Research paper intended for the course of



Name of student - Deepankar Srigyan GroupML 511 Name of teacher- Ph.D. S. S. Kupov Submitted in Dep.:

MOSCOW 2008 Republic of India (Hindi Bharat ) :

‘’WE DON’T WANT WAR, WE WANT LOVE’’ India, officially the Republic of India (Hindi: भारत गणराजय Bhārat Gaṇarājya), is a country in South Asia. It is the seventh-largest country by geographical area, the second-most populous country, and the largest democracy in the world. Bounded by the Indian Ocean on the south, the Arabian Sea on the west, and the Bay of Bengal on the east, India has a coastline of 7,517 kilometers (4,671 mi). It is bordered by Pakistan to the west; China, Nepal, and Bhutan to the north-east; and Bangladesh and Myanmar to the east. India is in the vicinity of Sri Lanka, the Maldives, and Indonesia in the Indian Ocean. Home to the Indus Valley Civilization and a region of historic trade routes and vast empires, the Indian subcontinent was identified with its commercial and cultural wealth for much of its long history. Four major world religions, Hinduism, Buddhism, Jainism and Sikhism originated

there, while Zoroastrianism, Judaism, Christianity and Islam arrived in the first millennium CE and shaped the region's diverse culture. Gradually annexed by the British East India Company from the early eighteenth century and colonised by the United Kingdom from the midnineteenth century, India became an independent nation in 1947 after a struggle for independence that was marked by widespread nonviolent resistance. CONTENTS Snapshot ………………………………………………………………………………… …………………………. 3 Preface …………………………………………………………………………………… …………………………. 5 MAIN CHAPTERS:



GENERAL SOCIAL-ECONOMIC DEVELOPMENT OF THE COUNTRY …… ……….... 6 • Administrative foundation ………………………………………………… ……………………. 6 • Climate-geographical particularities …………………………………… …………………... 9 • General economical growth, types of productivity ………………… ………………… 11 • Working conditions of population ………………………………………… ………………... 18 • Urbanization …………………………………………………………………… …………………….. 23 • Social-economic characteristics of residential life in a given region ………….. 24 SOCIAL-HYGIENIC PROBLEMS OF THE COUNTRY ……………………… ……………… 27 • Characteristic of nutrition ………………………………………………… ……………………. 27 • Living conditions ……………………………………………………………… ……………………. 33 • Water supply and canalization in an inhabited area ………………… ………………. 34 • Working conditions …………………………………………………………… …………………... 35 CHARACTERISTICS OF POPULATION’S HEALTH IN THE COUNTRY …… ……….. 37 • Demographic indicates ……………………………………………………… …………………… 37

………………….. 37 2. Population dynamics ……………………………………………………… ……………………..41 • Mechanical population movement ……………………………………… …………………....41 • Brain drain problem ………………………………………………………… …………………….. 47 • Infant mortality ……………………………………………………………… ……………………… 49 • Birth rate ……………………………………………………………………… ……………………….. 52 • Average life expectancy …………………………………………………… ……………………... 54 • Fertility and contraception ………………………………………………… …………………….58 • Morbidity ………………………………………………………………………… ……………………...59 • Physical growth ……………………………………………………………… ……………………….67 • Disability ………………………………………………………………………… ………………………69 IV. ORGANIZATION OF THE PUBLIC HEALTH SYSTEM ……………………… ……………. 70 V. MOTHER AND CHILD HEALTH CARE IN THE COUNTRY ………………… ……………73 VI. PUBLIC HEALTH PLANNING, FINANCIAL AND ECONOMIC PROBLEMS IN THE COUNTRY ………………………………………………………………… ………………………………..87 VII. MEDICAL STAFF ………………………………………………………………… ……………………...95 VIII. RELATIONS BETWEEN INTERNATIONAL ORGANIZATIONS AND PUBLIC HEALTH SYSTEM IN THE COUNTRY ……………………………… ………………………….. 98 IX. PUBLIC HEALTH DEVELOPMENT PERSPECTIVES ………………………… …………..106 X. ANALYSE AND SUGGESTIONS ………………………………………………… ………………. 113 XI. CONCLUSIONS …………………………………………………………………… Motto: …………………... Republic of India 116 "Satyameva XII. BIBLIOGRAPHY …………………………………………………………………… Jayate" …………………..117
सतयमेव जयते

1. Population statistics …………………………………………………………

"Truth Alone Triumphs" Snapshot : Anthem: Jana Gana Mana

National Song : Vande Mataram
I bow to thee, Mother National Emblem 4

Thou art the ruler of Flag the minds of all

Capital Largest city Official languages English Demonym Parliamentary democracy

New Delhi Mumbai Hindi, Indian Government Federal


President Patil



Independence colonial rule 1950 Declared Republic Area Total 3,287,240 km² (7th)

from British 15 August 1947 26 January

1,269,210 s q mi Water (%) Population 2008 estimate 1,147,995,904 (2nd) 2001 census 1,027,015,248 Density 349/km² (33rd) 904/sq m GDP (PPP) Total trillion (4th) $2,563 (165th) GDP (nominal) Total trillion (12th) $941 (132nd) Currency (₨) (INR) Time zone (UTC+5:30) Summer (DST) Drives on the Internet TLD 2007 estimate $2.965 Per capita 2007 estimate $1.100 Per capita Indian rupee IST not observed (UTC+5:30) left .in



Calling code


PREFACE This report explores the social conditions of the population, public health problems and public health services of India. This report captures the knowledge and experience of public health system in India. The level of social conditions of the population of India depends on the level of national economy. The social, political and economic problems worth today in front of India are complex. Therefore, it is important to pay attention on structure of economy of India, which is completely depend on agriculture, the industry, an infrastructure and foreign trade of India. It helps to define principles of the accelerated economic development and to plan economy of India which in turn can support development of social hygiene in the financial attitude. The tremendous accelerating population of India is the main barrier in the way of development of this country. The improved level of social condition of the population of India and the decision of tasks in view, planning and the organization of public health services to veil from the analysis of the present condition of the following areas of demography: parameters of the population, statistics of a life, social parameters, water supply and conditions hygiene, a level of a feed of children, the organization of services of public health services, management of public health services, protection and hygiene of work, a professional training in the field of public health services, financing and distribution of the humanitarian help, disease and death rate, care of patients and research activity in the field of public health services. Therefore, in the given work pays the big attention to the parameters, describing the present

level of social hygiene in these areas. It helps to define in further principles of development of social hygiene and to plan and carry out actions on improvement of public health services in India. The research work is mainly confined to the public health sector and presents information on four major areas, morbidity, mortality, resource availability and provision of services. The information has been revised and brought up to date to reflect, as for as possible the situation during 2004-2008.

India is a republic consisting of 28 states and seven union territories with a parliamentary system of democracy. It has the world's twelfth largest economy at market exchange rates and the fourth largest in purchasing power. Economic reforms have transformed it into the second fastest growing large economy; however, it still suffers from high levels of poverty, illiteracy, and malnutrition. A pluralistic, multilingual, and multiethnic society, India is also home to a diversity of wildlife in a variety of protected habitats.

The Constitution of India, the longest and the most exhaustive constitution of any independent nation in the world, came into force on January 26, 1950. The preamble of the constitution defines India as a sovereign, socialist, secular, democratic rep ublic. India has a bicameral parliament operating under a Westminsterstyle parliamentary system. Its form of government was traditionally described as being 'quasi-federal' with a strong centre and weaker states, but it has grown increasingly federal since the late 1990s as a result of political, economic and social changes. The President of India is the head of
National Symbols of India Flag Emble m Anthe m Song Anima l Bird Flowe r Tree Fruit Sport Calen dar Tricolour Sarnath Lion Capital Jana Gana Mana Vande Mataram Royal Bengal Tiger Indian Peafowl Lotus Banyan Mango Field hockey Saka


state elected indirectly by an electoral college for a five-year term. ThePrime Minister is the head of government and exercises most executive powers. Appointed by the President, the Prime Minister is by convention supported by the party or political alliance holding the majority of seats in the lower house of Parliament. The executive branch consists of the President, Vice-President, and the Council of Ministers (the Cabinet being its executive committee) headed by the Prime Minister. Any minister holding a portfolio must be a member of either house of parliament. In the Indian parliamentary system, the executive is subordinate to the legislature, with the Prime Minister and his Council being directly responsible to the lower house of the parliament. The legislature of India is the bicameral Parliament, which consists of the upper house called the Rajya Sabha (Council of States) and the lower house called the Lok Sabha (House of People). The Rajya Sabha, a permanent body, has 245 members serving staggered six year terms. Most are elected indirectly by the state and territorial legislatures in proportion to the state's population. 543 of the Lok Sabha's 545 members are directly elected by popular vote to represent individual constituencies for five year terms. The other two members are nominated by the President from theAngloIndian community if the President is of the opinion that community is not adequately represented. India has a unitary three-tier judiciary, consisting of the Supreme Court, headed by the Chief Justice of India, twenty-one High Courts, and a large number of trial courts. The Supreme Court has original jurisdiction over cases involving fundamental rights and over disputes between states and the Centre, and appellate jurisdiction over the High Courts. It is judicially independent, and has the power to declare the law and to strike down union or state laws which contravene the Constitution. The role as the ultimate interpreter of the Constitution is one of the most important functions of the Supreme Court.

The North Block, in New Delhi, houses key government offices. At the federal level, India is the most populous democracy in the world. For most of the years since independence, the federal government has been led by the Indian National Congress (INC). Politics in the states have been dominated by several national parties including the INC, the Bharatiya Janata Party (BJP), theCommunist Party of India (Marxist) (CPI(M)) and various regional parties. From 1950 to 1990, barring two brief periods, the INC enjoyed a parliamentary majority. The INC was out of power between 1977 and 1980, when the Janata Party won the election owing to public discontent with the state of emergency declared by the then Prime Minister Indira Gandhi. In 1989, a Janata Dal-led National Front coalition in alliance with the Left Front coalition won the elections but managed to stay in power for only two years. As the 1991 elections gave no

political party a majority, the INC formed a minority government under Prime Minister P.V. Narasimha Rao and was able to complete its five-year term. The years 1996–1998 were a period of turmoil in the federal government with several short-lived alliances holding sway. The BJP formed a government briefly in 1996, followed by the United Front coalition that excluded both the BJP and the INC. In 1998, the BJP formed the National Democratic Alliance (NDA) with several other parties and became the first non-Congress government to complete a full five-year term. In the 2004 Indian elections, the INC won the largest number of Lok Sabha seats and formed a government with a coalition called the United Progressive Alliance (UPA), supported by various left-leaning parties and members opposed to the BJP.

Foreign relations and military
The Sukhoi-30 MKI is part of the Indian Air Force. Since its independence in 1947, India has maintained cordial relationships with most nations. It took a leading role in the 1950s by advocating the independence ofEuropean colonies in Africa and Asia. India was involved in two brief military interventions in neighboring countries - Indian Peace Keeping Force in Sri Lanka andOperation Cactus in Maldives. India is a member of the Commonwealth of Nations and a founding member of the Non-Aligned Movement. After the Sino-Indian War and the IndoPakistani War of 1965, India's relationship with the Soviet Union warmed at the expense of ties with the United States and continued to remain so until the end of the Cold War. India has fought three wars with Pakistan, primarily over Kashmir but it also facilitated the creation of Bangladesh in 1971. Additional skirmishes have taken place between the two nations particularly in 1984 over Siachen Glacier and in 1999 over Kargil. In recent years, relations between the United States and India have improved. Shown here are PM Manmohan Singh and President George W. Bush exchanging handshakes in March, 2006.

In recent years, India has played an influential role in the ASEAN, SAARC, and the WTO. India has provided as many as 55,000 Indian military and police personnel to serve in thirty-five UN peace keeping operations across four continents. Despite criticism and military sanctions, India has consistently refused to sign the CTBT and the NPT, preferring instead to maintain sovereignty over its nuclear program. Recent overtures by the Indian government have strengthened relations with the United States, China and Pakistan. In the economic sphere, India has close relationships with other developing nations in South America, Asia and Africa.

India maintains the third-largest military force in the world, which consists of the Indian Army, Navy and Air Force. Auxiliary forces such as the Paramilitary Forces, the Coast Guard, and the Strategic Forces Command also come under the military's purview. The President of India is the supreme commander of the Indian armed forces. India maintains close defence cooperation with Russia, France and Israel, who are the chief suppliers of arms. The Defence Research and Development Organisation (DRDO) has overseen the indigenous development of sophisticated arms and military equipment, including ballistic missiles, fighter aircrafts and main battle tanks, to reduce India's dependence on foreign imports. India became a nuclear power in 1974 after conducting an initial nuclear test, Operation Smiling Buddha and further underground testing in 1998. India maintains a "no first use" nuclear policy. On 10 October, 2008 Indo-US civilian nuclear agreement was signed, prior to which India received the IAEA and NSG waivers, ending restrictions on nuclear technology commerce with which India became de facto sixth nuclear power in world.

India is a federal republic of twenty-eight states and seven Union Territories. All states, and the two union territories of Puducherry and the National Capital Territory of Delhi have elected governments. The other five union territories have centrally appointed administrators and hence are under direct rule of the President. In 1956, under the States Reorganisation Act, states were formed on a linguistic basis. Since then, this structure has remained largely unchanged. Each state or union territory is further divided into 610 districts for basic governance and administration. The districts in turn are further divided into tehsils and eventually into villages.

• Climate-geographical particularities

Topographic map of India.

India, the major portion of the Indian subcontinent, sits atop the Indian tectonic plate, a minor plate within the Indo-Australian Plate.


India's defining geological processes commenced seventy-five million years ago, when the Indian subcontinent, then part of the southern supercontinent Gondwana, began a northeastwards drift-lasting fifty million years—across the then unformed Indian Ocean. The subcontinent's subsequent collision with the Eurasian Plateand subduction under it, gave rise to the Himalayas, the planet's highest mountains, which now abut India in the north and the north-east. In the former seabed immediately south of the emerging Himalayas, plate movement created a vast through, which, having gradually been filled with river-borne sediment, now forms the Indo-Gangetic Plain. To the west of this plain, and cut off from it by the Aravalli Range, lies the Thar Desert. The original Indian plate now survives as peninsular India, the oldest and geologically most stable part of India, and extending as far north as the Satpura and Vindhya ranges in central India. These parallel ranges run from the Arabian Sea coast in Gujarat in the west to the coal-rich Chota Nagpur Plateau in Jharkhand in the east. To their south, the remaining peninsular landmass, the Deccan Plateau, is flanked on the left and right by the coastal ranges, Western Ghats and Eastern Ghats respectively; the plateau contains the oldest rock formations in India, some over one billion years old. Constituted in such fashion, India lies to the north of the equator between 6°44' and 35°30' north latitude and 68°7' and 97°25' east longitude. India's coast is 7,517 kilometers (4,671 mi) long; of this distance, 5,423 kilometers (3,370 mi) belong to peninsular India, and 2,094 kilometers (1,301 mi) to the Andaman, Nicobar, and Lakshadweep Islands. According to the Indian naval hydrographic charts, the mainland coast consists of the following: 43% sandy beaches, 11% rocky coast including cliffs, and 46% mudflats or marshy coast. Major Himalayan-origin rivers that substantially flow through India include the Ganges and the Brahmaputra, both of which drain into the Bay of Bengal. Important tributaries of the Ganges include the Yamuna and the Kosi, whose extremely low gradient causes disastrous floods every year. Major peninsular rivers whose steeper gradients prevent their waters from flooding include the Godavari, the Mahanadi, the Kaveri, and the Krishna, which also drain into the Bay of Bengal; and theNarmada and the Tapti, which drain into the Arabian Sea. Among notable coastal features of India are the marshy Rann of Kutch in western India, and the alluvial Sundarbans delta, which India shares with Bangladesh. India has two archipelagos: the Lakshadweep, coral atolls off India's south-western coast; and the Andaman and Nicobar Islands, a volcanic chain in the Andaman Sea. India's climate is strongly influenced by the Himalayas and the Thar Desert, both of which drive the monsoons. The Himalayas prevent cold Central Asian katabatic winds from blowing in, keeping the bulk of the Indian subcontinent warmer than most locations at similar latitudes. The Thar Desert plays a crucial role in attracting the moisture-laden southwest summer monsoon winds that, between June and October, provide the majority of India's rainfall. Four major climatic groupings predominate in India: tropical wet, tropical dry, subtropical humid, and montane.

Flora and fauna

The Bengal tiger, threatened by poachers and smugglers, faces declining population levels and possible extinction. India, which lies within the Indomalaya ecozone, displays significant biodiversity. One of eighteen megadiverse countries, it is home to 7.6% of all mammalian, 12.6% of all avian, 6.2% of all reptilian, 4.4% of all amphibian, 11.7% of all fish, and 6.0% of all flowering plant species. Many ecoregions, such as the shola forests, exhibit extremely high rates of endemism; overall, 33% of Indian plant species are endemic. India's forest cover ranges from the tropical rainforest of the Andaman Islands, Western Ghats, and North-East India to the coniferous forest of the Himalaya. Between these extremes lie the sal-dominated moist deciduous forest of eastern India; the teak-dominated dry deciduous forest of central and southern India; and the babul-dominated thorn forest of the central Deccan and western Gangetic plain. Important Indian trees include the medicinal neem, widely used in rural Indian herbal remedies. The pipal fig tree, shown on the seals of Mohenjo-daro, shaded Gautama Buddha as he sought enlightenment. Many Indian species are descendants of taxa originating in Gondwana, to which India originally belonged. However, volcanism and climatic changes 20 million years ago caused the extinction of many endemic Indian forms. Soon thereafter, mammals entered India from Asia through two zoogeographical passes on either side of the emerging Himalaya. Consequently, among Indian species, only 12.6% of mammals and 4.5% of birds are endemic, contrasting with 45.8% of reptiles and 55.8% of amphibians. Notable endemics are the Nilgiri leaf monkey and the brown and carmine Beddome's toad of the Western Ghats. India contains 172, or 2.9%, of IUCN-designated threatened species. These include the Asiatic Lion, the Bengal Tiger, and the Indian white- rumped vulture, which suffered a nearextinction from ingesting the carrion of diclofenac-treated cattle. In recent decades, human encroachment has posed a threat to India's wildlife; in response, the system of national parks and protected areas, first established in 1935, was substantially expanded. In 1972, India enacted the Wildlife Protection Act and Project Tiger to safeguard crucial habitat; in addition, the Forest Conservation Act was enacted in 1980. Along with more than five hundred wildlife sanctuaries, India hosts thirteen biosphere reserves, four of which are part of the World Network of Biosphere Reserves; twenty-five wetlands are registered under the Ramsar Convention.

• General economical growth, types of productivity (industrial and agricultural)

Del hi Metro.

«The Bombay

Stock Exchange, in Mumbai, is

For most of its post-independence history, India adhered to a quasi-socialist approach with strict government control over private sector participation, foreign trade andforeign direct investment. However, since 1991, India has gradually opened up its markets through economic reforms and reduced government controls on foreign trade and investment. Foreign exchange reserves have risen from US$5.8 billion in March 1991 to US$308 billion on 4 July 2008, while federal and state budget deficits have decreased. Privatisation of publicly owned companies and the opening of certain sectors to private and foreign participation has continued amid political debate. India's GDP in terms of USD exchange-rate is US$1.089 trillion. When measured in terms of purchasing power parity (PPP), India has the world's fourth largest GDP at US$4.726 trillion. India's per capita income (nominal) is US$977, while its per capita (PPP) is US$2700. With an average annual GDP growth rate of 5.7% for the past two decades, the economy is among the fastest growing in the world. India has the world's second largest labour force, with 516.3 million people, 60% of whom are employed in agriculture and related industries; 28% in services and related industries; and 12% inindustry. Major agricultural crops include rice, wheat, oilseed, cotton, jute, tea, sugarcane, and potatoes. The agricultural sector accounts for 28% of GDP; the service and industrial sectors make up 54% and 18% respectively. Major industries include automobiles, cement, chemicals, consumer electronics, food processing, machinery, mining, petroleum, pharmaceuticals, steel, transportation equipment, and textiles. Along with India’s fast economic growth comes its growing demand for energy. According to the Energy Information Administration, India is the sixth largest consumer of oil and third largest consumer of coal. Although the Indian economy has grown steadily over the last two decades; its growth has been uneven when comparing different social groups, economic groups, geographic regions, and rural and urban areas. Income inequality in India is relatively small (Gini coefficient: 36.8 in year 2004), though it has been increasing of late. Wealth distribution in India is fairly uneven, with the top 10% of income groups earning 33% of the income. Despite significant economic progress, a quarter of the nation's population earns less than the


government-specified poverty threshold of $0.40 per day. In 2004–2005, 27.5% of the population was living below the poverty line. More recently, India has capitalised on its large pool of educated, Englishspeaking people, and trained professionals to become an important outsourcing destination for multinational corporations and a popular destination for medical tourism. India has also become a major exporter of software as well as financial, research, and technological services. Its natural resources include arable land, bauxite, chromite, coal, diamonds, iron ore, limestone, manganese, mica, natural gas, petroleum, and titanium ore. In 2007, exports stood at US$145 billion and imports were around US$217 billion. Textiles, jewellery, engineering goods and software are major export commodities while crude oil, machineries, fertilizers, and chemicals are major imports. India's most important trading partners are the United States, the European Union, and China.

Economic development in India

Most Indians work in agriculture.

standards across India has helped its economic rise. Shown here is the Indian School of Business at Hyderabad, ranked number 20 in global MBA rankings by the Financial Times of London in 2008.

The economic development in India is highly dependent upon various sectors like agriculture, manufacturing and services. In nominal terms, India is the twelfth largest in the world, with a GDP of 1.1 trillion US dollars (2008), which is approximately equal to the state of Texas or Mexico.. India ranks fourth with respect to GDP (PPP). India followed a socialist-inspired approach for most of its independent history, with stiff regulation and strict "Licence Raj" control over private sector participation, foreign trade, and foreign direct investment. India's economy stagnated between 1947 and the 1980s. India's population grew rapidly from estimated 0.35 billion to over 1 billion. India still suffers from high levels of poverty, illiteracy, and malnutrition. Since the early 1990s, India has slowly opened up its markets through economic reforms. The overall growth has significantly improved. However, India has large regional disparities. Between

1999 and 2008, the best performing states grew at over 8% annualized rate compared to under 5% in the worst-performing states. Further reforms have proceeded slowly amid political debate. Two-thirds of the Indian workforce still earn their livelihood directly or indirectly through agriculture in rural villages. However, non-agricultural jobs and towns are playing an increasingly important role in India's economy. More recently, India has capitalised on its large pool of educated, English-speaking people, and trained professionals to become an important outsourcing destination for multinational corporations and a popular destination for medical tourism. Other sectors like manufacturing, pharmaceuticals, biotechnology, nanotechnology telecommunication, shipbuilding, aviation and tourism are showing strong potentials with high growth rates.


Composition of India's total production (million tonnes) of foodgrains and commercial crops, in 2003–04.

India ranks second worldwide in farm output. Agriculture and allied sectors like forestry, logging and fishing accounted for 18.6% of the GDP in 2005, employed 60% of the total workforce and despite a steady decline of its share in the GDP, is still the largest economic sector and plays a significant role in the overall socio-economic development of India. Yields per unit area of all crops have grown since 1950, due to the special emphasis placed on agriculture in the five-year plans and steady improvements in irrigation, technology, application of modern agricultural practices and provision of agricultural credit and subsidies since the green revolution. India is the largest producer in the world of milk, cashew nuts, coconuts, tea, ginger, turmeric and black pepper. It also has the world's largest cattle population (193 million). It is the second largest producer of wheat, rice, sugar, groundnut and inland fish. It is the third largest producer of tobacco. India accounts for 10% of the world fruit production with first rank in the production of banana and sapota. The required level of investment for the development of marketing, storage and cold storage infrastructure is estimated to be huge. The government has implemented various schemes to raise investment in marketing infrastructure. Among these schemes are Construction of Rural Go downs, Market Research


and Information Network, and Development / Strengthening of Agricultural Marketing Infrastructure, Grading and Standardization. Research and development The Indian Agricultural Research Institute (IARI), established in 1905, was responsible for the research leading to the "Indian Green Revolution" of the 1970s. The Indian Council of Agricultural Research (ICAR) is the apex body in agriculture and related allied fields, including research and education. The Union Minister of Agriculture is the President of the ICAR. The Indian Agricultural Statistics Research Institute develops new techniques for the design of agricultural experiments, analyses data in agriculture, and specializes in statistical techniques for animal and plant breeding. Prof. M.S. Swaminathan is known as "Father of the Green Revolution" and heads the MS Swaminathan Research Foundation. He is known for his advocacy of environmentally sustainable agriculture and sustainable food security.

Industrial output
India(the best country)is fourteenth in the world in factory output. Manufacturing sector in addition to mining, quarrying, electricity and gas together account for 27.6% of the GDP and employ 17% of the total workforce. Economic reforms introduced after 1991 brought foreign competition, led to privatisation of certain public sector industries, opened up sectors hitherto reserved for the public sector and led to an expansion in the production of fast-moving consumer goods. Post-liberalisation, the Indian private sector, which was usually run by oligopolies of old family firms and required political connections to prosper was faced with foreign competition, including the threat of cheaper Chinese imports. It has since handled the change by squeezing costs, revamping management, focusing on designing new products and relying on low labour costs and technology. 34 Indian companies have been listed in the Forbes Global 2000 ranking for 2007. The 10 leading companies are: Reven ue (billio n $) Profit s (billio n $) Asset s (billio n $) Market Value (billion $)

World Company Rank

L Industry ogo


Oil and Natural Gas Corporation

Oil & Gas Operations







Reliance Industries State Bank of India Indian Oil Corporation NTPC ICICI Bank Steel Authority of India Limited Tata Consultancy Svcs Tata Steel Infosys Technologies

Oil & Gas Operations









156.3 7



Oil & Gas Operations Utilities Banking





494 536

6.06 5.79

1.31 0.54

17.25 62.13

26.06 16.72








Software & Services






Materials Software & Services











source :

India is fifteenth in services output. Service industry employs 23% of the work force and is growing quickly, with a growth rate of 7.5% in 1991–2000, up from 4.5% in 1951–80. It has the largest share in the GDP, accounting for 53.8% in 2005 up from 15% in 1950. Business services (information technology, information technology enabled services, business process outsourcing) are among the fastest growing sectors contributing to one third of the total output of services in 2000. The growth in the IT sector is attributed to increased specialisation and availability of a large pool of low cost. Highly skilled, educated and fluent English-speaking workers on the supply side and on the demand side, has increased demand from foreign consumers interested in

India's service exports or those looking to outsource their operations. India's IT industry, despite contributing significantly to its balance of payments, accounts for only about 1% of the total GDP or 1/50th of the total services. The ITES-BPO sector has become the biggest employment generator especially amongst young college graduates. The number of professionals employed by IT and ITES sectors is estimated at 1287000 as on March 2006. Also, Indian IT-ITES is estimated to have helped create an additional 3 million job opportunities through indirect and induced employment.

Banking and finance

The Reserve Bank of India headquarters in Mumbai.

Since liberalisation, the government has approved significant banking reforms. While some of these relate to nationalised banks (like encouraging mergers, reducing government interference and increasing profitability and competitiveness), other reforms have opened up the banking and insurance sectors to private and foreign players. Currently, in 2007, banking in India is generally mature in terms of supply, product range and reach-even, though reach in rural India still remains a challenge for the private sector and foreign banks. In terms of quality of assets and capital adequacy, Indian banks are considered to have clean, strong and transparent balance sheets relative to other banks in comparable economies of Asia. The Reserve Bank of India is an autonomous body, with minimal pressure from the government. The stated policy of the Bank on the Indian Rupee is to manage volatility but without any fixed exchange rate.


Currently, India has 88 scheduled commercial banks (SCBs) — 28 public sector banks (that is with the Government of India holding a stake), 29 private banks (these do not have government stake; they may be publicly listed and traded on stock exchanges) and 31 foreign banks. They have a combined network of over 53,000 branches and 17,000 ATMs. The public sector banks hold over 75% of total assets of the banking industry, with the private and foreign banks holding 18.2% and 6.5% respectively.

India's resource consumption
Oil India had about 5.6 billion barrels (890,000,000 m3) of proven oil reserves as of January 2007, which is the second-largest amount in the Asia-Pacific region behind China. Most of India's crude oil reserves are located in the western coast (Mumbai High) and in the northeastern parts of the country, although considerable undeveloped reserves are also located in the offshore Bay of Bengal and in the state of Rajasthan. The combination of rising oil consumption and fairly unwavering production levels leaves India highly dependent on imports to meet the consumption needs. In 2006, India produced an average of about 846,000 barrels per day (bbl/d) of total oil liquids, of which 77%, or 648,000 bbl/d (103,000 m³/d), was crude oil. During 2006, India consumed an estimated 2.63 Mbbl/d (418,000 m³/d) of oil. The Energy Information Administration (EIA) estimates that India registered oil demand growth of 100,000 bbl/d (16,000 m³/d) during 2006. EIA forecasts suggest that country is likely to experience similar gains during 2007 and 2008. Sector organisation India’s oil sector is dominated by state-owned enterprises, although the government has taken steps in past recent years to deregulate the hydrocarbons industry and support greater foreign involvement. India’s stateowned Oil and Natural Gas Corporation (ONGC) is the largest oil company, and also the country’s largest company overall by market capitalization. ONGC is the leading player in India’s upstream sector, accounting for roughly 75% of the country’s oil output during 2006, as per Indian government estimates. As a net importer of oil, the Government of India has introduced policies aimed at growing domestic oil production and oil exploration activities. As part of the effort, the Ministry of Petroleum and Natural Gas crafted the New Exploration License Policy (NELP) in 2000, which permits foreign companies to hold 100% equity possession in oil and natural gas projects. However, to date, only a handful of oil fields are controlled by foreign firms. India’s downstream sector is also dominated by state-owned entities, though private companies have enlarged their market share in past recent years.


