CHAPTER- 1

INTRODUCTION

1.0 INTRODUCTION

―Childhood is the time for children to be in school and at play, to be confident and grow
strong with the encouragement and love of their family and a comprehensive community
of caring adults. By itself, childhood means much more than just the space between birth
and attainment of adulthood. It refers to the state and condition of child’s life, to the
quality of those years‖. (UNICEF, 2005).

From this definition three issues emerge – first a child‘s life, second quality of the
child‘s life and third is the responsibility of society or nation for the complete growth of
the child.

Child‘s life is an important issue because children are the real wealth of a nation. In
case of emerging nations like India, the interest of child health is much more important
than those of the developed countries because even though developing countries are
economically and technologically deprived, they have the condition of demographic
dividend. The present era of globalization (in which movement of labor is free from all
obstacles) and telecommunication revolution provides great opportunity to low income
countries to develop their service sector which is based on human beings only. But a
basic need of service sector is availability of healthier and skillful human resource. The
foundation of skillful human resources is laid down in the childhood mainly during first
five years of life, because this is the crucial time for mental and physical development.
That is why child mortality is an indicator of development and an important goal of
Millennium Development Goal. It is ―Goal no.4 (Reduce child mortality) in MDG, and
under five-year child mortality rate is considered as an indicator in MDG (4.1)‖. In 2015,
United Nation General Assembly set seventeen sustainable development goals, these are
intended to be achieved by year 2030. In sustainable development goals, ―Goal number-
1|Page
2, zero hunger‖ and ―target 2.2‖ is, ―by 2030 to end all forms of malnutrition, including
achieving the internationally agreed targets on stunting and wasting in children under
five years of age, by 2025”(www.un.org/sustainabledevelopment). And in Goal no. 3,
target 3.3 is related to under-five child mortality(Table1.2).Although in India, substantial
growth has been attained in the sector of elementary universal education, inclusion of
gender in education & health and the global economy, though progress in the field of
wellbeing indicators relating to morbidity and mortality is not satisfactory, and also
progress is not satisfactory in various physical environmental factors those are
responsible to poor health conditions (Nath, 2011).

Table 1.1 Child health & Nutrition in the Millennium Development goals (MDGs)

Goal Target Indicators

“Prevalence of
underweight in
children (Under 5
Target 2: ―Halve,
years of age)”
Goal 1: ―Eradicate between 1990 and
extreme poverty 2015, the proportion ―Proportion of
and hunger‖. of people who suffer population below
from hunger‖. minimum level of
dietary energy
consumption‖.

“Under five mortality

Target 5: ―Reduce by rates”
two-thirds, between
Goal 4 : ―Reduce child “Infant mortality rate”
1990-2015, the
mortality‖
under-five mortality “Proportion of one-year
rate‖ children immunized
against measles”.

Source: The determinants of child health and nutrition: A Meta data analysis, WHO report

2|Page
 Table 1.2 Child health & Nutrition in the Sustainable Development goals

Goal Target

Target 2.2: “By 2030 end all forms of

malnutrition, including achieving by 2025 the
Goal 2: “End hunger, achieve food internationally agreed targets on stunting and
security and improved nutrition, wasting in children under five years of age, and
and promote sustainable address the nutritional needs of adolescent girls,
agriculture‖. pregnant and lactating women, and older persons‖.

Target 3.3: “By 2030, end preventable deaths of

Goal 3: ―Ensure healthy lives and
promote well-being for all at all
ages‖.
newborns and children under 5 years of age, with
all countries aiming to reduce neonatal mortality to
at least as low as 12 per 1,000 live births and
under-5 mortality to at least as low as 25 per 1,000
live births”.

Source: sustainabledevelopment.un.org

1.1 CONCEPT OF UNDER 5 MORTALITY RATE AND CHILD

HEALTH

―The under-five mortality rate (U5MR) is the probability (expressed as a rate per 1,000 live
births) of a child born in a specified year dying before reaching the age of five, if subject to
current age-specific mortality rates‖.

―A live birth is the complete expulsion or extraction from its mother of a product of conception,
irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any
other evidence of life‖ (UNSTATS).

Child health comprises overall health of children including both mental health and physical
health. It is a crucial issue because childhood is the time which decides the physical and mental
development of an individual. In developing countries children suffering from various diseases
related to physical environments, malnutrition and lack of immunization.

3|Page
1.2. INTERNATIONAL AND NATIONAL SCENARIO OF U5
MORTALITY RATE: -

Although globally, under five mortality rates has decreased by 59 percent from an estimated rate
of 93 deaths per thousand live births in 1990 to 39 deaths per thousand live births in 2018, but
still it is quite high. Around 5.3 million under five children died in 2018, nearly 14,500 every day.
Considerable variations have been observed in under five child mortality rate among different
regions or countries. More than 70 percent of all deaths in the world occur in two WHO regions:
African and South East Asian regions. About half of under five deaths occur in only 5 countries.
These countries are namely China, India, Congo, Nigeria, and Pakistan. Disparity in income also
shows differences in under five mortality rate. In low-income countries under five child mortality
was estimated as 68 deaths per thousand live births which is almost 14 times the average rate in
high income countries (5/1000 live births), (WHO-Global Health Observatory 2013).

India contributes the highest global burden of under-five mortality. India reported 8.8 lakh under-
five children death in 2018 (the State of the World‘s Children report-2019, UNICEF). India‘s
rank was 49th from bottom with respect to under five mortality among worst performing countries
(The State of the World‘s Children 2008, New York: UNICEF; 2007.p. 150). Now, India‘s under
five mortality rates is 37 deaths per thousand live births (SRS-2017), it is lower than world
average under five mortality rate, which is 39 per one thousand live births (WHO 2018). Place of
residence also plays an important role in under five mortality rate. On the basis of place of
residence, rural areas had more (35 percent more) under five child mortality rate (42/1000 live
births) than urban areas (25/1000 live births) (Table-1.3). Significant variations have been
observed amongst the states of India. Madhya Pradesh has the highest under five mortality rate
which is 55/1000 live births, followed by Assam (58), Odisha and Chhattisgarh (57) and Uttar
Pradesh (46/1000 live births) (SRS, 2017) while Kerala is the best performing state in under five
child mortality which has only 12/1000 live births under five mortality rate followed by Tamil
Nadu, having 19/1000 live births under five child mortality rate (Table 1.3).

