Population Growth Experience of Punjab and Kerala

Sawarn Singh The large size of the Indian population and its rapid growth continues to be a major concern for public and policy makers in India and abroad. The demographic situation arising from ever expanding population is even morphined as Population Bomb (Dreze & Sen, 2002). Conflicting argument about the positive and negative consequences of population growth notwithstanding, there is broad consensus that people would be better off if population grows more slowly (Cassen, 1994). Realising the severity of the population problem, India was the first country in the world to launch the family planning programme in 1952. In fact, stabilising population is believed to be essential for sustainable development with more equitable distribute (GOI, 2002). Implicit is the belief that rapid growth of population leads to heightened pressure on authorities for provisioning of more rudimentary economic, health and social services to population severely like safe water, sanitation, housing, transport and communication, education and many other components of public amenities (Tadaro, 2003; Dreze & Sen 2002).

India being a big country with well known regional disparities and health and population being a state subject, the dynamics of population growth may present different scenario across states. The aim of the present study is to analyse the dynamics of population growth in Punjab. The spectacular development of Punjab economy during post independence period in general and during the post Green Revolution period in particular is well known. The state continues to rank top among major Indian states so far agricultural growth and per capita income is concerned. In fact the remarkable performance of {Punjab during last half a century might have brought a significant quantitative and qualitative changes in its population as the inter-relation between economic development and growth rate of population by now is well established. Historical evidence from economic growth in developed and developing countries suggests a two-way relationship between growth rate of population and economic development (Wadhva et al, 2003). Rising population through enhanced supply of productive labour force generally leads to generation of more income and wealth.

Improvement in human development through better and affordable provision of health, education and other basic necessities generally leads to decline in rate of the growth of population. However, there is no unanimity in literature in economics of population whether growth of population facilitates, restricts or is neutral to economic growth. View swing from gloomy forecast of Malthus putting forth the argument that rising population has a tendency to out compete supply of food resulting in major catastrophic situation. Coale and Hoover (1958) in their well-quoted work also found the adverse impact of rising population on economic growth. Simon Kuznet (1973) on the basis of historical data also found close relationship between economic growth and declining tendencies in morality and fertility. However, none of the empirical studies has conclusively established that population growth is obstacle to economic growth. Controversies notwithstanding, the desirability to control the growth of population is now well accepted in policy circles. Consequently the investment in family planning becomes popular with the passage of time to curb the rising population in developing countries. The implicit idea behind the population control programme in India is that the rising population would result in additional burden of expenditure on existing resources to meet the basic needs of peoples.

There is rich body of empirical evidence on many issues related with the dynamics of population growth in Punjab. For instance success story of Punjab to fulfill the nutritional requirements of its population, rapid alleviation of poverty and high level of human capital development of its population is well documented (see Singh in this volume). However not much information in existing literature is available on many other issues related with population growth. For instance, why Punjab inspite of being among the most prosperous states lags behind many other states like Kerala and Karnataka on many accounts related with population growth. For instance TFR (Total Fertility Rate) in Punjab during 1990s was 2.7, much higher than Keralas 1.8 whereas Kerala is much below Punjab so far as per capita income is concerned. Main purpose of this paper is is explore into the various facets of the dynamics of population growth in Punjab and to compare it with leading state of Kerala. The study is expected not only to provide insight

into population problem in Punjab but is likely to generate information on lacunae in policies and programmes related with population and its growth. The Chapter is organised as follows. Following the introduction, Section II deals with the pattern of the growth of population during past half a century in Punjab. Section III examines the proximate determinants of growth of population and human development in Punjab. Section IV analyses the rural-urban differences in human

development and provisioning of health infrastructure in Punjab. Finally, Section V draws conclusions regarding the policy implications.

II Growth of Population: 1950-2001 Population in Punjab has increased from 9.2 million in 1951 to 24.3 million at the dawn of 21st century (Table-1). Over the last fifty years the population growth in the present day Punjab peaked to 23.9 per cent during the decade of 1971-1981 and started thereafter to 20.8 per cent during 1980s and to 19.8 per cent during 1990s.

