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Maitrey Environment Education & Research Association

As an independent nation we embarked on a journey at the time of our independence

and it has been sixty years since then. Our aspirations had been to overcome many
obstacles some of which we have been successful in and others partly. We still have
to overcome some basic obstacles such as the health of the nation. Healthy citizens
go on to make a healthy nation is not just a cliché but also a proven fact. This study
has therefore attempted to explore this crucial aspect. It deals with inter-linkages
between health, poverty and underdevelopment. The scope of the study though is
limited to the region of Uttar Pradesh, a federal entity of Indian nation holding the
dubious distinction of having the highest population after China, Indonesia, United
States of America, Brazil and rest of India. To understand it in the context of UP the
study has however explored situation in other Indian states and countries abroad.
Other aspects of health mentioned under various topics, headings and chapters are
also analyzed in the course of this study.

Foremost it has been looked into the various indicators of health. The universally
recognized indicators of health are: IMR, MMR, Birth rate, Death rate, Fertility
Rate, sex ratio, nutritional status, diseases. It has been explained how these
indicators help in determining the status of health of the people of UP. Though all
indicators are equally important and inter-linked and need to be considered, it is the
last one which has crucial importance particularly in the context of UP. There are
many diseases in UP which may also be called specific killers of the people most
dangerous of them being TB (being the largest killer), Malaria, Japanese
Encephalitis, Jaundice. Though prevalence of diseases in UP are region specific and
are dealt with in the study further on. There are certain universal diseases which
effect all districts of UP. It is a matter of shame that some of these diseases continue
to take a toll of people which are no longer considered any serious menace to most
of the developed countries. AIDS also has raised its ugly head in UP. In this context
various reports regarding HIV and AIDS have been analyzed and noted. NACO
recently has given certain principles and guidelines to deal with the menace of
AIDS, which has also been dealt with in this study.

The chapter Health Status of Uttar Pradesh a comparative study deals with the
identification and extent of the problem of dismal health of UP under this through
the various indicators mentioned above, the health of the people of UP has been

The chapter Reasons for Dismal Health Status in UP deals with the root causes for
the present health status UP. Under it has been seen how inequality including gender
inequality, education, breakdown of social cohesion, role of market forces, and
government apathy and corruption in the health services and Public Distribution
System and non availability of proper water and sanitation have all contributed to
dismal health in UP.

The study has analyzed various reports, studies, concept notes, workshops,
conventions, conferences of important national and international organizations as
well as non-government organizations such as Alma Atta Declaration, Millennium
Development Goals, NACO presentation to National Advisory Committee. The
study has also dealt with important government plans and programmes which are
being implemented such as National Common Minimum Programme, ICDS III,
NHRM. , Eleventh Five year Plan.

Finally the study looks at the cause and effect relationship between poverty,
underdevelopment and poor health. It has been seen they all contribute to each other
and are linked together in a vicious circle, which to be broken needs considerable
effort by both people and government.

As we deal in detail on the various health aspects in UP we need to keep in mind

that it is truly a huge challenge. We cannot be a strong, proud and a prosperous
nation without addressing this challenge, no matter how many high sounding
slogans our political leaders may give, the path to prosperity and bringing those
slogans to reality goes through the important station namely good health of its
citizens. The challenge of achieving good health has been particularly compunded
by the unbalanced play of market forces. The process of economic reforms has left
the considerable population untouched primarily because it has regional and sectoral
disparity and also as it has not been accompanied with corresponding administrative

reforms. It has been seen that the mindset of the governing class remains the same.
They have not been able to breakout of the mould of the ‘mai-baap’ culture. The
system lacks accountability, transparency, and people’s participation. The governing
class wants to enjoy power without responsibilities. They see themselves as
guardians of people but theselves not performing responsibily. It has resulted in
government apathy and coruption which has been noted in the course of study. As
can be seen further on, due to above factors most of the government schemes have
not had the kind of positive affect on the health of people of UP. It is the need of the
hour that there should not be just the talk of economic reforms but of reforms overall
which effects all aspects of governance. A thorough governmental reform would
create an atmosphere where people’s money and ther resources are optimally
utilised. There is now a need for people, civil society and scholars to come together
and put pressure on the government. They have been doing so in the past but there is
urgency of increasing their efforts.

Health of the citizens should also be seen in the context of environmental

degradation. This necessitates urgent and immediate response as we may have not
much time. Environment degradation such as global warming, pollution, flora and
fauna destruction have occurred to an extent that their effects are started to be felt
world over in the form climate change. Addition of pollutants in air, food and water
chain through industrialisation and use of chemicals (pesticides and fertilisers) in
agriculture has added substances such as arsenic, flouride, zinc, lead etc. This
urgency necessitates that effcetive policies and programmes are formulated and
efficiently implemented. Such issues have been attempted to be dealt with in detail
in the course of the study and in the Chapter Solutions and Goals in the context of

An analysis of the three components of the HDI (the education index, life
expectancy index and the income index) shows that for UP as a whole, these indices
are positively correlated. But the mutual correlation between the two indices
reflecting health and educational capability are better correlated with each other than
with the income index. The correlation between the education and life expectancy
indices for UP’s districts is 0.69 while the correlation between the education and
income indices is 0.47. The lowest correlation is between the life expectancy index

and the income index (0.36). The state of health in UP is a human development
challenge and life expectancy is one of the lowest in the country.