Natural gas
As per the Oil and Gas Journal, India had 38 trillion cubic feet (Tcf) of confirmed natural gas reserves as of January 2007. A huge mass of India’s natural gas production comes from the western offshore regions, particularly the Mumbai High complex. The onshore fields in Assam, Andhra Pradesh, and Gujarat states are also major producers of natural gas. As per EIA data, India produced 996 billion cubic feet (Bcf) of natural gas in 2004. India imports small amounts of natural gas. In 2004, India consumed about 1,089×109 cu ft (3.08×1010 m3) of natural gas, the first year in which the country showed net natural gas imports. During 2004, India imported 93×109 cu ft (2.6×109 m3) of liquefied natural gas (LNG) from Qatar. Sector Organization As in the oil sector, India’s state-owned companies account for the bulk of natural gas production. ONGC and Oil India Ltd. (OIL) are the leading companies with respect to production volume, while some foreign companies take part in upstream developments in joint-ventures and production sharing contracts (PSCs). Reliance Industries, a privately-owned Indian company, will also have a bigger role in the natural gas sector as a result of a large natural gas find in 2002 in the Krishna Godavari basin. The Gas Authority of India Ltd. (GAIL) holds an effective control on natural gas transmission and allocation activities. In December 2006, the Minister of Petroleum and Natural Gas issued a new policy that allows foreign investors, private domestic companies, and national oil companies to hold up to 100% equity stakes in pipeline projects. While GAIL’s domination in natural gas transmission and allocation is not ensured by statute, it will continue to be the leading player in the sector because of its existing natural gas infrastructure. Table 01- STRUCTURE of the ECONOMY 1987 (% of GDP) Agriculture Industry Manufacturing Services Household final consumption 1997 2006 29.4 26.1 26.3 26.8 16.4 16.4 44.3 47.1 67.1 66.0 18.3 29.3 16.3 52.4 56.7 2 007 1 7.8 2 9.4 1 6.4 5 2.8 5 4.8

expenditure General gov't final consumption expenditure Imports of goods and services

12.3 11.4


1 0.1 2 4.4

7.1 12.1


• Working conditions of population
India’s expanding economy, consumer base and burgeoning capabilities in service sectors like information technology and business process outsourcing are making it a new go-to place for western companies large and small. Also increasing India’s attractiveness to western corporations is its huge population of capable workers. However, most of those workers are already employed, and the current economic expansion is further tightening the supply of skilled labor. So, for a company seeking to get the most out of an operation in India, a firm needs a trained workforce. Recruiting such a workforce requires a careful and proactive HR strategy that is adapted to the local culture and practices. But the many differences in laws, compensation and business culture can make HR in India a challenge. To meet that challenge, HR needs to become knowledgeable of India’s laws, practices and local conditions. Labor market overview India has a huge number of employable workers. Out of India’s population of 1.1 billion people, about 160 million are in the non-agricultural workforce. The population is matched by a large educational network of over 10,000 colleges of various sorts. India has over 22 million college graduates, 7.2 million of those in science and engineering, and it turns out 2.5 million new graduates each year. Since 2002, seasoned technical and managerial staffs have been in high demand in India, with salaries for those employees rising sharply every year. Competition is fierce, with frequent job-hopping and poaching the norm. But, despite the higher demand for talent, salaries are significantly less than among U.S. counterparts. Legal environment Although deregulation in the 1990s made it much easier to do business in India, the legal system is still onerous by American standards. Among the legal hazards a company must deal with are a huge number of non-codified, ambiguous laws (estimated at over 2,000) and joint federal and state government authority over labor. However, restrictions are often lighter for the newest service industries, and the regulatory burden is no longer so heavy that it deters investment. Working conditions


Standards for working conditions in India depend on state and federal laws as well as whether the workplace is a “specified establishment.” Factories, mines and plantations are usually put in this category. When in effect, regulations set standards such as 19 days of annual paid leave; a working day not less than 12 hours; and double pay for overtime above nine hours a day or 48 hours a week. In addition, governmental permission is needed for female employees to work at night, though this is usually granted in service sectors. Managerial staffs are almost always excluded from regulations on working conditions. While managers usually receive the same leave terms, they do not receive overtime pay. Contracts and termination The standard hiring practice in India is for employers to provide new employees with a letter of appointment, which serves as a binding contract, though legal requirements take precedence. The letter usually includes the terms of salary, starting date, position, workplace, transfers, ethics, confidentiality, probation and termination. Terminating a worker in India can be difficult. By law, a number of procedures must be followed, involving just cause, notice and arbitration. But, while the procedures are not applicable to managerial staff, it is important to observe the termination process with non-managerial employee because if they are not observed a firing can be challenged in court. The possibility of a terminated employee raising a court challenge increases the need to document the circumstances surrounding a termination, but HR departments need to remember that although misconduct is accepted as a cause for termination, inefficiency is not always accepted. Compensation structures and levels For Westerners, one of the most unfamiliar aspects of employment in India is the prevalence of non-salary benefits. The structure of compensation usually comes out to about 40 percent base salary, 35 percent flexible benefit plan, and 25 percent retirement benefits and performance-based pay.This system was developed mainly because most non-salary benefits were tax-exempt for the company. However, these tax advantages are being chipped away at, especially with the fringe benefit tax (FBT), a new corporate tax established in 2005. The FBT lists tax valuations for many different benefits, such as entertainment, travel and gifts, up to 30 percent of the benefit’s actual value. As a result of the FBT and other changes, benefits are being reduced somewhat, but they are still a significant part of the Indian HR landscape. The flexible benefit plan (FBP) is a standard corporate practice where an employee is assigned a fixed monetary amount to receive in benefit form. The employee chooses how to take benefits, depending on personal and tax circumstances. Common benefits include rent, house payments, transportation, medical insurance, children’s education and subsidized loans.


Salaries in India vary sharply by education quality and experience. An entrylevel information technology (IT) hire may earn as little as $2,000 annually, while an engineer freshly graduated from a reputed university will easily make $12,000. In some of the highest-demand sectors, salaries for particularly experienced staff have even risen to surpass American levels, IT managers with 15 years’ experience, for example, command about $220,000. However, IT is an exceptional sector as department leaders’ pay in most other industries is generally about 25 percent of American levels. But wage levels are changing, and overall salaries are increasing annually by from 10 percent to 30 percent. Public retirement, disability programs The most prominent social security program in India is the “Provident Fund.” Although it is mandatory only for employees making under about $141 monthly, it is used almost universally because of its tax benefits. The Provident Fund deducts 12 percent from an employee’s wages, which the employer matches. The funds collected are earmarked to a retirement pension or to make lump sum payments for worker death or disability. There is also the Employees State Insurance (ESI) program, mandatory for employees in specific industries making under about $163 monthly. The ESI pays benefits for worker death and disability as well as sick pay and maternity pay. Types of employees Expatriates are less common in India than in most Asian countries, except for top positions, with the pharmaceutical, hospitality and airline industries among the leading companies that most often hire expatriates. Returnees are becoming more common but are still limited overall, and they rarely command higher salaries than locals. In addition, work visas are generally tied to a job, thereby preventing most foreigners from moving easily from job to job on the same permit. Some Indian employees’ written communication skills may need improvement. Some socialization with colleagues and bosses is expected. In deciding whether to take a job, most potential Indian hires will consider such factors as responsibility, career prospects, company reputation and profitability, their offered title, travel opportunities, and the possibility of going overseas. Multinational companies tend to have more prestige among Indians, even as the gap between multinational firm’s salaries and domestic companies’ salaries is narrowing. Recruiting methods Like the United States, India has a wide range of recruiting methods, but most recruiting is fairly informal, with walk-in interviews common below the managerial level. In specialties like finance, engineering and marketing, oncampus recruitment is often used to find entry-level candidates.

Advertisements and recruitment agencies can be effective and even necessary to recruit for managerial positions. Internet job sites like and are coming into wider use.

Emerging issues
Child labour
There are more children under the age of 14 in India than the entire population of the United States. The great challenge of India, as a developing nation, is to provide sufficient nutrition, education and health care to these children. Children under 14 constitute nearly 3.6% of the total labor force in the country. Of these children, 9 out of every 10 work in their own rural family settings. Around 85% of them are engaged in traditional agricultural activities. Less than 9% work in manufacturing, services and repairs. Child labor is a complex problem that is basically rooted in poverty. The Indian government is implementing the world's largest child labor elimination program, with primary education targeted for ~250 million. Numerous nongovernmental and voluntary organizations are also involved. Special investigation cells have been set up in states to enforce existing laws banning employment of children (under 14) in hazardous industries. The allocation of the Government of India for the eradication of child labor was $10 million in 1995-96 and $16 million in 199697. The allocation for 2007 is $21 million.

Corruption :

Extent of corruption in Indian states, as measured in a 2005 study by Transparency International India. (Darker regions are more corrupt).

Corruption has been one of the pervasive problems affecting India. It takes the form of bribes, evasion of tax and exchange controls, embezzlement, etc. The economic reforms of 1991 reduced the red tape, bureaucracy and the Licence Raj that had strangled private enterprise and was blamed for the corruption and inefficiencies. Yet, a 2005 study by Transparency International (TI) India found that more than half of those surveyed had firsthand experience of paying a bribe or peddling influence to get a job done in a public office. The chief economic consequences of corruption are the loss to the exchequer, an unhealthy climate for investment and an increase in the cost of government-subsidised services. The TI India study estimates the monetary value of petty corruption in 11 basic services provided by the government, like

education, healthcare, judiciary, police, etc., to be around Rs.21,068 crores. India still ranks in the bottom quartile of developing nations in terms of the ease of doing business, and compared with China, the average time taken to secure the clearances for a startup or to invoke bankruptcy is much greater. The Right to Information Act (2005) and equivalent acts in the states, that require government officials to furnish information requested by citizens or face punitive action, computerisation of services and various central and state government acts that established vigilance commissions have considerably reduced corruption or at least have opened up avenues to redress grievances. The 2006 report by Transparency International puts India at 70th place and states that significant improvements were made by India in reducing corruption. Environmental Degradation About 1.2 billion people in developing nations lack clean, safe water because most household and industrial wastes are dumped directly into rivers and lakes without treatment. This contributes to the rapid increase in waterborne diseases in humans. Out of India's 3119 towns and cities, just 209 have partial treatment facilities, and only 8 have full wastewater treatment facilities (WHO 1992). 114 cities dump untreated sewage and partially cremated bodies directly into the Ganges River. Downstream, the untreated water is used for drinking, bathing, and washing. This situation is typical of many rivers in India as well as other developing countries. Globally, but especially in developing nations like India where people cook with fuelwood and coal over open fires, about 4 billion humans suffer continuous exposure to smoke. In India, particulate concentrations in houses are reported to range from 8,300 to 15,000 μg/m3, greatly exceeding the 75 μg/m3 maximum standard for indoor particulate matter in the United States. Changes in ecosystem biological diversity, evolution of parasites, and invasion by exotic species all frequently result in disease outbreaks such as cholera which emerged in 1992 in India. The frequency of AIDS/HIV is increasing. In 1996, about 46,000 Indians out of 2.8 million (1.6 % of the population) tested were found to be infected with HIV. Future predictions It has been estimated by the economists that the domestic political scene will be dominated by the upcoming general election, which is due to be held by May 2009 but might be held sooner. The Reserve Bank of India (RBI, the central bank) is most likely to maintain a bias towards monetary tightening during the remainder of 2007 in order to keep inflation under control. Monetary policy will move to a more neutral orientation in 2008 to 2012, provided that the wholesale price inflation remains within the RBI's mediumterm target range of 4 to 4.5%. The government will remain committed to increased spending on public facilities such as health, education and rural welfare projects in a bid to

improve living standards outside the country's fast-growing urban localities. Also, the strong economic growth will increase tax revenue, allowing the government to continue to reduce the budget deficit. The real GDP growth (on an expenditure basis) is forecast to slow from 9.4% in fiscal year 2006/2007 (from April to March) to an annual average of 7.7% in 2007/2008 to 2012/2013. Information technology (IT) and IT-enabled services (ITES) output will grow rapidly in the upcoming period, owing to India's cost advantages in these sectors. The strength of the Indian rupee against the US dollar will mitigate inflationary pressures by limiting import-led price rises. However, strong domestic demand, together with supply-side bottlenecks, will keep consumer price inflation at an average of nearly 5.1% a year in 2008 to 2012. For the years 2008-2010, India, is the second largest destination for Foreign direct investment, after China.

• Urbanization
Rural Population which Migrated to Urban Areas. 25% of the country's poor live in urban areas, 31% of the urban population is poor. Growing urbanization is a recent phenomenon in the developing countries. The proportion of the urban population in India has increased from 11% in 1901 to 27.8 % in 2001.The United Nations defines mega-cities as those with a population of 10 million or more. In 1950 only New York was classified as mega-city. By 1995 the number rose to 14 mega-cities and Mumbai, Kolkata and Delhi were included in the list. Population projections indicate that by 2015 Hyderabad will also become a mega-city. The increase in urban population has been attributed both to natural growth(through births) and migration from villages because of employment opportunities, attraction of better living conditions and availability of social services such as education, health, transport, entertainment etc. Traditional rural-urban migration exists in India as villagers seek to improve opportunities and lifestyles. In 1991, 39 million people migrated in rural-urban patterns of which 54% were female. Caste and tribe systems complicate these population movements. Seasonal urban migration is also evident throughout India in cities like Surat where many migrants move into the city during periods of hardship and return to their native villages for events such as the harvest. The main reason of increasing urbanization now- a- days is internal migration for better profession and education i.e. profession migration and student migration. India's largest cities / urban areas are Mumbai, Kolkata, Delhi, Chennai and Bangalore (rank wise).

India's largest cities / urban areas

(Source: India's national census of


Table – 02. Rank 1 2 3 4 5 6 7 8 9 10 City / Urban Area Mumbai (Bombay) Kolkata (Calcutta) Delhi Chennai Bangalore Hyderabad Ahmadabad Pune Surat Kanpur Population 16,368,000 13,217,000 12,791,000 6,425,000 5,687,000 5,534,000 4,519,000 3,756,000 2,811,000 2,690,000

• Social-economic characteristics of residential life in a given region Economic trends :
Gross national product (GNP) per capita increased from Indian Rs. 6340 in 1991/92 to Rs. 13,193 in 1997/98. The annual growth rate of the GNP increased from 0.5% in 1991/92 to 7.0% in 1995/96, but declined to 4% in 2000/2001. The percentage of poor in rural areas increased from 20.5 in 1991/92 to 22.9 in 1992/93 and to 37.3% in 1993/94. Since the early 1990s, overall economic growth has been faster. The situation regarding balance of payments has strengthened considerably, and the central government's fiscal deficit as a proportion of the gross domestic product (GDP) has declined significantly.

Social trends :

From the 2001 population census, the literacy rate for males is 75.85% and for females is 54.16%. The changing economic situation created by urbanization, industrialization and new economic liberalization has transformed the Indian social structure and values from a traditionally agrarian economy to a modern industrial order. The emerging nuclear family is exposed to severe economic and social constraints and changes. The traditional mechanisms for social security and adjustment in times of crisis and conflict are fast disappearing. This transformation has resulted in the creation of several social problems for individuals and groups such as older persons, the disabled, drug addicts, street children, child labor, HIV-infected populations, etc. There has also been increased violence - individually as well as collectively - especially towards women and young girls, which has assumed a national dimension. The problem of drug abuse is no more confined to a particular section of society but has infiltrated all strata. The large uncontrolled influx of rural migrants to urban areas in search of better earnings and job opportunities leaves them totally vulnerable, particularly the children of these migrant families. The negative influence of the electronic media appears to have resulted in an increase in juvenile delinquency, vagrancy, robberies, murders and kidnappings.


Data from the 2006-07 National Family Health Survey also reveal a wide gap between SCs and other castes in health status and access to public services (Table 2). Infant and child mortality is much higher in SC households than in others, and women’s health and childbearing are much worse (perhaps a contributing factor). The extent of malnutrition and undernutrition among children of SCs is also much higher than among children of other castes. Table 03. Health Indicators for Women and Children Indicator Scheduled Castes Other Infant mortality (per 1,000) 83.0 62.0 Under-five mortality (per 1,000) 119.0 82.0 Proportion below 3 standard deviations of the average weight for age (%) 21.2 13.8 Proportion below 2 standard deviations of the average weight for age (%) 53.5 41.1 Women with anemia (%) 56.0 48.0 Women with antenatal checkup (%) 61.8 72.1 Home-delivered births (%) 72.1 59.0 Source: National Family Health Survey, 2006-07 (Central Statistical Office, New Delhi).


While the purpose of this brief has been to highlight the direct and indirect effects of economic discrimination on poverty and the need for socially inclusive policies, above all, the brief draws attention to the current paucity of knowledge on the full impact of discrimination and how this knowledge gap can be effectively addressed. Studies on these issues, as outlined above, are a necessary foundation for the development of appropriate policies to combat discrimination and reduce poverty. Reference: • A. de Haan, “Extreme Deprivation in Remote Areas in India: Social Exclusion as Explanatory Concept,” presented at the conference on Chronic Poverty (Manchester, April 2003); • A. Sen, “Social Exclusion: Concept, Application, and Scrutiny,” Social Development Papers No. 1 (Office of Environment and Social Development, Asian Development Bank, 2000); • S. Thorat, A. Negi, and P. Negi, Reservation and Private Sector: Quest for Equal Opportunity and Growth (Jaipur, India: Rawat, 2004). •

»The World Bank Group: This graph was prepared by country unit
staff; figures may differ from other World Bank published data. 9/24/08. Figure :01

Source :

»The World Bank Group: This table was prepared by country unit staff;
figures may differ from other World Bank published data. 9/24/08. ,




• Characteristic of nutrition
Food supply and nutritional status :
The proportion of newborns weighing less than 2500 grams at birth was reported as 23% in 2006/07. The proportion of children under 3 years whose weight-forage was less than minus 2 SD below the median was 47% (2006/07). It is estimated that 200 million people are exposed to the risk of iodine deficiency disorders (IDDs) and that 63 million suffer from goitre. Surveys conducted in 275 districts have revealed that 235 districts are endemic for IDDs. In 2001, 87.5% of pregnant women were found to be anaemic (haemoglobin <11g/dl). The National Institute of Nutrition in Hyderabad reported that 56% of children under five years of age had iron deficiency anaemia. The contribution of vitamin A deficiency to blindness was estimated to be 2% in 1975 and 0.04% in 1990. A national IDD control programme was launched in 1992, which covers all states and union territories. The strategy is the use of iodated salt and all aspects of programme implementation are being addressed. Anaemia contributed to 20% of maternal deaths in 1991. An intervention programme that commenced in 1992 prioritized pregnant women for iron and folic acid administration. During 1994/95, 85.8% of pregnant women were covered with the recommended daily dose of iron folate tablets. The most susceptible group for vitamin A deficiency blindness is preschool children. The child survival programme seeks to administer five doses of vitamin A to all children under three years. During 1994/95, 72.6% of infants and 54.8% of 1-2 year old children were administered vitamin A. Other actions include the Integrated Child Development Service (ICDS) programme that provides a package of services to 54 million beneficiaries comprising preschool children, pregnant women and lactating mothers, and the mid-day meal programme for primary school children. The following goals have been set to be achieved by the year 2000: reduction by 50% of moderate and severe protein-energy malnutrition (PEM) in preschool children,reduction of low birth weight to less than 10%, elimination of blindness due to vitamin A, reduction of iron deficiency anaemia among pregnant women to 25%, and reduction of IDDs to less than 10% in endemic districts.

Rural children :
Several studies including NNMB surveys show that the heights and weights of rural children are lower than ‘well-to-do’ Indian children or NCHS standards. Longitudinal data are also available from special studies of linear growth in Indian children. In a study conducted by NIN, Hyderabad, a cohort of 700 rural children were followed from the age of 5 years to 20 years. They were classified into different nutritional grades, based on their height at the age of 5 years, and their growth rate was compared with that of ‘well-to-do’ children of Delhi. Peak height velocity was similar in all groups, while the peak weight velocity was lower in undernourished Indian children. Another interesting feature is the age at which the growth spurt occurs. The well-nourished Indian children had a

growth spurt around 14 years, similar to that observed in Western children, while among undernourished boys the growth spurt is delayed by about 2 years. The total height gain between 10-20 years is around 40 cm in both Western and Indian boys. However, the rural children are shorter than the ‘wellto-do’ group at all ages, with the deficit in height being noted before puberty and then carried through to the adult stage. Unlike height gain, the increase in weight from 10-20 years was found to be lower in rural boys. If the rural adults are compared with the well-to-do group, the differences in heights and weights are about 7 cm and 10 kg respectively. The heights and weights of rural girls were also found to be lower compared to the well-to-do group at all ages. The growth process in rural girls continued for a longer period and in fact, the increments in this group were much greater between 14-18 years. This is because the menarche, and consequently the adolescent growth spurt is delayed by 1-2 years in the case of poor rural girls. The mean age of menarche is around 12 years in well-to-do girls and 13-14 years in rural girls. If the rural women are compared to the well-to-do group the differences in heights and weights are about 6 cm and 7 kg respectively.
Table 04: Percentage distribution of children (1-5 years) according to Gomez classification and NCHS weight-for-age standards

Year 1988-90* 1995-96** 2002-03* 2007-08**

n 6428 2244 13432 3542

Normal 5.9 7.4 13.9 20.4

Mild 31.6 34.7 35.6 33.5

Moderate 47.5 46.3 42.8 40.9

Severe 15.0 11.6 7.7 5.2

* repeat surveys, ** linked surveys ; Source: NNMB Reports (2007-08).

Figure 02. Underweight Prevalences - 1-5 year olds, by state
Source: NNMB Reports (2007-08).


Clinical nutritional deficiency signs :
protein-energy malnutrition The major nutritional deficiency signs encountered among preschool children are those of protein-energy malnutrition and vitamin A deficiency. The NNMB surveys conducted during 2004-05 showed that the prevalence of deficiency signs was lower compared to the earlier surveys between 2001-02. The prevalence of marasmus decreased from 1.3 to 0.6% and kwashiorkor from 0.4 to 0.1% at the overall level. There were considerable variations between states, with Gujarat showed the highest prevalence of kwashiorkor (1.1%) and marasmus (4.9%). The prevalence of vitamin A deficiency (Bitot spots) declined from 1.8% to 0.7%. These observations thus also indicate an improvement in the nutritional status of children in the last 10-15 years. Birth Weight Birth weight, an important determinant of child survival, is influenced by the nutritional status of the mother. National survey data indicate that the mean birth weights in India range from 2.49 to 2.97 kg with about 30% new-borns being less than 2.50 kg. There has been little change in the past three decades (Srikantia 1989). A gender difference has been noted in mean birth weights, female infants tending to be lighter than male counterparts. Hospital-based studies have shown differences ranging from 50-100 gm, while in the well-to-do group the weight difference was more pronounced, ranging from 100-300 gm.


The incidence of low birth weight is highest in low-income groups. A number of factors have been identified as risk factors: maternal age, weight, height, parity, literacy, income, infections and pregnancy-related complications. Even within low-income groups, a gradual increase in birth weight is evident with rising income, the differences between the poorest and the less poor being 100150 gm (NIN 1983). Differences of a similar magnitude have been recorded between infants born to illiterate and educated mothers. With increasing maternal height from below 145 cm to 160 cm, differences in birth weights are of the order of 200-400 gm. Similarly, with increasing maternal weights from around 35 to 55 kg, differences in birth weights are of the magnitude of 100250 gm. A recent study showed a good correlation between birth weights and BMI of mother. The mean birth weight in women with BMI less than 16 (severe CED) was 2.50 kg and it showed a progressive increase with increase in BMI status of mothers. The mean birth weight was around 2.80 kg in women with BMI 18.525. The incidence of low birth weights was highest (53%) in severe CED and gradually declined to about 15% in those with normal BMI. Anaemia is common among pregnant women, the prevalence rates ranging from 40-50% in urban areas and 50-70% in rural areas. A significant fall in birth weight has been observed with decrease in haemoglobin levels. In one study , the incidence of low birth-weight babies was 40% in anaemic women with haemoglobin less than 8 gm as against 23% in women with normal haemoglobin levels. One of the goals of the National Health Policy is to reduce the prevalence of low birth weight to 10% by 2000 AD. There is an urgent need to strengthen health care services so as to reach all pregnant women in need and to improve their nutritional status to achieve this goal. In the current programmes, women receive attention only after the onset of pregnancy. The preceding years of adolescence are crucial and special efforts are needed to reach girls at this stage.

Maternal nutritional status
Women of child bearing age constitute the vulnerable segment of the population because of their special reproductive needs. According to the 1981 census there were 143.5 million women of child bearing age, constituting about 21% of the total population. An average Indian woman has 6-7 pregnancies resulting in 5-6 live births, of which 4-5 survive. She is estimated to spend a greater part of her reproductive years in pregnancy and lactation. Chronic maternal undernutrition and overwork among the low income group pose a serious threat to the welfare of the mother and the infant. Studies in Indian women of a high-income group have shown that their dietary intakes range between 2000-2500 kcals per day during pregnancy. In this group, women generally do not perform hard physical labour and there is a

reduction in activity during pregnancy . The average weight of this group ranges between 45-55 kg and the mean weight gain during pregnancy is about 11 kg - observations similar to those reported in women from developed countries. Studies in urban women of a low-income group have shown that their dietary intakes range from 1200-1600 kcals per day. The average pre-pregnancy weight of these women is around 43 kg and they gain 6 kg during pregnancy. In rural India, dietary intakes of women are slightly higher (1600-1900 kcal). However, rural women have to spend more energy in daily household chores. For instance, they have to fetch drinking water from sources which may be 1-2 kilometers away from home, and gather and bring firewood from forests miles away. Most rural women from low-income groups are heavily engaged in agricultural activities. It is therefore not surprising to find that these women weigh less than the urban women. The NNMB surveys showed that the average weight and height of rural women are 42 kg and 152 cm. About 33% of 18 year old women have body weights below 40 kg and 15 percent have heights less than 145 cms (NNMB 2001). These women fall into high risk category as they are likely to suffer from obstetric complications and give birth to small babies. Micronutrient Deficiencies Apart from protein-energy malnutrition, deficiencies of specific micronutrients such as vitamin A, iron and iodine are common in India, affecting large segments of the population.

Vitamin A deficiency
Studies conducted by ICMR during 1965-69 showed that 7% of preschool children had ocular signs of vitamin A deficiency (ICMR 1977); 4.2% had Bitot spots. The NNMB surveys between 1975-79 (NNMB 1991) showed that the prevalence of Bitot spots in preschool children was around 2%. More recent surveys (2004-05) repeated in the same areas showed a decline in the prevalence (to 0.5%). There is a wide variation in the prevalence rate, ranging from 0.4% in Kerala to 1.0% in Andhra Pradesh (NNMB 2001). Most of the community surveys are based on clinical signs of mild xerophthalmia while severe deficiency resulting in corneal xerophthalmia and blindness is relatively rare; the risk of mortality is also high (60%) in such cases. A nationwide survey conducted by the ICMR during 1971-74 (ICMR 1991) showed that, of the 9 million blind people in the country, 2% cases were attributable to corneal disease caused by vitamin A deficiency. In the more recent survey 0.04% of the total blindness has been attributed to vitamin A deficiency. This is clearly an underestimate of the problem as corneal scars have been excluded although vitamin A deficiency is an important cause of corneal blindness. Mortality is also high in such cases. Assessment of nutritional blindness by cross-sectional surveys does not reveal the true picture since only the survivors can be examined in these surveys. The reported incidence of

corneal xerophthalmia among preschool children is 0.05% The estimates based on these figures suggest about 30,000 cases of corneal xerophthalmia per year, of which nearly half would result in permanent blindness. The Government of India launched the national vitamin A prophylaxis programme in 1971. Under this programme, sponsored by the Ministry of Health & Family Welfare, children between 1-5 years are given a massive dose of 200,000 IU every six months. The programme is now in operation in almost all the states in the country covering about 30 million children. An evaluation study has shown that in areas where the vitamin A programme was implemented well, there was a significant reduction in the prevalence of xerophthalmia, while in other areas the coverage was unsatisfactory. Reasons for poor coverage include inadequate supplies of vitamin A, irregular distribution of the dose, poor coordination between the various health functionaries, non-involvement of village level workers and absence of supporting nutrition education. Based on the recommendations of a review committee, the programme is now being modified to improve the outreach of the target population. The new approach involves integrating the vitamin A distribution programme with other child care services and involving village level workers (anganwadi workers) in the distribution of the dose.

Iron deficiency anaemia
Anaemia is a problem of serious public health significance, given its impact on physical work capacity, mental performance, maternal morbidity and mortality. The most vulnerable groups are pregnant women and preschool children. A number of sample surveys carried out during 1960s showed that more than 50% of the pregnant women have haemoglobin levels below 11 gm/1 and are thus classified as ‘anaemic’. More recent surveys indicate that anaemia is common even in other segments of the population. In rural areas around Hyderabad and Delhi, the prevalence of anaemia ranged from 40-70%, while in villages near Calcutta where hookworm infestation was common, more than 90% of the population were anaemic (AJCN 1982). In all the areas, women of child-bearing age had the highest prevalence of anaemia, followed by preschool children, school children and adult men. These data indicate that anaemia in India is much more widespread than hitherto believed and suggests the need to cover the entire population of pregnant and lactating women in rural areas in any intervention programme designed to control anaemia . The Government of India started a national anaemia prophylaxis programme in 1970 for reducing the prevalence of anaemia in vulnerable groups. The target population comprise pregnant and lactating women, women acceptors of family planning, and children between 1-12 years. Adult beneficiaries are given iron folate tablets containing 60 mg elemental iron and 500 ug of folic acid, while children are given smaller tablets containing 20 mg iron and 100 ug folic acid. The programme is implemented through all the institutions providing MCH services e.g. primary health centres, health sub-centres and maternity clinics. An evaluation study conducted by the Ministry of Health and Family Welfare (1989) revealed a poor performance in all the states. The coverage of pregnant women

ranged from 3-26%. The number of children covered was also negligible. The reasons for poor coverage included inadequate supplies of iron folate tablets, poor supervision, and poor compliance of women due to lack of knowledge and ignorance. More than 80% of the pregnant women had haemoglobin less than 11 gm. Thus there was no impact on the prevalence of anaemia. There is an urgent need to strengthen the national anaemia prophylaxis programme with better control over actual delivery of tablets. Adequate supply of iron folate tablets, involvement of village-level workers in the distribution of tablets and a greater motivation of health workers and the community will be important for the successful implementation of the programme.