However the pattern and pace of population growth in Punjab during last fifty years is quite different from the country as a whole (Table-1). For instance, contrary to the acceleration in growth of population for the country as a whole form 21.5 during 1950s to 24.8 per cent during 1960s, population in Punjab continued to grow at almost same rate during these two decades. Decadal growth of population in Punjab accelerated from 21.7 during 1960s to 23.9 per cent during 1980s whereas for nation as a whole population growth occurred at almost same rate during these two decades. Similarly, during the 1990s population growth decelerated by 2.6 per cent whereas for Punjab it decelerated only by 1.0 per cent. The pattern to population growth in Punjab is contrary to the widely held view and available empirical evidence that rising per capita income brings down growth rate in population. For instance, Wadhva and others (2003) in state level analysis found that TFR declines with rising per capita income in majority of the states (including Punjab) in India. Though the issue needs further explorations, it seems to be closely related with factors like migration of population into the state. It may be seen the period (1970s) of rapid rise in growth of population in Punjab (contrary to no significant increase in India) is also happens to be the earlier phase of the Green

Revolution in Punjab agriculture that brought remarkable improvement in production and productivity in its agriculture. New technology expanded the employment in rural and urban areas leading to influx of migrant labour the Punjab. The migrants might have distorted the population transition in Punjab. Therefor, in spite of the fact that the growth in Punjab stagnated a decade earlier in Punjab than the nation as a whole, but accelerated again rather than declining during 1970s. Besides the uninterrupted migration into Punjab, phenomenon of slow pace of deceleration in the growth rate of population in the later period also seems to be related with the high fertility among the migrants as almost whole of the immigrants are low income households that tends to have high fertility.

Another important dimension, which has been repeatedly mentioned, is the low sex ratio in Punjab. Information provided in Table-1 indicated that the sex ratio in Punjab was improving during 1951-1991 period, but it declined during 1990s. Phenomenal expansion of the use of ultrasound facilities leading to female feticide is generally considered to be the main factor behind the falling sex ratio during 1990s.

Besides the sex ratio, net migration, birth and death rates, total fertility rate (TFR) also determine the pattern and pace of population growth. Information provided in Table2 indicates that there is a big decline in TFR in Punjab from 5.3 during 1970-2 to 2.6 by end of the 20th century. This decline in TFR is much sharp in Punjab as compared to India as a whole. Interestingly TFR in Punjab was approximately the same as the all India level in 1970-72 but by 2000 TFR in Punjab is about 20 per cent less than the all India level. This implies that growth of population would have considerably decelerated grown in absence of a large-scale immigration of labour in Punjab. Notwithstanding the sharp decline in TFR, Punjab still ranks 18th among the 32 state/union territories in 2001 so far as current TFR is concerned. Punjab is still much behind nine states/Union Territories (UTs) (including Kerala and Tamil Nadu) that has already achieved TFR of less than 2, required to stabilise the population growth in India.

II Health Status of Population: Where Punjab Stands? Health status of population in a region can be captured by comparing it with some other ideal region on various characteristics of their inhabitants. Various facets capturing different dimensions of population can be broadly divided into two groups. One set includes demographic, social, economic and cultural factors. This includes marriage age of the girls, education, birth rate, awareness about family planning, nutritional level in general and that of women and children in particular, son preferences, attitude towards social security, sex of the children preferences etc. The other set of factors is related with access to public and private health facilities, water and sanitation and overall health environment in the region where people generally reside. The impact of these factors on population growth is channelled through intervening variables like antenatal care, institutional delivery, postnatal care, and immunisation etc.

Role of these various facets of population as determinant of health status can be examined either through a temporal study of these aspects or by comparing current status of Punjab with some other leading state, so far as achievement on population front is concerned. However, consistent temporal information on many of these aspects is not available over a sufficiently long period of time. The only information available over this context in information generated during the National Family Health Survey (NFHS)-I and II. However the time gap between is too small NFHS-I and NFHS-II whereas the population dynamics is long term phenomenon. Therefore to analyse the growth of population in Punjab, we preferred to compare the latest information available in this context i.e. NFHS (1998-99) for Punjab with Kerala. Kerala is chosen specifically due to its widely celebrated achievement of demographic and social development. In fact state is treated as role model for other states in India. Information on various aspects in this regard is provided in Table-3 and Figure-1.