A summary of important human development indicators for 18 major States of the

country given in Table below shows that in terms of per capita income UP ranks just
above Bihar and Orissa, while in terms of poverty it ranks 11th, just ahead of Orissa,
Bihar, Assam and Madhya Pradesh. UP’s literacy rate is an improvement only from
Bihar and Jharkhand. UP’s life expectancy ranks 11th and the infant mortality rate is
considerably lower than the national average.

Selected Human Development Indicators for UP and Other States

Overall mortality has been higher in UP compared to the country as a whole, as per
Sample Registration System (SRS)
estimates. The temporal pattern of Crude
Death Rate (CDR) for India, UP and
Kerala, the state with the lowest mortality
rate in India. While India’s crude death rate (CDR) was 14.9 per thousand
population in 1971, that of UP was 20.1. In 1981 the corresponding figures were
12.5 and 16.3 respectively. The gap continued in 1991 with India’s average being
9.8 and UP’s being higher at 11.3. Thus, inspite of the decline in overall mortality
over the years, UP has maintained a CDR higher than the national average, though
the difference has declined over time. Kerala remains much below both UP and the
national average for all years, though death rate in Kerala has almost stagnated since

UP has one of the highest rates of infant and maternal mortality in the entire country.
The incidence of several major communicable diseases such as tuberculosis and
leprosy is also high. Maternal and child health is poor and there now looms the
spectre of AIDS. By the end of July 2000 there were 259 full-blown cases of AIDS
and 889 persons had already tested sero-positive.

Social status determines access to healthcare. Infant Mortality Rate (IMR) is two
and half times higher amongst the poor. At the same time, a lower proportion of
public resources are spent on the bottom 20 percent of the population in comparison
to what is spent on the top 20 percent.

To evolve an understanding about status of health in UP we need to identify it through certain
markers or indicators. The below mentioned indicators have been used as such for
understanding health related issues world over. The various national, international and state
reports regarding health have been using these indicators. These indicators are as follows:
• Nutritional status
• Infant M ortality Rate IM R
• M aternal M ortality Rate MM R
• Birth rate
• Death Rate
• Fertility Rate
• Sex Ratio
These indicators although generally known to the experts and the laity have been briefly
explained in the box for the sake of the uninitiated.

Nutritional Status:is measured by the extent of malnutrition for which the indicators are
prevalence of LBW in children, low height for age (stunting), low weight for height (wasting), low
weight for age (underweight), low body mass index BMI, iodine deficiency, low haemoglobin and
vitamin A deficiency.

Infant mortality:Annual number of deaths of infants under one year of age per 1000 live births.

M M R:Number of maternal deaths per 100,000 live births.

Birth rate:Annual number of births per 1000 population.

Death Rate:Annual number of deaths per 1000 population.

Fertility Rate:Average number of children that would be born to a woman if she experience the
current fertility pattern throughout her reproductive span : 15-49 years.

Sex Ratio:Number of females per 1000 males.

However, inspite of the broad coverage of these indicators and their use for understanding
health status they may not be considered comprehensive until we consider the incidence of an
important indicator which is inextricably intertwined with all the entities named above. This
indicator is that of prevalence of diseases in the various regions of UP. Importantly most
studies overlook this aspect, no health indicator can be complete without it.

Following aspects need to be recognized when this indicator is seen:

• kind of disease,
• incidences of its occurrence,
• number of affected individuals,
• intensity of its damage,
• availability of its treatment (particularly state health services)
• response of medical science towards it,
• approach of people in tackling them.
It would not be stretching this contention too far if it is taken into consideration that
the various aspects of diseases are the most fundamental factor which affects the
health of people of UP. It is to be remembered that these diseases are specific to the
various regions of UP in terms of the amount of damage which they do. They are
also specific for certain segment of population, a particular disease for e.g.
responsible for mortality/ premature deaths may mainly target the poorer segments
of the population. We therefore need to delve into the kinds of diseases mainly those
which are largely responsible for premature deaths. This has been dealt with further
on in the study.


India is an old and ancient civilization having rich traditions and customs yet it also
contains inherent inequality embedded in these very customs and traditions. This
phenomenon has deeply pervaded even the mindset of the Indian people. Though
stratification and inequality are found in cultures all over the world, it has always
had an acute dimension in India. This inequality is exemplified in the form of caste
system, a phenomenon unique to India. However the modern era has brought with it
many changes and today the situation is very different from earlier times. This
change though has been itself unequal in rural and urban areas. Living in a rural area
is a marker for disadvantage as greater inequalities can be seen here moreover
poverty rates are higher and access to services is lower, malnutrition is lower in
urban areas as compared to rural areas. The proportion of fully vaccinated children
is higher in urban than in rural areas.

