The ill-health of Bharat mata requires another, more urgent surgical strike

After absorbing the views of those far more learned, let me sum up my interpretation of the process of reducing 86% of India’s currency to scrap paper (technically, this isn’t demonetisation, it’s “old for new”, as Praveen Chakravarty, explains here): To spite our nose, we’re cutting off our head.

Of course, this extreme method – more scorched-earth than surgical strike – should not be a cause for concern, because we can also always affix a new head, a technique India has been famous for since prehistory, as the prime minister himself once said, with regard to the elephant head on Ganesha.

But this column does not concern itself with India’s head or crown or other contentious upper extremities or issues that invite extreme reactions. I would like to focus your attention on a topic that is of far greater importance than the currency imbroglio but mostly attracts disinterest. I refer to the Indian body – our collective health.

To illustrate how it is a crisis that needs our utmost attention, I will sharp focus on the health of the Indian mother – Bharat Mata, to use a nationalist label and metaphor. Because the Indian woman is a keystone species, her health is a precursor to the health of the new generation, the same generation that will grow up and determine the health of everything the government currently propagates: Make in India, Skill India and every other great idea to transform India.

This is not to say that there has been no progress on health. Much has improved, as we shall see, but India lags so far behind its peers in the emerging nations – and, in some cases, poorer countries – and has invested so little on health, sanitation and women that no more than a radical new approach will suffice.

My colleagues at IndiaSpend regularly track various health-related data sets, and their regular stories – which I have drawn from for this column – make clear the depth of the crisis. To begin with, unless we can secure the two stages of the Indian woman’s life, it is a fallacy to believe that India can feel secure about its future.

Stage 1: Birth and childhood

Being born is the first hurdle that the Indian woman faces. India’s child sex ratio – the number of girls per 1,000 boys aged 0-6 years – has never been worse in 60 years. It tells us that girls continue to be aborted, killed or die because they are deprived of medical services and nutrition.

Once she gives birth, the Indian woman not only has an unacceptably high chance of dying – maternal mortality has almost halved over 12 years to 2013, but it is still six times higher than Sri Lanka and worse than Cambodia – but may produce a malnourished child, as a result of her own poor health and lack of access to poor sanitation, water and food. There are other indicators of malnourishment, but let’s consider stunting, children who are short for their age.

In June this year, the president of the World Bank, Jim Yong Kim, came to Delhi and drew India’s attention to its stunting problem, an indication that children were not getting healthcare, adequate and proper nourishment. “This is the bottom line,” said Kim, “If you walk into the future economy with 40% of your workforce having been stunted as children, you are simply not going to be able to compete.”

In general, children who are stunted are more likely to have reduced cognitive skills; spend less time in school; have lower test scores; be sicklier, less literate and poorer. For women in particular, the effects of childhood stunting is correlated with being younger mothers, having more children and, to complete the depressing circle, a greater chance of those children being malnourished.

In 1997, 46% of India’s children were stunted. That figure fell to 39% by 2013, which is not enough of an improvement (the global average is 24%). In 1997, 60% of Bangladesh’s children were stunted, but today 36% are, which means our poorer, eastern neighbour has done better than us. India has the highest stunting rate among Brazil, Russia, India, China and South Africa. Of our neighbours, Pakistan (45%) and Nepal (41%) do worse. In parts of Maharashtra, India’s richest state, more than 47% of all children are stunted.

“Childhood stunting is one of the most significant impediments to human development,” noted a World Health Organisation policy brief. “Stunting has long-term effects on individuals and societies, including: diminished cognitive and physical development, reduced productive capacity and poor health, and an increased risk of degenerative diseases such as diabetes.”

Not surprisingly, India’s healthiest children happen to be in states that provide the best maternal healthcare.

In 1974, 37% of Brazil’s children were stunted, almost the same rate as India’s nearly 40 years later. Brazil’s stunting rate today is about 7%. What Brazil did is what India urgently needs to do – focus on making women more literate, make maternal and child health services widely available, grow wealth through cash transfers, get small farms to grow more nutritious food and expand water and sanitation services.

Of these interventions, Narendra Modi has attracted welcome attention to sanitation, but experts and workers on the ground will tell you that while the programme is good on promises, slogans and construction, it is short on mindset change and details.

Stage 2: Adolescence and motherhood

If India continues to discriminate against the birth of its girls, over the next 14 years, 23 million of them will not be born.

Of those who are being born currently, it is true that greater numbers will be educated and marry later than ever before. But these women will, still, find it hard to escape early marriage and motherhood. Over 20 years to 2011, the female literacy rate rose by 26%, but women could extend their average age of marriage by only 1.9 years to 21.2. This improvement also hides the fact that 61% of women are married before 16. Women who marry early, as we already know, are likely to produce sicklier children.