(a) Household Specific Indicators It is evident from Table-3 that though the median marriage age of girls in Punjab and Kerala is approximately same but proportion of below 18 years age at marriage of girls in Punjab is higher than that of Kerala. This mainly results in onset of fertility at the

earlier age and effecting adversely the health status of both mother and child. Besides, with a higher proportion of Punjabi women entering into marriage at an earlier age, fertility of Punjabi women is higher than that of Kerala women. For instance, proportion of the high birth order women (>=3 births) is almost double in Punjab (39.6 per cent) than that of similar high fertility women (21.1 percent) in Kerala. Early age and high fertility, inter aliea, both generally leads to high risk of child survival after birth. Information on neonatal mortality, postnatal mortality, infant mortality and child mortality given in Table-3 indicates the wide gap between Punjab and Kerala on these indicators. Risk of an infant not reaching one year of age in Punjab is three times higher than in Kerala. Situation is far worse so far as the survival of children of age 1-month to 1 year is concerned. The post-natal mortality in Punjab (15.9 percent) is six times higher than in Kerala (2.6 percent).

Not to speak of the survival chances, the physical health of surviving children is equally worse in Punjab vis--vis their counterparts in Kerala. Percentage of children with anemia and chronically under nourished (stunted) is almost double in Punjab, than in Kerala. This implies of risk of surviving children not to survive in future is much higher in Punjab, which along with high mortality rate feed back to high fertility rate in Punjab.

Besides the malnutrition among children physical health of women in Punjab is also worse off compared to 22.7 percent in Kerala 41.4 percent of women in Punjab are suffering from anemia. High incidence of anemia among womens in from households in particular, adversely affects their working capacity and hence perpetuates the low level of living and poverty among them. Furthermore mothers problem may pass on to the newly born children severely affecting their health. Consequently, high incidence of anemia may result in high fertility through high mortality among the babies inheriting anemia from mothers.

In addition to poor health status another important probable cause of high fertility in Punjab is related with socio-cultural factor- preference. Proportion of women who want more sons than daughters (29.1 percent) is two times more in Punjab than in Kerala

(14.9 percent). In fact the phenomenon is also reflected in low sex ratio in Punjab that declined seriously during 1990s. It is know well known that the phenomenal expansion in the use of ultrasound machines facilitated the people to realise their preference for sons.

Among the various household specific characteristics literacy is general and female literacy in particular is important contributory factor to socio-economic conditions and well being of the population. Rising level of literacy not only helps in building human resource development, earning capabilities and economic independence of the females, it also has direct effect on fertility behaviour of the household. For instance, TFR varies from 3.2 among the households with illiterate women to 2.4 in literate but below middle educated to 1.7 among households having high school and above educated women (IIPS,2000). Therefore the high illiteracy among Punjabi women may be one of the reasons for high fertility in Punjab. For instance, proportion of illiterate females (35.1 percent) in Punjab is much higher than that of Kerala (14.9 percent). The situation is worse among 15+ age group females as proportion of households with no literate female in Punjab (42.8 percent) is more than 4 fold than that in Kerala (9.9 percent). Comparison of Punjab with Kerala on various aspects of health status suggests that early marriages, poor nutritional level, low literacy, high risk of child survival and preference for sons in Punjab seem to be closely related with high TFR in Punjab. In fact all these factors were found to be significantly determining the inter-state variations in fertility in India (Dhesi and Dhariwal, 1982).

(b) Access to Health Infrastructure Comparison of access and utilisation of health services in Table-3 indicates wide disparities between Punjab and Kerala. In case of sickness, people generally utilise either public or private or NGO/hospital/clinic for treatment. In case of sickness in Punjab, 13.8 percent of people go to public sector, 85.9 go to private sector and 0.2 percent to NGO/trust medical facilities in Punjab. The proportion of these three types of institutions used by Kerala public is 37.9 percent, 60.5 percent and 1.2 percent respectively. It indicates that access/utilisation of public medical sector is very low in Punjab as compared to Kerala. Preference for private sector in Punjab may be due to either low

provisioning of required health services in the public sector or preference of high-income people to private medical services. Information collected during the National Family health Survey-2 reveals that the type of health care services used is influenced only slightly by the standard of living of the household in Punjab (IIPS, 2001). Even 81 per cent of the low-income households in Punjab prefer private-sector medical services in case of sickness (IIPS, 2001). Therefore, poor status of the health services in the state seems to be main reason forcing even the poor in Punjab to rely on the private medical sector to meet their health care needs.