Gender inequality
Gender disparities are among the deepest and most pervasive of inequalities. They
are revealed most brutally in India. The mortality rate among children ages 1–5 is
50% higher for girls than for boys. The presence of two X chromosomes which
results in that girl child also results sometimes in them being deprived the right to
live. The higher mortality rates among females from birth to about 30 years points to
structural inequalities in nutrition, healthcare and status. Higher mortality rate
inverts the normal demographic gender balance. In the context of UP, there are
striking gender and income-based inequalities thus aggravating the situation. Four
states namely Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh account for
more than half of child deaths. These states also are marked by some of the deepest
gender inequalities in India. Contrasts with Kerala are striking, girls born in Kerala
are five times more likely to reach their fifth birthday, are twice as likely to become
literate and are likely to live 20 years longer than girls born in Uttar Pradesh. The
differences are linked to the chronic under provision of health services in high-
mortality northern states, which in turn are linked to unaccountable state-level
governance structures.
It is seen that income inequality reinforces unequal health outcomes for women.

Nowhere are power inequalities and their consequences more clearly displayed than
for women. Women experience inequality in power relation to men from the
household level to the national level, where they are universally under represented in
legislative bodies, organs of the government and local political structures. Women,
especially those with low incomes, tend to have less control over household
resources, less access to information and health services and less control over their
time. These factors also go on to determine their nutritional status, the quality of
care they receive and the nutritional status of their children.

Education is closely linked with nutritional status of the people. They are many
times not aware about the healthy eating practices for example they may have an
unbalanced diet due to heavier intake of only one kind of food e.g. grains and
vegetables. Due to ignorance they may not provide the required nutrients to their
children during crucial growing years even though they may be in a position to
afford those food items. Provided below is the table of a balanced diet for different
age groups:

The low status and educational disadvantage have a

direct bearing on the health of women and children.
About one-third of India’s children are under weight at
birth, which also reflects poor maternal health.
Women’s education matters most crucially in this
regard, it is also closely associated with child
mortality. The under-5 mortality rate is more than
twice as high as for children of illiterate mothers as for
children whose mothers have completed middle
school. Apart from being less prone to malnutrition,
better educated mothers are more likely to use basic health services, have fewer
children at an older age and are more likely to space the births—all factors
positively associated with child survival. About 1 in 4 girls and more than 1 in 10
boys do not attend primary school. Apart from depriving girls of a basic right of
education these inequalities in India translate into more child deaths.

Lack of education compounds the problem of immunization of children. Fifteen
years after universal childhood immunization was introduced, national health
surveys suggest that only 42% of children are fully immunized. Coverage is lowest
in the states with the highest child death rates, and less than 20% in Bihar and Uttar


The break down of traditional mode of economic system has led to an adverse effect on the rural
poor. Of course there has been an overall econom ic impact on such people to which health is
inextricably linked. The traditional economic system was exemplified
in thesystem
where the local landlord in lieu of labour and services provided to the poor plot, foodgrains etc.
as well as support for their other rituals. The remarkable feature of this system was that it was
not based on the m arket forces and monetary gains. The villages were economically self-
sufficient. Its population experienced a social cohesion based on a network of services and
reciprocal paym ents done in kind. It comprised of people specializing in different occupations
including of carpenterbadhai
( ) , barber(naai) , cobbler mochi
( ) , fishermenmalhaa
( ), shepherds
(gadheria) , ironsmith lohar
( ), priest purohit
( ), local landlord jajmaan/zamindaar
( ). Thus
resident of a village experienced a considerably higher level of economic security which was
based on social cohesion. This does not mean that there were no problem s of course the m utual
relations between segments of population could be highly exploitative. Earlier they were also
not cures available to the many deadly diseases of that time which today are non-existent or
easily curable. Yet modern times have resulted in the break down of this social cohesion and
hence social security, the population has become dependant on market forces completely. The
monetary dependance has m eant that effects of national and international price fluctuation for
various food products are even felt by people living in rem otest of villages. It may result into a
product or an item becoming unaffordable almost overnight to the rural poor. Food may be
available in the village yet out of the reach of the poor. This has had an adverse affect on the
health of the people.


The government policy has a critical role play in addressing the three A's for
reducing inequality:
• Access

• Affordability
• Accountability
Access: The poor often live in areas that are sparsely covered by basic health
services or by facilities that lack drugs and trained staff. Chronic under financing is
also part of the problem.
Affordability: Charges of basic health care increases inequality. Payments for health
care can consume a large share of the income of poor people leading to poor
standards of living, uncompleted treatments and increased debts.
Accountability: Even where public services are available, they are often not used by
poor people. Poor households use private health providers even when nominally free
public services were available an important reason for closure of over half of health
centers when they were supposed to be open. When facilities are open they often
lack a trained staff member on site.

However due to governm ent apathy and corruption the above goals of the governmental policy
are never achieved. Though apathy and corruption in government affects each individual of the
society and prevalence of above are cause of concern to any governm ent departm ent but for our
scope of study i.e. regarding health status the misgovernance and corruption found in the health
departments (governm ent hospitals, health schemes etc) are a particular concern.

