CHAPTER 19

PART A

SOCIAL SECTORS IN INDIA - HEALTH &

EDUCATION

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Contents
1 Health: What is it? ................................................................................................................................................ 3
1.1 Health: A State Subject: ................................................................................................................................ 3
2 Maternal Health Care: .......................................................................................................................................... 3
3 Key findings of the NFHS – 4:................................................................................................................................ 3
3.1 Antenatal Care (ANC):................................................................................................................................... 3
3.2 Total Fertility Rate (TFR): .............................................................................................................................. 4
3.3 Institutional births: ....................................................................................................................................... 4
3.4 Maternal Death: ........................................................................................................................................... 5
3.5 Health of women in India: ............................................................................................................................ 5
3.6 Women with Low BMI (Body Mass Index): .................................................................................................. 5
3.7 Anemia in Women: ....................................................................................................................................... 6
4 Child Healthcare: .................................................................................................................................................. 7
4.1 Situation of Child Mortality in India: ............................................................................................................ 7
4.2 Causes of Child Mortality in India: ................................................................................................................ 8
4.3 Immunization rates:...................................................................................................................................... 8
4.4 Current Status of Malnutrition in India: ....................................................................................................... 8
4.4.1 What is the extent of malnutrition in India? ........................................................................................ 8
5 Government Interventions: .................................................................................................................................. 9
6 National Health Policy, 2017: Salient Features: ................................................................................................... 9
7 National Nutrition Strategy: ...............................................................................................................................10
8 Health related targets in NITI Aayog’s three year short-term action Action Plan: ............................................11
9 The Mental Healthcare Act 2017 ........................................................................................................................12

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Health: What is it?
• The term ‘health’ is a positive and dynamic concept. In common parlance, health implies
absence of disease.
• The World Health Organization (WHO) has defined health as: “a state of complete physical,
mental and social well-being and not merely the absence of disease or illness or infirmity”.

1.1 Health: A State Subject:

Health is a State Subject in India. That is, it is mentioned in the State List of the Seventh Schedule of
the Indian Constitution.

Maternal Health Care:

• Maternal health care is a rather wide term. Often, the term is confused with only the period
of time, when the women gives birth to the child.
• However maternal health care is a concept that encompasses family planning,
preconception, prenatal (antenatal) and postnatal care.

Antenatal Care:

It is the routine health control of presumed healthy pregnant women without symptoms
(screeening), in order to diagnose diseases or complicating obstetric conditions without symptoms,
and to provide information about lifestyle, pregnancy and delivery.

Postnatal Care:

• A postpartum period or postnatal period is the period beginning immediately after

the birth of a child and extending for about six weeks.
• The World Health Organization (WHO) describes the postnatal period as the most critical and
yet the most neglected phase in the lives of mothers and babies; most deaths occur during
the postnatal period.
• It is the time after birth, a time in which the mother's body, including hormone levels
and uterus size, returns to a non-pregnant state.

Key findings of the NFHS – 4:

1.2 Antenatal Care (ANC):

• NFHS-4 findings reveal that there is better care for women during pregnancy and childbirth -
contributing to reduction of maternal deaths and improved child survival.
• Almost all mothers have received antenatal care for their most recent pregnancy and
increasing numbers of women are receiving the recommended four or more visits by the
service providers.

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 • The number of pregnant women receiving more than 4 ANC visits has also gone up by
38.37% in the last decade, from 37% in NFHS-3 to 51.2% in NFHS-4.

1.3 Total Fertility Rate (TFR):

Overall, the Total Fertility Rate (TFR) or the average number of children per woman has also gone
down from 2.7 in NFHS-3 to 2.2 in NFHS-4.

1.4 Institutional births:

• More and more women now give birth in health care facilities and rates have more than
doubled in the last decade in some States like Chhattisgarh (by as much as 390%), Jharkhand
(by 238%), Uttar Pradesh (by 229%), Bihar (by 220%), Assam (by 215%), Madhya Pradesh (by
208%) and Rajasthan (by 183%).

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 • However, in terms of absolute values, institutional births continues to remain extremely low
in Nagaland (32.8%), Meghalaya (51.4%), Arunachal Pradesh (52.3%), Jharkhand (61.9%) and
Bihar (63.8%), which are the bottom five states with respect to institutional births.