Another important aspect of health services related with infant and maternal mortality and well being of mother and child is the provisioning and utilisation of antenatal and delivery related services. Data on sources of ante-natal services provided in Table-3 indicate that more than one fourth of pregnant women in Punjab never go for ante-natal (ANC) check up, whereas almost every pregnant women in Kerala prefers ANC check-up. It is interesting that 85 per cent mothers not going in for ante-natal check-up (ANC) felt it not necessary for going in for such check-ups (IIPS, 2001). Clearly a lack of awareness prevails among Punjabi women about the necessity/utility of such services during pregnancy. Studies conducted by various researchers suggests at least 4 ANC check-ups as minimum necessity for health safety of mother and outcome of pregnancy (Park & Park, 1989 and IIPS, 1998).

Punjabi women not only lack awareness regarding the utility of ANC check-ups but also equally unaware of the need of getting these services from the trained medical personals. In Punjab only 41.3 percent of the pregnant women visited a qualified doctor for ANC check-up whereas in Kerala almost every pregnant women (98.5 percent) preferred to go for ANC from a qualified doctor.

Besides the ANC check-up, the number and timing of ANC check-ups are important factor for the health and outcome of pregnancy. In India under the Reproductive and Child Health (RCH) programme average 3 ANC visits by ANM to every pregnant women are recommended. The programme requires that the health worker

at sub-centre level (ANM) be required to pay at least 3 visit for ANC check-up. However, only one-fourth of pregnant women was visited by ANM in Punjab. This indicates the inefficiency/ poor status of medical extension services in Punjab as 86.1 per cent of the pregnant women visited by ANM in the state of Kerala.

On the whole, information indicates poor availability and utilisation of ANC services in Punjab. Phenomenon is partly related with lack of awareness regarding utility of ANC among potential mothers in the state and partly related with poor provisioning /extension of ANC services to the pregnant women in the state. Furthermore, potential mothers also lack awareness of the utility of getting ANC services from qualified doctors. Probably poor status of ANC services by the health department forces the pregnant women to get the same from untrained traditional personnel - (dais). Besides the ANC, health of the mother and outcome of pregnancy are equally affected by the type of services given at the time of delivery. One of the important thrust areas of RCH programme in India is to encourage deliveries under hygienic conditions and also under the supervision of trained health professional. In Punjab the situation is worse in this context also. Compared with 92.9 percent deliveries taking place in health institutional facilities in Kerala, in Punjab only 37.4 percent of the births took place in health facilities. It is amazing that in spite of high per capita income of Punjabi population, 37.4 percent of the deliveries in Punjab occurred in unsafe hands. On the contrary in Kerala almost all deliveries are in safe hands (92.9 per cent). Furthermore, such a larger number of deliveries in unsafe hands might be one of the reasons for high Post Neo-Natal Mortality (PNN) rate (28.8 per thousand) in Punjab as compared with negligible incidences of PNN 2.4 per thousand live births in Kerala (IIPS,2000).

Furthermore, dis-aggregation of institution deliveries show that only 7.6 percent of the deliveries took place in public health facility compared to 36.3 percent in Kerala. Same is true about the birth in private health facilities. Even in case of NGO/Trust Hospitals. Punjab is lagging much behind as only 0.2 percent births took place at these places in Punjab compared to 2.9 percent in Kerala.

Very low utilisation of public health services for delivery purposes indicate that either the services are not available or the poor accessibility and poor quality of such services that erode the confidence of users in these institutions. Poor accessibility/quality of services of public services seems to be main reason as only 8 percent of the pregnant women from low income households in Punjab went to public institutions for delivery whereas 19 percent of the low income pregnant women went to private institutions (IIPS, 2001).