Public Health Services

Public health centres work on the basic principle of enabling accessibility to basic
health care for all people at minimum cost which is why the services are provided
free of cost. However, there is a large gap between principle and practice and the
performance of the public sector in health leaves much to be desired. Uttar Pradesh
has a large public sector health infrastructure comprising one Super Speciality Institution
(SGPGI), 7 government medical colleges & hospitals, 53 district hospitals, 13 combine
hospitals, 388 Community Health Centres, 823 block PHCs, 2817 Additional PHCs apart from
20521 Sub-Centres, yet only 9% of the State’s population actually makes use of this facility
(HDR) for treatment of ordinary ailment and people mostly depend on private hospitals/nursing
homes at District level in the state. It is evident that only around 10% of the people in rural
areas seek outpatient care from public facilities in UP as compared to 22% at the national level.
In urban areas only 13% of the people seek outpatient care from public facilities against

national average of 19%. In rural UP only 27% of the people seek inpatient care from public
sector against a national average of 42%. 31% of the people seek inpatient care from public
sector facilities against the national average of 38% (HDR). M oreover it is estimated that 11%
of people in Uttar Pradesh are not able to access medical care due to locational reasons.
Further, even when accessed there is no guarantee of sustained care. Several other deterrents
such as bad roads, the unreliability of finding the health provider, costs for transport etc., make
it cheaper for a villager to get some treatment from the local quack.

A comparison with Kerala, which has high Yet UP has seen fairly significant
levels of social development, is instructive investment in health infrastructure
in this regard. Compared to 6.7 hospitals in the decades since Independence.
per lakh population, UP had only 0.6 Between 1961 and 2001, the
hospitals per lakh population in 1998. number of hospitals and
While Kerala had 309 beds per lakh dispensaries increased from 1368 to
population, UP had only 42. Kerala had 4.2 4939 and the beds in hospitals grew
PHCs and 22.9 sub-centres per lakh from 26,420 to 65,154. Primary
population – somewhat higher than the Health Centres increased from 590
norm, whereas UP had 3 PHCs and 15.8 to 3640. Health sub-centres grew
Sub-centres per lakh population – both from 3974 in 1971 to 18,565 in
lower than the norm. Kerala had more than 2001. The number of nurses grew
8 times the number of nurses and more four-fold from 3,408 in 1971 to
than twice the number of doctors per lakh 12,197 in 1991 whereas the number
population compared to UP. of doctors increased more than ten
times from 2701 in 1961 to 31561
in 1991. Most of the quantitative increase in hospitals/ dispensaries took place in the
1970s and 1980s, whereas PHCs and sub-centres expanded rapidly in the 1980s.
Although impressive, on most counts it was barely able to keep pace with the
increase in population. The numbers of hospitals and dispensaries per lakh
population was smaller in the 1990s than it was in the 1960s and 1970s. The number
of hospital beds per lakh population also remained stagnant throughout the decades.
However, the number of PHCs and sub-centres per lakh population continued to
expand during the 1970s and 1980s, although this too saw a decline in the 1990s
(HDR). Compared to the all India availability of health infrastructure and
availability in other states, UP generally performed badly. The average availability

of infrastructure was poorer in UP compared to the national average in all indicators
such as hospitals, dispensaries, beds, PHCs, sub-centres and doctors and nurses.
Inter-regional disparities in the provision of health infrastructure is also a problem.
The former hill region was the best endowed with health infrastructure, with more
than three times the state average in terms of medical institutions and hospital beds
per lakh population, twice the number of CHCs and nearly one and a half times the
number of PHCs per lakh population compared to the overall average. Among the
other regions, the provision of health infrastructure is highest in Bundelkhand,
followed by the Central region.

One of the major problems in health provisioning is the urban-rural imbalance.

Medical personnel continue to shun remote rural postings resulting in absenteeism
or irregular attendance. Another major weakness of the health care system is staff
shortage. The Auxiliary Nurse and Mid Wife (ANM), the most significant extension
of health workers are seriously over-burdened and lack promised back up and
support. One ANM sub-centre is currently sanctioned for every 6200 population.
However, 1016 ANM vacancies were recorded in 1997. It is found that there have
been no new ANM postings against vacancies in a number of areas during the last
eight years (World Bank 2002). Interestingly, while there are more than 1000 ANM
vacancies in the state, there are around 7000 women trained as ANMs who are
waiting for assignments. As a consequence of these staff shortages, most ANMs in
the district are forced to cover a population larger than what is defined by
regulations. These organizational and structural problems are exacerbated by
shortages of medicines and equipment and lack of accountability. Studies suggest
that despite the availability of such massive public health infrastructure, the health
care in Uttar Pradesh lacks flexibility, imposes substantial costs on health consumers
who are generally dissatisfied with the quality of services being offered. The
National Sample Survey (52nd Round) found that in 1995-96, 90.22 percent sought
outpatient treatment from private doctors, 5.45 from mixed or unspecified sources
and only 4.33 from government sources. When asked patients said that the single
most important reason for not availing of government facilities was dissatisfaction
with the services. This was followed by relatively poor access of services and easier
availability of private doctors (Srivastava 2002). The public health system suffers
seriously from the problem of access and quality of services delivered. Gross

inefficiency, corruption and apathy along with poor quality of services are forcing
the poor to seek more expensive private health services. Free medicines are never in
stock or have expired or not properly stored, rendering them ineffective and even
dangerous to consume. Public healthcare in UP is a byword for decay.

The lack of proper human resource development policies (lack of incentives, in-
service training, performance rating system, poor monitoring etc.) contributes to low
employee morale, indiscipline and poor performance. Similarly, inappropriate skills
mix complicates the challenge further, for example, a gynecologist is posted at a
CHC where there is no anesthetist, results in underutilization of skills. Likewise,
transfers are often arbitrary and without adherence to any norms.