It does not help that a failing healthcare system does not allow women to space their children. “More than 10 million women terminate their pregnancies in the privacy of their homes, reflecting the government’s failure to adequately address family planning needs, endangering mothers and keeping India more populated than it might be if women had access to, and knowledge of, contraceptives,” my colleague Charu Bahri wrote earlier this month.

As more children are born in poor families without access to proper healthcare, these children are more likely to be neglected and even more sickly. This is particularly worrisome because the public health systems in the poorest states, where the vast bulk of Indians live, are worse than inadequate. In Bihar, for instance, up to a fourth of children who suffer “severe acute” malnourishment – meaning, they are at risk of death – are likely to face a relapse because the state’s specialised nutrition rehabilitation centres can only treat 0.3% of such children. It is little girls, as this Thomson-Reuters foundation story details, who bear the brunt of “India’s vicious cycle of malnutrition”.

The lack of access to health systems for Indian women is now starkly evident even at death, with a new census report revealing that a larger proportion of men (63%) were likely to be with a medical professional at death than women (38%).

Women suffer most, but healthcare is in crisis

Although the number of medical colleges and seats almost doubled over the past decade, India is short of about half a million doctors and even in the most prosperous states, particularly in the south, home to the majority of India’s private medical colleges, a doctor may serve more than 1,000 people (in poorer northern states, that number may go up to 25,000).

The shortage of doctors is particularly evident in India’s rural areas, where the frontline of the public healthcare system – the primary health centres – is short of more than 3,000 doctors, the scarcity rising three times over 10 years. In Uttar Pradesh, India’s most populous state with 200 million people, these centres decreased 8% over 15 years to 2015, a period when the state’s population increased by more than 25%.

With government-run healthcare scarce or unreliable, 89.2% of the health expenditure in India is out-of-pocket, which means it is met by individuals, according to World Bank data. Out-of-pocket expenses are an indicator of the health of the public healthcare system. In India, an additional 39 million people fall back into poverty every year because of health-related spending, as this Lancet paper reported. Yet, the proportion of out-of-pocket expenses greatly exceeds that of comparable and poorer countries, such as Brazil (47.2%), Botswana (12.7%) and Liberia (44.8%).

Although it is four time costlier, on average, than public healthcare, and 15 times more than the average monthly expenditure of the poorest 20% of Indians, more than half of Indians living in rural areas use private healthcare. To access reliable healthcare, Indians make great journeys, often staying in thousands – including on footpaths, for months – outside premier medical centres, such as the Tata Memorial Hospital for cancer care in Mumbai and the All India Institute of Medical Sciences in Delhi. Nearly 48% of overnight trips made by Indians from rural areas, and 25% from urban areas, are not for tourism but for medical reasons, according to National Sample Survey Office data.

The data that my colleagues gather are endlessly revealing in general but what they show is that women always bear the brunt and play a central part in numerous vicious circles:

• The proportion of anaemic, pregnant women dropped 12% over a decade in 2015, but India still has more anaemic women than any other country. An anaemic, pregnant woman is more likely to die or deliver a baby lighter than normal. That means the baby is at greater risk of death.
• Nearly eight in 10 Indian babies are now delivered in hospitals but 343 healthcare institutions surveyed by WaterAid India across six states often lacked basic hygiene, toilets, clean water and waste disposal. In Madhya Pradesh, a state with a higher maternal mortality rate than war-ravaged Syria, half the post-natal wards of primary healthcare centres lacked toilets, as did 60% of larger community health centres.
• Up to 62% of government hospitals don’t have a gynaecologist on staff and an estimated 22% of sub-centres are short of auxiliary nurse midwives. Gynaecologists and nurse midwives comprise the frontline of the battle against infant and maternal mortality.

Funding is certainly an issue. For instance, although the budget for the centrally funded National Rural Health Mission rose 67% over a decade to Rs 11,196 crore in 2015-16, such investments have fallen behind requirements, at a time when a tide of ill-health and disease is rising. As a share of gross domestic product, India’s health expenditure has never reached 1.5% over the last two decades. That is among the lowest levels in the world, according to World Bank data, comparing unfavourably with not just Cuba (10.6%), Brazil (3.8%), China (3.1%) and South Africa (4.2%), but even Ethiopia (2.9%), Tanzania (2.6%) and sub-Saharan Africa (2.3%).

With Delhi handing over more responsibilities and money to the states, their share of central tax revenue has risen to 42% from 32%, but this has resulted in a spending cut on social programmes, specifically affecting health and education financing. In conjunction with education, which, as noted above, is an important factor in making mothers more empowered, healthcare affects the wellbeing of Indians from cradle to death, the circle beginning with its women.

The bottom line: India ignores its collapsing healthcare system at its immense peril. If the Prime Minister really wants to do the best by India and the women he often eulogises (“Mothers and sisters are partners in our development journey,” he said this year), he should take the states along and consider his next surgical strike against the healthcare system. Nothing could be less controversial and more beneficial.

Samar Halarnkar is editor, IndiaSpend.org, a data-driven, public-interest journalism non-profit.