IV Are Rural People Left Behind? Rural-Urban differentials in every walk of life are well known worldwide. In fact better availability of public utilities related with education, health and sanitation in urban areas is considered to be one of the pull factors for migration from rural to urban areas. Comparison of various aspects of quality of life and access to the health related services in rural and urban areas are provided in Table-4 and Figure-2. It is evident from this information that the general impression of poor health status, and quality of life in rural areas compared in urban areas is true in Punjab. Rural areas have higher TFR (total Fertility Rate) which may be due to higher proportion of higher order births women in rural areas.

Information detailed in Table-4 also reveals that the incidence of various aspects of mortality among children, like neo-natal, post-natal and infant mortality, are significantly higher in rural than urban Punjab. Though the proportion of children and women with anaemia and wasted children is not different in rural areas, the proportion of stunted children is significantly higher in rural areas as compared with urban areas in Punjab. The evidence on health status of women and children on the whole indicates that the nutritional status of surviving children though does not differ much in rural and urban Punjab, but the chances of not surviving of newly born is significantly higher in rural areas than in urban areas.

It is quite possible that lack of awareness among rural women regarding ante-natal and delivery precaution along with access to health utilities may be leading to observed

high total fertility and mortality among children in rural areas. Information provided in Table-4 supports our assertions as compared with 9.7 percent women in urban areas, 30.8 percent pregnant women in rural areas had no ANC check up. Furthermore, proportion of pregnant women utilising ANC given by doctor is almost half (34.8 percent) in rural areas compared with 63.1 percent in urban areas. More than half of urban pregnant women in Punjab delivered birth in institutions whereas the proportion of such women in rural areas is just one third. Similarly proportion of women undergoing for safe delivery is much less in rural areas than in urban areas. Information provided in this table on human capital also reveals that besides medical facilities, there is a big gap in proportion and level of literacy in rural and urban areas.

There is enough empirical evidence indicating the plight of the rural population so far as the accessibility of safe drinking water (piped water), sanitation such as toilet facilities, connectivity to drainage etc, is concerned. These facilities impact the health status/quality of life, (IIPS, 2001 and Singh G. in this volume). Observed high fertility and mortality of rural areas of Punjab may therefore be partly owing to the poor provisioning of these utilities in rural areas.

Not to speak of the poor accessibility/availability of health services in Punjab compared with Kerala even the available health infrastructure is poorly equipped and managed in Punjab. Information provided in Table-5 indicates that 54 percent of community Health Centres (CHC), 54 percent of Primary Health Centres (PHC) and 15 percent of Sub-Centres (SC) are without their own buildings. 16 percent of SCs, 29 percent of PHCs and 16 percent of CHCs are functioning with inadequate staff. None of the CHCs has any physician.

Even lack of staff notwithstanding there is high level of absenteeism in the available staff. A recent survey shows that on an average on any day, 39 percent of the doctors and 44 percent of other medical personnel are found absent from their work place. It is really amazing that inspite of higher per capita income and expenditure state, Punjab is ranked 11th in quality of services delivery across 16 major states (WB,2004).

A comparison of Punjab with Kerala on state outlay on rural health (Table-6 and figure-3) indicates that the per capita outlay in rural health services in Punjab is approximately half the expenditure level in Kerala. Interestingly even the composition of health expenditure differs in the two states. For instance per capita expenditure in Kerala on maintenance of sub-centre/training to ANM/LHV is much higher than in Punjab.

Therefore, poor condition of rural health services and hence health status of rural population is not just an incidence or mainly due to factors like early marriage age, lack of health consciousness but seems to be mainly due to comparatively poor provisioning and inadequately equipped of health services. Low priority is given in state outlay and expenditure on rural health services in Punjab. This may be probably the one of the reasons why Punjab in general and rural area in particular are lagging much behind than Kerala so far population transition to net reproduction of one and quality of life of its population is concerned.

V Some Conclusions Growing population continues to a major concern for policy makers in India. Recognising the seriousness of the problem, programme for family welfare has been made an integral part of strategy for economic development in India. Though a significant improvement in quality of life, per capita income and control on growth of population has been achieved since independence but there are wide differences across regions, social groups and gender in this regard. The state of Punjab is a paradox in this context. While Punjab continues to be top ranking state in per capita income, lags behind many states in on many counts of human resource development. Analysis of the population growth in Punjab since independence its comparison with Kerala in this study brings out many interesting aspects of population dynamics in Punjab

The study finds that Punjab lags much behind Kerala in provisioning of MCH care to the pregnant women. It is desirable that there should be universal registration of care of all the pregnant women and check-up by trained personnel in the state. Health

care agencies in the state required chalking out special programmes in the state to inform people about the utility of having pre- and post-natal care from trained medical professionals. Utilisation of public infrastructure is very poor. Even the persons from the very poor households are going to private institutions for delivery purposes.