There is a vast network of private health providers available throughout UP.

According to government figures, the availability of allopathic doctors is the highest
in the Western region, followed by the Central and Eastern regions, while the
Bundelkhand region was served the least well. Although most private practitioners,
especially in the rural areas are not sufficiently qualified, yet they have flourishing
practices. There are many instances in which their efforts have caused complications
more grave than the original problem (Rhode and Vishwanathan, 1995). The World
Bank Living Standards Survey carried out in the rural areas of Eastern UP and
Bundelkhand in 1997- 98 showed that people generally used the services of
unqualified medical providers and quacks. Faith healers, quacks and chemists
rendered medical care in 58.2 percent cases. Private doctors, including ‘Registered
Medical Practitioners’ or RMPs (usually an euphemism for unqualified
practitioners) provided health care in 24.5 percent cases. Even relatively affluent
households often turn to unqualified practitioners.

Public Distribution System

The nutrition status of the poor depends disproportionately on cereals, while pulses are complete
out of their reach. However, large groups of poor in India do not have access to the minim um
required cereals. Public Distribution System is a network of fair-price shops all over the
country, an intervention adopted by Central Government of India. However, no central

government agency in India has viewed the PDS as an instrument to serve the food and nutrition
security needs of the poor. PDS is plagued by a number of distortions:
• The PDS is undifferentiated, generalized, non-targeted, and essentially an urban
metropolitan system, which does not guarantee the entitlem ents of a certain quantity of
essential commodities required by households. The result is the poor are always
elbowed out of access in this free-for-all PDS by the better off in society.
• Food grains, including staple cereals, wheat and rice are steadily going out of reach of
the poor due to the ever-increasing m inimum support price guaranteed to surplus
farm ers.
• Lack of com mitment on the part of most state governments to provide staple cereals to
the poor at affordable prices under the PDS.
• The Indian government unlike uniform sugar price all over India has not laid down
such a fixed rice for foodgrains meant for the poor in the fair price shops, thus m aking
the fair-price shop dealer the sovereign, seriously damaging the consumer rights of the

Water and Sanitation

92% of hospitalization cases in rural areas fell in the infectious and parasitic diseasecategory,
more specifically within diarrhoea and gastroenteritis. This indicates widespread problem of
poor water quality and lack of basic sanitation and hygiene.
Estimates1 suggest 80% of all sickness and diseases are linked to poor quality of drinking water
and sanitation conditions. 26.8 lakh people in habitations with ‘quality problem’ are yet to have
safe drinking water. Out of the total sources, 1.5% have water quality problem. There are five
districts, which have more than 5% affected drinking water sources. Besides 22 districts of the
state have average water quality problems. In remaining 43 districts, there is no major quality
Sanitation is a problem in UP, out of 70 districts of the State, only 30 have more than 33%
sanitation coverage. The problem in 40 districts is severe.

World Health Organisation


Infant Mortality

Uttar Pradesh has one of the highest incidences of infant and maternal mortality in the entire
country. India has Infant M ortality Rate of 58, in general, is very high. W ith the exception of
Kerala, there is no state in India where IMR is observed lower than 40 (in 2000). One of the
biggest IM R in India happens to be poor performance on high IM R levels in UP. It is observed
that nearly 25 of IM R incidence in the country (in total of 99) is accounted for by UP alone.

IMR in the rural areas is nearly 50% higher than urban areas. Children in rural area experience
80% higher risk of dying before their fifth birthday than the urban children. As per NFHS-II,
UP had the highest under-5 Mortality Rate in the country (122.5 deaths per 1000 live births as
compared to all India average of 94.9). A large number of children in UP receive no
vaccination. The change in vaccination coverage is a meager 3% between 1997 and 2005. The
vaccination level in the rural areas is worse than the rest of the state average.

Maternal Mortality Rate

38000 women die every year in the state; almost half the deaths occur at home and another
10% -15% die on the way to the hospital. In 1997, there were an estimated 707 maternal deaths
per 100,000 live births in UP. This is almost eight times higher than Kerala and 70% higher
than the national average (436).

In UP only about half of the total pregnant women get ANC services. Only around 11% of the
eligible population gets full antenatal care while the corresponding figure for Tamil Nadu was
75% and for Kerala 85%.

India’s 72 million children are undernourished and UP accounts for 10-12 million of these
children. UP has 52% prevalence of malnutrition, with every second child below three years of
age suffering from chronic malnutrition. Besides children, malnutrition in the form of Chronic
Energy Deficiency is very high in women in the reproductive age group, aggravated by early
marriage combined with early conception. On an average 80% of pregnant women are
anaemic. M oreover, maternal malnutrition is often a major contributing cause of low birth
weight babies.

Besides the normal malnutrition challenge, UP also suffers from micronutrient deficiency.
M ore than 75% of preschool children and mothers suffer from iron deficiency anaemia (IDA)
and 57% of preschool children have sub-clinical Vitamin A Deficiency (VAD). Iodine
deficiency is endemic in 85% of districts.

Status of Children in UP Report 2007 (Draft)

Distribution of Reported Ailments across Categories in UP.

The people of UP suffer from a high burden of illness, particularly in comparison with the rest
of the country.
Chronic degenerative ailments are much more prominent in urban areas than in rural areas
while infectious and parasitic dominate the rural areas.