4|Page
 Table 1.3 Under five child Mortality Rate (Per 1000) live Birth

Under Five Child Mortality Rate (per 1000 live Birth

States Total Rural Urban

Assam 48 51 22

Madhya Pradesh 55 61 34

Odisha 47 49 37

Uttar Pradesh 46 49 35

Rajasthan 43 47 29

Bihar 41 42 34

Chhattisgarh 47 50 33

India 37 42 25

Jharkhand 34 35 28

Gujarat 33 40 22

Haryana 35 38 28

Andhra Pradesh 35 39 25

Himachal Pradesh 25 26 19

J&K 24 26 19

West Bengal 26 27 25

Karnataka 28 30 24

Punjab 24 26 21

Delhi 21 17 21

Maharashtra 21 25 16

Tamil Nadu 19 22 17

Kerala 12 12 12

Source-SRS-2017

5|Page
 Though there has been a continuous decline in U5MR in India, in terms of newborn
and child survival, India has progressively improved. From an infant mortality rate in
1990 of 84 per thousand live births to 33 in 2011 (SRS 2017) and an U5MR of 118 per
one thousand live births in 1990, the statistics have improved to 37 in 2017 (SRS, 2017).
The rate of decline was higher in the previous decade. But current under-five mortality
rate is still higher in comparison to those countries which have the similar socio-
economic character. It is because of disease prone environment (tropical country), weak
physical infrastructure, overcrowding, high fertility rate and low level of health care
facilities. With respect to the sustainable development goal no. 3 target for 2030 for the
neo-natal mortality rate and the under-five mortality, For the sample period, the estimated
neo-natal mortality rate for India is around 2.4 times higher, while the estimated U5MR is
about two times higher. At district level, 9 percent of the districts have already achieved
the NMR targeted in SDG3 among 643 districts. However nearly half districts (315) are
unlikely to meet the 2030 SDGs target even though the NMR reductions have been
attained between the last two rounds of India's National Family Health Survey. Similarly,
less than one-third of the districts (177) of India are not likely to meet the SDG3 target on
the under-five mortality rate by 2030. Although the majority of neo-natal mortality rate
and under-five mortality rate high-risk districts are situated in the deprived states of
north-central and eastern India, a few high-risk districts for NMR also fall in the affluent
and progressive states. For example, about 97% of districts in Chhattisgarh and Uttar
Pradesh are not likely to achieve the SDG3 target for preventable deaths, regardless of
gender, among infants and children under the age of five. (Bora and Saikia, 2018). Table
1.3 shows the state wise relative analysis of U5MR based on SRS 2017.

6|Page
1.3 STATEMENT OF THE PROBLEM

Around 5.3 million children under age five died in 2018. The foremost causes of
death in U5 children are ARI, preterm birth difficulties, birth asphyxia, diarrhoea and
malaria (WHO, 2018).

Table 1.4, Principal cause of death in children under five in the world-2011

Leading Cause of Death in Children U5

in the World-2011

Causes Percentage

All Causes 100

ARI 17

Prematurity 17

Birth asphyxia 11

Diarrhoea 9

Malaria 7

source-WHO

Severe infections including sepsis/pneumonia, tetanus, diarrhea and asphyxia are

among the major causes of death at a very early age (Lawn et al., 2006). Globally,
diarrhea and ARI are the main leading diseases which are responsible for U5 child death.
ARI constitutes more than 17% and diarrhea constitutes 9% deaths in under five children
to overall under five children‘s death (Table 1.4). In India Preterm birth complication,
Pneumonia, Intrapartum-related issue and diarrhea are the top four major causes of
U5MR, contributes 27.5 percent, 15.9 percent, 11.6 percent and 9.3 percent respectively
of total U5MR (Table-1.5). Pneumonia (ARI) and diarrhea are the top two main causes of

7|Page
death among children aged one month to fifty-nine months in India (Table-1.5). Among
all child deaths each year in India, seven out of ten of these deaths are due to diarrhea,
acute respiratory infections, malnutrition or combination of these conditions (Aggrawal,
2005).

Table- 1.5 Leading causes of death in India in 2015

Post neonatal
Neonatal death U5MR (In
Cause (In Percentage)
death (In
Percentage)
Percentage)

Deaths 57.9 42.1 100

Preterm birth complication 25.5 2 27.5

Pneumonia 3 12.9 15.9

Intrapartum-related issue 11.1 0.5 11.6

Diarrhoea 0.4 8.9 9.3

Sepsis or Meningitis 7.9 2.2 10.1

Congenital disorders 6 2.3 8.3

Injury 3.4 3.4

Measles 1.9 1.9

Source-The Lancet-2019

Child health status is determined by many factors. Some factors directly affect the child
health while others are intermediate determinants which means they affect child health
indirectly. Childhood diseases such as ARI, Diarrhea, malnutrition and immunization are
the factors which determined the child health status directly while socio-economic
indicators and indicators of physical environment are the intermediate indicators (Mosley
and Chan, 1989).

8|Page
 Immunization plays the most significant role in child health status because it is a
preventable measure (Mosley and Chen, 1984) which protects children from life
threatening diseases such as BCG, diphtheria, pertussis, hepatitis B, measles, tetanus and
Japanese encephalitis. In India there is a wide variation among states in term of
immunization coverage. The proportion of children fully immunized in BIMARU (EAG)
states were 48 per cent as against 63 per cent at all India level. (Singh and Yadav, 2000).
Among EAG states, the highest negligence in vaccination is reported in Uttar Pradesh
with 7.6% children not covered under any vaccinations (AHS 2010-11). In Bundelkhand
region, out of 7 districts three districts namely- Jhansi, Mahoba and Jalaun are
performing well, having higher percentage of children fully immunized as compared to
state average while four districts namely- Chitrakoot, Hamirpur, Banda, Lalitpur lag
behind the state average (AHS 2010-11).