A high incidence of anaemia among pregnant women and children in Punjab is a serious matter. Anaemia is basically iron deficiency problem mostly prevalent among the poorest segments of the population where malnutrition is predominant and the population exposed to a high risk of water and sanitation-related infections (like hookworm, malaria and schistosomiasis). The probability of the former as the root cause of problem seems to be low as peoples in Punjab continues to enjoy a high consumption level and poverty is almost on verge of being elimination from the state. Therefore, poor hygiene, sanitation, safe drinking water and water management seems to be the significant contributors to anaemia in Punjab. According to recent estimates by the World Health Organisation, anaemia contributes to up to 20 per cent of maternal deaths in the developing world (WHO, 2000). It also causes serious mental, motor and behaviour problems among anaemic children. Multidimensionality of anaemic problem requires identification of the factors and the causes and the type of anaemia. Besides correctional measures to meet iron deficiency and launching of public awareness programmes about ill effects of the problem, there is urgent need for improving hygiene, sanitation and water supply in general and in rural areas in particular.

Last but not the least programmes need to be initiated to rejuvenate the serious deceleration in Punjab economy in general and agriculture in particular. After all the Bucharest slogan of Development is the best Contraceptive is widely accepted. Infrastructure facilities in the state need to be strengthened and restructured on Kerala pattern with greater emphasis on strengthening the sub-centres and giving priority to training of the staff (ANM) at the SCs.

Our study indicates a vast rural-urban gap in almost all the indicators of well being of population including health, education and other basic amenities of life.

Therefore, rural areas should be given top priority in various policies and programmes to bridge this gap and to provide equitable justice to the rural population. The grassroots organization like Panchyat, NGOs/Charitable Trusts need to be involved in various policies and programmes like RCH so as to ensure wider participation of rural masses and effective implementation of various programmes. The commendable work of some NRI promoted Trusts providing quality health care and education to rural masses need to be extended and encouraged by the government. The success stories of the type of Guru Nanak Mission, Nawashahr needs to be encouraged and replicated elsewhere in rural Punjab. Last but not the least, provisioning of quality education and skill generation of peoples in general and of downtrodden and females in particular may go a long way to complement other policies and programmes aims to meet aspiration of peoples of Punjab for safe and healthy living environment.

References Cassen Robert H (1994), Population Policy: A New Consensus, Washington D.C: Overseas Development Council. Coale, AJ and E.M. Hoover (1958), Population Growth and Economic Development in Low-Income Countries; Princeton N.J.: Princeton University. Dayson, Tim; Robert Cassen and Leela Visaria (2004), Twenty-first Century India: Population, Economy, Human Development and the Environment, New Delhi, Oxford University Press. Dhesi, Autar S. and M.S.Dhariwal (1982), Nutrition Reduction and Fertility Behaviour, Margin, Vol. 14 (2). Dreze, Jean and Amrtya Sen (2002), India: Development and Participation, New Delhi: Oxford University Press. IIPS (1993), National Family Health Survey (NHFS 1) 1992-93: India, Mumbai International Institute for Population Sciences. IIPS (2000), National Family Health Survey (NHFS 2) 1998-99: India, Mumbai International Institute for Population Sciences. IIPS (2001), National Family Health Survey (NHFS 2) 1998-99: Punjab, Mumbai, International Institute for Population Sciences. Kuznet, Simon (1973), Population, Capital and Growth: Selected Essays, Norton: New York. Park J.K.& K.Park (1989), Textbook of Preventive and Social Medicine, 12th edition, Jabalpur. Ms. Banarsidas Bhanot Publisher. Tadaro M & Smith (2003), Economic Development, (8th. ed.) Delhi, Pearson Education Asia. Wadhva C.D. Saumya Singh, and Nawal K.Paswan(2003); National and State Level Popoulation Stabilization Policies and Economic Development: State Level Analysis with Focus on EAG State in Wadhva C.D. and B.N.(eds.): Population Stabilization Through District Action Plans, New Delhi: APH Publishing Corporation. WB (2004), Punjab Development Report, Washington D.C: The World Bank. WHO(2000), Turning the tide of malnutrition: responding to the challenge of the 21st century. Geneva: World Health Organization.