Japanese Encephalitis is a bigger and unique challenge in Uttar Pradesh. It is found that 60% of
total JE cases in country are accounted for by UP followed by the states like Assam (14%),
Karnataka (11%) and Bihar (5%). It has shown a consistent rise from 35 deaths in 1994 to 228
deaths in 2005. The disease has emerged as a major killer particularly in the eastern region of
the state. Around 32 districts emerge as worst effected by the disease of which majority are

The prevalent rate of Leprosy in UP, 222 cases per lakh population, is higher than the national
average of 120 cases per lakh population. This was higher in the rural areas than in urban areas.

Among all the diseases covered in surveys malaria had the highest incidence and does not show
any discernible decline. The high incidence district were those that fall in the Terai belt or are
districts like Kanpur and Nagpur, which have relatively poor quality of sanitation and hygiene.

Blindness affects a large number of the population too. Rural residents are twice as likely to be
completely blind (6 per 1000) than urban residents (3 per 1000). Females are slightly more
prone to complete blindness than males in rural areas and backward districts and slightly less
prone than males in urban areas.

Tuberculosis (TB) has a higher prevalent rate in UP than the national average being more
prevalent in rural than in urban areas. It is much higher in W estern and Central UP.

The prevalence of asthama in the state is very high being higher in rural areas than in urban
areas and also much higher for males than for females.

Jaundice incidence is higher in urban than in rural areas. However, in case of males, jaundice
incidence in rural areas was higher than in urban areas. On the whole jaundice was more
prevalent in males than in females.

Falling life expectancy is one indicator capturing the

HIV/AIDS is a very much reality
impact of HIV/AIDS. But the epidemic is generating
in Uttar Pradesh. There are atleastmultiple human development reversals, extending
12 districts in the state which arebeyond health into food security, education and other
regarded as high prevalenceareas. HIV-affected households are trapped in a
districts of Human Immuno-financial pincer as health costs rise and incomes fall.
Costs can amount to more than one-third of household
deficiency Virus (HIV). The high
income, crowding out spending in other areas.
illiteracy rate accompanied by high
Households resort to distress sales of food and livestock
incidence of poverty and highto cover medical costs, increasing their vulnerability.
gender disparity raises theMeanwhile, HIV/AIDS erodes their most valuable asset:
vulnerability quotient. 21-40 agetheir labour. Beyond the household, HIV/AIDS is
eroding the social and economic infrastructure.
groups are most vulnerable and
HIV/AIDS suppresses the body’s immune system and
shows highest incidence of AIDS
leads to malnutrition. At the same time, nutritional
cases in the state. The prevalence isdeficiencies hasten the onset of AIDS and its
also due to little or no surveillanceprogression. Women with HIV/AIDS suffer a loss of
in the more vulnerable pockets,status. At the same time, gender inequality and the
subservient status of women are at the heart of power
shortage of well-trained and
inequalities that increase the risk of contracting the
dedicated personnel and lack of
disease. Violence against women, especially forced or
understanding the source points ofcoercive sex is a major cause of vulnerability. Another is
Female Sex Work. Also revealed inwomen’s weak negotiating position on the use of

ORG mapping, Uttar Pradesh has a large presence of high risks groups. The state has 10
million migrants, 52741 truckers (8 National Highways), 8234 Commercial Sex W orkers and
approximately 9000 intravenous drug users/ MSM. A long porous Indo-Nepal Border adds to
the vulnerability of the state.

The above discussion regarding the prevalence of various diseases in UP is particularly

pertinent because of its important linkages to health and underdevelopment in UP. Among the
poor segments of society an analysis of data brings forth an obvious observation that as a result
of these diseases an important part of their valuable purse strings goes in their treatment.
Although many times the subsidized health services of the state are available to them yet
inspite of it the seriousness of the diseases still causes considerable financial drain on their


Progress in human development requires advances across a broad front: losses in

human welfare linked to life expectancy, for example, cannot be compensated for
by gains in other areas such as income or education. Moreover, gains in any one
area are difficult to sustain in the absence of overall progress. For example, poor
health can constrain economic growth and performance in education, and slow
growth reduces the resources available for social investment.

Financial burden of illness in Uttar Pradesh is very high. The policy of free health care at the
cutting edge rural facilities in particular, the de facto situation is that care at PHCs is not free.
Primary Health centers are chronically short of medications. The patients have to purchase these
medicines. Cost of transportation, absence of doctors (non-availability), man days (wages) lost
etc. also add up to the cost. The people end up either paying from their lifetime savings or
purchasing a debt for a lifetime to receive inappropriate care from inappropriate provider. Also
the expenses and the burden of hospitalization continues to be a major reason for poverty in
Uttar Pradesh.

Average medical expenditure per hospitalization case in rural and urban UP and India
(in Rs.)
Rural Urban
Public Private Loss of Public Private Loss of
household household
income income
U.P. 7648 9169 620 5144 10351 536
India 3238 7408 636 3877 11553 745

The above table captures the cost of health care in the state. Average medical expenditure per
hospitalization case in rural UP in the public sector is estim ated at Rs. 7648. This is more than
twice as much as the national average of Rs. 3238. Even the cost in private sector is much
higher than the national average. W hile in Kerala good quality health care is available at
reasonable cost in public as well as private sector.