Table-1.6 Malnutrition burden in Bundelkhand Region

All UP
Under-
Districts of Stunted Wasted CIAF Rank in
weight
Bundelkhand CIAF

Jhansi 36.1 27.2 39.5 58.62 26

Mahoba 44.6 23.9 47.7 61.31 39

Banda 46.7 18 41.5 61.68 41

Hamirpur 38.5 32.3 39.8 64.10 50

Jalaun 45.6 32.2 49.2 66.33 60

Chitrakoot 50.9 33.3 52.5 71.92 68

Lalitpur 40.7 39 48.8 74.33 71

Uttar Pradesh 46.3 17.9 39.5 60.14

Source- NFHS-4

9|Page
Under-nutrition, especially for children and reproductive women, is a major public health
issue. It has significant effects for wellbeing, morbidity, longevity and economic growth.
It is also associated with poorer cognitive growth which can contribute later in life to
severe health impairments that can decline economic productivity (Scrimshaw, 1996).

Bundelkhand region is performing well in health indicators but not doing well in
terms of nutrition. Malnutrition among children is a serious issue in Bundelkhand. Out of
all seven districts only Jhansi performing well than state average in terms of any type of
malnutrition burden. Among all indicators of malnutrition, the situation is alarming in
terms of wasting (weight for height) and underweight (weight for age). All the districts of
Bundelkhand have more percentage of children than state average who are suffering from
wasting and underweight (Table-1.6). Lalitpur, district of Bundelkhand have the highest
burden of overall malnutrition among all district of Uttar Pradesh.

The Government of India launched the Integrated Child Development Services

(ICDS) in 1975 under the aegis of the ministry of women and child health in association
with UNICEF to resolve the underlying causes of constant under-nutrition among
children and women and to encourage child development (UNICEF). Since then, this
robust programme has been operational. The integrated child development scheme
follows an all-inclusive approach to the well-being of children, aimed at achieving well-
being, education and nutrition-related goals through a network of community-level
Anganwadi centers (AWCs) (Gragnolati et.al., 2006). NFHS 4 data and many articles
clearly depict that at national level the utilization of Integrated Child Development
Scheme is controlled by or is associated with many socio-economic variables such as
Caste-system among the Hindus, Religion, Wealth Quintiles, Maternal education and
Maternal work status and also sex of the children. So, it will be interesting to note if
Bundelkhand, which is a micro region, also follows the same pattern or utilization of
ICDS as is governed by these socio-economic variables. And if so, then it is to be
ascertained if the correlation between them is similar to the national level or is different.

Out–migration of both types, long term and short term, for work, is the main
issue relating to Bundelkhand region. Both the types of migration influence child health
10 | P a g e
status. But short-term or seasonal migration has high negative correlation with child
health. It is because of exploitation and exclusion that is associated with short-term
migration. Government of India launched many schemes associated with rural
employment. MGNREGA is one of them. MGNREGA is the world largest social welfare
scheme. Its prime objective is to provide employment to rural people or improving the
income protection of the people in rural areas. MGNREGA affected child health in many
ways. First of all, it provides employment in rural areas and unemployment has been
deeply linked with food insecurity and poverty in India and is an important determinant
of child nutrition‘s (Engle PL, 1993). MGNREGA also provides women autonomy and
special care for children under age 5. These are some provisions of MGNREGA-
―Schedule II (6) priority is to be given to women for work, and at least one-third of
workers at the worksite to be women. Schedule II (28) demands child-care facilities to be
provided at worksite if children are below the age of six are accompanying their working
mothers. Schedule II (34) provides legal space for prohibiting gender discrimination in
wages‖ (www.mgnrega.co.in/aim-of-mnrega.htm).

The high emphasis on the child survival programmes like nutrition, vaccination and
health promotion interventions have led to reduce in the new-born mortality in the current
decades. At the same time, in order to cater these services appropriately to the household,
especially in the country areas, the need for better health care delivery system was
realized. It is often argued that for reducing infant mortality rates, the sufficiency and
accessibility of dedicated child and maternal health staff as well as easy access to
neonatal and maternity services to pregnant women is indispensable for better health of
both mother and child (Rammohan,A. & Awofeso,N., 2011). This was further supported
by the World Health Report, 2006 which stressed that the probability of infant, child and
maternal survival is positively correlated with the availability of adequate and competent
health staff (WHO, 2006).

11 | P a g e
1.4 LITERATURE REVIEW

In developing countries, under five mortality rates (U5MR) was 82deaths per 1000
live births which are more than 13 times the average rate in developed countries
(6/1000live birth) (WHO,2013). The findings of many demographic researchers confirm
strong negative co-relations between socioeconomic status, physical environment and
under-five mortality rate. There are many factors linked with physical environment and
socioeconomic status that may have inconsistency effects on infant and child health and
mortality which includes family income, housing conditions, education, father's
occupation, mother‘s occupation, access to healthcare, family structure and exposure to
the media. (Encyclopedia of Population, 1982: 341).

1.4.1 THEORETICAL FRAMEWORK

The theoretical framework is the most important part of the study because it provides the
theoretical base of the study. It gives the knowledge about proximate determinants which
affect intermediate variables most and what are the main intermediate variables which
affect the overall study.

In the theory of Child Survival in developing countries given by Mosley and Chen
(1984), environmental contamination factors like air, food and water quality, cleanliness
of fingers, soil, skin and inanimate objects, insect vectors etc. are designated as one of the
five Proximate determinants which affects child health, with each determinant known to
exert individual influence. According to this theory, the socio-economic determinants
operate through the first four proximate variables, they are-: ―Maternal factors: age;
parity; birth interval. Environmental contamination: air; food/water/fingers;
skin/soil/inanimate objects; insect vectors. Nutrient deficiency: calories; protein;
micronutrients (vitamins and minerals). Injury: accidental; intentional”. Environmental
contamination leads to the spread of infectious agents to mothers and children. Mosley
and Chen (1984) discussed the four routes through which infectious agents are
transmitted to the human body. These routes are air, from which respiratory and many
contact diseases are transmitted; food, water and finger routes which are the main routes
12 | P a g e
for the spreading of diarrhea and intestinal diseases; skin/soil/inanimate objects, through
which transmission of skin diseases take place; insect vectors which transmit the parasitic
(bacterial, viral, protozoans etc) diseases like malaria etc. The Fifth variable ―Personal
illness control‖ influences the specific health state of the infant through prevention and
treatment of any disease. An important aspect of this model is that it tries to look how the
disease in an individual is an indicator of the proximate determinants affecting health,
rather than looking at the cause of death. Environment, education, poverty and
technology are some of the other variables that affect child survival.