Table 1 Population Growth in Punjab and India, 1951-2001 Year Punjab Decadal Total Population Population Growth Punjab (%) (Million) 9.2 11.1 21.6 13.6 21.7 16.8 23.9 20.3 20.8 24.3 19.8 India Decadal Population Growth (%) 21.5 24.8 25.0 23.9 21.3 Sex Ratio (Number of Females per 1000 Males) 844 854 865 876 882 874

1951 1961 1971 1981 1991 2001

Source : GOP(2004), Statistical Abstract of Punjab, Chandigarh: Economic and Statistical Organisation, Government of Punjab.

Table 2 Estimated Total fertility rates for India and Punjab Year 1970-2 1980-2 1990-2 1996-8 Percent decline Source : Dyson et.al.(2004). India 5.2 4.5 3.7 3.3 36.5 Punjab 5.3 4.0 3.1 2.7 49.1

Table 3 Health Status of Population: Punjab and Kerala Indicator Household level indicators of status 1 2 Total fertility rate (TFR) Marriage age of girls (a) Median age at marriage (b) %age married below 18 years %age of higher order birth women(>= 3 birth) Child mortality (a) Neo natal mortality (NNM) (0-1 month) (b) Infant mortality rate (IMR) (0-1 years) (c) Child mortality (0-4 years) Malnutrition (a) % children with anemia (b) % women with anemia (c) % stunted (Chronically undernourished) (d) % wasted (acutely undernourished) Sex ratio Son preferences -% women who wants (a) more sons than daughters (b) at least one son Literacy (a)% illiterate female (15+ age group) (b) % households with no literate (15+)female (a) %matric and above (i) Male (ii) Female Access to Public Services 20.0 11.2 39.6 34.3 57.1 15.9 80.0 41.4 39.2 7.1 874 29.1 86.2 35.1 42.8 21.1 9.1 21.1 13.8 16.3 2.6 43.9 22.7 21.9 2.6 1027 14.6 72.6 14.9 9.9 2.7 1.8 Punjab Kerala

3 4

6 7

Source of medical treatment in case of sickness (a) Public (b) Private (c) NGO/trust hospitals 10 Ante Natal Services (ANS) (a) no ANC (b) % ANC by doctor (c) % ANC visit (at least 3) by 11 Delivery Services (a) % safe deliveries (b) institutional deliveries Place of deliveries (a) Public (b) Private (c) NGO/trust hospitals Source: IIPS (1998)

13.8 85.9 0.2 26.0 41.3 25.4 62.5 37.4 7.6 29.6 0.2

37.9 60.5 1.2 0.3 98.5 86.1 94.1 92.9 36.3 53.7 2.9

Table 4 Health Status of Population in Punjab: Rural-Urban Differentials Indicator Household level indicators of status 1 2 Total fertility rate (TFR) Marriage age of girls (c) Median age at marriage (d) %age married below 18 years %age of higher order birth women(>= 3 birth) Child mortality (a) Neo natal mortality (NNM) (0-1 month) (b) Infant mortality rate (IMR) (0-1 years) (c) Child mortality (0-4 years) Malnutrition (e) % children with anemia (f) % women with anemia (g) % stunted (Chronically undernourished) (h) % wasted (acutely undernourished) Literacy (b) % illiterate (i) Total (ii) Male (iii) Female (b) % households with no literate female(15+) (c) 5age of matric and above (i) Male (ii) Female Access to Public Services Source of medical treatment in case of sickness (a) Public (b) Private (c) NGO/trust hospitals Ante Natal Services (ANS) (a) no ANC (b) % ANC by doctor (c) % ANC visit (at least 3) by Delivery Services (a) % safe deliveries (b) institutional deliveries Place of deliveries (a) Public (b) Private 19.5 41.9 40.2 62.7 16.1 80.9 42.5 42.2 7.0 34.8 28.3 42.1 47.2 17.4 11.6 20.7 32.2 23.7 39.6 18.2 77.2 39.0 29.4 7.4 21.9 17.0 23.4 37.2 31.5 30.4 2.4 1.8 Rural Urban