Iodine deficiency disorders
Goitre has been recognised as an endemic problem in the Himalayan and subHimalayan regions in the past half century. Surveys between 1945-53 in subHimalayan belt, stretching from Kashmir in the North-West to Nagaland in the East indicated a prevalence of goitre ranging from 26-90% (ICMR 1981). Surveys carried out most recently by the Directorate General of Health Services and other agencies indicated the presence of goitre even outside the conventional goitre belt of Himalayas. ICMR conducted a survey covering 14 districts of 9 states with diverse geological, metrological and geochemical characteristics (ICMR 1989). The study confirmed a high prevalence of goitre in all the areas. In some districts like Dibrugarh, which lies in the Himalayan belt, the prevalence was as high as 66%. In the extra-Himalayan regions the prevalence ranged from 24% in hilly districts to 19% in coastal districts and 12% in the plains, with prevalences higher among tribals than non-tribals. The prevalence rates in each of these districts were well above the level recognised for endemicity. More alarming is the prevalence of endemic cretinism in all the 14 districts surveyed, though in varying proportions, with Manipur having the highest prevalence of 6.1%. Apart from cretinism, children in endemic areas show varying degrees of thyroid deficiency and developmental defects. A study conducted by the All India Institute of Medical Sciences, Delhi revealed a high prevalence of neonatal chemical hypothyroidism (NCH), as defined by thyroxine <30 ug/dl and TSH >50 ug/ml. In one particular district (Gonda) of Uttar Pradesh, the prevalence rate of NCH was as high as 15%. Without treatment, these infants are likely to develop physical and mental defects. In the villages of Uttar Pradesh and Bihar where goitre prevalence was high, deaf-mutism, mental retardation and other clinically detectable problems of environmental iodine deficiency were found in 4% of the children. It is estimated that, today, more than 54 million people in India are suffering from endemic goitre and 8.8 million from different grades of mental/motor handicaps. The magnitude of the problem is thus far greater than hitherto believed. Although the national goitre control programme has been in operation for the last three decades, it has gained momentum only recently. Initially, iodised salt production was managed by the Hindustan Salt Ltd., a public undertaking. The production was grossly inadequate and could not meet the demands of even


the endemic areas. Transportation of salt from production centres also posed serious problems, as did poor supervision and the lack of quality control. Recently, following the recommendations of the review committee, the Government of India has liberalised the production of iodised salt to include the private sector, in addition to the public sector. More important is the historic decision taken in November 1984 to iodate the entire edible salt in the country in a phased manner. The Government of India stands committed to universal iodisation of the entire edible salt supply by 1992. A financial outlay of Rs. 300 million has been provided during the 7th Five Year Plan, and goitre control cells and quality control laboratories are being set-up in all states.

• Living condition and Lifestyle :
The proportion of males 15 years and over who were regular smokers in the 2000s has been estimated at 32-74% (rural) and 46-63% (urban), and females 20-50% (rural) and 2-16% (urban). Currently there is an increasing trend in smoking among youth. Other significant changes in lifestyles relate to lack of physical activity among the affluent, increased use of fast foods, substance abuse, and violence, particularly against young women and children. The government has taken action to promote healthy lifestyles through sports, health education, setting up of no smoking zones, legislation banning smoking in public places, and establishing drug detoxification centers. A major constraint is the government revenue derived from tobacco, sponsorship of activities, especially sports events by tobacco companies, and high-pressure advertising. POVERTY ALLEVIATION PROGRAMMES

A. The Integrated Rural Development Programme (IRDP)

The IRDP, initiated in selected districts in India in 2001-02, was rapidly extended nationally during the sixth Five Year Plan in 1980-81. The programme, targeted at rural families below the poverty line, is designed to provide a capital subsidy and complementary credit at low interest rates to finance productive investments in income generating assets. Subsidies for asset acquisition range from 25% for small farmers, 33.3% for marginal farmers, agricultural labourers and rural artisans, and as much as 50% for scheduled castes and tribes. Block-level staff select potential beneficiaries in consultation with the village council (Gramsabha), help them select viable investments (such as animal husbandry, agriculture, horticulture, weaving, handicrafts etc), and provide back-up support when needed. In the sixth Five Year Plan, IRDP coverage (including coverage of scheduled castes/tribes) exceeded targets. However, resource allocations between states were not based on incidence/intensity of poverty, and even the investment per beneficiary varied tremendously among states - partly as a consequence of inadequate credit mobilization in many cases. While both Andhra Pradesh and Tamil Nadu performed slightly above the national average in credit mobilization, states with large tribal populations performed poorly.

Table 05: Impact of IRDP on beneficiaries Study % hhs that crossed poverty line NR 17* 47 % hhs that received incremental incomes 84 51* 82

Institute for Financial Management and Research Reserve Bank of India National Bank for Agriculture and Rural Development

Programme Evaluation 49 88 Organisation (GOI) * Incomes of beneficiaries at current prices were discounted by 27% to arrive at real incomes at 2001 prices. Source: Bandopadhyay (2004) as quoted in Gaiha (2006)

B - The National Rural Employment Programme (NREP)
The NREP initiated in 1990 to replace the food-for-works programmes, aimed to "generate additional gainful employment for the unemployed and underemployed persons in rural areas, to create productive community assets for direct and continuing benefits to poverty groups and to strengthen the rural, economic and social infrastructure to bring about a general improvement in the overall quality of life in rural areas. It also aims to improve the nutritional standards of rural poor through the supply of food grains as part of wages".

• Water supply and sanitation : "The wars of the next century will be about water."
The proportion of the population with safe drinking water available at home or with reasonable access was 92.6% in 2006/07 for urban areas and 72.3% for rural areas. The proportion of the population with adequate excreta disposal facilities was 80.7% in 2006/07 in urban areas and 18.9 in rural areas. At the time of formulation of the 8th plan, it was estimated that with regard to water there were about 3000 hard-core 'no source' villages out of a list of 'problem' villages numbering 162,000. Besides this, about 150,000 villages were only partially covered. Regarding urban water supply, the service levels are far below desired norms. During the mid 90s, an accelerated urban water supply programme was initiated for towns having less than 20,000 population. The provision of hygienic sanitation facilities through conventional sewage and

on-site low cost sanitation has not been given priority. Though the 8th plan envisaged conversion of all existing dry latrines, the final result is nowhere near the target. The main constraints with regard to water supply are inadequate maintenance of rural water systems, lack of finances and poor community involvement. Most municipalities do not have any system for monitoring the quality of water, with contamination causing episodes of water-borne diseases even in metro cities like Delhi and Calcutta. Most of the people in rural areas are not aware of the health and environmental benefits of improved sanitation. Future actions include phasing of the rural water supply programme, more financial support from the state finance commissions, more responsibilities given to local bodies and village panchayats, water supply and sanitation agencies to have full autonomy in declaring tariffs, improving manpower and equipment support to municipal authorities, and creating public awareness regarding safe water and sanitation.

• Working conditions :

Due to an increase in unplanned urbanization and industrialization, the environment has deteriorated significantly. Pollution from a wide variety of emissions, such as from automobiles and industrial activities, has reached critical levels in many urban and industrial areas, causing respiratory, ocular and other health problems. Monitoring of the urban environment in selected cities in recent years by the pollution control authority has identified 21 critically polluted areas in the country. Agricultural activities including widespread use of fertilizers, pesticides and weed killers also alter the environment and create health hazards. Water stagnation and the consequent multiplication of vectors has increased the risk of vector-borne diseases. The risk associated with disposal of hospital wastes has added to the overall unhealthy situation. India is a party to the UN Conference on Environment and Development (UNCED) held in 1992. In the same year, a national conservation strategy and a policy statement on environment were formulated. The policy addresses issues related to sustainable development including health. Thrust has also been given to management of hazardous waste, adoption of clean technologies by industries, establishment of effluent treatment plants, criteria for environmentally friendly products, phasing out of ozone depleting substances, and creating mass awareness programmes. A very far-reaching notification by the Ministry of Environment and Forests gazette in 1994 makes it obligatory for almost all development projects to conduct an environmental impact assessment study which has to be evaluated by an impact assessment agency. A Government constituted group at the highest level has identified six priority programme areas, namely urban low cost sanitation, urban waste water management, urban solid waste management including hospital waste management, rural environmental sanitation, industrial waste management and air pollution control, and strengthening of health surveillance and support services. These areas have

been addressed in the Dayal Committee Report that forms the basis for a comprehensive national programme on sanitation and environmental hygiene. There are many constitutional provisions and laws pertaining to the environment and its protection and improvement. However, the level of enforcement has been extremely poor. Besides, there is no comprehensive legislation on environment and health. In view of the current situation and the Dayal Committee Report, it was proposed that action be taken by the concerned ministries/departments to prioritize the areas and activities that should be included in the 9th plan. During the 9th FYP the Ministry has proposed the following actions: 1. Strengthen environmental health and health risk assessment in the country. A division of environmental health will be established in the Department of Health for this purpose. 2. Establish a hospital waste management programme. 3. Initiate drinking water quality surveillance as a part of disease surveillance.

Prevention and control of locally endemic diseases
The incidence of malaria remained around 2 million cases per year during 1984-1992. In 1997, 2.7 million and in 1999, 2.3 million cases were reported. The incidence of P. falciparum is increasing and reached to 50% in 1999. For filariasis, present estimates indicate that about 420 million people live in endemic areas. There are 206 control units, 198 clinics and 27 survey units. Visceral leishmaniasis, which reappeared in Bihar in the 1970s, is now endemic in 30 districts in Bihar and 9 districts in West Bengal. In 1996 there were 20,466 cases and 260 deaths reported. Japanese encephalitis (JE), though not a major public health problem, has over time been reported from as many as 24 states/UTs during one year, with an estimated 378 million people at risk. Dengue, dengue haemorrhagic fever (DHF) and dengue shock syndrome, all caused by the dengue virus, have been prevalent in India in almost all major urban areas, with periodic outbreaks of dengue fever and DHF. All four serotypes have been detected, and guidelines for prevention and control have been issued to all states. An expert committee drew up a malaria action programme in 1995. A key strategy is the implementation of short and long term measures in selected high risk areas, high powered boards to expedite intersectoral cooperation, community involvement in antimalarial


activities with intensified IEC, and capacity building at the central and grass roots levels through training. The progress of filariasis control is constantly under review and a strategy of selective treatment, vector control and IEC is being implemented. A revised strategy of mass drug administration has been initiated in some districts in Tamil Nadu and Maharashtra states. In view of the seriousness of visceral leishmaniasis, the government has accorded high priority for its control. Strategies involve early diagnosis and treatment of patients and interruption of transmission by DDT spraying.

Treatment of common diseases and injuries

The national tuberculosis control programme has not achieved the desired results. In 1992 the programme was reviewed and a revised control programme formulated with short term course chemotherapy using the DOTS strategy. The problem of protein-energy malnutrition (PEM) and micronutrient deficiency disorders are quite significant and are being dealt with through a number of national programmes with well defined goals. Diarrhoeal diseases, which are still a major cause of morbidity and mortality in infants and children, are being addressed through the promotion of exclusive breast-feeding, good child feeding practices, and the timely use of ORT during episodes of diarrhoea. Acute respiratory infections (ARIs) are a leading cause of death due to pneumonia in children under five years. A strategy aimed at early recognition of the signs of pneumonia and timely referral has been very effective in reducing mortality. HIV/AIDS is predicted to be a major problem in India. A total of 22,529 seropositive cases were reported up to March 1996, but this number does not convey the actual magnitude of the problem. Almost 4 million HIV cases are estimated as of June 2000. Of the noncommunicable diseases, cancer and cardiovascular diseases are emerging as major health concerns that will require considerable financial resources for case management.

Sources: 1. India, Census of India 2001 : Provisional Population totals,
March 2001. 2. India, Sample Registration System, Statistical Report 1998, October 2002. 3. India, Sample Registration System, SRS Bulletin, April 2007. 4. India, National Family Health Survey (NFHS-2), 1998-99, October 2002. 5. India, Health Information of India 1998 & 1999, July 2002. 6. Adapted from “WHO Geneva, The World Health Report 2001 : Mental Health, New Understanding, New Hope”, October 2001. 7. India, Press briefing by the Minister of Health, 23 October 2007. 8. India, Sample Registration System, SRS Bulletin, April 2004.


Demographic indicates

1. Population statistics
Demographics With an estimated population of 1.13 billion, India is the world's second most populous country. Almost 70% of Indians reside in rural areas, although in recent decades migration to larger cities has led to a dramatic increase in the country's urban population. India's largest cities are Mumbai (formerly Bombay), Delhi, Kolkata(formerly Calcutta), (formerly Madras), Bengaluru (formerly Bangalore), Hyderabad and Ahmedabad . Population density map of India. India is the most culturally, linguistically and genetically diverse geographical entity after the African continent. India is home to two major linguistic families: Indo-Aryan (spoken by about 74% of the population) and Dravidian (spoken by about 24%). Other languages spoken in India come from the Austro-Asiatic and Tibeto-Burman linguistic families. Hindi, with the largest number of speakers, is the official language of the union. English, which is extensively used in business and administration, has the status of a 'subsidiary official language;' it is also important in education, especially as a medium of higher education. The constitution also recognises in particular 21 other languages that are either abundantly spoken or have classical status. While Sanskrit and Tamil have been studied as classical languagesfor many years, the Government of India, using its own criteria, has also accorded classical language status to Kannada and Telugu. The number of dialects in India is as high as 1,652. Over 800 million Indians (80.5%) are Hindu. Other religious groups include Muslims (13.4%), Christians (2.3%), Sikhs (1.9%), Buddhists (0.8%), Jains (0.4%), Jews,Zoroastria ns, Bahá'ís and others. Tribals constitute 8.1% of the population. India's literacy rate is 64.8% (53.7% for females and 75.3% for males). The state of Kerala has the highest literacy rate (91%); Bihar has the lowest (47%). The national human sex ratio is 944 females per 1,000 males. India's median age is 24.9, and the population growth rate of 1.38% per annum; there are 22.01 births per 1,000 people per year. DEMOGRAPHIC TRENDS IN INDIA


Demography is the scientific study of human population. A slogan for family planning“Delay the first,postpone the second and prevent the third” India is the 2nd most populous country in the world,next only to China,whereas 7th in land area.With only 2.4 % of the world’s land area,India is supporting about 16.87 % of the world’s population.India’s population is currently increasing at the of 16 million each year.India’s population numbered 238 million in 1901,doubled in 60 years to 439 million(1961);doubled again,this time in only 30 years to reach 846 million by 1991.India’s population to crossed 1 billion mark on 11 May 2000,and is projected to reach 1.53 billion by the year 2050.This will then make India the most populous country in the world,surpassing China. Cities by population


R ank 1 2

Core City



R Core ank City Jaipur



Mumbai Mahara 13,66 11 shtra 2,885 Delhi Delhi 11,95 12 4,217 5,180 13 ,533

Rajasth 2,997 an ,114 2,621 Mumbai ,063

Luckno Uttar w Prades h

3 4

Bangalo Karnat re aka Kolkata

Nagpur Mahara 2,359 shtra ,331 Indore Madhy a Prades h Bihar 1,768 Delhi ,303

West 5,021 14 Bengal ,458

5 6

Chennai Tamil Nadu

4,562 15 ,843


1,753 ,543 1,742 ,375

Hyderab Andhra 3,980 16 ad Prades ,938 h Ahmeda Gujarat 3,867 17 bad ,336 Pune Surat Mahara 3,230 18 shtra ,322 Gujarat 3,124 19 ,249 Uttar Prades h 3,067 20 ,663

Bhopal Madhy a Prades h Thane Ludhia na

7 8 9

Mahara 1,673 shtra ,465 Punjab 1,662 ,325

Visakh Andhra 2,845 apatna Prades ,938 m h Vijaya wada Andhra 1,961 Prades ,152 h



source : Age and Sex composition: The proportion of population below 15 years is showing decline,whereas the proportion of elderly in the country is increasing.This trend is to continue in the time to come.The increase in the elderly population will impose a greater burden on the already outstretched health services in the country.

Table 06: At Basic facts and Figures of India : Country INDIA

source :


Population Area Population growth rate Population density Urban / Rural distribution Health and Education: Life expectancy(average) Infant mortality rate Population per doctor Population per hospital bed Literacy rate

1130 million 3 million sq km 1.4 % 363 persons per sq km Urban-30 % , Rural- 70 % Male-62 yrs ; Female-64 yrs 56 deaths per 1,000 live births 2500 people 1300 people 70 %

Number of students per teacher, primary 41 students / teacher school Sex Ratio: Sex ratio is defined as “the number of females per 1000 males”. One of the basic demographic characteristics of the population is the sex composition. In any study of population, analysis of sex composition play a vital role. The sex composition of the population is affected by the differentials in mortality conditions of males and females, sex selective migration and sex ratio at birth. The sex ratio in India has been generally adverse to women, i.e., the number of women per 1000 men has generally been less than 1000.Apart from being adverse to women, the sex ratio has also declined over the decades. In 1901 the sex ratio of India was 972 females per 1000 males and after wards the ratio is continuous decreasing and in 2001 the ratio was 933 females per 1000 males. Kerala has a ratio of 1058 females per 1000 males in 2010.It is only state with a sex ratio favourable to females. Dependency Ratio: The proportion of persons above 65 years of age and children below 15 years of age are considered to be dependent on the economically productive age group(15-64 years).The ratio of the combined age groups 0-14 years plus 65 years and above to the 15-65 years age group is referred to as the total dependency ratio.It is also referred to as the societal dependency ratio and reflects the need for a society to provide for their younger and older population groups. The dependency ratio can be subdivided into young age dependency ratio (0-14 years); and old age dependency ratio (65 years and more).These ratios are, however, relatively crude, since they do not take into consideration young persons who are employed or working age persons who are unemployed. Density of population: One of the important indices of population concentration is the density of population. In the Indian census, density is defined as the number of persons, living per square km. Density of population in India in 1901 was 77 persons/ but in 2001, 324 persons/ Family size: It refers to the total numbers of persons in a family. The family

size depends upon numerous factors, like, duration of marriage, education of couple, the number of live births and living children, preference of male children, desired family size, etc. Total fertility rate in 2004 was 3.1 in India.

Population Pyramids for India

figure : 03 , source :

Urbanization: Growing urbanization is a recent phenomenon in the developing countries. The proportion of the urban population in India has increased from 11% in 1901 to 27.8 % in 2001.The United Nations defines mega-cities as those with a population of 10 million or more. In 1950 only New York was classified as megacity. By 1995 the number rose to 14 mega-cities and Mumbai, Kolkata and Delhi were included in the list. Population projections indicate that by 2015 Hyderabad will also become a mega-city. The increase in urban population has been attributed both to natural growth(through births) and migration from villages because of employment opportunities, attraction of better living conditions and availability of social services such as education, health, transport, entertainment etc. Literacy and Education: The 1948,the Declaration of Human Rights stated

everyone has a right to education. Education is a crucial element in economic and social development. Spread of literacy is generally associated with modernization, urbanization, industrialization, communication and commerse. Higher levels of education and literacy lead to greater awareness and also contribute to improvement of economic conditions, and is required for acquiring various skills and better use of health care facilities. It was decided in 1991 census to use the term literacy rate for the population relating to 7 years age and above. A person is deemed as literate if he or she can read and write with understanding in any language. A person who can merely read but cannot write is not considered literate. The national percentage of literates in population above 7 years of age is about 66% with literate males about 76% and females lagging behind with about 54%.State Kerala has occupy the top rank in the country with 92% literates. Government of India has made education compulsory upto age 14 years in the country. Life expectancy: Life expectancy - or expectation of life – at given age is the average number of years which a person of that age may expect to live, according to the mortality pattern prevalent in that country. Life expectancy at birth has continued to increase globally over the years. Most countries in the world exhibit a sex differential in mortality favouring women – females live longer than males. Contrary to this biological expectation, the life expectancy of women in Nepal and Maldives is lower than that of men, while in Bangladesh and India it is almost equal. Life expectancy(average) in India for Male-62 yrs and for Female-64 yrs .

2. Population dynamics • Types of mechanical Public movement:
Mechanical Public movement can be Internal or External or both. Migration from one area to another in search of improved livelihoods is a key feature of human history. While some regions and sectors fall behind in their capacity to support populations, others move ahead and people migrate to access these emerging opportunities. Industrialisation widens the gap between rural and urban areas, inducing a shift of the workforce towards industrialising areas. In some regions of India, three out of four households include a migrant. The effects of migration on individuals, households and regions add up to a significant impact on the national economy and society.


figure : 04

source -

Short duration labour migration

Our special interest is in temporary, short duration migration, because such migrants lack stable employment and sources of livelihood at home and belong to the poorer strata. These migrants find work in agriculture, seasonal industries, or are absorbed in the amorphous urban economy, either as casual labourers or as selfemployed. They may move from one type of job to another or even from rural to urban areas. There is another category of poor and destitute migrants who have virtually no assets in the areas of origin and have lost all contact with their origin. Thus not all poor migrants would fall in the category of seasonal/short term migrants. But as discussed earlier, for one reason or another, all these categories are likely to be underestimated in data. TRENDS AND PATTERNS IN INTERNAL MIGRATION The two main secondary sources of data on population mobility in India are the Census and the National Sample Survey (NSS). These surveys may underestimate some migration flows, such as temporary, seasonal and circulatory migration, both due to empirical and conceptual difficulties. Since such migration and commuting is predominantly employment oriented, the data underestimate the extent of labour mobility. Furthermore, migration data relate to population mobility and not worker mobility, although economic theories of migration are primarily about worker migration. It is not easy to disentangle these, firstly because definitions of migrants used in both surveys (change from birthplace and change in last usual place of residence), are not employment related. Secondly, migration surveys give only the main reason for migration, and that

only at the time of migration. Secondary economic reasons could be masked, as in the case of married women, who would cite other reasons for movement. Another problem is that migration data relate to stocks of migrants and not to flows, although different policy concerns relate to stocks (of different ages) and flows. Many of these concerns can be handled only by micro surveys, which have their own problems. Causes of migration Given the diversity in the nature of migration in India, the causes are also bound to vary. Migration is influenced both by the pattern of development (NCRL, 1991), and the social structure (Mosse et al, 2002). The National Commission on Rural Labour, focusing on seasonal migration, concluded that uneven development was the main cause of seasonal migration. Along with inter regional disparity, disparity between different socioeconomic classes and the development policy adopted since independence has accelerated the process of seasonal migration. In tribal regions, intrusion of outsiders, the pattern of settlement, displacement and deforestation, also have played a significant role. Most migration literature makes a distinction between ‘pull’ and ‘push’ factors, which, however, do not operate in isolation of one another. Mobility occurs when workers in source areas lack suitable options for employment/livelihood, and there is some expectation of improvement in circumstances through migration. The improvement sought may be better employment or higher wages/incomes, but also maximisation of family employment or smoothing of employment/ income/consumption over the year. The migrant labour market Migrants at the lower end of the market comprise mostly unskilled casual labourers or those who own or hire small means of livelihood such as carts or rickshaws and are self-employed. We focus in this section primarily on migrants who work as casual labourers, although several of the conditions discussed below are also common to other categories of migrants. Migrant labourers are exposed to large uncertainties in the potential job market. To begin with, they have little knowledge of the market and risk high job search costs. The perceived risks and costs tend to be higher the further they are from home. There are several ways in which migrants minimise risks and costs. For a number of industries, recruitment is often done seeking jobs independently may still find the labour processes in the destination dominated by contracting and sub-contracting relationships. Workers have to depend upon advances and irregular payments. Migrants often get lower wages than local labourers. International migration from independent India Two distinct types of labour migration have been taking place from India since independence: • People with technical skills and professional expertise migrate to countries such as the USA, Canada, UK and Australia as permanent migrants (since the early 1950s).


• Unskilled and semi-skilled workers migrate to oil exporting countries of the Middle East on temporary contracts, especially following the oil price increases of 1973–74 and 1979. Migration to industrialised countries: magnitude and composition Although labour flows to the industrialised countries have continued for a long time, information on them is scanty. Whatever analyses have been carried out to date on the composition of these flows is based on immigration statistics of destination countries. The USA received the largest number of Indian emigrants. The general trend shows that Indian immigration, which constituted a negligible proportion to the total immigrants in the USA and Canada, increased rapidly during the 1960s and 1970s. Of the total immigrants in the United States and Canada, Indians constituted declined. However the share of white-collar workers (clerical, sales and service) remained almost unchanged and the share of workers engaged in farming, horticulture and animal husbandry rose significantly. Economic impact of labour migration At the aggregate level, labour emigration affects the sending country’s economy through its impact on the labour market, on macro-economic variables (savings, balance of payments and so on), and social relations. These impacts are summarised below. TABLES ON EXTERNAL MIGRATION Table 07: Trends in immigration from India to selected industrial countries: 1961–2000 Immigration to 1961-70 1971-80 1981-90 1991-2000 United States From India 31,214 172,080 261,841 412,640 From all Countries 3,322,000 4,493,000 7,338,000 6,327,000 India’s Share(%) (0.9) (3.8) (3.6) (4.3) Canada From India 25,722 72,903 79,304 89,407 From all Countries 1,409,677 1,440,338 1,336,767 2,152,874 India’s Share (%) (1.8) (5.1) (5.9) (6.8) United Kingdom From India 125,600 83,040 51,480 63,390 From all Countries 635,000 732,900 516,870 597,650 India’s Share (%) (19.8) (11.3) (10.0) (13.1)

Source: Country’s migration report, Nayyar, 2004 Table : 08, source -


Definition of Net migration rate: This entry includes the figure for the difference between the number of persons entering and leaving a country during the year per 1,000 persons (based on midyear population). An excess of persons entering the country is referred to as net immigration (e.g., 3.56

Y ear Net mi gra tio n rat e (mi gra nt( s)/ 1,0 00 po pul ati on) 2 000 -0.0 8 2 001 -0.0 8 2 002 -0.0 7 2 003 -0.0 7 2 004 -0.0 7 2 005

Figure : 05 , India - Net migration rate (migrant(s)/1,000 population)


Impact on labour markets
The labour market impact of international migration depends on factors such as size of outflow, employment status before migration, skill composition of migrants and, in the case of temporary migration, on the size of the return flow. The labour market implications of migration from India may be examined both in relation to permanent emigration to the industrialised countries and to the outflow of temporary migrants to the Middle East countries. From the discussion on the magnitude of permanent migration from India to the industrialised countries taken up earlier, it is abundantly clear that they form an insignificant proportion of the total workforce in India. Even though a large proportion of those who migrate to industrialised countries are fairly highly educated, the absolute number of migrants is small and their proportion of the total educated population of graduates is insignificant. In fact, total emigration to the four industrialised countries (USA, UK, Australia and Canada) constituted a mere 0.13% of the population of graduates in 1991. Similarly considering the large reservoir of educated unemployed in India, it may be reasonable to presume that permanent migration to the industrialised countries could have hardly created any supply shortages in the labour markets. In such a situation it may be prudent to assume that the aggregate labour market effects of permanent migration is negligible in the Indian context. Problems encountered by migrants Problems encountered by the migrant workers may be examined at two levels. First in relation to recruitment violations and the second in relation to working and living conditions in destination countries. Commonly reported violations are delayed deployment or nondeployment of workers, overcharging or collection of

fees far in excess of authorised placement fees and illegal recruitment. Delayed deployments are often caused by factors beyond the control of the recruitment agency, such as visa delays or when the employer requests a postponement. Non-deployment is however a serious case and the magnitude of its implications are amplified if an excessive placement fee is collected from the worker. Overcharging is a serious offence and is prevalent in all labour-sending countries in Asia. What makes overcharging doubly serious is that the workers end up paying huge amounts equivalent to many months salary (Sasikumar, 2000). Minimising, if not totally eliminating, overcharging poses a serious challenge to overseas employment administrators. Illegal recruitment is another serious violation of the rules as workers get recruited and deployed overseas without the government knowing about them. Being unlicensed, illegal recruiters are beyond the reach of the normal regulatory machinery of the national overseas employment policy. They are and should be the concern of police and other enforcement agencies. Some major problems encountered by the migrants in their countries of employment include: a) premature termination of job contracts, b) changing the clauses of contract to the disadvantage of the workers, c) delay in payment of salary, d) violation of minimum wage standards, e) freezing of fringe benefits and other perks, f) forced over-time work without returns and g) denial of permission to keep one’s own passport. Migrant labourers seldom lodge any complaint against the erring employers for the fear of losing their jobs. In cases where migrant workers decide to complain against the erring employer, they have two options. First, the employee may inform the home embassy in the country of employment. This is mainly done by people lacking the means to return home. Embassy officials sometimes seek the help and assistance of the local government to take actions against the erring employers. Apart from that, the Embassy also passes information about the complaints made to it to the Protector of Emigrants (POE) offices in India. If a registered recruiting agent recruited the complainant, then the POE refers the complaint to the concerned agent seeking explanation. In most cases the agents maintain that it was the foreign employer who committed any violation. However, if the POE office finds the explanation unsatisfactory it proceeds with further action. Secondly, the employee registers the complaint after he/she reaches India. To facilitate the lodging of such complaints, a system of public hearing is conducted at the POE offices, where emigrants, recruiting agents, project exporters etc. can meet the most senior officer on duty to obtain information and voice their grievances. When complaints are received against foreign employers, the POE office forwards them to the Indian embassy in the concerned country of employment for taking necessary actions. As in the case of first option, if a registered agent has recruited the complainant, the POE office seeks the agent’s explanation. If the agent does not provide satisfactory explanations, a case is registered for the violation and the case is referred to

the police for investigation. In some instances, the POE officials themselves conduct the inquiry. Apart from this, generally no action can be taken against foreign employers as they are governed by laws of another nation state. Suggestions and recommendations Some specific suggestions relating to international labour migration are: 1. Developing migration information systems: One of the areas requiring immediate policy intervention is the creation of an appropriate information system on international emigration. This would enable closer surveillance and better management of emigration. The status of out-migrant data can be improved by making the registration of entry by migrant workers mandatory in the Indian missions operating in labour receiving countries. The nature of outflow data at home can be strengthened by a fuller utilisation of the data already available with government departments and recruitment agencies. A chief requirement in this connection would be the strengthening of the statistical wings of the concerned government departments. International experience suggests that it is possible to extract labour outflow and return flow data on key variables from embarkation/ disembarkation cards. An essential first step to make use of this source is to redesign the existing arrival/departure cards to yield required information. To obtain further information, periodic airport surveys could be resorted to. Data on migration are as much essential at the state level as they are at the national level. Apart from relevant disaggregation of national data sources, it would be desirable if the National Sample Survey Organisation (NSSO) conduct detailed surveys on international migration periodically, say once in five years. To strengthen the information base abroad, an identification and networking of Indian associations operating in different Middle East countries is necessary. The Gulf crisis of 1990 had highlighted the vital role played by various Indian associations and bodies in safeguarding the interests of Indian migrants in the Gulf at a time of emergency (Sasikumar,1995). Discussions with evacuees from Kuwait revealed that the majority of Indian migrants maintained very close liaison with community organisations even in times of stability. 2. Financing outmigration: It would also be worth establishing a government system of offering low interest loans to less well-off emigrants to finance outmigration. Such a system of financing outmigration may also ensure that those emigrants availing the lowinterest loans would resort to formal banking channels to transfer their remittances back home. This would further augment the foreign exchange resources, which are vital for a developing country like India.