Healthcare in UP is primarily financed by private spending with out-of-pocket expenses

accounting for over 71% of the total expenditure. Total household sector spending accounts
87% of the spending and the government health care funding accounts for only 13% of the total

spending. National Health Accounts estim ates suggest that the household sector spends
Rs.17158 crores on health in UP whereas government spends only Rs.2650 crore. In Kerala the
household sector spends only Rs.8373 crore while in Tamil Nadu household sector spends
Rs.3624 crore only.

The steep inequalities in health and increased vulnerabilities associated with unequal
access to healthcare are associated with deep differences in opportunities. Repeat
episodes of ill health undermine productivity, diminish the ability of children to
benefit from education and lock households into the vicious cycle of poverty.

The state shows significant variation in health related burden and disability across regions and
income groups. Both rich and poor face a very high burden of health related disability.
However, the poor and women seem to be at a greater disadvantage, the incidence of IM R
alone is found to be two and a half times higher among the poor. At the same time much lesser
proportion of public resources are spent on the bottom 20% of the population, in comparison to
what is spent on the top 20%.

The combined loss due to premature death and disability from non-fatal illness are very high in
the state. UP has the highest Disability Adjusted Life3 Years
loss rate among all the Indian
states examined. The overwhelming cause of premature death and disability are from
communicable diseases, malnutrition, and prenatal conditions, a disease pattern common
among very poor population that are still quite early in their epidemiological transition.

Poor people and disadvantaged groups often lack the capacity to influence
institutions controlled by elite groups. More broadly, the disadvantage is perpetuated
by inequalities in what can be thought of as the factors shaping; the political
capabilities of the poor, self-confidence and capacity to influence political processes
and recognition by the rest of society.


DALYs- which measures the combined loss due to pre-mature death and disability due to non-fatal

Widespread poverty resulting in chronic and persistent hunger is the single biggest
scourge of the developing world today. The physical expression of this continuously
re-enacted tragedy is condition of malnutrition, which manifests itself among large
sections of the poor, particularly among the women and children. Under-nutrition
results in deterioration of physical growth and health. The inadequacy is related to
the food and nutrients needed to maintain good health, provide for growth and allow
a choice of physical activity levels. The condition of under nutrition, therefore
reduces work capacity and productivity amongst adults and enhances mortality and
morbidity amongst children. Such reduced productivity translates into reduced
earning capacity leading to further poverty and the vicious cycle goes on.
Children from poor households are more than one and a half times as likely to be
underweight and stunted than children from non-poor households.

Low earning Low intake of food
capacity and nutrient

Impaired Under nutrition

Productivity results in diseases
and infections

Small body
size of Adults
Stunted Development of Children
and Growth Faltering

The above picture m akes is clear that it is not so much the shortage of financial resources as it is
the inappropriate organization and flow of resources. M uch of out-of-pocket expenses comes
from the pockets of ordinary citizens. He spends through his nose often getting inappropriate
care and ending up in poverty.

The linkage between the cycle of poor health, poverty, under-development is
easily understood when we look at the study conducted by BETI Foundation in 20
Gram Panchayats of Talbehat Block of Lalitpur district of UP comprising 359
respondents. The study was done based on BMI (Body Mass Index), which has
been widely used to determine malnourishment, energy deficiency and overall
indicator of physical well-being. Lalitpur is one of the most economically
backward districts. The soil is red laterite which is not very suitable for crops other
than maize, lentils and legumes. The production is lower than those districts
situated in the Gangetic plain. This continuous lack of food security is one of the
principal reasons of malnutrition. 64% of the respondents show BMI less than 19
which indicates their stunted growth, malnourishment and poor physical ability to
undertake hard manual work. There is not much variation between BMIs of
different caste groups suggesting that poverty leading to acute malnourishment
goes beyond social castes. The respondents also had some serious sickness (life
threatening or making them unable to work) 30.9% SC’s, 27.3% ST’s and 30%
OBC’s respondents who have BMI < 19 fell seriously ill once or twice in a time
frame of 6 months. Serious ailments affect families in two ways; firstly an earning
member loses his wages and secondly the cost of medical treatment is very high.
The government health facilities are near to nothing in the block. Even at the
district level, the government hospitals are ill equipped with reluctant medical staff
who often refuse to treat a patient. Thus, most of the people depend on private
medical practitioners and local quacks. The majority of respondents said that they
have to take loans from moneylenders for their medical treatment. 76.9% SC,
100% ST and 84.6% OBC who fell sick borrowed from local moneylenders at
very high interest rates - this pushing them further into deeper Poverty.


There is a need for a holistic approach. There needs to be convergence of other

departments responsible for santitation, drinking water, elimination of maternal and
child malnutrition, education and health awareness with the department of health
and family welfare. Safe drinking water, availability of laterines, drainage and
sewage systems and waste disposal should be a priority. The quality of drinking
water should regularly monitored by the health boards and the findings publicised
through radio and newspapers.

The health care should be made affordable. Health insurance may be introduced for
all the classes of society to address emergency needs & reduce indebtedness. Some
other health financing interventions such as voucher system, Conditional Cash
Transfers may also be introduced.

Health care services and delivery should comprise a healthy mix of state supported
health care systems and private sector initiatives.