UNICEF‘s framework for nutritional analysis was well developed in 1990. This
framework recognizing ―immediate, underlying and basic causes of under-nutrition‖.
Immediate causes of malnutrition are ―inadequate dietary intake and disease‖. The food
intake and susceptibility of a child to illness is influenced by underlying variables.
Underlying variables are ―household food insecurity (lack of availability of, access to,
and/or utilization of a diverse diet), inadequate care and feeding practices for children,
unhealthy household and surrounding environments, and inaccessible and often
inadequate health care”. The basic causes of poor nutrition include social systems and
mechanisms that violate human rights and promote poverty, restrict or refuse access to
vital resources for vulnerable populations. Social, political and economic factors can
affect maternal and childhood malnutrition in the long term. In addition, acute
malnutrition can lead to poverty and create a vicious cycle.

In the analytical framework used by Jain, A.K. (1985) in Determinants of Regional

Variations in Infant Mortality in Rural India, he distinguishes factors at three levels:
―village, household and individual”. Individual level factors are further divided into two
types -Medical care and Non-medical care. Non-medical care comprises protection from
environmental contamination, sanitation and feeding practices. The second level of
factors i.e. household consists of the economic, social condition and physical
environment of the households. The physical environment comprises the house condition,
overcrowding, safe and hygiene drinking water, latrine facilities and source of fuel for
cooking and lighting. Social atmosphere consists the education of the mother, parity,

13 | P a g e
interval between pregnancies and age. Economic conditions are shown by factors like
household income, household expenditure. The third level of factors i.e. village level
related to physical, economic and social environment at the society or community level.
These terms are indicated by the accessibility of physical infrastructure facilities like
water supply, schools, medical care facilities, transport and communication.

1.4.2 DETERMINANTS OF CHILD HEALTH STATUS

The first six years of life have a critical and enduring impact on the health, well-
being, skills and opportunities of a child (Dreze, 2006). Child health status is determined
by many intermediate variables and many proximate variables. In this study, there are
four intermediate variables – diarrhea, Acute Respiratory Infection, burden of
malnutrition and Immunization. There are many proxy indicators which determine the
child health status like-the place of residence, physical environment, socioeconomic
variables and demographic variables. Here is the brief review of some more important
variable of child health status.

Overall high level of inequality of opportunity among Indian children in vaccination and
nutrition with substantial geographical variations (Singh, 2011). Place of residence plays
the most important role in U5MR. South Asian countries show rural children‘s
disadvantages in terms of death during early childhood and infancy (Pandey et al., 1998).
At both national and state levels in India, the rural disadvantage of infant longevity
persists. This rural-urban gap in infant mortality rate are present in socioeconomically
backward states such as Madhya Pradesh, Assam and Orissa as well as socio-
economically and demographically well doing states like Kerala and Goa (Saikia et al.,
2013).

Studies on developing countries have clearly shown that the rural bad performance in
infant mortality in developing countries is because of so-called ‗urban prejudice‘
(Crenshaw and Ameen, 1993), which depicts an unequal advantage gained by an urban
community in comparison to rural community in the allotment of public funds (Redclift,
2013). In India rural place residence provides the residence to approximate 60% of the

14 | P a g e
population, now which showed declined growth rate in public investment in electricity,
drainage, water, infrastructure, irrigation, health care and education etc as compare to
urban areas (Klaauw, 2011). The situation of improved sanitation is very hazardous in
rural areas of the country. Only 6% of household have improved sanitation in the rural
area and still 69% of rural residents practice open defecation (UNICEF/WHO, 2010).
Among all the states in rural India, only five states have achieved more than three-quarter
of rural households to have access to improved sanitation. The EAG states have very bad
sanitation situation. And in case of urban place of residence, all EAG states except
Uttarakhand and many developed states like Tamil Nadu, Manipur and Karnataka have
only 25% to 50% households which did not have access to unimproved sanitation.
Unimproved sanitation contributes to the transmission of many infectious diseases, of
which India is still vulnerable (Sharma et al., 2012).

Arulampalam (2007) mentions that regarding physical and health infrastructure, social
and economic growth, India's rural place of residence lags behind than other developing
economies. He is mainly attracted in environmental and socioeconomic attributes, like
education status of mother, the source of drinking water, hygienic situation, access to
electricity, type of fuels used for cooking and availability of health facilities. In
developing economies, Health services consume a substantial percentage of the share of
families spending (Pritchett and Summers, 1996). And in India urban-based health care
services continue to get a huge percentage of shares of government fund, leading to lesser
investments in rural health care services (Balarajan and Subramanian, 2011)

Throughout the low-income countries of the world, the condition of life in rural areas for
infants and children are often worse than they are in urban areas (Amonker and Brinker,
1997). India also shows a similar picture. In India, overall mortality and infant mortality
in urban place of residence is lower than in rural areas (Amonker and Brinker, 1997). In
rural area of India, per one thousand (1000) live-birth, almost hundred (100) children die
before attainment the age of five years, and within the first month after birth, about half
of them die. (Klaauw, 2011). According to the study based on NFHS data, the author
concluded that there is a low correlation between the percent women employed and the

15 | P a g e
percentage of urban population (-0.148), while each is negatively correlated with both
infant mortality rate and child mortality rate (Amonker and Brinker, 1997).