3 4

14.2 85.5 0.3 30.8 34.8

13.0 86.6 0.4 9.7 63.1

10

11

58.1 31.6 7.1 24.5

77.8 56.1 9.3 46.8

Source: IIPS (1998)

Table 5 Rural Public Health Infrastructure in Punjab 2001

1. 2. 3. 4. 5. 6. 7. 8.

Number of Institutions Population Norm for Providing Service Population Covered per Institution Number of Villages Covered (Average) Number of Institutions required as per 2001 Population Institutions without Building (Percent) CHCs without Physicians (Percent) Institutions without Staff (Percent)

Community Health Centre (CHC) 105 1,20,000 1,53,000 118.36 134 54% 100% -

Primary Health Centre (PHC) 484 30,000 33,148 25.64 534 54% 29%

Sub Centre (SC) 2852 5,000 5,625 4.36 3209 15% 16%

Note : CHC is a 30 beds Hospital/Referral unit for 4 PHCs with specialized services. PHC is Referral unit for six SCs with 4-6 beds with a Medical Officer incharge and 14 paramedical staff. SC is the most peripheral contact point between Primary Health Care System and Community with one MPW(F)/ANM and one MPW(M) worker. Source : GOI (2002), Bulletin on Rural Health Statistics in India: March 2002, New Delhi: Rural Health Division, Ministry of Health and Family welfare, Government of India.

Table 6 State Outlay and expenditure on Rural Health Schemes in Punjab and Kerala : A Comparison 2001-2002 (Rs. In Lakhs)

1. 2. 3. 4. 5. 6. 7.

Maintenance of Sub Centres Health and Family Welfare Training Centre Training of ANM/LHV Primary Health Care Village Health Guide Scheme Regional Family Welfare Centres (RFWCs) Training of MPWs Total Expenditure Rural Population (in Millions) Expenditure per 1000 Persons (Rs.)

Punjab 785.00 22.50 95.00 452.50 13.70 962.00 48.00 2378.20 16.0 14,823

Kerala 3000.00 45.00 350.00 800.00 0.00 1216.00 32.00 5443.00 23.6 23,091

Source : Same as Table-5

Figure Health Status of Population and Access to Public Services Panjab and Kerala
2.7 1.8 57.1 16.3 15.9 2.6 80 43.9 41.4 22.7 39.2 21.9 7.1 2.6 42.8 9.9 13.8 37.9 26 0.3 41.3 98.5 62.5 94.1 7.6 36.3

Total Fertility Rate

Punjab

Kerala

Infant Mortality Rate

Child Mortality

Anaemic Children %

Anaemic Women %

Stunted %

Wasted %

No Literate Female HH %

HHs using Public

Health facilities

No Ante Natal Care %

ANC by Doctor

Safe Deliveries %

Delivery in Pub Hospital % 0

20

40

60

80

100

120

Figure Health Status of Population and Access to Public Services Rural and Urban Punjab

2.4

Total Fertility Rate

Rural

Urban

1 .8 6 2.7

Infant Mortality Rate

39.6 4 2.2

Stunted %

29.4 7

Wasted %

7.4 3 4.8

Illertaes %

21.9 47.2

No Literate Female HH %

37.2 30.8

No Ante Natal Care %

9.7 3 4.8

ANC by Doctor

6 3.1 5 8.1

Safe Deliveries %

7 7.8 7.1

Delivery in Pub Hospital %

9.3

20

40

60

80

100

Figure Composition of Expenditure on Rural Health Schemes

Punjab
4.0% 0.9% 19.0% 33.0% 0.6% 0.8% 6.4%

Kerala
55.2%

2.0% 40.4%

14.7% 22.3%

0.6%

Maintenance of Sub Centres Health and Family Welfare Training Centre Training of ANM/LHV
Village Health Guide Scheme Training of MPWs Primary Health Care Regional Family Welfare Centres (RFWCs)