• Brain drain problem : Scale and Magnitude of the ‘Brain Drain’  Occupational migration


In a forty-seven-country ranking of brain drain arrived at on the basis of a survey whether "well-educated people emigrate or do not emigrate abroad," and presented in the World Competitiveness Yearbook 2000, India has been placed at position forty-second from the top, sixth from the bottom. India has also been assigned a significance score of 3.291 calculated on a ten-point scale between 0 and 10, using a special standard deviation method (SDM) to assign each country a standardized (STD) value or score. The low ranking and score both mean that India has a high degree of brain drain in terms of well-educated people emigrating abroad. The USA is at the top with a score of 8.524, meaning very few educated Americans emigrate UK's ranking is thirteenth with a score of 6.343, meaning that some people emigrate. India is better off, relatively speaking, than Venezuela, Philippines, Russia, Colombia, and South Africa, but worse off than Argentina. Traditionally, the U.K. has been the main recipient of Indian migrants - both skilled and unskilled until the end of the 1960s. This was mainly due to the colonial ties between the two countries and the advantage of the English language as medium of education in India particularly at the higher, professional and technical levels. The fact that emigration of skilled labour to the US comprises a significant proportion from the UK - a country which also receives emigrants from developing countries including India - makes Britain's emigration more of a 'brain exchange' than 'brain drain', if one were to make use of a specific distinction. Keeping this in view, it may be said that not only to UK, Indian migration of skilled labour to other developed countries like Canada, Australia, New Zealand, Western Europe (mainly Germany, and France in the EU), and now also Japan, and Singapore (relatively substantially more developed than India, though small in size and economy) too is largely a function of some kind of derived demand' for skilled labour from the United States. Given that the emigrating Indians' preferences and priorities too are in favour of the United States as compared to each of these countries, the migration to these countries may perhaps be described as a stopover 'intermediate' supply rather than a terminal one. This kind of 'hopping migration' has a negative effect on retention of migrants in the labour markets of Europe, particularly the recipient countries in the EU. Apart from the 'external brain drain' of skilled people leaving India for taking up jobs abroad, there is also an 'internal brain drain'. For example, the selection of the IIT engineering graduates, and doctors in the Civil Services Examination (CSE) is called the 'internal brain drain', because the professional skills acquired by the selected ones are obviously wasted when they join the Indian bureaucracy for undertaking administrative job responsibilities. There is also a high social opportunity cost of a wasted seat because, like selection in the CSE, admission to public engineering and medical colleges is highly competitive in India. A recently conducted study based on a sample survey in two premier institutions of higher education in India - one general, and the other professional, by the author (Khadria 2001a/UPSC 2001) estimated that over Rs.10 billion (US $1= Rs.45 approximately) are being spent by all the examinees (i.e., their families) put together (on an annual average number of 125,000 examinees) every year for aspiring to enter into the Indian Civil

Service. Only 500 out of the 125,000 examinees are finally chosen. Many of these are engineers, doctors, managers trained at great public costs. Their entry into the civil service is also considered a brain drain so far as the application of their skills or the usefulness of subsidies sunk in their education is concerned - an 'internal brain drain'. A substantial number amongst those who fail to make it into the Indian Civil Service emigrate to other countries in search of jobs or higher education because they simultaneously keep trying that route to 'success' as well - leading to the 'external' brain drain.

Student migration

Professionals holding post-graduate degree or diploma from Indian institutions of tertiary education are not the only ones who are considered of value abroad. Many of the Indian immigrants in the United States who fuelled Silicon Valley were educated in America at the post-graduate level after they emigrated with a first engineering degree (B.Tech/B.E.) from the Indian Institutes of Technology (IITs)/Regional Engineering Colleges/ Banaras Hindu University - all institutions of excellence. Similarly, scientists with M.Sc/M.Tech from universities like the Jawaharlal Nehru University or the University of Delhi, or doctors with MBBS from the All India Institute of Medical Sciences, and managers with Post-Graduate Diploma in Business Management (PGDBM) from the Indian Institutes of Management (IIMs) have emigrated for the purpose of pursuing higher studies abroad and then entering into the labour market there. Impact of Migration on India The issue of impact of brain drain on sending home countries, most of which are also 'developing' countries, needs to be examined in the light of the shifting paradigms of the phenomenon of skilled labour migration. There are three types of paradigm shifts that are discernible, and one of them pertains directly to the subject of impact. But there are backward and forward linkages to this particular shift of paradigm with the other two shifts: a geo-economic shift of paradigm for brain drain to become more of a demand-determined phenomenon from a supply-determined one (i.e., employers determine immigration, rather than employees; in other words, pull factors become more important than the push factors), and the other, a geo-political shift of paradigm in terms of looking away from temporary, short-term and ad-hoc remedies (of the malaise of brain drain) to more sustainable long-term solutions (towards developing immunity against the negative and very negative effects of the malaise) through policy. Perceptions and Debates on the ‘Brain Drain’ in India On the exodus of Indian talent abroad : Today, India is almost at the top of the list of countries so far as emigration of the "brain drain" category is concerned - to developed countries like the USA, Canada, Australia, Germany, France, Japan, and of course the UK.


• Infant mortality :
Infant mortality rate: total: 32.31 deaths/1,000 live births male: 36.94 deaths/1,000 live births female: 27.12 deaths/1,000 live births (2008 est.) Table : 09 Year Infant mortality rate Rank Percent Change Date of Information 2 003 2 004 2 005 2 006 2 007 2 008 59.59 56.29 56.29 54.63 34.61 32.31 59 56 55 55 73 74 -5.54 % 0.00 % -2.95 % -36.65 % -6.65 % 2003 est. 2004 est. 2005 est. 2006 est. 2007 est. 2008 est.

Source: CIA World Factbook - Unless otherwise noted, information in this page is accurate as of May 16, 2008 Definition: This entry gives the number of deaths of infants under one year old in a given year per 1,000 live births in the same year; included is the total death rate, and deaths by sex, male and female. This rate is often used as an indicator of the level of health in a country. Thirty percent of the world’s newborns die in India: India, which is home both to the highest number of births and neonatal deaths of any country in the world, faces a bigger challenge than any other country in improving newborn health and survival. Each year, 20 percent of the world’s infants—an awesome 26 million—are born in this vast and diverse country. Of this number, 1.2 million die—almost 30 percent of the world’s neonatal deaths—before completing the first four month of life. Neonatal mortality rate decline stagnating: The current neonatal mortality rate (NMR) of 44 per 1,000 live births accounts for nearly two-thirds of all infant mortality and half of under-five child mortality. The NMR declined rapidly in the

1980s, from 69 in 1980 to 53 in 1990, an unprecedented decrease of almost one quarter in a single decade. In recent years, however, the rate has been static; between 1995 and 2000, there was only a negligible decrease of four points, from 48 to 44 per 1,000 live births. This tapering off in the rate of decline is a cause for concern—and also for decisive action. The rate of neonatal mortality varies widely among the different states, ranging from 10 per 1,000 live births in Kerala to around 60 in Orissa and Madhya Pradesh. The states of Uttar Pradesh, Madhya Pradesh, and Bihar together contribute over half of all newborn deaths in India, or roughly 15 percent of the entire global burden. There are also significant rich-poor and rural-urban differences: The rate in the poorest 20 percent of the population is more than double that of the richest 20 percent , and the rate in rural areas is over one and a half times that in urban areas.

Table : 06, India - Infant mortality rate (deaths/1,000 live births

source : Causes of neonatal death: Prematurity, infections, and birth asphyxia are the leading causes of neonatal deaths, though there is limited population-based data available. The incidence of neonatal tetanus, formerly a major cause of mortality, has declined dramatically since the 1980s, but even in the year 2000, there were still an estimated 48,000 neonatal deaths per year from this entirely preventable disease. Few of these deaths are notified through the health system and estimates have wide statistical uncertainty. India’s population policy and commitment to meeting the Millennium Development Goals: The National Population Policy (NPP) calls for the reduction of the infant mortality rate to less than 30 per 1,000 live births by the year 2010. Given the high visibility of neonatal deaths and the lack of progress, addressing these issues is a high priority for the government, which aims to

reduce the NMR from the current level of 44 to about 20 per 1,000 live births. There is a consensus to incorporate a comprehensive maternal and newborn health strategy into the next five-year phase (2005-10) of the Reproductive and Child Health program Better health system and mortality data is required to manage these programs and to recognize if goals have been met. source - Table : 10 Y ear 2 001 2 002 2 003 2 004 2 005 2 006 2 007 2 008
100 90 80 70 60 50 40 30 20 10 0 1980
Figure 07
28 24 25 9 5 2 6 1 1 1 1 16 12 8 35 29 44

Infant mortality rate (deaths/1,000 live births) 63.19 61.47 59.59 57.92 56.29 54.63 34.61 32.31

Post neonatal Late neonatal Early neonatal







Time trends in infant mortality between 1983 and 2000, split by 62

early neonatal, late neonatal, and the post-neonatal period, contrasting high-income and low/middle income regions. Source: State of India’s
Newborns, Government of India. Based on Sample Registration Survey data for India.



70 67 67 66 60 60 58



25% 57 56 53 51 50 47















0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Figure 08 Recent trends in the neonatal mortality rate in India
Source: State of India’s Newborns, Government of India. Based on Sample Registration Survey data for India.

Conclusions Addressing neonatal deaths is essential to achieving MDG4 regarding child survival; these same interventions are also likely to promote progress towards reducing maternal deaths (MDG5). More data are required to guide decisionmaking. As the case of India illustrates, increasing visibility for neonatal mortality draws more national attention and action, facilitating the drive to meet the MDGs. References • Darmstadt GL, Lawn JE, Costello A. (2003) Advancing the state of the world’s newborns. Bulletin of theWorld Health Organization.:81:224-225. • Lawn J E, Cousens S N, Wilczynska K and the CHERG neonatal group. (Submitted) Estimating the causes of four million neonatal deaths in the year 2000. • Saving Newborn Lives. (2001) State of the World's Newborns. 1-44. Washington DC, Save the Children. Available at

• Birth rate :


Definition: This entry gives the average annual number of births during a year per 1,000 persons in the population at midyear; also known as crude birth rate. The birth rate is usually the dominant factor in determining the rate of population growth. It depends on both the level of fertility and the age structure of the population Birth rate: 22.22 births/1,000 population (2008 est.) Table : 11 Year Birth rate Rank Percent Change Date of Information 2 003 2 004 2 005 2 006 2 007 2 008 23.28 22.32 22.32 22.01 22.69 22.22 91 91 91 93 86 87 -4.12 % 0.00 % -1.39 % 3.09 % -2.07 % source The population clock in the Union Health Ministry, Nirman Bhavan, New Delhi, now ticks at the rate of 31 persons per minute. The clock shows that about 44,640 babies are born in India everyday. Hence the population of India increases by 16.29 million every year, which is equivalent to the total population of Australia. Here are some more facts about our motherland. The present population of India is around 1.4 Billion (1400 Million). The billionth baby is a girl. Her name is ASTHA (which means Faith). Her mother's name is Anjana Arora, and her father's name is Ashok Kumar Arora. She was born in Delhi at Saftharjung Hospital at 5.50 a.m. on Thursday, May 11, 2000. India with about 2.4% of the land area in the world contains about 16% of the population of the world.The density of the population in India has climbed up from 261 per square kilometer in 1981 to 267 per square kilometer in 1991. This is ten times greater than the density in the United States (26 per square kilometer) and 2.5 times greater than the density in China (109 per square kilometer). The birth rate in India (31 per thousand people) is greater than that of China (20 per thousand people). If this trend continues, India will beat up China by 2025 A.D., making India the most populous nation in the world. In 2025 A.D, India will have 1591 million people and China 1554 million people.

2003 est. 2004 est. 2005 est. 2006 est. 2007 est. 2008 est.

Only five countries in the world - China, USA, Brazil, Indonesia, and United USSR have more population than Uttar Pradesh (145 million), which is one of the 28 states in India. The total population of the South Indian state of Tamil Nadu was 55.6 million as of 1991. About 4,478,000 people die every year in Tamil Nadu, or to put it another way, 1,227 people pass every day into eternity without knowing Christ. Every year the total Population of Australia, is added to the population of India.One out of every seven people in the world lives in India. So if India, which is open for the gospel, is reached, then every seventh person in the world will be reached.More people live in India than all the people living in North America, South America, and Australia put together. The death rate in India is 8.39 million per year. This means that 23,000 people everyday, 958 people every hour, or 16 people every minute, pass into a Christless eternity. Are we "moved with compassion for them because they are weary and scattered" like Jesus Christ said in Matthew 9:26.

Figure : 09, Source: National Health Public Survey report 2006.

High Birth rate in different regions of India: Figure:10, source


• Life expectancy :
For the period 1996-2001, the life expectancy at birth is estimated to be 62.36 years for males and 63.39 years for females. In 1991 the sex ratio was 927 females per 1000 males which increased to 933 in 2001. To ensure the continued improvement in life expectancy, the health care delivery infrastructure is being expanded, MCH care is being improved, specific programmes such as the expanded programme on immunization (EPI), introduction of oral rehydration therapy (ORT), etc. are being strengthened, and efforts are continuing to contain locally endemic diseases. There is also an increased thrust in other development and poverty alleviation programmes. The main constraints are the diverse population groups, low literacy and income levels, and sociocultural beliefs and practices which adversely affect health. Definition: This entry contains the average number of years to be lived by a group of people born in the same year, if mortality at each age remains constant in the future. The entry includes total population as well as the male and female components. Life expectancy at birth is also a measure of overall quality of life in a country and summarizes the mortality at all ages. It can also be thought of as indicating the potential return on investment in human capital and is necessary for the calculation of various actuarial measures.

Life expectancy at birth: total population: 69.25 years male: 66.87 years female: 71.9 years (2008 est.) Table : 12, source Y Life expectancy R ear at birth ank 2 003 2 004 2 005 2 006 2 007 2 008 63.62 161 64.35 162 64.35 162 64.71 162 68.59 144 69.25 142 1.15 % 0.00 % 0.56 % 6.00 % 0.96 % Percent Change Date of Information 2003 est. 2004 est. 2005 est. 2006 est. 2007 est. 2008 est.

Source: CIA World Factbook - Unless otherwise noted, information in this page is accurate as of May 16, 2008 Figure : 11. State-wise Projected Levels of Expectation of Life at Birth by Sex in India (1996 to 2016) Male Female States 1996- 2001- 2006- 2011- 1996- 2001- 2006- 20112001 06 11 16 2001 06 11 16 Andhra 61.55 62.79 63.92 64.94 63.74 65.00 66.16 67.23 Pradesh Assam 57.34 58.69 60.44 61.77 58.84 60.87 62.70 64.36 Bihar 63.55 65.66 67.46 69.98 62.07 64.79 67.09 69.05

Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal India (Pooled) India

61.53 63.87 61.73 70.69

63.12 64.64 62.43 71.67

64.60 65.50 63.10 72.00

65.76 66.03 63.73 72.00

62.77 67.39 65.36 75.00

64.10 69.30 66.44 75.00

65.49 70.00 67.43 75.00

66.45 70.00 68.35 75.00 61.40 72.00 62.63 72.00 66.84 72.00 68.72 72.00

56.83 59.19 59.20 60.70 65.31 58.52 68.39 60.32 65.21 66.75 60.05 69.78 62.17 67.00 67.89 61.44 70.88 63.79 68.45 69.02 62.70 71.74 65.21 69.64

57.21 58.01 59.80 68.19 58.07 71.40 61.36 67.58 69.76 59.71 72.00 62.80 69.75 71.13 61.23 72.00 65.22 71.54

61.20 63.54 65.48 67.10 64.50 66.08 67.42 68.57 62.30 63.87 65.65 67.04 62.36 64.11 65.63 66.93

61.10 64.09 66.60 67.20 69.34 71.11

65.27 66.91 67.67 69.18 63.39 65.43 67.22 68.80

Life Expectancy and Health The healthier a person is, the longer he or she lives. The average Life expectancy of population of indicates the physical health conditions of the people. Wealthier population can afford private medical care and generally live longer, while the longevity of poor crucially depends on conditions of public health, nutrition and sanitation services. Developed countries in Europe, North America and Australia have a Life Expectancy at Birth (LEB) of over 75 years, whereas the poorest countries in Sub Saharan Africa have a life expectancy of less than 45 years. India, China and most Asian countries have seen a dramatic increase in LEB after the 1950’s. In the late 1940's, on an average Indians used to live for 33 years. We then had a steady increase in life expectancy to 65 years in 2001. Elimination of small pox, and a sharp reduction in deaths due to Cholera and Malaria contributed to this increase in LEB. States now show relatively less variation in life expectancy; Bihar (61yrs) slightly lags behind Maharashtra (66 yrs), even Madhya Pradesh (57 yrs) with the lowest LEB among Indian states is not too far behind. Swaminathan Iyer argues, “increased longevity has been the greatest single benefit to Indian citizens since independence, a benefit spread across all states and income levels”. A word of caution has to be exercised before generalizing an increase in longevity to excellent public health. There are many other indicators of public health like Infant mortality, maternal mortality and malnutrition, in which India lags behind even some developing countries. In the name of structural adjustments, the government spending on public health has in fact decreased after the Economic liberalization. With a mere 1% of GDP allocation, India’s public health spending is among the lowest in the world. There are only 40 doctors per 10,000 people

in India, where as in United States, it is as high as 2300. The scarcity of doctors can be addressed if we allow greater private participation in setting up medical colleges and hospitals. Only when we address these issues can we hope that our people will be healthier while the country is getting wealthier. Figure : 12, source -

State-wise data are included below; more indicators can be found in the "FACTFILE" section on the homepage for each state. Average life expectancy Table : 13. • =========================================== • STATE TOTAL MALE FEMALE • Andhra Pradesh 63.1 61.6 64.1 • Assam 57.2 57.1 57.6 • Bihar 60.2 60.7 58.9 • Gujarat 62.8 61.9 63.7 • Haryana 64.5 64.1 65.0 • Himachal Pradesh 65.6 65.1 65.8 • Karnataka 64.0 62.4 65.5 • Kerala 73.5 70.6 76.1 • Madhya Pradesh 56.4 56.5 56.2 • Maharastra 65.8 64.5 67.0 • Orissa 57.7 57.6 57.8 • Punjab 68.1 66.9 69.1 • Rajastan 60.5 59.8 60.9 • Tamilnadu 64.6 63.7 65.7

Uttar Pradesh 58.4 58.9 57.7 West Bengal 63.4 62.8 64.3 India 61.7 60.8 62.5 =========================================== Source: Registrar General of India (2003) SRS Based Abridged Lefe Tables, SRS Analytical Studies, Report No. 3 of 2003, New Delhi: Registrar General of India.
• • • Table 14. Vital Rates and ---------------- ---------Births Country or area/ per 1,000 Year population ---------------- ---------India 2004 24.0 7.2 -0.1 1.68 1.68 2005 23.6 7.0 -0.1 1.67 1.66 2006 23.2 6.8 -0.1 1.64 1.63 2007 22.7 6.6 -0.1 1.61 1.61 2008 22.2 6.4 -0.1 1.58 1.58 ---------------- ---------- ---------- ---------------- --------------- ----------Note: Population estimates and projections for countries are revised on a flow basis. Therefore, migration streams across all countries may not balance to zero, and net migration for the world may be positive or negative. Source: U.S. Census Bureau, International Data Base.


---------- ---------------- --------------- ----------Deaths Net number of Rate of natural per 1,000 migrants per increase Growth rate population 1,000 population (percent) (percent) ---------- ---------------- --------------- -----------

Reproductive behaviour of adolescents has been a concern especially during recent decades. The fertility pattern and contraceptive use among adolescents help us to understand the implications for adolescent reproductive health in a society; it also gives insight to the future reproductive health situation as this group traverses through the reproductive span. The present paper focuses first on the levels of adolescent fertility in India and its constituent states using sample registration information and the second National Family Health Survey (NFHS 2) results. Using the NFHS-2 data set, it then examines the pattern of contraceptive use. Factors affecting contraception are studied using logistic regression analysis. The paper subsequently discusses the reproductive health and fertility implications of the findings. In India, the extent of adolescent fertility (defined as number of births per 1000 women in the 15-19 age group) declined from 100 per 1000 in 1971 to 52 per 1000 in 1999. Adolescent fertility in rural India is 58 per 1000 as compared to 30 in

urban India. While the total fertility rate decreased from 5.2 per woman to 3.2 during 1971-1999 (a decrease of 2 births per woman or a decrease of 38,5 percent), that among adolescents decreased from 0.5 to 0.3 births per adolescent (a decrease of 0.2 births or 40 percent) [total fertility among adolescents in the age group is obtained as 5 x adolescent fertility]. Comparing the share of adolescent fertility to total fertility, it can be seen that contribution of this age group declined only marginally; during the 28 years from 1971, the percentage of adolescent fertility to total fertility rate decreased from 9.7 percent to 8.1 percent. This decline became visible only by 1996 till when there was an increase in the share, possibly due to the younger age structure of women consequent to high fertility in the previous years. As contraceptive use is important for a better reproductive health in adolescent years (when pregnancy and child birth should be avoided as far as possible), the paper tries to examine the factors associated with contraceptive use in India. Logistic regression analysis shows that the most important variables affecting contraceptive use among adolescents are education, age at marriage, media exposure, standard of living and experience of physical violence. Those who are literate have chances 1.7 times higher to use contraception, those married after completing 18 years have a lesser chance to use contraception, those with some exposure to media have 1.8 times higher chance to use, those from high standard of living strata have 1.7 times higher chance to use, and those have had experience of physical violence have 1.2 times chances higher compared to others. Given that the age at marriage in all Indian states is increasing, the high extent of adolescent pregnancies among certain Indian states needs special attention; the higher extent of adolescent fertility among some of the states with low fertility is certainly disturbing. A finding from the analysis indicates that a second demographic transition is unlikely to happen in the near future in Indian states which are nearing the completion of first transition. Total fertility rate (births per woman) Net reproduction rate (female births per woman) ( Source : Government of India 2005) 2.5 1.1

• Morbidity :
The number of reported cases of the following diseases were: leprosy 560,000 (2000), malaria 2,276,788 (1999), measles 26,986 (1991), neonatal tetanus 1896 (1995), polio 142 (2000/2001), and tuberculosis 1,223,127 (1999). The vaccine-preventable diseases (referred


to in Section 6) have declined significantly since implementation of the EPI. In India about 14 million people are estimated to be suffering from active tuberculosis and about 0.5 million die of the disease each year. Currently, short term chemotherapy using DOTS has been introduced and accessibility to tuberculosis treatment centres improved. The prevalence of leprosy has declined from about 39 per 10,000 population in 1985 to about 7 per 10,000 in 1995 and further down to 3.7 in 2000. The spectacular reduction in this disease has been due to the new regimen of multidrug therapy. The number of new cases detected annually has, however, remained more or less the same, at about 0.5 million. Morbidity There is limited experience in collecting morbidity data from population-based demographic sample surveys. NFHS-1 collected data on five major morbidity conditions— partial and complete blindness, tuberculosis, leprosy, physical impairment of the limbs, and malaria— among all persons in the sampled households. The results were found to be generally plausible and useful. For these reasons, it was decided to include similar morbidity questions in NFHS-2. In NFHS-2, questions on blindness, leprosy, and physical impairment of the limbs were replaced by questions on asthma and jaundice. The questions on tuberculosis and malaria were retained, and a question on medical treatment of tuberculosis was added to get a better measure of the prevalence of tuberculosis. The household head or other knowledgeable adult in the household reported morbidity for all household members, and no effort was made to do clinical tests for any of the disease conditions. The prevalence of asthma, tuberculosis, jaundice, and malaria in the household population by age, sex, and place of residence. There are several reasons why the results of NFHS-2 may understate the prevalence of these conditions. Respondents may underreport diseases carrying a stigma, such as tuberculosis, due to intentional concealment. Underestimation may also occur because the household respondents are unaware that they or other members of the household have the condition. It is also possible that the respondents know that a household member suffers from a given condition but fail to report it because they do not recognize the term used by the enumerator to describe the condition. On the other hand, a factor contributing to a possible overestimation of prevalence without clinical verification is that some other disease can be

mistaken by the respondent as one of the listed diseases; for example, chronic bronchitis may be reported as asthma or tuberculosis, or common flu may be reported as malaria. Asthma Asthma is a chronic respiratory disease characterized by sudden attacks of laboured breathing, chest constriction, and coughing. There has been a rapid increase in asthma cases in recent years in many parts of the world. In India, 2,468 persons per 100,000 population were reported to be suffering from asthma at the time of the survey. The prevalence of asthma is considerably higher in rural areas (2,649 per 100,000 population) than in urban areas (1,966 per 100,000 population), and is slightly higher among males (2,561 per 100,000) than among females (2,369 per 100,000). Age differences are marked, with the prevalence of asthma increasing from 950 per 100,000 at age 0–14 to 10,375 per 100,000 at age 60 and over. Tuberculosis Tuberculosis, which is also resurgent worldwide, is an infectious disease that affects the lungs and other body tissues. Tuberculosis of the lungs, the most commonly known form, is characterized by coughing up mucus and sputum, fever, weight loss, and chest pain. According to NFHS-2, the overall prevalence of tuberculosis in India is 544 per 100,000 population. This is 16 percent higher than the prevalence recorded in NFHS-1 (467 per 100,000), indicating that tuberculosis may be on the rise in India. The prevalence of tuberculosis is much higher in rural areas (600 per 100,000) than in urban areas (390 per 100,000). The prevalence rate is much higher for males (624 per 100,000) than for females (460 per 100,000). The sex differential in the prevalence of tuberculosis is about the same in urban and rural areas. Probable reasons for the much higher prevalence of tuberculosis among males than females are that men are more likely than women to come in contact with people who suffer from active tuberculosis and that men in India smoke more than women. The prevalence of tuberculosis increases rapidly with age. It is substantially higher among persons age 60 and above (1,374 per 100,000) than among those age 15–59 (675 per 100,000) or age 0–14 (153 per 100,000).