In low-income countries, even the urban areas do not show a better picture. In urban
areas, high child and infant mortality (however it is less in comparison to rural areas) is
due to the presence of urban slums in which, due to most difficult and unhygienic
environmental condition, overcrowding and urban waste increases the potential for
exposure to pathogens and a slightly greater need for hygiene levels that allow sufficient
water and sanitation (Bartlett, 2008).

Children‘s right to survival and to the utmost achievable benchmark of health based to a
critical level on healthy and safe atmospheres (Bartlett, 2008). The status of the health of
the people is not only determined by PHCs, CHCs and number of doctors but also
determined by the hygienic and clean physical environment (Chakravarty, 1986).

The quality of materials used for building houses also significantly affects child
mortality. It is negatively correlated with houses that are built of high-quality material
(Pucca) (Klaauw and Wang, 2011). Crowded living condition or lesser number of rooms
is the leading factor behind the respiratory tract infection i.e. Bronchitis, pneumonia etc.
(Visaria, 1984).

Child death rate is lesser when a specific room has been used as a kitchen, and when the
household has electricity connection and some kind of toilet facility. Even if the family
does not have a separate room for cooking, the child mortality rate could be lowered if
the family usages clean and affordable fuels for cooking in place of unclean fuel for
cooking (Klaauw and Wang, 2011). Using cooking fuels that produces smoke within the
home causes indoor air pollution. Having a specific room for cooking significantly
decreases child death rate even if smoky cooking fuels like cow dung cake, crop residue
and wood are used (Klaauw and Wang, 2011).

Millions of kids still die from preventable illnesses yearly which can be the result of the
poor provision of water and sanitation (Bartlett, 2008; Global Burden of Diseases, 2000;

16 | P a g e
Pruss et al., 2002). Sustainable Development Goal Number 6 guarantees access and
sustainable management of clean water and sanitation for all. It is accepted in large scale
because clean and fresh water is a very serious concern for child health. Preventable
illnesses, particularly when united with malnutrition, may so weaken the body‘s defense
to such an extent that they are vulnerable to other causes of death too, like measles,
tuberculosis and pneumonia (WHO, 1992). Town level data from Global Urban
Indicators indicate that child death rates are typically more closely associated with a lack
of access to clean and drinkable water and sewage connections rather than other
frequently mentioned factors, like the availability of health care services or the number of
households below poverty lines (Shi, 2000). Cutler and Miller (2005) on the study of U.S.
cities find that ―clean water was responsible for about half of the observed decline in
mortality and nearly two-thirds of the reduction in child mortality in cities.‖ A case study
in India also confirmed that micro-loan-funded latrine construction can boost wellness
and family income. (UNDP). Therefore, sanitation and clean drinking water get more or
equal importance as the number of doctors and hospitals (Chakrawarty, 1986).

Cutler and Miller (2005) also wrote in their article that Supplying piped water and
sanitation services will significantly decline child mortality as these are the main reasons
behind rapid decline in child mortality in 20th century in the USA. The time that one
needs to access water and distance of the water source also plays a significant role in
child mortality. For households that take more than 5 minutes to get to the water source,
child mortality is greater, but after 5 minutes, it does not increase with the time to get to
the water source (Klaauw and Wang, 2011). Situation of the village also plays a crucial
role in child survival. (Klaauw and Wang, 2011).

Infant mortality is substantially decreased by access to sanitation facilities

(Klaauw and Wang, 2011). In the deprived countries, unhygienic and germ-diseases
living conditions probably account for at least half of the total health burden
(Satterthwaite et al., 1996). It shows that poor and developing countries are worst
affected by the unsanitary environment. Being a developing country, it plays a very
important role in the case of India. Deepak Parekh Committee also suggested that

17 | P a g e
improvement in child health and malnutrition cannot be abolished till sanitation
conditions do not improve. Sanitation coverage is not only playing an important and
positive role in combating child stunting during first year of life but also targets girls
implicitly (Augsburg and Lesmes, 2018). The main reason behind malnutrition is bad
sanitation, basically open defecation because it leads to several dysenteric infection
disease specially Diarrhea. Episodes of diarrhea and infections of the respiratory tract as
well as malaria etc. results partially from the contaminated water supply, inadequate feces
disposal and unhygienic home conditions (Visaria,1984). The variable percentage of the
households with sanitary toilets is only statistically significant at the 1 percent level
infant mortality rate (-0.617) (Amonker and Brinker, 1997). As a consequence of
improved living standards during the 1990s, the decreasing trends in child mortality rates
are the outcome. The proportion of the population that is either illiterate or has not
completed primary education, for example, is steadily decreasing. (Klaauw and Wang,
2011).

Regional variation is also found in child mortality. Southern states show better picture
while northern states mainly EAG states show the worst situation in child health status
(Jain, 1985). The reason behind this are variations in the structure of kinship and woman
autonomy between north and south, which can affect child - care practices and thus child
mortality, although modern health education and facilities are lacking in both regions,
(Dyson and Moore,1983).

Economic inequalities also play a crucial role in child health and mortality. In the
poorest 20 percent of the population, the infant mortality rate is 2.5 times greater than
that of the wealthiest 20 percent of the population, meaning that an infant born in a low
income family is twice as likely to die in infancy as an infant born in a rich family (Jain
et al., 2013). The burden of health insecurity has been seen at the state level in the less
financially developed states of Bihar, Odisha, Jharkhand, Chhattisgarh, Madhya Pradesh,
Uttar Pradesh and Rajasthan (Pathak, 2013). After controlling other typical socio-
economic factors (education and job status) of children and their families, a gradient
correlation continued between family income and child health outcomes. Children are

18 | P a g e
more prone to have disease if their family is nearer to poverty line. There were substantial
correlations across health outcomes and potentially mediating factors, such as parental
mental health, family structure and number of children (Victorino and Gauthier, 2009). In
estimates of the determinants of nutrition outcome and child health, income is a major
indicator. More money available to a family should result in more spending on health and
food (Charmarabagwala et al. 2003).

There are poor people living in slums in urban areas. Slums are characterized by poor
health especially the poor health of children; this is because of poor housing condition
and unsanitary and unhygienic environmental conditions and overcrowding (Natarajan,
2014). Prevalence of morbidity is also high in slum children in comparison to other
children (Ray, 1990).