Health care should be equitably distributed between rural and urban areas and
among different regions of the state.

Local information and local health care institutions by people’s committees linked to
the representative institutions at the local level (such as village health committees,
district health boards etc.) must be encouraged.

Health care services should be aimed at maximising health gains by improving

quality of health services. A check on this may be routed through evaluation studies,
feed back and mid course corrections. Capacity building also closely related to
quality that helps in bridging the gap providing appropriate health care in the state.

Improving access to reach the remotest areas of Uttar Pradesh with interventions like
camps, mobile hospitals and transport facility for reaching out to the unreached.

Strengthening health facilities such as increasing number of sub-centres, improving
the existing infrastructure, strengthening PHC/CHC for quality prevention,
promotion, curative, supervisory and out of reach services and upgrading them.

Delegation and decentralisation of power by strengthening the process of village and

district level planning in order to establish the spirit of bottom up approach. Local
inputs should be used to prepare district health plans. These plans should identify
needs and requirement gaps from the primary health care level upwards and set clear
goals which are linked to key health outcomes. The performance of health care
functionaries should be periodically assessed.

Health plans should be able to find solutions that don’t require additional resources.
At the same time, the health plans should be able to identify critical resource gaps.

Implementation of public health laws and continuous monitoring by food health

inspectors for ensuring the three A's – Access, Affordability and Accountability.

There is need to strengthen rather nascent and ill equipped cadre of para medicals,
ayurvedics and others who can be more accessible for preventive and routine health
care. Specialised hospitals and community hospitals can be established at district
and block level. Referral systems need to be strong and in place.

There is need for strong Public Private Partnership whereby the private partners are equally
responsible for the accelerating health status of the state and may be penalized at par for the
deceleration. The partnership m ay be introduced in contracting the hospital facilities and service
delivery. W here there are no hospitals but a governm ent building exists may be given to private
partners to run clinics/hospitals. The government should identify such regions and facilities
where its services are critically needed and no other reasonable alternative to the governm ent
exists. The government m ay focus on the role of the provider for enabling an environm ent and
regulating ad planner where private sector is capable of providing services.

The Alma Atta declaration embodied a number of fundamental principles of health

(a) the governments had the responsibility for the health of the people,
(b) emphasis had to be on preventive and promotive measures well-integrated
with curative, rehabilitative and environmental measures.
(c) There should be equitable distribution of health resources.
(d) It is the right and duty of people to participate in the development of health
both individually and collectively and
(e) There should be allocation of resources to those in greater social need and
the health system should adequately cover all.

The goal of Health for All by 2000 A.D. was set for all the signitaory countries. The
above have not really been addressed till now. In the year 2000 the world leaders
agreed on eight Millennium Development Goals (MDGs) of which three MDGs
mainly MDG4, MDG5 and MDG6 focus on health related issues. MDG4 focused on
reducing child mortality, MDG5 emphasised improvement in maternal health and
MDG6 focused on HIV/AIDS, malaria and other diseases. Health has been a
neglected sector. It is now necessary to address it in a holistic & focused manner.

Vertical set up of the public health systems, changing economic priorities, invasion
of private interests into political decision-making and lack of political determination
lead to undermining of our public health system. This breakdown of public health
and primary health care systems over the last two decades has proved to be highly
detrimental to the capacity of our health system to cope up with treatment and care.

Health care in UP can be summarized as a composite challenge of Access, Quality and

Demand. The large public sector does not have adequate access besides being found waiting in
the quality of care at the cutting edge (PHCs and Sub-Centres). The private sector has
phenomenol access but a vast majority of this sector presents picture of serious lack of quality
to the extent that it often becomes a serious threat to the health of the people. It appears that a
re-orientation of the health strategy in U.P., where the focus is increasingly on functionalising
existing structures, synergy through public private partnership particularly for reaching out to
the poor and marginalized; and on finding solutions through decentralization and innovative
interventions can enable us to meet UP’s health challenge.

India is being named a potential superpower – unhealthy
population cannot achieve to the league desired. Hence the health
of all citizens needs to be safe and protected to ensure that the
country’s potential indeed becomes a reality.


Government of Uttar Pradesh, State Planning Commission, (2002), Tenth Five Year
Plan 2002-2007 and Annual Plan 2002-2003, Vols. -I and 2, Lucknow.
Government of India, Department of Planning, Ninth Five Year Plan 1997-2002 and
Annual Plan, 1997-98, Vol. 1.

Government of India, Department of Planning, Annual Plan, 2000-2001 Volume 1

Part 1 and Vol. 2, Part 2.

Government of India, Department of Planning, Annual Plan, 2001-2002 Volume 1

Part 1 and Vol. 2, Part 2.

Voluntary Health Association of India & W orld Health Organization (April 2000), ,National
Profile on W omen, Health and Development , Country Profile-India.

Voluntary Health Association of India, Report of The Independent Commission On Health in

India (1997).

W orld Development Report 2004 - Making Services W ork for Poor People.

Hum an Development Report 2005.

Hum an Development Report 2003, Uttar Pradesh.

India Developm ent Report 2004-05.

NACP III To Halt and Reverse the HIV epidem ic in India.

UP Development Policy- Observations & Analysis.

Case study (BM I study of Lalitpur )