Medically treated tuberculosis is expected to give a more reliable measure of the prevalence of active tuberculosis than the measure based on all reported cases considered in the preceding paragraph. As expected, the prevalence of medically treated tuberculosis is considerably lower (432 per 100,000) than the prevalence based on all reported cases (544 per 100,000). Differentials in the prevalence of medically treated tuberculosis by residence, age, and sex are similar to differentials in the prevalence of all reported cases. Jaundice Jaundice is characterized by yellowish discolouration of the eyes and skin, fever, liver enlargement, and abdominal pain. NFHS-2 asked household respondents if any member of the household had suffered from jaundice at any time during the 12 months preceding the survey. In India as a whole, 1,361 persons per 100,000 population were reported to have suffered from jaundice during the 12 months preceding the survey. People living in rural areas were somewhat more likely to have suffered from jaundice (1,410 per 100,000) than those living in urban areas (1,225 per 100,000). Males were 42 percent more likely to have suffered from jaundice than females. Jaundice is the only condition measured that decreases with age. The prevalence of jaundice was highest for the age group 0–14 (1,515 per 100,000), followed by the age groups 15–59 (1,339 per 100,000) and 60 years and above (826 per 100,000). The age and sex differentials in the prevalence of jaundice are similar in urban and rural areas. Malaria Malaria is characterized by recurrent high fever with shivering. NFHS-2 asked household respondents whether any member of their household suffered from malaria any time during the three months preceding the survey. In India, 3,697 persons per 100,000 population were reported to have suffered from malaria during the three months preceding the survey. Since the prevalence of malaria is known to vary considerably by season, the NFHS-2 estimates should not be interpreted as representative of the level throughout the year. It would also be misleading to compare this estimate with the lower NFHS-1 estimate because the months of the year comprising the reference period for the malaria estimates from the two surveys are different. Rural residents are almost twice as likely to suffer from malaria (4,254 per 100,000) as are urban residents (2,156 per 100,000). The reported prevalence of malaria is slightly higher for males than for females. The prevalence of malaria during the past three months increases with age, from 3,552 per 100,000 in the population under age 15 to 4,146 per 100,000 in the population

age 60 years and above. The steady increase with age occurs in rural areas but not in urban areas. Comparisons by State The prevalence of asthma varies considerably by state, from a low of 1,204 per 100,000 in Delhi to a high of 5,995 per 100,000 in Meghalaya. Other states with relatively low levels of asthma prevalence are Punjab and Himachal Pradesh, and other states with relatively high prevalence rates are Nagaland, Kerala, Sikkim, and Andhra Pradesh. State variations in the prevalence rate of tuberculosis are also large. Tuberculosis prevalence ranges from 207 per 100,000 in Punjab to 1,654 per 100,000 in Nagaland. All states in the Northeast Region except Assam have prevalence rates above 1,000 per 100,000. Tuberculosis prevalence rates are also noticeably high in Bihar and Orissa. Variations in the prevalence of medically treated tuberculosis are generally in line with the variations in all reported cases of tuberculosis. State differentials are also substantial for jaundice. Jaundice is most common in Nagaland, but it is also a substantial problem in most other northeastern states and in West Bengal and Goa. The prevalence of malaria varies widely across the states, at least partly because of seasonal variations in the timing of the survey fieldwork. Malaria was most often reported in Meghalaya, Nagaland, Arunachal Pradesh, and Madhya Pradesh, where 10–17 percent of the population were reported to have malaria during the three months preceding the survey. On the other hand, there were very few reports of malaria in Kerala, Himachal Pradesh, and Tamil Nadu. Four states (Arunachal Pradesh, Meghalaya, Nagaland, and Andhra Pradesh) have a higher prevalence of all these diseases than the national average, and six states (Haryana, Himachal Pradesh, Jammu and Kashmir, Punjab, Karnataka, and Tamil Nadu) consistently have a lower prevalence than the national average. Vitamin A Supplementation Vitamin A deficiency is one of the most common nutritional deficiency disorders in the world, affecting more than 250 million children worldwide (Bloem et al., 1997). The National Programm on Prevention of Blindness targets children under age five years and administers oral doses of vitamin A every six months starting at age nine months. NFHS-2 asked mothers of children born during the three years before the survey whether their children ever received a dose of vitamin A. Those who said that their child had received at least one dose of vitamin A were asked how long ago the last dose of vitamin A was given. The percentage of children age 12–35 months who received at least one dose of vitamin A and who received a dose of vitamin A within the past six months by selected background characteristics. In the country as a whole, only 3 out of 10 children age 12–35 months received at least one dose of vitamin A, and only 17 percent

received a dose within the past six months. This indicates that a large majority of children in India have not received vitamin A supplementation at all and even fewer children receive vitamin A supplementation regularly. Children living in urban areas, children of more educated mothers, and children living in high standard of living households are considerably more likely than other children to receive vitamin A supplementation. Children of birth order 4 or above are much less likely than children of birth orders 1, 2, or 3 to have received any vitamin A supplementation. Muslim, Hindu, and Christian children are less likely to receive vitamin A than other children. Similarly, children from schedule castes, schedule tribes, and other backward classes are less likely to receive vitamin A than other children. State variations in the percentage of children who received at least one dose of vitamin A and the percentage who received at least one dose within the six months preceding the survey are shown. The percentage of children age 12–35 who received at least one dose of vitamin A supplementation ranges from 7 percent in Nagaland to 78 percent in Goa. In addition to Nagaland, Bihar (10 percent), Uttar Pradesh (14 percent), Assam (15 percent), Tamil Nadu (16 percent), and Rajasthan (18 percent) stand out as having very low proportions of children receiving at least one dose of vitamin A. In addition to Goa, Himachal Pradesh (71 percent) and Maharashtra (65 percent) stand out as having relatively successful vitamin A supplementation programmes. State variations in the percentage of children receiving at least one dose of vitamin A supplementation within the past six months follow closely the variations in the percentage of children receiving at least one dose at any time in the past. Child Morbidity and Treatment This section discusses the prevalence and treatment of acute respiratory infection (ARI), fever, and diarrhoea. Mothers of children born during the three years preceding the survey were asked if their children suffered from cough, fever, or diarrhoea during the two weeks preceding the survey, and if so, the type of treatment given. Accuracy of all these measures is affected by the reliability of the mother’s recall of when the disease episode occurred. The twoweek recall period is thought to be most suitable for ensuring that there will be an adequate number of cases to analyze and that recall errors will not be too serious. The percentage of children with cough accompanied by fast breathing (symptoms of acute respiratory infection), fever, and diarrhoea during the two weeks preceding the survey and the percentage with acute respiratory infection who were taken to a health facility or provider, by selected background characteristics. Acute Respiratory Infection

Acute respiratory infection, primarily pneumonia, is a major cause of illness among infants and children and the leading cause of childhood mortality throughout the world (Murray and Lopez, 1996). Early diagnosis and treatment with antibiotics can prevent a large proportion of ARI/pneumonia deaths. NFHS-2 found that 19 percent of children under age three in India suffered from acute respiratory infection (cough accompanied by short, rapid breathing) at some time during the two-week period before the survey. A comparison with NFHS-1 ARI data is not meaningful since the two surveys took place at different times of the year and rates of ARI are affected by the time of the year when the measurements are taken. ARI is somewhat more common among boys than girls and among children living in rural areas than urban areas. Children of mothers who have at least completed high school have a lower occurrence of ARI than other children. The prevalence of ARI is higher among scheduled-tribe children than among other children, and children living in lower standard of living households also have a higher prevalence of ARI. Children living in households that use piped drinking water and in households that use a water filter for the purification of water have a lower prevalence of ARI than do other children. Sixty-four percent of children received some advice or treatment from a health facility or health provider when ill with ARI. This percentage, as expected, is relatively low for children whose mothers are illiterate or who live in households with a low standard of living. The percentage is relatively high for children whose mothers do not belong to a scheduled caste or scheduled tribe. Notably, boys, urban children, and children of birth order one are also more likely than other children to have been taken to a health facility or provider for advice or treatment. There is considerable variation in the prevalence of ARI by state . The percentage of children under age three who suffered from ARI during the two weeks preceding the survey ranges from 8 percent in Karnataka to 30 percent in Sikkim. Interstate variations in the prevalence of ARI, fever, or diarrhoea should be interpreted with caution, however, because these conditions vary throughout the year and the fieldwork was conducted at different times of the year in different states. Fever Fever is the most common of the three conditions examined, with 30 percent of children suffering from fever during the two weeks before the survey. The prevalence of fever is lower among children under age six months (21 percent) than among older children (28–34 percent). In general, the prevalence of fever does not vary widely or in a predictable way with most of the remaining demographic and socioeconomic characteristics. As with acute respiratory infection, fever tends to strike young children irrespective of their demographic and socioeconomic background. The prevalence of fever varies from 21 percent in Gujarat to 42 percent in Kerala.

Diarrhoea Diarrhoea is the second most important killer of children under age five worldwide, following acute respiratory infection. Deaths from acute diarrhoea are most often caused by dehydration due to loss of water and electrolytes. Nearly all dehydration-related deaths can be prevented by prompt administration of rehydration solutions. Because deaths from diarrhoea are a significant proportion of all child deaths, the Government of India has launched the Oral Rehydration Therapy Programme as one of its priority activities for child survival. One major goal of this programme is to increase awareness among mothers and communities about the causes and treatment of diarrhoea. Oral rehydration salt (ORS) packets are made widely available and mothers are taught how to use them. NFHS-2 asked mothers of children born during the three years preceding the survey a series of questions about episodes of diarrhoea suffered by their children in the two weeks before the survey, including questions on feeding practices during diarrhoea, the treatment of diarrhoea, and their knowledge and use of ORS. The 19 percent of children under age three suffered from diarrhoea in the twoweek period before the survey. There are seasonal variations in the prevalence of diarrhoea, however, so that the percentages cannot be assumed to reflect the situation throughout the year. Among children age 1–35 months, those age 6–11 months are most susceptible to diarrhoea (as is the case with ARI and fever). Differentials by sex of child, birth order, place of residence, and caste/tribe are small. Sikh children are considerably less likely to suffer from diarrhoea than children belonging to other religions. As expected, children of mothers with high school or more education and children in high standard of living households are somewhat less likely to suffer from diarrhoea than other children. Also consistent with expectations, diarrhea is somewhat less common among children living in households that boil water or use a water filter for purification of drinking water than among other children. Children living in households that use surface water for drinking are more vulnerable to diarrhoea than children living in households that use other sources for drinking water. Three percent of all children age 1–35 months (14 percent of children who suffered from diarrhoea in the two weeks before the survey) suffered from diarrhoea with blood, a symptom of dysentery. Children under age six months had the lowest prevalence of diarrhoea with blood (less than 1 percent). Children of birth order four or higher, children living in rural areas, children whose mothers are illiterate, scheduled-tribe children, children living in low standard of living households, children living in households using surface water for drinking, and children living in households using ‘other’ means of water

purification or using unpurified water for drinking all had an elevated risk of having diarrhoea with blood. The 62 percent of mothers with births during the three years preceding the survey know about ORS packets, up from 43 percent among women who gave birth during the three years before NFHS-1. Knowledge of ORS packets is somewhat lower among mothers age 15–19 and among mothers age 35 years or older than among mothers in the middle age groups. As expected, knowledge is considerably higher among urban mothers (76 percent) than rural mothers (59 percent), and among more educated mothers, especially literate mothers as compared with illiterate mothers. Knowledge of ORS is higher among Sikh, Jain, and Christian mothers than among mothers belonging to other religions. Mothers belonging to scheduled tribes are less likely to know about ORS packets than mothers belonging to other caste/tribe groups. Among all the groups shown in the table, knowledge of ORS packets is lowest among mothers who are not regularly exposed to any mass media (48 percent). In order to assess mothers’ knowledge of children’s need for extra fluids during episodes of diarrhoea, all mothers of children born in the three years preceding the survey were asked: ‘When a child has diarrhoea, should he/she be given less to drink than usual, about the same amount, or more than usual?’ In India as a whole, only 29 percent of mothers report that children should be given more to drink than usual during an episode of diarrhoea and, contrary to the standard recommendation, 34 percent report that children should be given less to drink. This suggests that mothers in India need much more education in the proper management of diarrhoea. The proportion reporting correctly that children with diarrhoea should be given more to drink is particularly low among rural mothers, illiterate mothers, mothers belonging to a scheduled tribe, and mothers not regularly exposed to any mass media. The proportion reporting correctly that children with diarrhoea should be given more to drink is much higher among Sikh and Christian mothers than among mothers belonging to other religions. Mothers age 15–19 and 35 years or older are less likely to answer correctly than mothers age 20–34. Literate mothers and mothers exposed to mass media areslightly more likely to know the danger signs. Notably, however, knowledge of two or more signs of diarrhoea that suggest the need for medical treatment is universally low across all demographic and socioeconomic groups. This suggests a need for further educating mothers with regard to children’s diarrhoea so that they are better able to recognize the danger signs of diarrhoea for which a health provider should be consulted. HIV/AIDS Acquired Immune Deficiency Syndrome (AIDS) is an illness caused by the HIV virus, which weakens the immune system and leads to death through secondary infections such as tuberculosis or pneumonia. The virus is generally transmitted through sexual contact, through the placenta of HIV-infected women to their unborn children, or through contact with contaminated needles (injections) or blood. HIV and AIDS prevalence in India have been on the rise for more than a decade and have reached alarming proportions in recent years. The Government of India established a National AIDS Control Organization

(NACO) under the Ministry of Health and Family Welfare in 1989 to deal with the epidemic. Since then there have been various efforts to prevent HIV transmission, such as public health education through the media and the activities of many nongovernmental organizations (NGOs). NFHS-2 included a set of questions on knowledge of AIDS and AIDS prevention. Evermarried women age 15–49 were first asked if they had ever heard of an illness called AIDS. Respondents who had heard of AIDS were asked further questions about their sources of information on AIDS, whether they believe that AIDS is preventable, and if so, what precautions, if any, a person can take to avoid infection. Knowledge of AIDS Sixty percent of women in India have never heard of AIDS. Knowledge of AIDSvaries little by women’s age, but it is somewhat higher among women age 25–34. Urban residence, education, and the standard of living all have a very strong positive association with AIDS knowledge. Seventy percent of urban women in India have heard about AIDS compared with only 30 percent of rural women. Knowledge of AIDS increases from only 18 percent among illiterate women to 92 percent among women who have at least completed high school. Similarly, knowledge of AIDS increases from 20 percent among women in households with a low standard of living to 74 percent among women in households with a high standard of living. Jain (83 percent), Christian (78 percent), Buddhist/Neo-Buddhist (69 percent), and Sikh (54 percent) women are much more likely to know about AIDS than Hindus, Muslims, or women belonging to other religions (28–39 percent). Only 17 percent of scheduled-tribe women have heard about AIDS compared with 32 percent of scheduled-caste women, 42 percent of women belonging to other backward classes, and 48 percent of ‘other’ women. Exposure to mass media increases women’s knowledge about AIDS substantially. Eighty-five percent of women who read a newspaper or magazine at least once a week know about AIDS compared with only 10 percent of women who are not regularly exposed to any mass media (newspapers, magazines, radio, television, cinema, or theatre). State variations in the percentage of ever-married women who have heard about AIDS. Knowledge of AIDS ranges from a low of only 12 percent in Bihar to 93 percent in Manipur and Mizoram. Bihar, Uttar Pradesh, Rajasthan, and Madhya Pradesh all have very low levels of AIDS awareness (below 23 percent). On the other hand, Tamil Nadu, Kerala, Delhi, Goa, and Nagaland (in addition to Manipur and Mizoram) have relatively high levels of AIDS awareness (above 72 percent). However, in all of the 12 states with comparable information currently available, awareness of AIDS increased substantially between the two surveys. Particularly dramatic increases in AIDS knowledge have taken place in Tamil Nadu (from 23 to 87 percent), Delhi (from 36 percent to 79 percent), Maharashtra (from 19 to 61 percent), and Goa (from 42 percent to 76 percent). Source of Knowledge about AIDS As part of the AIDS prevention programme, the Government of India has been using mass


media, especially electronic media, extensively to create awareness among the general public about AIDS and its prevention. Television is the most important source of information about AIDS among evermarried women in India. Seventy-nine percent of women report television as a source of their information about AIDS. Other important sources are the radio (42 percent), friends or relatives (31 percent), and newspapers or magazines (27 percent). Only 4 percent report that they received information about AIDS from a health worker. Television is the most important source of information about AIDS in both urban and rural areas, followed by the radio. Rural women are more likely than urban women to have learned about AIDS from the radio, a health worker, or a friend or relative. On the other hand, urban women are more likely to have learned about AIDS from television, cinema, newspapers or magazines, or posters or hoardings. More educated women are less likely than less educated women to have learned about AIDS from a friend or relative, but they are more likely to have learned about AIDS from each of the other sources. Scheduledtribe women are less likely than other women to have learned about AIDS from television or cinema, but are more likely than other women to have learned about it from a health worker or a friend or relative. Women in households with a high standard of living are more likely than other women to have learned about AIDS from television, cinema, newspapers or magazines, or posters or hoardings; they are less likely to have learned about AIDS from a friend or relative. Finally, women who are not regularly exposed to mass media are much less likely to have learned about AIDS from any media sources, but they are more likely to have learned about AIDS from a friend or relative, as might be expected. Among ever-married women who have heard about AIDS, television is the primary source of information in most states, followed by the radio. Newspapers and magazines are also important sources of information about AIDS in most states. The percentage who received AIDS information from a health worker is much higher in Mizoram, Sikkim, Himachal Pradesh, and Goa than in other states, but even in those states only 10–13 percent of women mention health workers as a source of information. Friends and relatives are a relatively important source of AIDS information in the northeastern and southern states, as well as in Orissa, Goa, and Maharashtra. Knowledge of Ways to Avoid AIDS Respondents who have heard of AIDS were asked if a person can do anything to avoid becoming infected. Those who reported that something could be done were asked what a person could do to avoid AIDS. The percentage of ever-married women who know of no way to avoid AIDS and the percentages who report that AIDS can be avoided in specific ways, by selected background characteristics. Among women who have heard about AIDS, 33 percent do not know any way to avoid infection. As expected, this percentage is higher among rural women than among urban women and among women not regularly exposed to mass media than among other women. The percentage who do not know any way to avoid

becoming infected with AIDS decreases sharply with increasing levels of education and household standard of living, as expected. This percentage is also considerably higher among Muslim women (40 percent) than among women from almost all other religious groups. Scheduled-tribe women are less likely to know any way to avoid AIDS than other women. Among women who report that something can be done to prevent AIDS, the most commonly mentioned ways of avoiding AIDS are having only one sex partner (40 percent) and avoiding injections or using clean needles (30 percent). Avoiding sex with commercial sex workers, using condoms, and avoiding blood transfusions are also mentioned as ways to avoid AIDS by substantial proportions of women (25, 20, and 19 percent, respectively). Only 7 percent mention abstaining from sex, 3 percent mention avoiding sex with homosexuals, and 2 percent mention avoiding intravenous drug use. The percentage reporting each means of avoiding AIDS is lower among rural than among urban women and among women not regularly exposed to mass media than among other women. The level of education and the household standard of living are strongly and positively associated with women mentioning each of these ways of avoiding AIDS. ‘Having only one sex partner’ is mentioned more often than ‘avoiding injections or using clean needles’ in 16 out of 25 states. ‘Abstaining from sex’ is mentioned much less frequently as a way to avoid AIDS in the southern and western states than in other states. The lack of knowledge of AIDS, its modes of transmission, and ways to avoid infection among women in India is a major challenge to efforts to avoid the spread of AIDS. Most evermarried women in their childbearing years have never heard of AIDS, and many of those who have heard of AIDS do not know even one way to avoid infection. It is clear that AIDS prevention organizations need to strengthen the educational components of their programmes, in addition to trying to reduce high-risk behaviour, since even basic information about AIDS is seriously deficient, at least among women in India.

• Physical growth


Growth Problems The term growth problem is a common occurrence in households having small children. But most of the time this is basically a misconception and a result of over-anxious parents. Growth problems in children can arise due to a number of causes, one of them being the inability of a child to put on weight or if the child is putting on extra weight than that is needed. There might be other disorders in the growth and development [pattern of a child, but before striking a panic attack, it musty be studied whether the child is genuinely having a growth problem, or he or she is just having a normally delayed growth. Generally the growth and development of children have their own patterns, which are different for girls and boys. The normal cycle of growth in any child is demonstrated throughout his or her growing years, but is especially apparent by his or her attaining the puberty. The age of attaining this puberty is also somewhat different for boys and girls. While girls have their puberty between 8 to 13 years of age, for the boys it is often between 10 to 15 years of age. This growth in girls are manifested through the development of their rounded hips, breasts, growth of pubic hair, and their menstrual cycle, whereas in boys it is the growth in the size of the testicles and the penis, growth of facial hair, and changes in the voice. Though this growth is early for some, and somewhat late for others, this cannot be marked as a growth problem. But for some children there is a constitutional growth problem that needs to be treated. Symptoms of Growth Problems The symptoms of growth problems are generally not very apparent till a certain age, and if some problem in the growth pattern is suspected, then the doctor must be consulted immediately. These symptoms differ from one individual to another according to the causes and their individual growth pattern, but some more general symptoms are as follows: » Failure to put on weight for babies Fig. 13. Calculation of Target Height and Target Height Centile. Measure the » Excessive weight gain parent’s heights and make a head of their heights on the chart. Calculate the » Disproportional length and note circumference child’s target height (TH) and plot it at 18 years and mark it with an arrow on » Below normal height and weight ratio the growth chart. This represents the child’s projected height and the target Causes of Growth Problems range are a number of factors two pointsto growthabove and below of them are There is produced by plotting that lead 7.5 cms problems. Some for a boy and 6 cm above and below for a girl (representing the 10th and the 90th centile for as follows: » Premature babies that child). In the parents shown above, the 50th percentile for the general » Babies of small example population is theweight » Failure to gain 90th centile for the child measured and the 10th centile for the child is below the 10th centile for the population. » Physical illness » Improper feeding Source: Cowell CT. Short Stature. In: Clinical Pediatric Endocrinology, 3rd edn. » Emotional neglect Ed. Brook CGD. London, Blackwell Science, 2002; pp 136-172. » Coelic disease » Cystic fibrosis » Crohn's disease » Infections » Eating disorders, like anorexia » Not getting adequate amounts of protein, calories, and other nutrients in your diet » Number of other chronic medical conditions such as kidney, heart, lung, and intestinal diseases » People with sickle cell anemia » Hormonal imbalance, like hypothyroidism, hyperthyroidism, or Turner’s syndrome » Genetic causes Diagnosis of Growth Problems :

Disability Disability prevalence rates per 100,000 population estimated in 1994 are as follows: physical disability 3574, visual disability 827, hearing 806, speech 510, and locomotor disability 2041. The incidence rates per 100,000 population of these disabilities are: physical 173, visual 45, hearing 27, speech 10 and locomotor disability 105 (national sample survey). The main cause of blindness is cataract (80.1%), with about 6.5 million (2000) persons blind due to cataract. The national blindness control programme is centrally sponsored with a four-pronged strategy to strengthen service delivery, develop human resources, promote outreach activities and develop institutional capacity. Due to changing lifestyles, mental disorders are likely to increase in the future. The total number of mental disorders treated in specialized mental hospitals was 48,396 in 1991 and 38,323 in 1992. The majority of cases have been diagnosed as suffering from psychosis (85.7%).

The goal is to achieve optimal health for the people, which would allow them to lead socially and economically productive lives and be in keeping with the principles of the HFA strategy. The health care system envisaged would have a public-private mix, with the latter encouraged to take a greater share of secondary and tertiary health care services. The National Conservation Strategy and Policy Statement on Environment and Development (1992) aims at ensuring that the demands on the environment do not exceed its carrying capacity for the present as well as for future generations. Proposed strategies (a) Enhancing equity for health: Making health services and facilities accessible and available to the people, especially the underprivileged, through the regionalization of health services, rational transfer policies, incentives and career development opportunities, and minimizing inter and intrastate differences. (b) Strengthening of health promotion and protection: Development of an integrated education and health promotion programme with locally relevant content, implementation of an integrated noncommunicable disease control programme (9th FYP), strengthening of intersectoral coordination for implementing preventive and promotive health in an integrated and comprehensive manner, and strict and effective enforcement of available legislation relating to health and the environment. (c) Strengthening the health sector through partnerships in health development: This includes public and private sector involvement, better use of indigenous systems of medicine, etc. (d) Developing and strengthening specific health programmes. (e) Developing and using appropriate health technology. (f) Strengthening international partnerships for health.

Health expenditure, insurance and human resources :

Household expenditure on various services of health was assessed for one month prior to the survey. A household in India on an average spent 118 rupees in the previous month for health treatment. Of this, the households on an average spent 52 rupees on drugs, seven rupees on traditional medicines and 18 rupees on other expenses related to treatment in a month. The amount spent on in-patient treatment was five rupees and out-patient treatment was 35 rupees. A major share of health expenditure is on drugs and out-patient care. Household health expenditure on in-patient treatment, out-patient treatment, drugs and other related expenses rose with increasing income quintiles. However, health spending on traditional medical treatment declined for higher income quintiles, suggesting the dependence of poorer respondents on traditional medicines. Average household health expenditure is the highest of 203 rupees in Maharashtra and 138 rupees in West Bengal. Household health expenditure is the lowest 90 rupees in Karnataka. Eighty percent of households reported that they paid their health expenditure through current income followed by 16 percent from borrowed sources. Health expenditure paid through savings (bank account) is nine rupees and income from outside the family (family members or outside) constitutes about 11 percent each. About seven percent of the households financed their health expenditure through sale of assets such as furniture, cattles, jewellery etc. Less than one percent of households relied on health insurance for their health payments.

Out-of-pocket expenditure on health In sixty four percent of households, out of pocket expenditure as a share of households’ capacity to pay (OOPCTP) is less than 10 percent. In 16 percent of households, out of pocket expenditure as a share of household capacity to pay range between 10 and 20 percent and in 12 percent of households out of pocket of expenditure as a share of capacity to pay is between 20 and 40 %. In eight percent of the households, out-of-pocket expenditure as a share of capacity to pay is equal to or above 40 percent, which by definition constitutes catastrophic payments. The highest proportion of out of pocket health payment is for drugs (45 %) followed by 30 % for out-patient treatment, 15 percent in other category and six percent for traditional medicines. The lowest four percent share of out of pocket expenditure on health is for in-patient care. Catastrophic expenditure Twelve percent of households in India are assessed as having catastrophic health spending. In all, the 1229 households with catastrophic spending on health on an average spent 201 rupees for health treatment in the last one month. Of this, the amount spent on drugs was the highest of 77

rupees followed by 49 rupees for out-patient fees. Households spent 22 rupees for in-patient fees, 40 rupees for other treatment and 14 rupees for traditional medicines. Catastrophic health expenditures rise with increasing levels of income quintiles. At the lower income quintiles, on an average, the catastrophic health expenditure is 151 rupees compared to 260 rupees at the higher income quintile. Higher income quintile households on an average spent 12 times higher for in-patient treatment compared to the low-income quintile households in India. Impoverishment The proportion of households with catastrophic expenditure in the first and second expenditure decile is 13 percent and 25 percent respectively. About 30 percent of the households had catastrophic expenditure in the third decile. Households in the middle expenditure decile e.g. fifth and sixth deciles experienced highest impoverishments. Both households of catastrophic expenditure and impoverishment due to catastrophic expenditure are concentrated in the middle health expenditure decile categories. As economic status improves that is in very high health spending categories, the catastrophic expenditure and impoverishment levels come down. Insurance In India, only two percent of the population are insured and the rest 98 percent of respondents are uninsured. Of the two percent insured, 1.5 percent are covered under mandatory insurance and 0.5 percent are covered under voluntary insurance. Both voluntary and mandatory insurance coverage exists at a minimum scale, but mainly in urban areas. Rajasthan and west Bengal have slightly higher levels of insurance coverage than other states. Overall, the poor insurance coverage indicates that it requires a serious policy intervention to develop it as an important source of health financing. Human resources for health(2004) :

The World Health Survey indicates 60 physicians, 135 nursing and mid-wife and 245 other health related support staffs per 100,000 population in India.

All these professionals are trained in a health related areas or they ever worked in health related occupations. The highest ratio of health professionals such as physicians, professionals in nursing-midwifery and other health personnel per 100,000 population is reported in Maharashtra. The availability of health professionals per 100,000 population is greater among males compared to females, urban compared to rural, higher income quintile compared to lower income quintile. Males dominate in physician category while females dominate in nursing profession with 218 female nurses compared to 57 male nurses per 100,000 population of the respective sexes.

Physicians are three times higher in urban areas compared to rural areas. Physicians and nursingmidwifery professionals are concentrated in higher income quintile whereas the professionals in other health and support occupations are evenly distributed in income quintiles. Among the health professionals, 14 percent are physicians, 31 percent are nurses and mid-wifery professionals and 56 percent are other health and support staff. All physicians, 17 percent of nursing and midwifery personnel, 42 percent of health and support occupation professionals have university degrees. More than 90 percent of health professionals in nursing-midwifery and other health and support occupations have secondary or less than secondary education. Among the three categories of professionals in health occupations, physicians have the highest participation in the health occupations in the last one year. Eighty eight percent of the physicians have worked in the last one year and the rest 12 percent did not work not because they could not find a job or for other reasons. About 71 percent of the nursing and the midwifery personnel have worked in the last one year and 27 percent did not work for other reasons. Three percent of nursing and midwifery personnel could not find a job in the last year. The primary work location of the health professionals indicates that three fourth of the physicians (79 percent), one fourth of professions in other health and support occupations (26 percent) and 31 percent of nursing and midwifery personnel are working in the private health facility. 21 % of physicians, 54 percent of nursing and midwifery professionals and 25% of health and support occupation professionals are working in public health facility. The proportion of professionals in non-health services is 20 percent among nursing and midwifery professionals and 44 percent among other health and support occupations. The nature of work reflects that direct patient care is the major activity of the physicians (90 %). About 43 percent of nursing/mid wives and five percent other health professionals are involved in direct patient care. Those who are engaged in health education/research are more among other health staff (56 percent) and 10 percent from physicians. About 53 percent of nursing and midwifery professionals are involved in health education, research and other health related activities. Twenty percent professionals in health and support occupations and four percent of nursing professionals are involved in non-health activities. Table : 15 Country INDIA (2006) Population 1130 million Population growth rate 1.4 % Population density 363 persons per sq km Urban / Rural distribution Urban-30 % , Rural- 70 %

Health and Education: Life expectancy(average) Infant mortality rate Population per doctor Population per hospital bed Literacy rate Number of students per teacher, primary school

Male-62 yrs Female-64 yrs 56 deaths per 1,000 live births 2500 people 1300 people 70 % 41 students / teacher


Overall, 16 percent of women in ages 18-69 had undergone cervical cancer screening and four percent of women in ages 40-69 have had breast cancer screening. The highest coverage of cervical cancer (31 percent) screening and breast cancer screening (nine percent) is reported in Maharashtra. The lowest seven percent of woman who had cervical cancer screening is reported each in Assam and Uttar Pradesh. In urban areas, 25 percent of women respondents reported having had cervical cancer screening and nine percent of women had breast cancer screening. In rural areas, fifteen percent of women had cervical cancer and four percent had breast cancer screening. Expectedly, a higher percentage of uninsured respondents and higher income quintile had been screened for cervical and breast cancer. Nearly, half of the women (48 percent) have received full antenatal care and 34 percent received care at the time of delivery in India for births that occurred in the last five years. Full antenatal coverage of women is the highest of 66 percent and 46 percent for delivery care in Maharashtra. Antenatal coverage is the lowest of 27 percent in Uttar Pradesh and care for delivery is the lowest of 10 percent in Assam. The percent of women receiving antenatal care and care for delivery is higher for urban compared to rural, insured compared to uninsured, higher income quintile compared to lower income quintile, educated mothers compared to illiterate mothers. Overall, as per the immunization card, 43 percent of children received three doses of DTP immunization and 32 percent of children received measles immunisation. The highest level of immunisation coverage for three doses of DTP (59 percent) and measles immunisation (55 percent) is reported for Karnataka followed by Maharashtra. The reported coverage of three doses of DTP immunisation is lowest in West Bengal (24 percent), Assam (16 percent), and West Bengal (17 percent) have shown lowest coverage of

measles immunisation. Immunisation of three doses of DTP is unfavourable to female and rural children, indicating a gender and residential gap in immunisation coverage. Maternal and child care, along with household food security, adequate health services and a healthy environment is a third necessary (but in itself insufficient) precondition for adequate nutrition. In fact, ‘care’ may be considered as a pivotal link between these two other conditions, representing the behavioural component of intra-household decision-making and resource use. It refers to the provision in the household and the community, of time, attention and support to meet the physical, mental and social needs of the growing child and other family members. In the child nutrition context, most importantly it involves the optimal use of household resources for child feeding, protection from infection, and care for the sick child. While the issue of ‘caring capacity’ refers to all the household members -- male and female -- who are potential caretakers of children, in practice in India, the main responsibility for child care lies with the mother (who often also has a major role as an incomeearner). Her capacity to manage the many competing demands on her time will govern the degree to which she can maintain a clean household environment, feed her children, care for them when sick as well as providing and preparing food for other household members. In turn, this capacity will be governed by the quantity, control and use of resources such as food, income, time and knowledge. The control of such resources at a societal level may be influenced by factors such as her socioeconomic and educational status. We thus start with an examination of the feeding and caring practices in the household before examining the possible basic causes relating to the role of women in Indian society and their educational status and literacy levels relative to men. This integral precondition for adequate nutrition may not be as well 89ecognized by policy-makers, compared to food and health. Partly this may be as a result of its many linkages with the areas of food and health, and partly as little data is routinely collected to reveal the gender dimensions of nutrition problems. These are discussed in the concluding section.