Immunization plays the most significant role in child health status because it is a
preventable measure (Mosley and Chen, 1984). There is a significant difference between
states in terms of vaccination coverage in India, the percentage of fully immunized
children in BIMARU (EAG) states was 48 percent as compared to 63 percent at all India
level. These results ranged from 37 percent in Bihar to 68 percent in Madhya Pradesh
within BIMARU (EAG) states. (Singh and Yadav, 2001). The main determinants of
immunization are literacy of mother and father, size and accessibility of villages, lack of
information, place of residence (Singh and Yadav, 2001); lack of faith, considering polio
as the only vaccine (Nath et al., 2007); mass media exposure, standard of living and
availability of health card (Kumar & Mohanty, 2011). Maternal health literacy is
independently related to child immunization. Health literacy programs could increase the
coverage of immunization (Johri et al., 2015). Study based on urbanized village of Delhi
concluded that level of literacy, ownership status and place of birth of a child are also
important determinants. Children whose mothers were schooled for eight or more years
were twice as likely to be fully immunized as those whose mothers were not literate.
Children of clerks, shopkeepers or semi-professional were more likely to be wholly
vaccinated than those who were trained or untrained employees. Children of renters who

19 | P a g e
were migrants from other places were less likely to be vaccinated than the permanent
residents of the region or city (Chhabra et al., 2007)

Breastfeeding is the major determinant of overall child health and development. The
promotion of breastfeeding should help to decrease infant mortality from Acute
Respiratory Infections and diarrheal diseases (BMJ, 1989). Promotion of breastfeeding to
reduce undernutrition among children below 5 years of age is an important part of the
National Action Plan for Children (BMJ, 1989). Apart from being highly nutritious,
breast milk also contains high levels of antibody-rich proteins, particularly secretory
immunoglobulin A and lactoferrin, which provide anti- infective defense to the neonatal
(Bern- shaw, 1991). The maternal antibodies found in human breast milk also defend the
baby against respiratory infections (Kremer and Zwane, 2007).

Breastfeeding is the best way to get rid of problem of malnutrition among infants in early
childhood in developing countries because breast milk alone can support adequate child
growth for the first several months of life (Huffman, 2015). And in quality concern of
breast milk of the malnourished and fully nourished mother, in general, there is no
difference in terms of lactose and protein content in the milk (Hartmann and Fiattigan,
1985).

As documented and stated by several researchers, age of the mothers is the most
important factor determining child health and therefore it can be said that children born to
adolescent mothers are more prone to diseases and are likely to experience inferior
health. Poor infant and child health outcomes are strongly associated with the early age of
mothers, due in part to young women‘s physical vulnerabilities and in part to the lack of
social and reproductive health services for this high-risk group (Greene, 2003). In
neonatal mortality, a quarter of the infants died to disease like pneumonia, diarrhea,
malaria, neonatal sepsis, pattern delivery, and asphyxia at birth. While some of the
diseases can be prevented by vaccination, the latter are mostly the result of the early age
of mother (WHO, 2001).

20 | P a g e
A leading determinant of child health is parental education status. The mortality of
children at all ages is substantially lower when parents have completed primary
education. For the mother, the result is stronger than for the father (Klaauw and Wang,
2011). Mother‘s education affects child health in two ways- through high standard of
hygiene and better child care practice and greater and more rational use of curative and
preventive measures of health (Mosley and Chen, 1984; Cleland and van Ginneken,
1988). ―Mother’s education has an independent, strong and positive impact on the
survival of her children" (Caldwell, 1994). Children of literate mothers have a lower
prevalence of suffering from diarrhea in comparison to illiterate mother‘s children.
Children whose mothers are educated are less likely to suffer from fever (Natarajan,
2014). Maternal education may be a proxy indicator of the socio-economic status of a
household and a characteristic of a community of a residence (Desai and Alva, 1998).
Visaria (1985) also observed a negative relationship between the level of education of
mothers and the infant and child mortality in several developing countries including
India. Generally, educated mothers are healthy and give birth to healthier children. In
order to provide a healthier atmosphere to children, they are more likely to have more
awareness of care taking and higher prenatal care standards (Maitra, 2004). Maternal
education positively affects immunization level and access to health facilities too. (Desai
and Alva, 2000). Parental education's role in determining the health and nutritional status
of children is of two way. First, better education would lead to higher incomes, Better
educated parents are more aware about child health and nutrition (Charmarabagwala et al.
2003).

Working nature of a mother also plays important role in child health, the relationship
between child health and female labour work participation is even complex. On the one
side, labour force participation has adverse impact on child health, which happen
probably in those families where women must participate in labour market soon after
delivery because of poverty, and on the other side, female work participation increases
the household earning which will have a positive effects on child health and child
nutrition (Tulasidhar, 1993). If women are engaged as agricultural labour other than other
blue-collar jobs it is presumably good for infant and child because agriculture tends to be
21 | P a g e
seasonal and permits flexibility in work (Visaria, 2011). Generally, women work
participation and child care have shown the inverse relation because working women
spend 1.7 hours less time in child care in comparison to non-working women (Sivakami,
1997). This adverse effect is observed when working activity is mismatched to child
nurturing or where the mother lacks access to another person to be able to care for the
child (War, 1984).

Birth order also affects the child health, if children whose birth order is second or third
have lower prevalence of fever and diarrhea and cough, in comparison to children whose
birth order is first, because in case of first child mothers do not have any child care
experience (Natarajan, 2014). But burden of under-nutrition is directly proportional to
birth order. With birth order, India's height disadvantages rise rapidly (Jayachandran and
Pande, 2017). Family size and composition can act differently with child health. In family
size, dependency ratio matters more, children belonging to household of higher
dependency ratio and higher birth order being usually vulnerable (Charmarabagwala et al.
2003).