1.5 Maternal Death:

Maternal death is defined as death of women while pregnant or within 42 days of termination of
pregnancy from any cause related to or aggravated by pregnancy or its management. The maternal
mortality ratio is maternal death per 100,000 live births in one year.

1.6 Health of women in India:

• As a natural process, females do gain considerable amount of weight during pregnancy and
this carries on even after child birth.
• But many of them ignore this change and remain unaware of the complications which arise
due to them.
• More than 40 percent of women in India are underweight when they begin pregnancy,
according to a new study published by Princeton University.
• On average, these women gain only 15 pounds throughout pregnancy – just half of the
recommended amount.
• The findings are a concern as body mass and weight gain during pregnancy are important
indicators of maternal health.
• Babies born to undernourished mothers are more likely to be underweight, a characteristic
influencing height, cognition and productivity across a lifetime.

1.7 Women with Low BMI (Body Mass Index):

• As per NFHS 3, every third woman in India was undernourished (35.5 % with low Body Mass
Index) and every second woman (15-49 years) was anemic (55.3%).
• About 15.8 % were moderately to severely thin, with BMI less than 17. Bihar (45%),
Chhattisgarh (43%), Madhya Pradesh (42%) and Odisha (41%) were the states with the
highest proportion of undernourished women.

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 • In chronically undernourished women, pregnancy and lactation have an adverse effect on
maternal nutritional status. Low pre pregnancy weight and low pregnancy weight gain are
associated with low birth weight and all its attendant adverse consequences.

1.8 Anemia in Women:

• The figure below presents the status of anemia among women and girls between 15-49 years
of age.
• It is seen that overall, the levels of anemia among women and girls has stagnated over the
last decade from 55.3% in NFHS-3 to 53% in NFHS-4.
• In terms of percentage points, States which have witnessed maximum decrease in the levels
of anemia are- Sikkim (24.6), Assam (23.3), Mizoram (15.6), J&K (11.7), Tripura (10.6) and
Chhattisgarh by 24.6 (10.5).
• Alternatively, 8 States/ UTs (Punjab, Himachal Pradesh, Meghalaya, Delhi, Haryana, Uttar
Pradesh, Tamil Nadu and Kerala) have seen an increase in the prevalence of anemia.

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Child Healthcare:

1.9 Situation of Child Mortality in India:

Neonatal mortality Rate (NMR): The number of neonatal deaths per 1000 live births. A neonatal
death is defined as a death during the first 28 days of life (0-27 days).

Infant mortality rate (IMR): It is the number of deaths per 1,000 live births of children under one
year of age.

Under-five mortality rate: The under-five mortality rate 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.

Neo-natal Mortality Rate is 28/1000 live births.

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1.10 Causes of Child Mortality in India:
• The major causes of child mortality in India (as per WHO, 2012) are - Neonatal causes (53%),
Pneumonia (15%), Diarrhoeal diseases (12%), Measles (3%) and others.
• Besides these, malnutrition is a contributory factor in 33% child deaths.

1.11 Immunization rates:

• NFHS 4 (2015-16) shows that there have been promising gains in child health care.
• The immunization rates have gone up. The number of children aged 12-23 months who were
fully immunized (BCG, measles and 3 doses each of Polio and DPT) has gone up from 43.5%
in NFHS-3 to 62% in NFHS-4.

1.12 Current Status of Malnutrition in India:

1.12.1 What is the extent of malnutrition in India?

• India’s performance on key malnutrition indicators is poor according to national and
international studies.
• According to UNICEF, India was at the 10th spot among countries with the highest number of
underweight children, and at the 17th spot for the highest number of stunted children in the
world.

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 • Malnutrition affects chances of survival for children, increases their susceptibility to illness,
reduces their ability to learn, and makes them less productive in later life.
• It is estimated that malnutrition is a contributing factor in about one-third of all deaths of
children under the age of 5.
• Figure 1 looks at the key statistics on malnutrition for children in India.

Government Interventions:
Based on the identified causes of mortality, five major strategic areas have been identified to
improve child health outcomes. These are:

1. Newborn Health Interventions

2. Nutrition related interventions
3. Interventions to address pneumonia and diarrhoea
4. Interventions to address birth defects, disabilities, delays and deficiencies
5. Immunization activities

National Health Policy, 2017: Salient Features:

• The Union Cabinet has approved The National Health Policy, 2017 replacing the previous
one, which was framed 15 years ago in 2002.
• The aim of the policy: It aims at providing healthcare in an “assured manner” to all and thus
will address current and emerging challenges arising from the ever changing socio-economic,
technological and epidemiological scenarios.
• Highlights:
• It intends on gradually increasing public health expenditure to 2.5% of the GDP.
• The government aims in shifting focus from “sick-care” to “wellness”, by promoting
prevention and well-being.