Mother and Child Health Care:

The type of care received at child birth is often critical for the health and survival of both infant and mother. A significant proportion of neo-natal deaths is attributed to poor birth practices. During 1987, only about 32% of births in rural areas and 74% in urban areas were in institutions or attended to by trained personnel (Registrar General of India 1979-86). Traditional birth attendants are unable to attend to complications and health professionals are contacted too late. Both these factors point to the need to identify mothers at risk during the prenatal period. Recent reports show that tetanus toxoid immunisation coverage is 77% of pregnant women in India (EPI 1990). Started in 1960, and boosted in the second half of the 1980s by the immunisation mission, this intervention is picking up as part of ante-natal care (see Figure 18). The national average of tetanus toxoid


coverage however masks variations between states ranging from 16% in Assam to 99% in Kerala. Even though abortion has been legalised in India since 1972, mortality and morbidity due to illegal abortions and birth attention by incompetent persons in unhygienic conditions remain a major problem, mainly because of ignorance of the law and inaccessability of professional services in rural areas. Only around half a million pregnancy terminations were performed through the health services in the fiscal year 1987-88 which is around 9% of the induced abortions likely to have been performed during the same period. Since the inception of this formal facility in 1972, 5.8 million abortions have been performed under it; less than the total number of induced abortions likely to happen in one year (UNICEF 1990 p15). Induced abortions in fact reflect an unmet need of women for family planning, and highlight gaps between demand for family planning on one hand and availability, accessibility and actual use of services on the other. India is the first country to launch an official family planning programme to control population. However, the programme has not had the desired impact. The trend in the percentage of couples protected by various methods of family planning are shown in Figure 19. The target fixed by the National Health Policy is to cover 60% couples by 2000 AD, while the present protection is 41% (all methods). Efforts must be made through different channels of mass media to propagate the acceptance of a small family norm. Child Caring and Feeding Practices Child feeding practices such as breastfeeding, weaning and feeding sick, anorexic children have a bearing on the nutritional status of the child. A comprehensive study on infant and child feeding practices carried out by the ICMR in six different regions of the country - Coimbatore, Gandhigram, Hyderabad, New Delhi, Pune and West Bengal (ICMR 1990) - indicated that a great majority of women started to breastfeed their new-borns on the third day after delivery, while liquid/semi solid supplements were rarely given to infants before six months (except in West Bengal). Figure 14. Family Planning - Couples using contraceptives


Source: GOI Ministry of Health and Family Welfare A collaborative study on contemporary patterns of breast feeding conducted by WHO (1981) indicated that the prevalence of breastfeeding in the rural regions was related to socio-economic background. In general, it was more common in rural than urban areas, and within the urban population it was more prevalent among the poor than the economically advantaged. As many as 95% of infants belonging to poor rural and poor urban mothers were breastfed, even at 15 months of age, while corresponding percentages for high and middle income groups were 18% and 51%. In another study (GOI 1975-88), comparison of child feeding practices in ICDS (Integrated Child Development Services) and control areas had shown that nearly 85% mothers started breast feeding their newborn children within 6 hrs after delivery. The report indicated that though there was no significant difference in the breast feeding practices between ICDS and control areas, delayed weaning was more common in non-ICDS children (28% vs 59%). The ICDS is reviewed in Part II. The four-state ICDS study undertaken by NIN (Sarma et al. 1990) has indicated that nearly 50% of the mothers did not alter the diets of their children when they were sick. Quality of intranatal care is another important indicator of health service availability and utilisation. The ICDS report shows that 76% of the deliveries in ICDS areas were conducted by trained personnel compared to 49% in non-ICDS areas. The immunisation coverage of children between 12-24 months also showed that the ICDS children in most of the states were better protected. In the states of Tamil Nadu and Maharashtra, however, the coverage was more or less similar in ICDS and non-ICDS areas. Similar results were

observed in the four-state ICDS study undertaken by NIN where immunisation coverage, antenatal care, massive dose vitamin A administration, folifer distribution etc., was two to three fold better in ICDS areas. Food Distribution within the Household Analysis of dietary data to assess intra-family distribution of food has shown that in 50% of the households surveyed, levels of energy adequacy did not differ between preschool children, adult men and women. Either all of them were consuming adequate amounts (31% of households) or inadequate amounts (19% of households). When intakes were corrected for requirements, it was observed in NNMB surveys that the average calorie intake levels of women were close to 94% of their RDI as against 85% in men. This is contrary to the general belief that women get least. However, in 59.4% of the households, the diets of preschool children were deficient in energy when judged on the most conservative cut-off of -2SD RDI. The average food/nutrient intakes of preschool children were assessed by oral questionnaire method in the NNMB repeat surveys. The intake of cereals and to some extent fruits and sugar, showed an increase between 1975 and 1990, and no remarkable changes were seen in the consumption of other foods. The average daily per capita intake of calories among children 1-3 years old during 1988-90 was 908 kcal as against 834 kcal in the seventies, although the RDI is 1240 kcals (NNMB 1991); corresponding figures for 4-6 year olds were 1260 kcal and 1118 kcal, while the RDI was 1690 kcals. The increase over time in both cases has been mainly due to increased consumption of cereals rather than other foods. It shows that, although overall household food consumption has not changed much in the last 15 years, there has been some preferential allocation to children -- probably via an increased awareness of the nutritional needs of growing children by parents, along with the beneficial effects of direct nutrition interventions initiated during this time period. There was no notable difference in food consumption between boys and girls -- a finding in line with the lack of gender differentials in anthropometry and IMRs. Education Resource allocation The total expenditure on education increased from 1.2% of the GNP in 1950-51 to about 4% in 1986-87, against an optimal target level of 6%. The real per capita expenditure also increased steadily, particularly in the late 1980s, from $ 0,68 in 1975-76 to $ 1.64 in 1989-90. The share of education as a proportion of plan outlay in the public sector has shown a declining trend through the plan periods. Within the education sector, the share of elementary education has been falling from 56% in the first fiveyear plan to 29% in the seventh plan; higher education has benefited at the cost of primary education. There is a need to step up the resources for formal and non-formal education. Assuming that 70% of the 6-14 age group will be

provided education through formal and 30% through non-formal channels, the annual per capita cost for universal elementary education has been estimated at Rs. 103 and Rs. 54 (informal) by the year 2000. Infrastructure development As of 1987-88, there were 543,677 primary, 141,014 middle and 71,305 secondary and higher secondary schools in India. The growth of educational facilities during the last one and half decades has been steady (GOI 1987). Inter-state variations in school enrolment indicate that gender differentials are pronounced, though the percentage of scheduled castes/tribes out of the children enrolled at primary level is at par with, or higher than, the percentage of scheduled castes/tribes in the total population (UNICEF 1990). The ruralurban divide also shows up sharply in school enrolment and as a gender differential. Available information on retention rate in primary classes indicate that it is quite low, particularly for girls. For example, in 1985-86, the retention rate for class V was 56.9% for boys and 51.0% for girls (CSO 1989). The drop-out rate worsens as girls move from lower to higher classes. Existing measures therefore need to be strengthened in order to have continuous education for girl children. The new educational policy adopted by the Government in 1986 accords a very high priority to universalisation of education to ensure essential minimum education to all children up to the age of 14 years. Female literacy outcomes Changes in literacy rates during the 1980s are impressive for both males and females (Registrar General of India 1991). According to the 1991 census, about 52% of India’s population is literate. At the time of independence in 1947, the female literacy rate was a mere 6%. Over the years however, there has been a steady improvement in the rate, although the absolute number of female illiterates has increased from 215 million in 1971 to 242 million in 1981. This backlog is estimated to have further swollen to 253 million in 1988, notwithstanding the rise in the female literacy level reported by the 1987-88 National Sample Survey. Of the 340.5 million illiterates above 5 years in India in 1981, as many as 200.3 million were women. Of them 170.7 million live in rural areas. In other words, more than half of the total illiterates in India in 1981 were rural females, and this proportion remained throughout the 1980s. The female rural literacy rate in the 10-14 year age group was 36.4%, but it declined progressively with increasing age and is only 8.6% in the above-35 age group (UNICEF 1990 p88). Overall, female literacy rates improved threefold from 1961 to 1991 (from 13.3 to 39.4%) while for males the level has gone up from 34.4% to 63.8% during the same period. Clearly however the female rate is still much lower than that

of males (Registrar General of India 1991) - in fact the female rate in the early 1990s can be seen to approximate the male literacy rate of a quarter a century ago. The regional variation with regard to female literacy is striking. In the 1981 census, the highest female literacy rate (5 years and above) of 78.9% is registered by Kerala (UNICEF 1990 p102). By contrast, among the 14 most populous states, four states viz., Rajasthan (28.4%), Madhya Pradesh (32.3%)Uttar Pradesh (31.4%) and Bihar (30.2%) ranked the lowest. These states accounted for half the illiterate rural women in India (as well, in fact, as the majority of India’s poor). There have been efforts to correlate female literacy with age at marriage, fertility rates and child mortality. In rural areas, a higher proportion of married women are illiterates as compared to urban areas. Further, among illiterates, around two-thirds of women got married before reaching the age of 18 years, suggesting a positive correlation between age at marriage and level of education. Available data also suggest an inverse correlation between a woman’s level of education and her fertility. Child mortality rates are about five times higher among illiterate mothers compared to graduates (Registrar General of India 1989). Better child survival among the educated group may be due to several factors such as better hygiene, improved nutrition and feeding practices, and timely medical intervention. A study conducted by NIN (Brahman et al. 1988) showed that, controlling for income, the energy content of the diet of children whose mothers were literate tended to be better than those whose mothers were illiterate. There are other case studies showing that maternal education has a significant influence on the nutritional status of the children (Walker and Ryan 1990). Women’s literacy and their use of health facilities go hand in hand. Krishnan (1985) examined overall death rates in terms of literacy, doctor, hospital and bed population ratio, per capita income and % per capita expenditure on medical and health services. He observed that literacy was the most important factor while health services also had some explanatory power. Socio-economic Status The capacity of a mother to care for her children depends on her social status and economic activities. In many poor societies patriarchy is likely to be the main obstacle in securing a fairer distribution of work and decision-making power between adult household members. Increases in the ratio of female to total income is expected to improve the economic status of women within the household and their control over resources. Their ability to realise their own preferences within the family (of which health and well-being of children is likely to be a priority) may consequently be strengthened. However, working outside the house may leave

her little time for child care. It is a complex situation and women’s problems are difficult to capture in national surveys. There have been a few case-studies to assess the impact of women’s work and income on child nutrition. The analysis of women’s work and child survival undertaken by Rosenzweig and Schultz (1982), whose two-stage regression analysis of an all-India sample of rural households demonstrated that female employment had a significant influence on the survival of the girl child. A case study undertaken in Kerala (Gulati 1978) indicated that the nutritional adequacy of households dependent on agricultural labour was more related to women’s employment than men’s. A study undertaken by the Maharashtra Employment Guarantee Scheme (Walker and Ryan 1990) indicated that in households where women exercise control over their wages, more money was spent on food and other basic needs while men tend to spend more on liquor, cigarettes etc. These studies suggest that women’s gainful employment and decision-making power in the family influence the child health and survival (see ‘Gender Issues in Child Care’ section below). Labour-force statistics under-report female contributions at a national level. In the Indian census of 1981 only 14 per cent of the total female population were classified as "workers" although an estimated 54 per cent of rural women and 26 per cent of urban women are engaged in work activities. The basic difficulty in reporting lies in the extremely hazy demarcations between economically productive employment and domestic work within the subsistence sector, especially as it relates to agricultural activities (though the latter should also be considered as economically productive in that it maintains the labour force). Gender Issues in Child Care Data on gender differences in child care and access to food and health care are contradictory. While recent NNMB data fail to show evidence of gender discrimination in food consumption (and by implication, in food access and allocation), anthropological and other evidence to the contrary has been reported from numerous studies. Miller (1981) has collated evidence from thirty one ethnographic studies from several regions in India on allocation of food, medical care, and love and affection. Of the 13 studies that report on food allocation among young children, only two studies indicate no gender differentiation in feeding practices, while 11 studies indicate caretaker bias against female children. This bias is most often exhibited during early infancy in breastfeeding, weaning and supplementation practices, and in later years in apportionment of quality foods such as milk, butter, snacks and sweets. Most studies conclude that gender biases are small (which may be one of the reasons why these are unlikely to be picked up by generic surveys), but as one study states "in an emergency...[a daughter] is more readily expendable than a son". Twelve other studies that document gender-related food practices during adolescence present evidence for allocation of special foods to girls for periods ranging from a few days to a few months at/around the time of menstruation. Of the ten

studies that report on allocation of medical care, all but one infer better medical care for boys. Only two of the studies reviewed address the issue of sex differences in nutritional status, and both present evidence for consistently higher prevalences of underweight girls than boys. Many of the studies also suggest more pronounced gender differences in northern India, and among the less privileged classes. The report presents further evidence that sex ratios at birth are similar in all regions of the country, while juvenile sex ratios (females/males) are significantly low in North India - the region where evidence for gender discrimination is most strong (sec Table 13). While some evidence of female infanticide may explain this differential, the implication is that overt or covert marginalization in child care in North India translates into greater female mortality in the early years and a consequent rise in the sex ratio.

Table 16: Sex ratios in Indian regions (females per 1000 males) Region North Zone East Zone South Zone West Zone Central Zone Sex ratio at birth # 962 943 943 935 926 Juvenile sex ratio * 847-980 952-1031 980-103 952-1000 1000-1031

North West 935 901-952 Zone Sources: # Miller (1991) Appendix A, * Extrapolated from Miller (1991), Figure 4 (expressed as numbers of females per 1000 males). Relatively recent evidence of female infanticide has been provided by a study carried out in North Arcot district of northern Tamil Nadu . Between April 1st 1997 and September 3.0 1999, of 759 live births (from a study population of 13,000), 56 infants died - 23 males and 33 females. Of these 19 were confirmed as infanticides, and all were girls. Thus more than half of all female infant deaths in the 12 study villages during this two and a half year period were infanticides. An infant mortality rate for the whole study population was calculated at 69 per 1,000 live births. If infanticides are subtracted out, this leaves an IMR of 46 per 1,000 live births. Put another way, in the 6 villages (of

the 12) were female infanticide was practised, this was the outcome of 9.7 per cent of all female births! These are frightening statistics, even more so when research has shown that the problem is much worse in the north of the country. The question of why it is that all the Indian states with IMRs higher than the national average (of 94) are concentrated in the north of the country demands investigation from this perspective? While the relative incidence of poverty in the north vis-a-vis the south may explain some of this, the findings above suggest that research into the degree of female infanticide in other parts of India, particularly the north, is urgent. What underlies such an extreme manifestation of discrimination? Differentials in child mortality and nutritional status can be considered as being related to female economic and social status which may be influenced by both material and cultural factors. Material explanations relate to the economic undervaluation of women. This, in turn, depends on female labour demand, participation and earnings, as well as the gender distribution of inheritance rights (that governs control of property) and the exchange value of the female at marriage (reflected in dowry costs). Household income differentials may have paradoxical effects. In poorer households, women (who are less dowered) may participate more in the wage labour markets and suffer less from the adverse effects of patrilinearity. However, resources being more scarce, the results of less discrimination may nonetheless be more fatal. The World Bank study mentioned above argues further that regional differences in female access to food and health resources are determined by the economic value of women’s labour. Data from complement these conclusions with evidence for a synergistic relationship between female survival and economic productivity of adult females. Cultural factors on the other hand determine not only the gender division of waged tasks within which market mechanisms may operate, but also systems of property owners. In a tribal south Indian population, for example, increased income from female wage work was not associated with an increased female control over household food allocation decisions. The impact of the concurrent decrease in capacity for child care was disproportionately borne by girls under the age of one, a bias that was reflected in excess female child undernutrition. Material factors in this case appear to have been less important than cultural factors in influencing gender-differentials in child care and nutrition. The process of Hinduisation which is diffusing throughout tribal societies in South India, with the practice of dowry becoming increasingly widespread and the costs of the dowered increasing, may here be reflected in the relative neglect of the nutritional and health needs of girls vis-a-vis boys. The role of women in nutrition-relevant actions in the states of Andhra Pradesh and Tamil Nadu in South India will be investigated in Part II of this report.


Table 17: Selected Socioeconomic characteristics of Households in Sample All India N=85091 Variable Mean Age of Mother 31.17 Urban Household (%) 31.46 Rural Household (%) 68.54 Mother’s Education in single 4.02 years Father’s Education in single 6.59 years Religion (%) 78.44 Hindu 11.12 Muslim 5.54 Christian 2.38 Sikh 2.46 Other Caste (%) 17.01 Scheduled Caste 12.30 Scheduled Tribe Read Newspaper once a week 24.70 (%) Watch TV once a week (%) 50.70 Mother Working (%) 34.90 North India (%) 69.15 South India (%) 16.87 Live in Big City (%) 11.29 Living with Mother in Law (%) 1.6 Source: NFHS 2006-07 Maternal Mortality It is estimated that out of half a million maternal deaths in the world each year about 20% are in India. Maternal deaths are caused either by direct causes arising from complications of pregnancy, delivery or their management; or indirect causes due to aggravation, by pregnancy or child birth, of an existing abnormal condition. India’s maternal mortality rate, estimated at 3.4 per 1000 live births, on average between 1980-87 (UNDP 1990 pp.148) compares with an average of 2.9 for ‘all developing countries’ and 0.24 for industrialized countries. There is no figure for the maternal mortality rate of the country which can be considered as reasonably conclusive, more so because levels as high as 13 have been noted in certain rural areas. The actual life-time risk of an Indian woman dying from a maternity-related cause is far greater than comparative rates between India and the industrialized countries would suggest owing to the higher total fertility rate (4.0 in 1990 according to the World Bank 1992). Maternal age and

number of births have a strong effect on maternal mortality. A woman giving birth to children at 20-35 years of age faces a much lower risk than women below 20 and over 35 years. An estimated 8% of the 26-27 million annual births in India are to mothers below 19 years, whose growth and maturation may be retarded. Maternal illness and death rose significantly with the fourth pregnancy and reached a high level after the fifth. Some 35% of live births in rural areas and around 29% of live births in urban areas are of the fourth birth order and above (Registrar General of India 1984). In India, as in many developing countries, maternal mortality accounts for the-largest, or near-largest, proportion of deaths among women in their prime years (UNICEF 1990 p14). The trend in the percentage distribution of deaths by causes related to child birth and pregnancy in rural India is given in Table 7. Table 18: Percentage distribution of deaths by cause related to child-birth pregnancy 2001-06 Specific causes Abortion Toxaemia Anaemia Bleeding of pregnancy Obstructive labour Puerperium sepsis Non-classifiable Total Sample number of deaths 2 2 2 2 2 2 001 002 003 004 005 006 13.7 10.1 10.7 10.8 11.5 8.0 8.0 12.5 12.1 10.8 6.7 11.9 17.7 24.4 18.9 23.3 23.1 17.0 23.4 26.2 23.5 18.8 15.9 21.6 9.2 7.2 8.3 6.2 7.7 6.2

13.1 8.3 11.6 10.8 13.9 13.1 14.9 11.3 14.6 19.3 21.2 22.2 100. 100. 100. 100. 100. 100. 0 0 0 0 0 0 175 168 206 176 208 176

Percentage of total 1.0 1.0 1.2 1.0 1.2 1.0 deaths Source: Registrar General of India, Survey of Censuses of Deaths (Rural) 200107 In 1997, deaths related to pregnancy and child birth accounted for 13.2% of deaths among rural women aged 15-45 years; and 14.0% of those in the 15-24 years age group. Most of maternal deaths are associated with malnutrition, particularly anaemia. Other major causes such as toxaemia and septicaemia reflect the inadequate health care available to women during ante-natal, intranatal and post-natal periods. The share of deaths from toxaemia and puerperal sepsis is higher in the 15-24 year age group which also faces a considerable threat from abortion, anaemia and bleeding (the latter two are inter-related). These young women are thus particularly at-risk, in addition to their greater propensity for delivering low-weight babies and to infant loss.

Structure of School Education System in India:
In India the kinds of Schools are - public schools, private school, girls schools, boys schools ...etc. The minimum age for starting scholing is 4-5 yrs, initial standards are LKG( lower kinder garden), UKG( upper kinder garden).

Pre-Primary School Grade LKG & KG Age of entry: 4 to 6 Length of program in years: 2

Primary School Grade 1 to 5 Length of program in years: 5 Age level from: 6 to 11

Middle School Grade 6 to 8 Length of program in years: 3

Secondary School

Higher Secondary School

Grade 9 and 10 Grade 11 and 12 Length of program in years: 2 Length of program in years: 2

Age level Age level from: Age level from: from: 11 to 14 14 to 16 16 to: 18

Source : The Grade 10 and Grade 12 examinations are very important in India. These two exams are usually conducted by an external examination body that is different than the school. The student performance in these two examinations is vital for seeking admission to a University program in India. In India, this schooling system is commonly referred to as “10+2” (Ten Plus Two) schooling system. Advantages: Youth behavior changes drastically at about 16 years of age. By separating the schools for less–than 16–year olds from the 16+ year olds in 11 th and 12 th


grade, the less–than 16–year olds get a better chance to stay away from the influence of the 16+ youth. Immunization coverage The Government of India launched a universal immunisation programme in 1985-88 which, according to the number of children immunized and the percentage of coverage to target (See Figure 18) appears to be running smoothly, although it often fails to provide the complete dosage (which is more important than simple coverage). The National Health Policy document sets the goal to cover 100% of pregnant women and infants with tetanus toxoid, and 85% of children for DPT, polio and BCG vaccines by 2000 AD.

Vaccinations are offered to all children to help prevent outbreaks and
epidemics of infectious diseases. Whilst the vaccinations aren’t compulsory in the UK, medical professionals strongly advise that you have your child vaccinated. The government recommends the following immunisation schedule: At birth - Hepatitis B. Vaccine given: Hep B. At 1 month - Hepatitis B. Vaccine given: Hep B. At 2 months - Hepatitis B. Vaccine given: Hep B. - Diptheria, tetanus, pertussis (whooping cough), polio, Haemophilus influenzae type B. Vaccine given: DTaP/IPV/Hib. - Pneumococcal infection. Vaccine given: PCV. At 3 months - Diptheria, tetanus, pertussis, polio, Haemophilus influenzae type b. Vaccine given: DTaP/IPV/Hib. - Meningitis C. Vaccine given: MenC. At 4 months - Diptheria, tetanus, pertussis, polio, Haemophilus influenzae type b. Vaccine given: DTaP/IPV/Hib. - Meningitis C. Vaccine given: MenC. - Pneumococcal infection. Vaccine given: PCV. Around 12 months - Hepatitis B. Vaccine given: Hep B. - Haemophilus influenza type b. Vaccine given: Hib. - Meningitis C. Vaccine given: MenC. Around 13 months - Measles, mumps and rubella. Vaccine given: MMR. - Pneumococcal infection. Vaccine given: PCV. 3 years and 4 months (or shortly after) - Diphtheria, tetanus, pertussis and polio. Vaccine given: DTaP/IPV or dTaP/IPV. - Measles, mumps and rubella. Vaccine given: MMR. Between 13 and 18 years - Diphtheria, tetanus, polio. Vaccine given: Td/IPV.

Note - The BCG vaccine to prevent TB (tuberculosis) is no longer routinely given to children. It is now only recommended for children at high risk of the disease (e.g. those living in areas with a high rate of TB or whose parents or grandparents were born in a country where TB is highly prevalent). - Scares over the MMR vaccination have meant that some parents have not had their children vaccinated against measles, mumps and rubella. There have consequently been reported surges in the number of children with measles. If you’re concerned about this vaccination, it’s possible to obtain some of the vaccines individually and privately. MATERNAL MORTALITY IN INDIA: Introduction In spite of the growing concern about reproductive health, information on levels, trends and differentials in maternal mortality remains fragmentary in most developing countries. Policy initiatives often rest on judgements made on the basis of a small, selective cross-section of the population. For India, the National Family Health Survey of 1992-93 was the first to provide a national-level estimate of 437 maternal deaths per 100,000 births for the twoyear period preceding the survey (International Institute for Population Sciences, 1995). But in spite of surveying nearly 90,000 households, it could not produce estimates at regional or state-levels owing to the smallness of the sample. Even at the national level, the sample inadequacies of the NFHS came into sharp focus when the second round of the survey in 1998-99 produced a maternal mortality estimate of 520, but failed to confirm statistically the possible rise in the level of maternal mortality (International Institute for Population Sciences and ORC-Macro, 2000). To fill the data gap, in recent times, the potential of the Sample Registration System - a duel record system for collecting data on births and deaths - for estimating maternal mortality has also been explored. The source has recorded a maternal mortality rate of 408 and 407 for 1997 and 1998, respectively (India, Registrar General, 1999 and 2000). While the suggested level seems plausible at the all-India level, the state-level patterns indicated by this source appear highly improbable (such as very low estimates for Gujarat and Tamil Nadu and relatively

high estimates for Kerala). As direct investigations require a huge sample, several indirect methods have been proposed for the estimation of maternal mortality. One of these is the so called 'sisterhood method' developed by Graham and others (Graham et al., 1989). This method makes use of the data collected from female respondents in a sample survey on the number of ever-married sisters they had, the number who were not currently alive, and the number who died while pregnant, during childbirth or within six weeks after delivery. The procedure of estimation can be made more direct by adding a few more questions on siblings, as done in some Demographic and Health Surveys (See Rutenberg and Sullivan, 1991). The sisterhood method cuts down the required sample size drastically because women generally have several sisters who could have been exposed to the risk of maternal mortality, each time when they were pregnant. The method has been used to estimate maternal mortality with some success in African populations. In India, opportunities for using the sisterhood method have been limited owing to paucity of data. An indirect procedure of estimating maternal mortality from the sex differentials in mortality at reproductive ages has been developed by Bhat et al. (1995). Basically, it involves the regression of sex differentials in mortality rate on fertility rate, by age. The method can be applied to any source that provides estimates of mortality rates by age and sex, and fertility rates by age. The main advantages of this method are that it requires no special questions to be canvassed, and provides estimates for more recent times than the indirect version of the sisterhood method. Comparisons made with the estimates from other sources indicate that this approach gives quite plausible levels of maternal mortality for India. However, there have been few applications of the method to data outside south Asia. The objectives of this paper are two fold. First, it presents estimates of maternal mortality derived from the sisterhood questions asked in the Human Development Profile Survey (HDPS) conducted by the National Council of Applied Economic Research in 1994


(Shariff, 1999). As the relevant data have been collected from about 37,000 ever-married women, it is possible to derive from the survey data reasonably stable estimates of maternal morality for broad geographical regions and by socio-economic characteristics. The second objective of this paper is to update the estimates of maternal mortality derived using the indirect procedure developed by Bhat et al. (1995). The original paper carried estimates of maternal mortality for India and its major states for the period 1982-86 using the data from India's Sample Registration System. In this paper, estimates are presented using this method for the period 1987-96. An attempt is also made to compare the estimates derived from the two indirect methods to judge their relative performance. Indirect Estimates from Sisterhood Method The HDPS covered about 33,000 rural households spread over 1,765 villages and 195 districts in 16 major states of India. Table 1 shows the application of the sisterhood method to the allIndia data for rural areas. Nearly 37,000 women 15-49 years at the time of the survey have reported on an average 1.9 married sisters. Among them, 2,671 sisters were not alive at the time of the survey (i.e., 4.3 percent). The data available for 2,102 dead sisters indicate that 32 percent died around the time of childbirth. From this information, following the procedure developed by Graham et al., the lifetime probability of dying from maternal causes for a female baby has been calculated as 2.5 percent (see Table 1). This estimate of lifetime probability refers to, on an average, 11.8 years before the survey, or roughly to 1982. For computing the more conventional measure of maternal mortality rate, an estimate of average number of children born to women in their lifetime (i.e., total fertility rate) is required. The most convenient approximation to this is the average number of live births reported by the surveyed women of age 40-49 years. According to HDPS, the average number of children ever born to women of the age interval 40-49 was 4.4. But the reported sex ratio of 118 males for 100 female births suggests that women had underreported the number of daughters born to them. If a


correction is made by assuming a sex ratio at birth of 105, the total lifetime births to an average woman rises to 4.7. This figure is close to the total fertility rate of 4.9 reported by the Sample Registration System for rural areas of India in 1982. With 4.7 as the estimate of lifetime births, the sisterhood data from the HDPS imply a maternal mortality rate of 544 per 100,000 live births in rural areas of India in 1982. With 4.9 as the estimate of TFR, the data imply a maternal mortality ratio of 518. As only the survey can provide estimates of lifetime births for various population groups, for the sake of comparability, the former could be adopted as the estimate of MMR for rural India from HDPS.

The health system of a country deserve the highest priority to improve the health of the population as they provide the critical interface between life saving and life enhancing interventions and the people who need them (Deepa and Vinish, 2004). The World Health Organisation (2000) made an attempt to measure the efficiency of health systems in 191 countries across the globe using five performance indicators and found that regions vary enormously in their levels of development in health outcomes and in spite of similar levels of income and educational attainment. An assessment of the health system performance in India in terms of health outcome indicators shows tremendous improvement over the last 50 years. The crude death rate has declined from 26.1 in 1970 to 8.4 in 2001 (Registrar General, 2003). Life expectancy has risen from 36 years in 1951 to 62.1 years in 1995-2000 (United Nations, 2003). Infant mortality has been halved from 146 in 1951 to 66 in 2001. The factors contributing to such vast improvements in health have been the three tier system of community health centers, primary health centres and primary health sub-centers, countrywide immunization drives and improvements in determinants such as water supply, sanitation and socioeconomic conditions. However, this achievement has been very meager compared to our health policy goals. More importantly, there has been very


slow progress in the 1990s in health status improvement, as several of the above indicators show a plateauing. Moreover, the improvement in health status has been very uneven across the country, where states such as Kerala have health indicators comparable with the middle-income countries and other states such as Uttar Pradesh, Madhya Pradesh, Bihar and Orissa are at the lower end levels comparable to SubSaharan Africa.