1.4.3 NUTRITION AND CHILD HEALTH

Malnutrition is also a major determinant of child health. Malnutrition has

significant outcome for wellbeing, endurance and economic growth. It is also correlated
with slower cognitive development and may lead to severe health abnormalities later in
life that can restrict economic efficiency (Scrimshaw, 1996). The prevalence of
morbidities especially episodes of diarrhea, respiratory infection and measles and
childhood mortality is closely associated vitamin A deficiency (Gupta and Indrayan,
2002). This is because Vitamin A plays a multi type of function such as growth, vision,
immune function and survival (West, Sommer, et al. 1996). Nutrition- infection is a
vicious cycle. Under-nutrition reduces immunity and infection hinder hunger reduce
absorption and lead to loses of important nutrients. Hence apart from economic and
physical access to food, access to clean environment and safe drinking water are area of
great involvement (Bamji, 2009). Malnutrition is strongly associated with household
wealth (Chalasani & Rutstien, 2014). Children with illiterate mothers, mothers of lower
22 | P a g e
age group, or belonging from families of poor living standards are more likely to be
undernourished. Generally, state-wise distribution of under-nutrition showed a close link
between prevalence of malnutrition and development. Prevalence rate of malnutrition is
low in developed states and north-eastern states. But the economic growth alone is not
sufficient for substantially reducing under-nutrition (Bharati et.al, 2011). A sharp
economic growth doesn‘t have automatic immediate positive impact on combating
malnutrition (Ruia. et. al. 2018). Key schemes of the Indian government that addressing
food access and nutritional needs of poor are- Public distribution system (PDS), Mid-Day
Meal program for school children, ICDS program for pe-school children and National
Food Security Act (Marshall & Randhawa, 2017). Population density, open defecation
and lack of hygiene and sanitation are often described by constant malnutrition in India.
(Chambers & Medeazza, 2013). Indian children are severely malnourished, not only
because of food insecurity but also because of frequent gastrointestinal infections. The
stunting problem rotates more around poor hygiene than lack of food (Dobe, 2015).

1.4.4 INTEGRATED CHILD DEVELOPMENT SCHEME

Government of India started the land mark scheme namely Integrated Child
Development Scheme (ICDS) in 1975. ICDS works for fight against undernutrition
through a package of six complete services, namely supplementary nutrition programme,
Non-formal pre-school education, Nutrition and Health Education, Vaccination, Referral
services, Health Check-up (Ministry of women and child development). But there are
huge differentials in utilization of ICDS. The present study showed that the utilization of
the integrated child development scheme centre by the children was 77 percent for any
programs offered under the scheme (Das and Bhattacharjee, 2015).

A variety of factors may be attributable to the differential benefit-seeking

behaviour of the various groups of registered beneficiaries, like the lack of demand for a
service, the high cost of accessing services, the irregularity of the running of Anganwadi
centre, the lack of physical access to Anganwadi centre. Perhaps the variations in the
socio-economic background of those registered with the AWC may explain this
distinctive behaviour (Evaluation on ICDS vol.1, PEO, Planning Commission, 2011).
23 | P a g e
Ghose and Das (2011) also report that the utilization was away from satisfactory level
across social group, family wealth status and other characteristics. the utilization rate of
ICDS was highest for children belonging to the Scheduled Tribe and Scheduled Caste,
second or third birth order, poorest section of the society, residing in rural areas or in the
southern and western regions of India, for girl children, were exposed to media, those
belonging to and born to women who have finished at least middle school, and were
working (Ghose and Das,2011)And lowest among children and mothers from
economically and socially prosperous background (Rajpal et al.,2020). Age of children
and fathers‘ occupation were found to be important determinants of utilization of
integrated child development scheme (Das and Bhattacharjee, 2015). Basic education and
awareness in increasing the service uptake (Ghosh and Das., 2013). The government
program targeting to poor people have underlying issues in delivering services to the
people who need it (Himanshu, 2013).

The main challenges ICDS faces are: increasing focus on the providing of
supplementary nourishing and PSE to children 3 to 6 years of age at the cost of other
aspects of the program that are essential to mitigating chronic malnutrition; failing to
reach children under three efficiently; inappropriate targeting of the poorest states (Das
Gupta, et al. 2006). Lower rate of utilization of non-formal pre-school education in ICDS
is due to parents send their children to private play school or they think that their children
are under age for any programs there, this shows the lack of awareness about ICDS (Das
and Bhattacharjee, 2015). Lowest coverage of nutritional and health education among all
services are due to geographical distance from Anganwadi centre, lots of responsibility
for an Anganwadi worker at community level and AWW inadequately trained and
supervised (Rajpal et al.,2020). Gokhale, et.al., (2010) in their study also concluded that
present package of integrated child development scheme needs to be restructured soon
giving priorities to community intervention in improvement of sanitation, hygiene and
social attitudes of people.

Powerful barrier before service utilization among marginalized section of society in

rural areas are- Social and religious beliefs at the community level, geographical

24 | P a g e
accessibility to AWCs (Rajpal et al., 2020). Caste categories in rural areas were much
more important than wealth, while wealth in urban areas was more important than caste
(Rajpal et al., 2020). The main challenge for universalizing of ICDS with quality is to
make it a vibrant political issue. Significant hurdles to be dealt with universalizing of
ICDS with quality are, - fiscal conservatism, privatization frenzy, corporate intervention
in the social sphere, and the state's general mood to flee its social obligations (Dreze,
2006).

The following inequalities exist in the implementation of ICDS. First inequality is-
the coverage of ICDS is much better in rich states (Borroah, Diwakar & Sabharwal,
2014). Actually, coverage of ICDS increases with per capita net SDP (Gragnolati, et.al.
2005). Five states which have the highest occurrence of malnourished children (UP, MP,
Bihar, Odisha, Rajasthan) have the lowest coverage. The second type of inequality is in
spreading of Anganwadi Centres within state, coverage of ICDS is good in richest area
and poor in deprived area. The third type of inequality is location of AWCs within a
village (Borroah, Diwakar & Sabharwal, 2014). Mander and Kumaran (2006) have
observed that Anganwadi Centres never situated in the Hamlet of SC or ST, in mixed
caste villages. Forth, the form of discrimination is based on eliminating or limiting the
use of ICDS by individuals from certain classes. Despite the all above facts, utilization
rate is more in schedule caste and schedule tribes mothers and lower in mothers of
Muslim children as compared to Upper caste and OBCs mothers. This contradiction may
be because of- First, there may be trained and supportive individuals engaged in the
ICDS delivery process who vigorously encourage the use of ICDS services by SC/ST
mothers. Second, in upper-caste mothers, the impression may be that the quality of ICDS
programs is poor, especially in PSE and SNP. This is Hirschman‘s (1970) ―exit response‖
to meager quality services (Borroah, Diwakar & Sabharwal, 2014).

