development, as the 2011 Human Development Report (HDR) highlights, affects the poor the most, as they bear the brunt of the depletion of natural resources and erosion of livelihood opportunities.
The United Nations Development Programme’s (UNDP’s) inequality adjusted human development index (HDI) shows India loses 28.3 per cent of its HDI value due to inequalities in all three dimensions of human development — income, education and health attainments. Educational inequalities result in a 40 per cent loss in educational attainment, while health inequalities account for 27 per cent loss in life expectancy and 14.7 per cent on account of income.
Jairam Ramesh said if change has to happen, a lot of public funding should come into education and health. But do you think this funding, if routed by government through our primary health centres, with non-attendant doctors, could bring about a change?
Our country’s experiences show that public funding to provide a minimum level of education and health services is essential. Efforts are needed to improve the quality of services in public institutions, which cannot happen unless there is a minimum level of funding. Public spending, however, continues to be low with the total expenditure of states and Central government being 1.06 per cent of GDP in 2009-10, with the central government alone spending 0.35 per cent of GDP on health.
For instance, the early results of the Rashtriya Swasthya Bima Yojana, which provides state subsidised health insurance cover for below poverty line (BPL) households, is encouraging. Around 25 million smart cards have been issued benefitting more than 75 million individuals from BPL families.
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Technology can be harnessed to give the poor a choice between private and public sector health care providers. Using group insurance as a model can go a long way in improving access to quality health care.
Which aspect in health care India must address immediately, going by the UNDP report data? Is it maternal mortality, teenage pregnancies or basic medical care for all through health insurance?
The data presented in the report indicate areas where India is lagging when compared to other south Asian countries such as Sri Lanka and Bangladesh. Despite the sharp decline in the maternal mortality rate (MMR) in recent years, India’s MMR in 2008 at 230 (number of maternal deaths per 100,000 live births) is several times higher than Sri Lanka’s MMR at 39. Similarly, adolescent fertility rate (AFR) in India in 2011 is 86.3 births per 1,000 live births, as compared to Bangladesh’s 78.9 and Pakistan’s 31.6. So, there is a scope for improvement on several such indicators.
Which country do you count as a success story of this decade? What can India learn from it?
Based on the data available in the 2011 HDR, among the south Asian countries, Sri Lanka is the top performer on all four indices — the HDI, the inequality adjusted HDI, the gender inequality index (GII) and the multi-dimensional poverty index. With an HDI rank of 97, it is among the top three in the medium human development category and is four notches above China at 101. The country has low levels of income poverty (head count ratio of 8.9 per cent for the year 2009-10) and multi-dimensional poverty. The multi-dimensional poverty headcount ratio as reported in the HDR 2011 is 5.3 per cent, lower than most south Asian countries.
The country suffers the lowest loss in HDI due to inequalities in the south Asia region and has displayed considerable improvement in the GII and the HDI, despite decades of conflict and modest economic growth. We need to look at the strategies that caused this.
You have looked at early marriage, poor participation of women in parliament and total fertility rate (TFR) to rank India at the bottom of Asia Pacific countries in the GII you have created. Why? Is 2.5 TFR such a low? Besides, you have left out sex ratio, which is the most obvious anti-women indicator?
The GII in the global HDR reflects gender-based disadvantage in three dimensions — reproductive health measured by MMR and AFR; empowerment measured by seats in national parliament and population with at least secondary education; and labour market participation. The GII is a composite index of all three dimensions. The availability of data across a large number of countries is an important factor in determining the variables that can be included in the index. Apart from the indicators that are used to construct composite indices, data is provided on other dimensions that have a bearing on gender inequality — this year’s report presents data on contraceptive prevalence rate, at least one antenatal visit and births attended by skilled health personnel, which provide further insights on reproductive health parameters. TFR is not used as an indicator in the GII calculations.
Sex ratio is definitely a critical concern. However, the GII faces major data limitations. For example, we use national parliamentary representation. Participation at the local government level and elsewhere in community and public life is not included. The labour market dimension lacks information on incomes, employment and unpaid work by women. Asset ownership, gender-based violence and participation in community decision-making are also not captured, due to limited data availability, which is comparable across all countries.
With a targeted approach to birth control promoted by bilateral agencies, should the UN harp on TFR instead of insisting on access to medicines, contraceptives and doctors?
There is no emphasis on any single variable — these sets of indicators are used to rank countries on the GII. As I mentioned TFR is not part of the GII — AFR is one of the indicators. The HDRs have consistently advocated for widespread access to basic health and education services over the years, particularly female literacy to promote human development.
Pakistan and Bangladesh have lower TFR than India but are hardly comparable with India in size. Would it be accurate to say their TFR is lower than that of the whole of India?
The data included in the GII is AFR in which Bangladesh and Pakistan have lower values than India. Averages are always misleading as there are large regional variations within India. However, this does not undermine the broad picture presented in a global report that considers data over 187 countries. This analysis is only indicative of the gaps that exist.