Photo: 1, Medical college students explaining how to prevent from Dengue fever spreading. The experiences of some of the developing countries including India indicate that government participation in financing and provision of health care does not promote the objectives of equity. In the Indian context too, micro level studies found that the public sector spending is not equitably distributed across expenditure quintiles and other socio-economic strata. Also, the experience of many countries indicates that urban areas are favoured compared to rural areas. It is therefore necessary to understand the potential for health system improvements in the states. The concern for equity in terms of providing health care to the poor masses is clearly brought out in various health policy documents related to health in India. Eventhough, India spends about six percent of its Gross Domestic Product, the health status indicators in terms of health status index is sufficiently lower compared to many of the developing countries. So the health system performance needs to be assessed not only by the

health sector endowments but also by its efficient use. An empirical study in Cote d’ Ivoire found that health care utilisation at the lower end of the income spectrum was much more sensitive to distance when compared to their richer counterparts .


The Government of India and the states spend less than one percent of the nations Gross Domestic Product, or about three percent of all government spending, on health. Although not quite as large as the world average of 5.5 percent of GDP spent on health, it is still sounds significant. Ninety percent of the health finance is routed through the state (provincial) governments since the Indian constitution specifies that a large number of health related activities belong to the ambit of individual states (GOI, 1996; Reddy and Selvarajau, 1994). Also, the central government spends most of the remaining share, with local governments such as municipalities accounting for about 2.5 percent (World Bank, 1995). The public sector plays an important role in the rural health delivery system in the country. In urban areas the public and private health systems complement each other. The public sector does a offer a source of subsidized health care to the majority of India’s underprivileged, but this benefit comes at the price of subsidizing the richer groups out of proportion to their share in the population (NCAER, 2000). Rural health system performance determines the overall health outcome of the states and the country. Thus, the performance of public health system is of great significance in rural areas. In India, patients from both rural and urban areas overwhelmingly choose public facilities (Government hospitals, Community Health Centres and Primary Health Centres) for inpatient care. The reliance on public hospitals for in-patient care was greater in hilly and backward states, among Scheduled Castes and Scheduled Tribes and those belonging to the lower monthly per capita expenditure quintile (Shariff, 1995; National Sample Survey Organisation, 1998). In the public sector, 70 percent of hospitals and 85 percent of hospital beds are located in urban areas. These facilities are used more often in cases of severe and catastrophic illness, which the private practitioners are either reluctant or unable to handle. Poor patients depend heavily on public health services because the cost of treatment of illness is higher in private health care facilities. The patients with higher levels of income use private health care facilities because of better quality. However, other studies suggest that only 35 percent of the patients seek care from public facilities for major illness and largely depend on private health care facilities, irrespective of their level of income (Selvarajau, 2003). In the public sector, 70 percent of hospitals and 85 percent of hospital beds are located in urban areas. In India, the total health expenditure was 5.3 percent of the Gross Domestic Product (GDP) in 1997 and 5.1 percent in 2001 (World Health Report, 2003). This indicates a marginal decline in the proportion of health expenditure as a

percent of GDP. Private household health expenditure as a percent of total expenditure on health was 84 percent in 1997 and 82 percent in 2001. On average, a household spends 250 rupees per capita per annum on health services. Health expenditure is 40 percent higher in urban households than in rural households. Health expenditure is also positively related with overall household expenditure . Private health spending out of pocket expenditure in India is one of the highest in the world and indicates an inefficient way to finance healthcare that leaves people highly vulnerable. Studies in less developed countries in general shows that subsidies on public health are not necessarily targeted well to those most in need, the poor. Government expenditure on health as a percent of total government expenditure was 3.2 percent in 1997 and 3.1 percent in 2001. Also, the share of health budget in total revenue budget of the 16 major states has come down from 6.7 percent in 1987-88 to 5.4 percent in 1996- 97 (Selvarajau, 2003). Studies have shown that the use and availability of health care system varies between states, gender, and residence and by different socio-economic groups (NCAER, 2006). Table 19. Trends in health expenditure in India, 2000-2004 2000 2001 2002 2003 2004 Total expenditure on health 1(as a % of GDP) 5.3 5.0 5.2 5.1 5.1 General government expenditure on health 15.7 18.4 17.9 17.6 17.9 (as a % of total expenditure on health) Private expenditure on health 84.3 81.6 82.1 82.4 82.1 (as a % of total expenditure on health) General government expenditure on health 3.2 3.5 3.3 3.1 3.1 (as a % of total government expenditure) External resources for health 2.3 2.4 2.2 2.2 0.4 (as a % of total expenditure on health) Out of pocket expenditure 100 100 100 100 100 (as a % of private expenditure on health) 1 Includes all public and private expenditure on health Source: World Health Report, 2006 Private health facilities are greatly used in urban India. However, private practitioners are well spread even in remote and backward areas, and they are usually contacted for day-to-day health care needs before availing distantly located specialist public facilities. The growth of corporate hospitals is due to the demand for development of a health care market in which investment in state-of-the-art medical technology can give a good return. Although the private sector accounts for a significant portion of the health system facilities, human resources and expenditure in India, no

adequate mechanism has been developed for monitoring and regulating the private health sector. In most countries health sector reform involves a change in the respective shares of tax revenue, social or private insurance, user fees and external aid in financing the health sector. Services provided in the public and private sector tends to differ. Hospital subsidies are distributed much more evenly in urban population in comparison to the rural population (NCAER, 2000). A shift takes place in the role that the state plays in the regulation and provision of health care services and the development of various types of public-private partnerships. Decentralisation, integration of services, including sector-wide approaches and reforms in logistics occur. The reform process is also affected by the geopolitical context in which a health system is embedded. This includes the bargaining position of the country in the international setting, the level of external debt and financial stability of the country and the impact of the past political structure on the health care system. HEALTH SYSTEM GOALS Health for all by the year 2010 AD is a national goal set by the Indian policy makers over Alma Ata. Since then, a lot of planning, efforts and public expenditures have been focussed and concentrated to improve the human health both in rural and urban parts of India. Supply of medicine has also improved. Despite concentrated efforts, India is one of the many developing countries, which faces a high level of morbidity, especially among the infants, children, women and the elderly. Also high incidence of infectious, communicable diseases are associated with low levels of sanitation, public hygiene and poor quality drinking water. The main goals of the health system are health system responsiveness and fairness in financing. Health of the population should reflect the health of individuals throughout the life course and include prevention of both premature mortality and non-fatal health outcomes as key components. Responsiveness has two key subcomponents: respect of persons and client orientation (WHO, 2002). Respect for persons involves elements of dignity, autonomy and confidentiality and captures aspects of the interaction of individuals with the health system that often have an important ethical dimension. Client orientation includes prompt attention to health needs, basic amenities of health services such as clean waiting rooms or adequate beds and food in hospitals, access to social support networks for individuals receiving care and choice of institution and individual providing care.


There are also cross-system goals to evaluate how much the health system helps or hinders education, democratic participation, economic production etc. One of the more important cross-system goals that should be emphasised is the contribution of the health system to economic production and social aspects like education. NATIONAL HEALTH POLICY OF INDIA : In the broader context of health system goals, a new National Health Policy was formulated in 2002 to cater to the changes in the determining factors relating to the health sector since the National Health Policy of 1983. The old health policy was revised and restructured based on the United Nations Millennium Development Goals. The main objective of the National Health Policy 2002 is to achieve an acceptable standard of good health amongst the general population of the country. The approach would be to increase access to the decentralised public health system by establishing new infrastructure in the existing institutions. The National Health Policy (2002) of India has noted that improvement in health status in terms of indicators such as the infant mortality rate, morbidity prevalence, life expectancy etc. has been very uneven across the rural-urban areas. The statistics also bring out wide differences between the attainments of health goals in the better performing states (Kerala, Maharashtra, Tamil Nadu) compared to the low-performing states (Rajasthan, Uttar Pradesh, Orissa, Bihar, Madhya Pradesh, Chhattisgarh and Jharkhand). So, the national average of health indices hides the wide disparities in public health. Given a situation in which the national averages in respect of most indices are themselves at unacceptably low levels, the wide inter-state disparity implies that for vulnerable sections of society in several states, access to public health services is nominal and health standards are grossly inadequate.


Eradicate Polio and Yaws 2005 Eliminate Leprosy 2005 Eliminate Kala Azar 2010 Eliminate Lymphatic Filariasis 2015 Achieve zero level growth of HIV/AIDS 2007 Reduce mortality by 50 percent on account of TB, malaria and other vector and water borne diseases 2010 Reduce prevalence of blindness to 0.5 percent 2010 Reduce IMR to 30/1000 and MMR to 100/lakh 2010 Increase utilisation of public health facilities from current level of <20 to >75 percent 2010 Establish an integrated system of surveillance, National health accounts and Health Statistics 2005


Increase health expenditure by government as a percent of GDP from the existing 0.9 percent to 2.0 percent 2010 Increase share of central grants to constitute at least 25 percent of total health spending 2010 Increase state sector health spending from 5.5 percent to 7 percent of the budget 2005 Further increase state sector health spending to 8 percent of the budget 2010
Source: National Health Policy, 2004, Government of India, Delhi.

Photo: 2, » Pulse-Polio mission in India 2005. The New National Health Policy (2004) has specified the following goals: There is also a big divide with respect to health care access between the poor and the rich and by many indicators of socio-economic development. A comprehensive evidence base is an important input for effective health policy interventions. The lack of evidence base from routine health information system is a common limitation in many developing countries including India. Given this background, the World Health Survey intends to provide evidence on the health status of the Indian population.

» Public health functions include:
• • • • Health surveillance, monitoring and analysis Investigation of disease outbreaks, epidemics and risk to health Establishing , designing and managing health promotion and disease prevention programmes Enabling and empowering communities to promote health and reduce inequalities

• • • • • •

Creating sustaining cross-Government and intercostals partnerships to improve health reduce inequalities Ensuring compliance with regulations and laws to protect and promote health Developing and maintaining a well-educated and trained, multidisciplinary public health workforce Ensuring the effective performance of health services to meet goals in improving health,preventing disease and reducing inequalities Researching, development, evaluation and innovation Quality assuring the public health function

In India, Census and vital (sample) registration system provide reliable data on several social-economic and demographic aspects of the population. However, very little information is available on population health, morbidity and health system performance indicators. In view of lack of routine health information, organizations such as the National Sample Survey Organisation (NSSO) and the National Council of Applied Economic Research undertook national surveys on morbidity and healthcare. The NSSO surveys gathered information on physical and mental disability, morbidity, maternal and child health, utilisation of medical services, medical expenditure on different treatments and injuries in different rounds of the health and morbidity survey. Micro and macro level informations on medical care, health care needs of population in different states were gathered in NCAER surveys. More recent are the National Family Health Survey (NFHS) and Rapid Household Survey (RH-RCH). The two rounds of NFHS focus on the women in the ages 1549 and provide information on fertility levels, use of family planning methods, infant and child mortality, immunisation, morbidity pattern including the prevalence of diarrhoea, malaria, leprosy, nutritional status of women and children, maternal and child health, quality of health care etc. The RCH surveys are designed to provide data at the district level on maternal and child health and various health infrastructure facilities covering primary health sub-centres, primary health centres (PHC), community health centres (CHC), first referral units (FRU) and hospitals. In a nutshell, all these surveys are focussed on a variety of demographic indicators, general morbidity prevalence rates and maternal and child health indicators. The NSSO although focuses on morbidity prevalence more extensively, is not sufficient to assess the health system performance of a country in a broader framework.

The data from Census, Sample Registration System and National Family Health Survey (1998-99) are used. Population in the six states constitute about 47 percent of the country’s population. Uttar Pradesh has the highest share of 16 percent of population followed by Maharashtra with nine percent and Assam the lowest proportion of about three percent of the population. The annual growth rate of population in India was 1.93 percent during 1991-2001. The population growth rates in Karnataka, West Bengal and Assam are lower than the national average. Uttar Pradesh and Rajasthan indicate the highest population growth rate of 2.3 percent and 2.5 percent respectively in the country. West Bengal, Assam and Uttar Pradesh have higher densities above the national average of 324. For the country as a whole, 28 percent of the population are in urban areas. But, Maharashtra, Karnataka and West Bengal have higher levels of urbanisation above the national average with 42 percent, 34 percent and 28 percent respectively. Sex ratio for the country is 933 females per 1000 males. The sex ratio of the population for Maharashtra, Assam and Rajasthan are lower than the sex ratio for the country, indicating greater deficit of females. Rajasthan, Uttar Pradesh and Assam have literacy rates below the national average of 65 percent. Assam, Uttar Pradesh and Rajasthan have crude birth rates (CBR) and total fertility rates (TFR) higher than the national average. Maharashtra, Karnataka and West Bengal are more advanced in demographic transition than the country level average. The couple protection rate (family planning methods) in India is about 45 percent. Among the six states, Maharashtra and Karnataka have the highest proportion of couples protection rates and also higher proportion of elderly population, which is above the national average of 7.9 percent.

• The scope of public health :

Public health services are conceptually distinct from medical services. They have as a key goal reducing a population’s exposure to disease ⎯ for example through assuring food safety and other health regulations; vector control; monitoring waste disposal and water systems; and health education to improve personal health behaviors and build citizen demand for better public health outcomes. Thus they involve such disparate activities as improving slaughterhouse hygiene and cattle-keeping practices, cleaning irrigation canals to discourage vector breeding, and applying public health regulations. Public health services produce “public goods” of incalculable benefit for facilitating economic growth and poverty reduction. Consider, for example, the long-term growth

possibilities generated by draining the swamps around which Washington DC was built. And conversely, consider the global economic costs imposed by the avian flu and SARS epidemics, emanating from poor poultry-keeping and health practices in a few Chinese localities. In India, the 1994 plague epidemic following poor municipal sanitation in Surat is estimated by the WHO (1999) to have resulted in losses totaling $1.7 billion. Poor public health conditions take economic tolls in various ways, including reduced attraction for investors and tourists; continued expenditures on combating diseases which should have become history; and labor productivity foregone. The poor pay a high price in debility, reduced earning capacity, and death. The rich suffer little mortality from communicable diseases, but nevertheless suffer repeated episodes of morbidity which are reflected in high rates of stunting amongst their children. It has long been accepted that the most effective approaches to improving population health are those that prevent rather than treat disease. Moreover, they account for a small fraction of the total health budget in most countries. It is the norm for public health services to be publicly funded, since the market has limited incentives to provide them. This applies even in the US, where medical services are largely privately financed. But in India public policies and programs have focused largely on the provision of curative care and personal prophylactic interventions such as immunization, while public health activities have been relatively neglected. This helps explain why India’s health indicators are so much poorer than in East Asia and much of the rest of the world.

Photo: 3, Public services in India: Rural health facilities and Urban health facilities. Abstract Public health services, which reduce a population’s exposure to disease through such measures as


sanitation and vector control, are an essential part of a country’s development infrastructure. In the developed world and East Asia, systematic public health efforts raised labor productivity and life expectancies well before modern curative technologies became widely available, and helped set the stage for rapid economic growth and poverty reduction. The enormous business and other costs of the breakdown of these services are illustrated by the current global epidemic of avian flu, emanating from poor poultry-keeping practices in a few Chinese villages. For various reasons, mostly of political economy, public funds for health services in India have been focused largely on medical services, and public health services have been neglected. This is reflected in a virtual absence of modern public health regulations, and of systematic planning and delivery of public health services. Various organizational issues also militate against the rational deployment of personnel and funds for disease control. There is strong capacity for dealing with outbreaks when they occur, but not to prevent them from occurring. Impressive capacity also exists for conducting intensive campaigns, but not for sustaining these gains on a continuing basis after the campaign. This is illustrated by the near-eradication of malaria through highly-organized efforts in the 1950s, and its resurgence when attention shifted to other priorities such as family planning. This paper reviews the fundamental obstacles to effective disease control in India, and indicates new policy thrusts which can help overcome these obstacles. Sources: 1 Office of the Register General and Census Commissioner, Census of India, 2001, Provisional Population Tables, New Delhi: Office of the Register General and Census Commissioner. 2 Registrar General, India, 2005 Sample Registration System, 2003. 3 Family Welfare Programme in India year Book 1997-98, Department of Family Welfare, Ministry of health & Family Welfare, Government of India, New Delhi. 4 International Institute for Population Sciences (IIPS) and ORC Macro. 2000, National Family Health Survey (NFHS-2),2003-04: India. Mumbai: IIPS.

CURRENT SCENARIO In 1965, there were 86 medical colleges in India. This number increased to 112 by 1980 (a rate of growth of 30%), to 143 in the next decade (a rate of growth of 28%), and since 1990 over the past 17 years to 260, an increase of 82% compared with the figure in 1990. Of the 260 medical colleges recognized or permitted by the Medical Council of India (MCI), as listed on the MCI website in December 2006, just over half (53%) were in the private sector and the rest in

the public sector. With near doubling in the number of medical colleges over the past 15 years, it would be interesting to see whether the human resource in the form of medical college teachers has kept pace to fulfil the criteria of adequate staffing norms of the MCI. Gross shortage of teachers promotes unhealthy practices during inspections. The MCI is aware of these facts and has taken important measures to minimize, if not eliminate, these unhealthy practices. It has, however, not always been successful. Of the 260 medical colleges in existence, 181 are recognized by the MCI and 79 are MCI permitted; 26 of these 260 colleges admit 50 students per year, 146 admit 50–100 students per year and 88 admit >150 students per year. The total intake of medical students in these colleges is 29 072 (20 842 in MCI recognized institutions and 8230 in MCI permitted institutions). The annual student intake is a critical factor in assessing the requirement for teachers for various subjects.

Photo: 4, The top most Medical institute of India- All India Institute of Medical Sciences (AIIMS), New Delhi. TEACHER REQUIREMENT AND AVAILABILITY The teacher manpower required for different categories of institutions based on student intake is shown in Table I. The requirement varies from 2 per department to 7 per department for colleges with 50 admissions per year to 2– 12 per department for >150 admissions. The teacher requirement for Community Medicine includes the faculty for epidemiology, statistics and the rural and urban health centres. A total of 70 teachers are required per college

for 50 admissions, 90 for >50–100 admissions and 125 for 150 admissions per year. This manpower requirement is only for the MB,BS course. With these norms nearly 26 000 medical teachers are required to adequately staff 260 colleges for the MB,BS course alone. This number has been arrived at by multiplying the faculty required per college based on student intake by the number of colleges with that intake of students and summing up the total. Using the existing norms, the total teacher requirement for different disciplines for all medical colleges in India has been calculated (Table II). For the MB,BS course alone, over 2000 teachers are required for Community Medicine, General Medicine and General Surgery, 1600–2000 for Anatomy, Physiology, Pathology and Anaesthesiology and 1000–1500 for Pharmacology, Paediatrics, Orthopaedics, Obstetrics and Gynaecology and Radiodiagnosis. However, teachers are required not only for undergraduate but also for postgraduate courses. The available seats for postgraduates are highest for Medicine and Surgery and progressively decline in the pre- and paraclinical departments with the lowest intake in Forensic Medicine and Tuberculosis and Respiratory Diseases. However, many seats in the pre- and paraclinical departments remain unfilled for want of takers. Hence, the actual annual numbers available after postgraduation in various specialties is likely to be only about 75% of these numbers because of vacant seats, dropouts and attrition due to Acute shortage of teachers in medical colleges: Existing problems and possible solutions Human resources for health(2004) :

The World Health Survey indicates 60 physicians, 135 nursing and mid-wife and 245 other health related support staffs per 100,000 population in India. • Medical training :

Asian centres just as good, No one can argue against the fact that exposure to clinical material is far greater in third world countries than in the West. Medical information now flows freely over the Internet and doctors now have myriad ways of gaining access to ‘globalised’ knowledge, whatever that may mean. Globalised medical practice is not synonymous with Western medical practice. It is also somewhat patronising to insist that critical thinking skills are accessible predominantly via Western training traditions. They should remove their reflexive biases and examine the options of more cost-effective centres with high standards that can be found in India, Taiwan and even Thailand and the Philippines. US healthcare statistics may say something about the quality of some of these Asian medical schools. For example, in 2004 there were about 38,000 physicians of Indian origin practicing medicine in the US. About 12,000 Indians and Indian-Americans are medical students and residents (doctors in specialty training in teaching hospitals) across that country. Indians make up roughly 20 percent of foreign-trained doctors in the US and added to this number are Filipinos, Taiwanese, Pakistanis and other Asians. UK stats may convey a similar message.

1. Considering the large number of faculty required, there is an acute shortage of teaching manpower in medical colleges both in the long standing and newly started ones. This shortage is in the region of 20%–25% in most departments and as high as 33% in some departments (based on personal observations and discussions). The shortage is mainly attributable to non-availability of qualified personnel willing to take up employment in medical colleges on the current terms and conditions. 2. In addition to the existing vacancies, there is an annual decrement due to superannuation, resignation, etc. of 10%–15% of the existing faculty strength. If one matches the current shortfall in teacher strength in various departments to the actual number of newly available qualified teachers in that discipline, one can conclude that the current shortage in terms of annual requirement of teachers in different disciplines is more than two-thirds in most departments and is likely to increase by 10% every year due to superannuation and other losses. For example, the required number of anatomy teachers for undergraduate and postgraduate courses is 1888. A 25% vacancy rate amounts to a shortage of 472 teachers. The actual number of teachers qualifying in anatomy per year is about 170, which is 36% of the requirement. The shortfall at present is therefore 64% on an annual basis. The shortage particularly affects faculty posts at the senior level. 3. MCI norms require a 1:1 ratio to be maintained between students and postgraduate teachers. This is excellent in an ideal situation. Unfortunately, what it does is to create• Departments with more teachers at present will get more postgraduate seats and more teachers for future. • Departments with shortage of teachers at present will get less postgraduate seats and less teachers for the future. The current policy is therefore a vicious circle likely to lead to an increasing shortage. REFERENCES 1 List of MCI recognized and permitted colleges and list of postgraduate courses and colleges conducting them. 2 Minimum qualifications for teachers in medical institutions, Regulations, 1998. Medical Council of India, New Delhi. 3 Minimum standard requirements for the medical college–For 50 admissions annually, Regulations 1999. Medical Council of India, New Delhi. 4 Minimum standard requirements for the medical college–For 100 admissions annually, Regulations 1999. Medical Council of India, New Delhi.


5 Minimum standard requirements for the medical college–For 150 admissions annually, Regulations 1999. Medical Council of India, New Delhi.

MISSION OF WORLD HEALTH ORGANIZATION IN INDIA "Health for All--All for Health" The South-East Asia Region of the World Health Organization was established in 1948. It was the first of the six WHO regions. As such, 1998 marks the 50th anniversary of the region - and of the Organization itself. These five decades have seen a strong and ever-growing collaborative bond between WHO and India in their common endeavors to improve the health of the peoples of the country. This has posed daunting challenges indeed, as the Region is home not only to a quarter of the world's population but also to a formidable range of both communicable and non communicable diseases. Because of these unique attributes, the Region has been of deep interest to public health professionals and analysts. The health status of the world, it is said, is significantly influenced by the health status of the South-East Asia Region. It is hoped that the publication, in commemoration of the 50th anniversary of WHO, will serve as a vulnerable reference to those interested in health development in the country. These rare, interesting and useful insights help to underscore the Organization’s deep and abiding links with the health of the people of this Region. » WHO Programs : • the eradication of smallpox and virtual elimination of certain communicable diseases and the control of most communicable diseases in the country; • the changes in the health systems and the health infrastructure in the country; • the increase in life expectancy and the decrease in infant mortality and maternal morbidity and mortality. • how development works, from the early days of "assistance’’ to countries, to a participatory and collaborative approach now where planning and decisions are jointly made with the countries collectively and individually; • decentralization and community-based people’s movements reflecting the principles of WHO’s slogan "Health for All--All for Health"; • community-oriented education;

• reform and reorientation of medical education; • advocacy for equity, and social justice; • the role played by WHO in highlighting the vital role of health in development ; • the role played by WHO in getting health on the Human Rights agenda; • the role played by former WHO staff on their return to their own countries. • the effect on national institutions of being designated as WHO Collaborating Centres and working to develop approaches and tools for other countries to use. the new and dynamic relationships between WHO and its Member Countries, working as partners in health development.

» Priority Projects
Polio Eradication Rollback Malaria Tobacco Free Initiative AIDS Tuberculosis Women’s Health

In order to achieve its objective, the functions of the Organization shall be: • • • • • • to act as the directing and co-ordinating authority on international health work; to establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations as may be deemed appropriate; to assist Governments, upon request, in strengthening health services; to furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Government; to provide or assist in providing, upon the request of the United Nations, health services and facilities to special groups, such as the peoples of trust territories, to establish and maintain such administrative and technical services as may be required, including epidemiological and statistical services;


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to stimulate and advance work to eradicate epidemic, endemic and other diseases; to promote, in co-operation with other specialized agencies where necessary, the prevention of accidental injuries; to promote in co-operation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene; to promote co-operation among scientific and professional groups which contribute to the advancement of health; to promote co-operation among scientific and professional groups which contribute to the advancement of health; to promote co-operation among scientific and professional groups which contribute to the advancement of health; to propose conventions, agreements and regulations, and make recommendations with respect to international health matters and to perform such duties as may be assigned thereby to the Organization and are consistent with its objective; to promote maternal and child health and welfare and to foster the ability to live harmoniously in a changing total environment; to foster activities in the field of mental health, especially those affecting the harmony of human relations; to promote and conduct research in the field of health; to promote improved standards of teaching and training in the health, medical and related professions;

Photo: 5, Doctors of WHO campaigning in rural areas of India.

WHO has a crucial role to play in providing technical support to India in Human Immuno Virus / Acquired Immuno Deficiency Syndrome (HIV/AIDS) prevention and care. Nearly 40% of global burden of tuberculosis is in South-East Asia Region. WHO has taken a leadership role in accelerating implementation of DOTs strategy in India . The hazards of tobacco use have been proven and highlighted worldwide. Its use has increasingly been reported among women and youth. In the South-East Asia Region, tobacco poses tremendous health, economic and social challenges. Protecting vulnerable groups such as women and children and reducing the health and economic burden of tobacco use is a priority. WHO has, intensified its advocacy with India for more stringent tobacco control measures. WHO is supporting India in eradication of dracunculiasis, poliomyelitis, yaws and elimination of leprosy. WHO is also working for the prevention and control of priority diseases in the Region, e.g. Human Immuno Virus / Acquired Immuno Deficiency Syndrome (HIV/AIDS), Tuberculosis (TB), Malaria, Diarrhoeal Diseases, Respiratory Infection, Dengue Haemorrhagic Fever (DHF), Japanese Encephalitis and Rabies.

Photo: 6, Doctors of WHO campaigning in rural areas of India. WHO is supporting the India in promoting Environmental Health, especially water supply, sanitation and personal hygiene. (It is also spearheading the "healthy environment setting" initiative).


In recognition of the substantial proportion of burden of disease and disability related to reproductive health as well as prevailing high maternal mortality in many countries of the Region, WHO identifies Reproductive Health with life span perspective as a priority area with safe motherhood, family planning, prevention and treatment of complications of abortion, Reproductive Tract Infection /Sexually Transmitted Diseases (RTI/STD) and adolescent health as essential interventions. WHO is putting increased emphasis on prevention and control of noncommunicable diseases (NCDs).It is estimated, in 2006, about 3.7 million deaths out of 11.8 million total deaths (45%) in SEAR countries were due to NCDs. The diseases are rapidly increasing in developing countries where a much younger age group of population is affected than in the developed world. WHO is trying to address this challenge through an integrated prevention of the main risk factors.

Against the backdrop of the above scenario, the overall goal of the World Health Organization in India is to attain the highest level of health through Strengthening of the health system at national, provincial and district levels on Principles of equity, fairness and responsiveness with emphasis on the poor and the marginalized. This will be accomplished by forming partnerships with all stakeholders of the health sector, focusing on the development and adoption of norms and standards, initiate catalytic change through technical and policy support, advocating and articulating evidence based policies and strategies, stimulating research and development and monitoring of trends and performances. In summary, WHO’s strategic direction in India focuses on six priority areas (Clusters) for the period of 2005-2008: 1. 2. 3. 4. 5. 6. Health sector reform and health system development Communicable disease control Promoting healthy life styles and reducing environmental risk factors Integrating health services to enhance efficiency and effectiveness Emergency preparedness and response Partnerships and coordination

» UNITED NATIONS INTERNATIONAL CHILDREN’S EMERGENCY FUND. (UNICEF) UNICEF is one of the specialized agencies of the UN. It was established in 1946 by the UN to deal with rehabilitation of children in war-ravaged countries. In South Central Asian Reagan which covers Afghanistan, India, Sri-Lanka, the Maldives, Mongolia and Nepal. In the early years, UNICEF and WHO worked together on urgent problems such as malaria, tuberculosis and venereal diseases. Later, its assistance to countries covered such fields as maternal & child health, nutrition, environmental

sanitation, health centers and health education and programs which would directly or indirectly, benefit child health. More recently, the tendency has been for UNICEF to turn away from campaigns for the eradication of specific diseases unless they are of direct benefit to mothers and children. Greater attention is been given to the concept of the “whole child” meaning that assistance should henceforward be great not only to health and nutrition, but also to their long term personnel development and to the development of countries in which they live. » CONTENTS OF SERVICES … 1. Child healthUNICEF has supported India’s BCG vaccination. Assisted in the erection of a penicillin plant UNICEF has also assisted environmental sanitation programs emphasizing safe and sufficient water for drinking and household use. - Providing primary health care to mothers and children. 2. Child nutririon- aiding “applied nutrition” program in India. - Encouraging the development of national food and nutrition policies that make provotion for child health. 3. family and child Welfare-to improve the care children, both within and outside their homes through such means as parent education, day-care centres, child welfare and youth agencies and women’s club.