Following are the measures to increase the effectiveness and efficiency of ICDS- it
is important to distinguish its tasks, with a specialist individual delivering non-formal
pre-school education and another worker taking care of aspects of health and nutrition.
For maximum productivity, collaboration between the health and education departments

25 | P a g e
is essential (Sinha, 2006). Author is suggesting following step to improve utilization rate
of ICDS Anganwadi Workers must try within their territory to reach both pregnant and
lactating mothers and provide appropriate advice to bring them into the framework of the
scheme. Program managers should make an effort to proactively involve the community,
perhaps by involving it in supervising and monitoring the regular activity of AWCs.
(Ghose and Das, 2011)

Anganwadi Workers are the frontline and pivotal anchors of ICDS, the biggest
outreach project in the world. Anganwadi Workers/helper are assumed to take note of
contraceptive counselling, postnatal and neonatal care, nutrition supplementation,
immunization and PSE covering children (3-6 years) and women (15-45 years). After
performing such huge work, they are not a government employee. Anganwadi Workers
are part-time workers who get an honorarium (Editorial, EPW, June 8, 2013). Maximum
numbers of Anganwadi Workers had average knowledge score about different ICDS
component. Only few (13.3 percent) AWWs had high knowledge score (Bhattarai,
Walvekar & Narasannavar, 2017). CAG reports mention shortage of staff at all levels,
poor hygiene and sanitation in 52 percent of the AWCs, lack of medicine kits in 33-40
percent AWCs due to failure of the state governments in spending funds sent by the
centre.

1.4.5 MGNREGA AND CHILD HEALTH

MGNREGA affected the child health in the following ways. It combats the
seasonal out-migration. Various scholars and field-based studies from various states have
suggested that migration has been markedly reduced since MGNREGA was introduced
(Mennon et al, 2008). And child health is related with migration (Brockerhof, 1990;
Hildebrandt, 2005; Lee, 2011). Secondly it provides employment in rural areas.
Unemployment has been deeply linked with food insecurity and poverty in India and is
an important determinant of child nutrition‘s (Engle PL, 1993). And women autonomy is
directly linked with child care, child health expenses and overall child health (Ghuman
2003; Allendorf 2007, Das and Subba, 2015).

26 | P a g e
1.5. OBJECTIVE OF THE STUDY

The broad objective of this study is to analyze the child health profile of the study area;
for which pattern of child health status, determinants of child health in the study area,
differentials in utilization of ICDS and finally the impact of MGNREGA on child health
are important. More specifically, the key objectives of the study are as follows:

1. To examine the spatial pattern of intermediate determinants of child health status

and child health status in Uttar Pradesh with special reference to Bundelkhand
region.

2. To analyze the demographic, physical environment, socio-economic determinants

of child health and its intermediate determinants (among under 5 years of age) in
the study area.

3. To analyze the differentials (demographic, socio-economic, maternal factors etc.)

in utilization of Integrated Child Development Services in study area.

4. To address the main reason behind low qualitative coverage of ICDS.

5. To access the main issues of supply side regarding mechanism of delivery of ICDS
services.

1.6 RESEARCH QUESTION

1. Is there any spatial variation in intermediate determinants and child health status?

2. What are the socio-economic determinants of child health (under 5 years) in the
study area?

3. What is the level of accessibility and availability of ICDS infrastructure for quality
service delivery in the study area?

27 | P a g e
1.7 CONCEPTUAL FRAMEWORK

A conceptual framework is a model wherein a set of concepts are linked with each other
to set up a function and a relation. It explains either graphically or in a narrative form, the
key factors or concepts to be studied and the possible relationship between them. A
conceptual framework is one of the basic necessities of a study in order to understand the
internal link between the independent and dependent variables. Figure shows the causal
model for this analysis. The proximate determinants have been further categorized into
demographic, socio-economic determinants of child health and accessibility and
availability of health care services. All these variables together or individually affect the
child health status through the intermediate determinants that is preventive and curative
measures and factors of physical environment.

28 | P a g e
 Demographic Factors

Family Size
Preventive
Birth Order ICDS
Immunisation
Sex of the Children
Malnutrition

Social Factors

Religion

Caste

Education level of Mother Curative

Knowledge about child care Medical Care Diarrhoea

Facilities
Acute Respiratory Infec Child Health
MGNREGA Alcohalism
Status
Women autonomy All Type of Fever

Economic Factors

Wealth Quintles
Physical Environment
Household Income
Sources of Drinking Water
Seasonal-Out migration
Location of Water sources
Women employment status
Sanitation situation

Type of Fuel used for Cooking

Acessability and Availability Kitchen Facility

Location of AWC‘s or PHC‘s

Location of Village

Health Infrastructure 29 | P a g e
1.8 ORGANIZATION OF THE STUDY-

First chapter deals with statement of the problem, study area, review of literature.

Second chapter deals with database, sample design, objective of the study, methodology.

Third chapter shows spatial distribution level of malnutrition, Immunization, prevalence

rate of acute respiratory infection and diarrhoea, child health status and its determinants
of Uttar Pradesh with special reference of Bundelkhand.

Fourth chapter deals with analysis of differentials in utilization of Anganwadi Services.

Fifth chapter deals with main reason behind the low qualitative coverage of Anganwadi
Services in the study area.

Sixth chapter shows main issues of supply side during delivery of Anganwadi Services.

Seventh chapter is the last chapter of the study which is the conclusion of the study.

30 | P a g e