COMMUNICABLE DISEASE Environmental and social factors impose severe constraints on two of the communicable diseases, malaria and tuberculosis that pose a special threat. India accounts for a third of global tuberculosis cases. According to the available estimates about 2.2 million people are added each year to the existing load of 15 million active TB cases. Of these new cases, about 800,000 are infectious and about 450,000 die (WHO, 2003). India has been identified as a hotspot for multi drug resistant (MDR) tuberculosis, which is both difficult and expensive to treat. The resurgence of malaria and tuberculosis indicates the difficulty to control or treat along with the exponential rate of development of HIV/AIDS. It shows a new sense of urgency for disease control. The Government of India is seeking to reduce the burden of the most significant endemic diseases through projects to control the spread of AIDS, leprosy, cataract blindness, malaria and tuberculosis. The Indian Ministry of Health and Family Welfare first tested this revised approach through pilot projects in 15 rural and urban sites, curing more than 15,000 patients over a period of 16 months, with a very successful 80 percent

cure rate. Given the above background, the evidence from the World Health Survey on coverage of communicable diseases is presented below. TUBERCULOSIS AND HIV/AIDS Tuberculosis and HIV/AIDS are the two most important communicable diseases in India. Tuberculosis, which is resurgent worldwide, is an infectious disease that affects the lungs and other body tissues. Tuberculosis of the lungs, the most commonly known form is characterized by coughing up mucus and sputum, fever, weight loss and chest pain. The overall prevalence of tuberculosis in India is 544 per 100,000 population (National Family Health Survey, II). This is 16 percent higher than the prevalence recorded in NFHS-I (467 per 100,000) indicating that tuberculosis may be on the rise in India. The prevalence of tuberculosis is much higher in rural areas (600 per 100,000 population) than in urban areas (390 per 100,000 population). The prevalence rate is also much higher for males (624 per 100,000 population) than females (460 per 100,000). In India, six percent of respondents in ages 18-49 have reported that they are using condoms. The highest proportion of respondents using condoms is in Assam and Uttar Pradesh with about 10 percent each and Karnataka shows the lowest two percent of respondents using condoms. About seven percent of males and six percent of females reported using condoms. The use of condoms is higher in urban areas (10 percent) compared to rural areas (six percent). About 13 percent of insured respondents are using condoms compared to six percent among the uninsured. Use of condoms is three times higher among the respondents in the highest income quintile (12 percent) compared to respondents in the lowest income quintile (three percent). MALARIA AND DIARRHOEA Table 5.3 presents the percent of children with a reported episode of malaria and its treatment in the last one year in India. Also, information on the prevalence of diarrhoea is collected. The information on both the illness is collected from the respondents who have children less than five years of age. About six percent of children had an episode of malaria in India during the five years prior to the survey. Of them, 93 percent of children were treated. Rajasthan, the state with highest prevalence of TB also has the highest prevalence of malaria followed by Maharashtra (six percent). The lowest (less than one percent) prevalence of malaria is reported in Karnataka. Ninety four percent of male children and 91 percent female children with malaria received treatment. Significant urban rural difference is observed in terms of treatment of malaria is concerned. Sixty five percent of insured and 93 percent of uninsured received treatment for malaria. The proportion treated for malaria declines slightly with increasing income. The reported prevalence of diarrhoea is 30 percent in the last one year for child under 5 years in India with the highest prevalence in Rajasthan and the lowest

in Assam. The prevalence of diarrhoea is higher in rural (31 percent) compared to urban areas (23 percent). Prevalence of diarrhoea is 19 percent among the insured compared to 30 percent among the uninsured. The proportion of children reported with an episode of diarrhoea also declines with increasing income. MATERNAL AND REPRODUCTIVE HEALTH Improving maternal and reproductive health has been a major thrust of the 1994 International Conference on Population and Development Conference in Cairo. All the countries of the developing world initiated programmes to promote reproductive health status of women. The Government of India took certain steps to strengthen maternal and child health in the first (1951-55), second (1956-60) and fifth (1974-78) five year plans. Several programmes have been implemented for better maternal and child health. With regard to maternal and reproductive health, the government programmes seek to integrate maternal health, child health, and fertility regulation interventions with reproductive health programmes for both men and women. The coverage with respect to maternal and child health care are presented in the following sections. SCREENING OF WOMEN FOR CANCER Cancer of the cervix is the second most common cancer among women worldwide, with about 500,000 new cases diagnosed and 250,000 deaths each year (WHO, 2004). Almost 80 percent of the cases occur in developing countries; in many developing regions cervical cancer is the most common cancer in women. The only available treatments for the disease are surgery and radiotherapy, and these are not accessible to the most affected women in developing countries. The primary approach to control cervical cancer is therefore through prevention (WHO, 2004). Cervical cancer takes many years to develop, and changes can be detected in the cervix some time before the appearance of cancer. In principle, screening of women for these changes can allow treatment of these with early signs of developing disease, preventing the development of cancer. Screening programmes have been in operation in most developed countries for a number of years. While in some of these countries there have been significant reductions in the incidence of invasive cancer, overall the impact has often been less than expected. In middle income countries, the success of screening programmes has generally been even more limited. In urban areas, 25 % of women reported having had cervical cancer screening and nine percent of women had breast cancer screening. Compared to this, fifteen percent and four percent of women in rural areas have had cervical and

breast cancer screening The proportion of women screened for cervical and breast cancer increases with income. MATERNAL AND CHILD HEALTH Questions were asked to women in the ages 18-49 about maternal health care services availed for births during the five years prior to the survey. Of the total 1452 women who gave birth in the last five years, 48 percent had received full antenatal care and 34 percent had received care at the time of delivery. Amongst the states, full antenatal coverage (66 percent) and care for delivery (46 percent) are highest in Maharashtra. Sixty-two percent of insured women and 34 percent of uninsured women received delivery care. The proportion of women receiving care at the time of delivery is about three times and antenatal care is more than two times higher in the highest income quintile compared to the lowest income quintile. Mother’s education shows strong positive relation with antenatal and delivery care. About 85 percent of mothers with high school or higher level of schooling received antenatal care compared to just 30 percent of women with no formal schooling. COVERAGE FOR CHILD HEALTH CARE The coverage of three doses of DPT and measles immunization corresponds to children less than 5 years in the household. Overall, 43 percent of children received DPT immunization and 32 percent of children received measles immunisation. Among the states, Karnataka has the highest coverage for DPT3 (59 %) and measles immunisation (55 percent) followed by Maharashtra with 50 and 45 percent respectively. The reported coverage of DPT3 immunisation is the lowest 24 percent in West Bengal. Also, Assam (16 percent) and West Bengal (17 percent) have shown the lowest coverage of measles immunisation. About 40 percent of female children received three doses of DPT compared to 46 percent of male children, indicating a gender gap unfavourable to female children. Coverage of measles immunisation does not vary much between sexes. The proportion of children receiving both DPT3 and measles immunisation increases with mothers education. The information on child immunisation was collected only from respondents who could show the immunization card. NON-COMMUNICABLE DISEASES The burden from non-communicable diseases in developed countries remains stable at over 80 percent in adults aged 15 years and over, the proportion in middle-income countries has already exceeded 70 percent. Almost 50 percent of the adult disease burden in the high mortality regions of the world is now attributable to non-communicable diseases. Population ageing and changes in the distribution of risk factors have accelerated the incidence of non-communicable disease in many developing countries.

ANGINA, ARTHRITIS, ASTHMA, DIABETES, DEPRESSION AND PSYCHOSIS The World Health Survey gathered data on need and coverage of noncommunicable diseases such as angina, arthritis, asthma, diabetes, depression and psychosis in India. The need refers to population diagnosed with morbidity and coverage refers to population treated for the morbidity. The reference period in the analysis for noncommunicable diseases is one year prior to the survey. The reported prevalence of asthma (seven percent) and psychosis (four percent) are highest in Rajasthan. Except psychosis, the reported prevalence of all the above noncommunicable diseases is the lowest in Assam. A greater proportion of females have been diagnosed and treated for arthritis. There is no significant gender difference within diagnosed cases for major noncommunicable diseases except angina. However, the percentage of treatment for angina and asthma are higher among males, whereas treatment for depression, psychosis and arthritis is higher for females. The proportion of respondents diagnosed with arthritis, asthma and diabetes is higher among the insured compared to uninsured respondents. Prevalence of depression is highest among the uninsured respondents. However, a higher percent of insured respondents have been treated for all the non-communicable diseases except psychosis. The proportions diagnosed with depression, psychosis, angina, arthritis and asthma and are inversely related to income and that of diabetes is positively related to income. But, the diagnosed cases of depression are high in the higher income quintile (Q4) compared to lowest income quintile. COVERAGE FOR VISION CARE Cataract is a disease in which the lenses of the eyes become cloudy and opaque, causing partial or total blindness. If the cataracts become too thick, the eye lenses can usually be removed with laser surgery and replaced with clear, plastic lenses. The coverage module of the World Health survey asked the persons above ages 60 if they had cataracts in their eyes and if they had any access to appropriate medical treatment during the one year prior to the survey. Questions were asked to the respondents to determine whether the respondents were diagnosed by a physician or other health professionals in the last five years as having cataracts in one or both the eyes, and if they had the cataracts removed. The proportion of respondents diagnosed with cataract is 31 percent in urban areas compared to 15 percent in rural areas. There is not much variation between the insured and uninsured respondents in terms of cataract diagnosis. Among the insured, 66 percent had cataract surgery

compared to 52 percent among the uninsured. Both the proportions diagnosed and treated for cataract are higher in the higher income quintiles compared to the lower income quintiles.

Urban Health Care in India India is an under developed country and 50% of the population live in urban areas in an extremely below the poverty condition. As they are lured by massive industrialization, economic and educational opportunities in cities like Chennai, Mumbai, Kolkatta and Delhi are over crowed and the statistics says about one fifth live in slums Most of the health problems in India are generated from these slums only. Drainage system is poor in Chennai, Kolkatta and Mumbai which cause high incidence of infections disease and epidemics. High densities of dwellings and lack of internal roads cause poor accessibility for emergency and life saving services. New squatter settlements come up on the periphery often on inhabitable lands because of their low values and cause environmental hazards. In the recent Bhopal gas tragedy, around 3000 persons mostly from the peripheral slums were killed and it clearly revealed the vulnerability of squatters. Urban malaria, tuberculosis and pneumonia, leprosy, meningitis, preventable infections in children such as measles, whooping cough and polio, diarrhea diseases and intestinal worm infections are some of the most common health problems apart from higher morbidity and mortality due to accidents. Central council of health was formed as per the constitution to check all health problems in India. Health survey and Development Committee was the first committee to be formed in India which laid foundations for several activities in all five year plans to attend to all health problems attaching the millions in India. The ministry of health and family welfare is handled by secretary of the govt. of India. He is directed by the cabinet minister of state or by his deputy. The ministry is concerned with 1) maintenance of international health relations with other countries of the world and coordination among them 2) adoption of family welfare measures concerning population stabilization and family planning.


Photo: 7, Smoking prevention program a doctor

Photo: 8, Patient consultancy with

At the state level we have the Directorate of Health Services to administer public health, medical services and medical education. Due to increasing responsibilities and abundant health problems some states have established more than one Directorate and separated medical care facilities and medical education from the public health. To boost the family welfare activities some states have set up separate Directorate of family welfare or state family welfare Bureau. At the District level we have the District health office that is in charge of all activities concerning medical, public health and family welfare and district health administration. To lay more importance to family welfare programmes, a separate family welfare officer has been appointed. In urban areas we have local self governing bodies having three tier administrations. 1. Medical officer in charge 2. Zonal office in charge 3. The chief executive in charge

Health Care Delivery in India
Among the major public health programmes, the Maternal and Child Health Services constitute an integral part of the family welfare programmes and occupy an important place in the socio economic development planning. It also plays a crucial role in human resource development and in improving the quality of life of the people. The Government has sponsored immunization schemes for infants and children against nutritional anemia among mothers and children and prophylaxis against blindness due to vitamin ‘A’ deficiency are also in operation. Programme for oral rehydration therapy is another important child survival scheme. Diarrhea disease is a major health problem in India especially among children below five years of age. To liberate the children from common communicable diseases, the expanded programme of Immunization (EPI) was started by the Governments of India in

1978. The objectives of the programme are to reduce morbidity and mortality due to diphtheria, pertussis and tetanus, poliomyelitis, tuberculosis and typhoid fever by making vaccination services available to all eligible children and pregnant women. Universal Immunization Programme (UIP) is an important step towards achieving the goal of Health for All by the Year 2000. The programme was dedicated to the memory of the former Prime Minister, Mrs. IndiraGandhi. Under the UIP, it was proposed to cover all eligible infants and pregnant mothers by the end of 1990. A “Technology Mission on Immunization” has been launched covering all aspects commencing from research and development to actual delivery of services to the affected population. Urban Malaria Scheme was initiated in November 1971. The main objective of the scheme is to control malaria transmission by eliminating aquatic stages of vector mosquitoes by weekly application of larvicides in breeding sources. The scheme has at present been sanctioned for 133 towns distributed over 17 states and two Union Territories. National Filarial Control programme was taken up in urban areas from 1955 in order to contain the diseases. Anti-larval and antiparasitic measures are being taken in 199 towns distributed in 13 states and four Union Territories. Tuberculosis is a major public health problem in the country. The National Tuberculosis Programme was launched in 1962. A total of about 46,000 beds are functioning in the country for treatment of seriously sick and emergent TB patients. Leprosy control programme has been in operation since 1955 but it was only after 1980 that it received a high priority and it was redesigned as National Leprosy Eradication Programme (NLEP) in 1983 with the goal of arresting the disease in all known leprosy patients by the year 2000. Kala-azar which was almost on the verge of eradication, reappeared in Bihar in 1970s and in West Bengal during 1977. Later it spread to more states. The Kala – azar unit of National Malaria Eradication Programme (NMEP) is monitoring the Kala-azar situation along with the incidence of Japanese Encephalitis in the country. National AIDS Control Programme has emerged as a devastating fatal disease. Up to April 1989, as many as 2, 55,589 risk persons were screened. Of these, 941 have been HIV positive. Amongst these, as many as 29 are the full blown cases of AIDS which include 11 foreigners. The Government of India constituted a task force in the year 1985 under Indian Council of Medical Research and established two surveillance centers, viz., National Institute of Virology, Pune, and Christian Medical College, Vellore to screen high risk people for AIDS. An AIDS cell has been established in the Directorate General of Health Service to


coordinate all activities pertaining to AIDS control. At present, 40 surveillance centers and four referral centers are available in the country. Apart from the above national health programmes, there are programmes like, National Programme for Control of Blindness, National Mental Health Programme, Sexually – Transmitted Diseases Programmes and National Goiter Control Programme. Poor Macro – Micro Environment Overcrowding, poor housing, choked drains, high density of insects and rodents, lack of garbage disposal facilities, poor personal hygiene, and hygienic conditions are hall marks of urban slums in India. Unplanned and rapid urbanization put a strain on the already dwindling civic amenities. Under such conditions gastroenteritis and other infectious diseases are rampant. Children affected by serious diarrhea diseases are likely to spend 20 percent of their first two years of life suffering from serious diarrhea with a median number of 4.9 episodes per child per year. Studies from urban slums of Ludhiana show that children under two years of age had 3.8 episodes of diarrhea per year. Failure of Urban Health Care System Health Care System in India in the last 45 years has focused on increasing coverage in the rural areas. There has been little or no development of organized health care services for the vast urban areas. The 3,600 odd cities and towns of India with some 40 million people living in slums have to depend largely on private practitioners (mostly quacks) for their health care needs. Out of the 3,000 plus urban local bodies in India only about 100 have been some semblance to a health care service while the rest have only a sanitary inspector or even a lower functionary to look after the health care system. Although urbanization is one of the indicators of development, very fast growth of urbanization in developing countries has created problems of proliferation of slums. Slums have become the unavoidable and evil symbols of industrial and urban growth. The rate of urban growth cannot match housing, educational and health service facilities including drinking water and sanitation. Initially, rural to urban migration is limited to males. A rural migrant is deprived of his membership of his kin group in the village, suffers from loneliness and faces problems of residential accommodation. A slum gives him shelter and anonymity in urban area. This often leads to alcoholism and prostitution. A migrant getting cash wages is expected to save and support his family in the village. He, therefore, tries to save on food and gets malnourished. Slums vary greatly from each other. But the universal characteristics refer to overcrowding and congestion, extremely poor sanitation, lack of civic amenities and deviant behavior. It is reported that in Delhi slums, 400,000 people live on one square mile. In Bombay it is common for ten persons to live in a room-ten

by fifteen feet. However, slum cannot be defined only by housing. In India, temporary structures raised with the use of material such as rags, plastic pieces, rusted pieces of iron, pieces of canvass cloth, and places where there is almost total absence of tap water, latrines and roads are identified as slums. There may be very high density of population per square mile but if people are staying in multi-storied permanent structures sharing inadequate civic and sanitary facilities, these are not popularly identified as slums. Slums culture is marked by apathy, insecurity, social isolation and disease.

Photo: 9, Modernization of hospitals and health centres with modern medical equipments. In India, more than nine million people live in slums of which 12,50,000 are in Bombay, 11,00,000 in Calcutta, 9,00,000 in Madras and 7,00,000 are in Delhi. It is no wonder that slum dwellers should be the victims of air—borne and waterborne infections, and should suffer from nutritional deficiencies as also from undiagnosed mental illness. The disorganizations in various aspects of life breed apathy and psychology of defeat which is manifested in fatalism, crime or lack of enthusiasm about preventive aspects of health, although offered free of charge. Consequently, children remain undernourished and underweight with their growth stunted from insufficient food. Diarrhea, gastro – enteritis and respiratory ailments are common illnesses to which many succumb during their first year of life. Urban areas continued to develop being the seats of power, money and intellect. They also became the first places to experiment with ideas. As a result, various agencies of health representing municipal, provincial and national levels developed simultaneously with voluntary, private and philanthropic institutions. However, curative aspect got precedence over preventive and promotional aspects. Health care system continues to veer around doctors, drugs and patients. Piped water supply and modern sanitation also developed but in selected urban localities. However, the water supply is almost always intermittent, and in most of the cities / towns drainage often gets clogged for one reason or another.


It is not uncommon to see medical colleges and hospitals belonging to various medical systems such as modern, ayurveda and homeopathy in one Indian city. India provides an excellent example of medical pluralism. People follow home remedies, spiritual remedies and treatment from various medical systems simultaneously or one after another. Metropolitan urban areas provide medical facilities which are available in developing countries such as cardiac surgery, treatment of all kids of cancers, or in brief, for the diseases which are associated with affluence. The major diseases identified in South – East Asia Region under WHO are malaria, filarial and other mosquito – borne diseases, diarrhea diseases, leprosy, tuberculosis, sexually transmitted diseases, poliomyelitis and other children diseases, tetanus, nasopharyngeal and cervical cancers, visual impairment and blindness, etc. Urban poor whose hallmark in expenditure is cheapness get adulterated food and drugs. On an average, milk, milk-products, edible oils, wheat flour, spices and even tea leaves are adulterated to the tune of 50 per cent.

« Ambulance facility in rural areas.
It is often said that a large proportion of population suffers from protein calorie malnutrition. However, the range of nutrition in which people can function efficiently without getting nutritional deficiencies is wide and what are commonly given as recommended quantities for intake of nutrients are much higher than what are required. Urban poor are unfortunately use bottle feeding and baby feeds under the influence of commercial advertising on radio, television, and through other popular media like films.The revolution in drugs coincided with freedom from colonial rule. The drug industry has developed out of proportion in comparison with basic amenities like potable water and sanitation. Pharmaceutical industry measures developed out of proportion of country in terms of intakes of per capita consumption of drugs. In India, drugs are only consumed among 20 per cent urban people. The per capita consumption is perhaps the lowest in the world. However, this code does not represent the correct picture in view of the fact that about 75 per cent population in rural areas and urban poor has yet to have access to drugs. Major share of these drugs are taken away by vitamins, tonics, and antibiotics. It is estimated that out of the total production 25 per cent was taken away by vitamins and tonics, and 20 per cent by antibiotics. Primary health care is available to the whole population, with at least the following:


- Safe water in the home or within 15 minutes walking distance, and adequate sanitary facilities, in the home or immediate vicinity; - Immunization against diphtheria, tetanus, whooping cough, measles, poliomyelitis, and tuberculosis; - Local health care, including availability of at least 20 essential drugs, within an hour’s walk or travel; and - Trained personnel for attending pregnancy and child-birth, and caring for children up to at least one year of age. The nutritional status of children is adequate, in that: - At least 90 per cent of new born infants have a birth weight of at least 2000 gm;

Photo:11, Modernization of hospitals and health centres with modern medical equipments. Preventing HIV and Trafficking : India’s HIV/AIDS epidemic, which includes the third largest number of people living with HIV of any country, is uniquely propelled by the sex trade. The success of programs focused on increased condom use and decreased STI/HIV infection among adult commercial sex workers has led many HIVprevention experts to contend that such programs are also likely to benefit victims of sex trafficking. However, as discussed above, several factors unique to trafficked women and girls indicate the need for caution in applying existing models to these highly vulnerable individuals. HIV prevention efforts targeting sex workers in India have largely utilized a harm-reduction approach designed to increase condom use via a peer-education empowerment framework. Regrettably, assumptions of empowerment necessary to negotiate condom use run directly counter to the traumatic and exploitive realities of forced prostitution inherent to experiences of trafficked women and girls. Isolation and confinement to decrease detection by authorities, greater movement across settings, and restricted access to services of all kinds present clear obstacles to engaging in such programs. Further, victims often face extreme sexual violence during both trafficking and initiation into sex work, presenting


risk for HIV infection prior to any possible engagement in HIV prevention efforts.

International cooperation to accelerate sustainable development in developing countries and related domestic policies :
• Combating poverty • Changing consumption patterns • Demographic dynamics and sustainability • Protecting and promoting human health • Promoting sustainable human settlement development • Protection of the atmosphere • Integrated approach to the planning and management of land resources • Combating deforestation • Managing fragile ecosystems: combating desertification and drought • Promoting sustainable agriculture and rural development • Conservation of biological diversity • Protection of the quality and supply of freshwater resources: application of integrated approaches to the development, management and use of water resources • National mechanisms and international cooperation • Promoting education, public awareness and training » Article Source:

X. ANALYSE AND SUGGESTIONS : Analysis of demographic indicators:
• The total population of India is 1300 million and the annual population growth rate is 1.4 %, these indicators are quite more than normal. • The population density is 363 persons per sq. km., population density is much higher than other developing countries. • Morbidity rate is higher than other developing countries. • Literacy rate is approx. 75 % estimated at the end of 2008, it is lower than other developing countries. • Birth rate is 22.22 births/1,000 population (2008 est.), stands 87th rank in world, is higher than other developing countries. • Infant mortality rate is 56 deaths per 1,000 live births, is much higher than other developing countries. • Life expectancy(average) is for Males- 62 yrs and for Female- 64 yrs, is lower than other developing countries. • Fertility rate in India is 3.1, is quite high than other developing countries. • Very high external and internal migration.


Analysis of morbidity and mortality of population :
• Morbidity at all groups of diseases is decreased except AIDS (HIV inf.) and tuberculosis. • Indirect estimates suggest that 272,000 South Asians died from AIDS in 2004. This study will be the first to provide direct evidence of AIDS mortality in India. • About one in two male tuberculosis deaths and one in four of all male deaths in India may be attributable to smoking. • Anemia, trauma following severe bleeding and ischemic heart disease give high risk of mortality in hospitals. • Rare causes of death are food poisoning and ulcer diseases. • Mortality from all diseases is decreased except infant mortality due to anemia. • One in five of the world’s child deaths occurs in India, i.e. over 2 million deaths every year. • Childbirth is still a leading cause of death for women in India: more than 100,000 women are estimated to die each year from causes related to pregnancy.

Analysis of medical personnel’s :
• Quantity of doctors is comparatively low. • Quality of specialist doctors is defective in rural hospitals. • Quantity of medical personnel’s is decreasing in compare to last years due to fast increasing of population. » Sanitary services are not satisfactory but participation of WHO in country is satisfactory. » Quantity of primary and secondary schools, colleges, medical institutions and universities are low in number. PROBLEMS AND CHALLENGES ENCOUNTERED In the process of improving the status of basic education in the country the biggest challenge has been the rising population and the increasing demand for school places. Obviously, this has outstripped the investments made for expanding the system and reaching primary education to all children, not withstanding the multifold expansion of the system achieved during this period. Mobilizing resources to match the raising demand, undoubtedly, is a major challenge before the planners PUBLIC AWARENESS, POLITICAL WILL AND NATIONAL CAPACITY


The Government of India has adopted various schemes and programs for accelerating the rate of economic growth, eradication of rural poverty through wage employment and self-employment, redistribution of land and security of land tenures, enhanced purview for Minimum Needs Program, protection of minorities and availability of opportunity for socioeconomic uplift, and infrastructural development for uplift of urban poor. India has a three pronged strategy for poverty eradication: i) Economic growth and overall development; ii) Human development with emphasis on health, education and minimum needs, including protection of human rights and raising the social status of the weak and the poor; and iii) Directly targeted programs for poverty alleviation through employment generation, training and building up asset endowment of the poor. » The Government of India has so many good policies and these policies are issued on time when needed but those do not work properly and sufficiently because the fast growing population and illiteracy fails them. » Public Health Services in India are depending on some factors like Politics; economical conditions; quantity and quality of medical personnel’s; fast growing population; literacy; regional conflicts; tragedies like flood, earthquake, tsunami etc. • Political condition is very bad in India, I don’t know why?, may be it due to some mistakes in Our Respective Constitution or may be due to nature of our politicians. So, on respective to political conditions, public health services face major problems like not get proper money at time or not issue at due date. • Economical condition of our country is not well too because fast growing population and morbidity pull back it. • Quantity and quality of medical personnel’s is low here because lack of medical colleges again due to fast growing population. • Literacy is low again due to fast growing population and lack of schools. • Regional conflicts in Jammu and Kashmir or any other part of country stops its development and proceeds towards poverty. • Tragedies like flood, earthquake, tsunami etc. also disturbs our development.

Suggestions :

At first we have to control the ultimate cause of all withdraws i.e. Fast growing population. For this, need people should be literate and government should advertise the methods of contraception and methods of family planning. In India medical termination of pregnancy

• • • •

is prohibitory, so government should allow the safe medical termination of pregnancy on parent’s will. Need to increase the quantity of primary and secondary schools, colleges, medical institutions and universities. For controlling the infant mortality and abnormality, there should be some aims : Primary aims To identify children with growth deviation i.e., under nutrition and over nutrition and to identify diseases and conditions that manifest through abnormal growth. Secondary aims 1. To discuss health promotion related to feeding, hygiene, immunization and other aspects of the child’s health and behavior; education of parents to allay their anxiety about their child’s growth. 2. To sensitize pediatricians to use growth charts. For controlling morbidity at HIV infection and Tuberculosis, need to advertise in public the prevention and prophylaxis measures. For controlling morbidity at other diseases need to improve sanitary conditions and utilize the full support of WHO. Need some of the Programs like: National Malaria Eradication Program, national Tuberculosis Control Program, national AIDS Control Program, national Blindness Control Program. There is need to strengthening of rural health infrastructure through provision of buildings, equipment drugs and vaccines and training of all levels of Personnel. For facing the ‘’Brain-drain problems’’, need to control the external profession and student migration. For this, have to open the opportunities inside the country. For decreasing maternal mortality and increasing safe delivery, need to increase the number and improve the conditions of ladies doctors and nurses. Full sanitary and hygienic control of all communities, food products, drinking water and well canalization system can decrease the epidemics and morbidity. We can’t stop the tragedies like flood, earthquake, tsunami but for facing them we should prepare well always with extra med personnel’s, drugs and other objects. I don’t know what should do with our political conditions but at least need to elect well literate and active politician who can understand and solve these problems.


This report has reviewed the different ways public health, the Indian healthcare sector can be viewed as a glass half empty or a glass half full. The challenges the sector faces are substantial, from the need to improve physical infrastructure to the necessity of providing health insurance and ensuring the availability of trained medical personnel.But the opportunities are equally compelling, from developing new infrastructure and providing medical equipment to delivering telemedicine solutions and conducting cost-effective clinical trials. For companies that view the Indian health care sector as a glass half full, the potential is enormous. India is one of the leading developing countries, the term “developing countries” encompasses very different countries, which experience different levels of economic development and disease burdens. In order to design solutions that have relevance in different national and local settings, relevant macroeconomic and institutional features need to be taken into account. At present, one sees a greater political will to address public health needs via the National Rural Health Mission. This affords a good opportunity to innovate and experiment with a restructured healthcare system, but such restructuring will be possible only if certain conditions are met: • The healthcare system, both public and private, is organized under a common framework. • The financing mechanism of healthcare is pooled and coordinated by some single-payer system. • Access to healthcare is organized under a common system which everyone is able to access without any barriers. • The providers of healthcare services have reasonable autonomy in managing the provision of services. • The decision-making and planning of health services is decentralized within a local governance framework. • The healthcare system is subject to continuous public/community monitoring and social audit, under a regulatory mechanism geared to ensuring the accountability of all the stakeholders involved. All resources, financial and human, must be transferred to the district level governments that will need to work out detailed district plans based on local needs and aspirations. An appropriate regulatory and accreditation mechanism must be put in place to facilitate the inclusion of the private health sector. Private health services, both ambulatory and hospital, must be contracted in on appropriate terms. Detailed bottom-up planning must be undertaken with regard to budgeting and the allocation of resources appropriately to different institutions and providers. Finally, all stakeholders must be trained to understand and become part of this restructuring process. Public healthcare services should be organized and regulated, using both public and private resources, for social benefit. Furthermore, the delivery of healthcare should be decentralized at an appropriate community level rather than (as at present) planned at the central or state level. The role of the centre and the state should be to formulate strategies, mobilize and disburse resources, and monitor outcomes. Such is the global experience where healthcare is universally accessible with equity. Why should it be different in India?

So, we should follow the steps of the public health systems of developed countries and make the complete command on services of healthcare system, population, poverty, maternal health, medicine distribution, fatal diseases like AIDS, TB, malaria, plague and leprosy. India's government must open more public medical schools. These steps bring the country in a new era of development.

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