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 • It aims to strengthen health systems by ensuring everyone has access to quality services and
technology despite financial barriers. The policy proposes increasing access, improving
quality and reducing costs.
• It proposes free drugs, free diagnostics and free emergency and essential healthcare services
in public hospitals.
• It focuses on primary health care: The policy advocates allocating two-thirds (or more) of
resources to primary care. It proposes two beds per 1,000 of the population to enable access
within the golden hour (the first 60 minutes after a traumatic injury).
• It promotes ‘Make in India’ initiative by using drugs and devices manufactured in the
country.
• It aims to reduce morbidity and preventable mortality of non-communicable diseases (NCDs)
by advocating prescreening.
• It highlights AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy) as a
tool for effective prevention and therapy that is safe and cost-effective. It proposes
introducing Yoga in more schools and offices to promote good health.
• Quantitative targets listed in the policy:
• Increase Life Expectancy at birth from 67.5 to 70 by 2025.
• Reduce Under Five Mortality to 23 by 2025.
• Reduce infant mortality rate to 28 by 2019.
• To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic
respiratory diseases by 25% by 2025.
• Achieve the global 2020 HIV target (also termed 90:90:90; 90% of all people living with HIV
know their HIV status, 90% of all people diagnosed with HIV infection receive sustained
antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral
suppression).
• Reduction of TFR to 2.1 at national and sub-national level by 2025.
• Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025.
• Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar by 2017 and
Lymphatic Filariasis in endemic pockets by 2017.
• To achieve and maintain a cure rate of >85% in new sputum positive patients for TB and
reduce incidence of new cases, to reach elimination status by 2025.
• To reduce the prevalence of blindness to 0.25/ 1000 by 2025 and disease burden by one
third from current levels.
• It seeks to establish regular tracking of disability adjusted life years (DALY) Index as a
measure of burden of disease and its major categories trends by 2022.

National Nutrition Strategy:

• To bring nutrition to the centre-stage of the national development agenda, government
think tank NITI Aayog has drafted a National Nutrition Strategy.
• The strategy lays down a roadmap for effective action, among both implementers and
practitioners, in achieving nutrition objectives.

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 • The nutrition strategy envisages a framework wherein the four proximate determinants of
nutrition– uptake of health services, food, drinking water and sanitation and income and
livelihoods–work together to accelerate decline of under nutrition in India.
• The nutrition strategy framework envisages a ‘Kuposhan Mukt Bharat’—linked to Swachh
Bharat and Swasth Bharat. The aim is to ensure that states create customized state/district
action plans to address local needs and challenges.
• The strategy enables states to make strategic choices, through decentralized planning and
local innovation, with accountability for nutrition outcomes.

Health related targets in NITI Aayog’s three year short-term action Action Plan:
NITI Aayog has put forth three-year 'Action Agenda' from 2017-18 to 2019-20. This has replaced the
five year plans of the Planning Commission.

The action plan states that:

• India faces a double burden of disease, wherein communicable diseases still account for a
significant proportion of disease burden.
• In 2012, out of the total number of Disability-Adjusted Life Years (DALY) lost, 33% were
attributable to these diseases. Non-communicable diseases accounted for 55% of DALYs with
injuries accounting for the remaining 12% in the same year.

Disability-Adjusted life year:

The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the
number of years lost due to ill-health, disability or early death. It was developed in the 1990s as a
way of comparing the overall health and life expectancy of different countries.

The following box lists down specific Health Goals to be achieved by the Year 2020:

(Note: For some of the parameters mentioned the latest estimates are available in NFHS-4; refer
those in the appropriate section of this document)

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As we have mentioned at the start of the chapter, health is not only about healthy body, but it also
includes ‘a healthy mind’.

In this regard, there is an important act, ‘The Mental Healthcare Act 2017’. We shall have a look at
the key points of this act in brief:

The Mental Healthcare Act 2017

• The Mental Healthcare Act, 2017 decriminalizes suicide attempt by mentally ill people and
provides services for people with mental illness.
• It aims to provide for mental healthcare and services for persons with mental illness and
ensures these persons have the right to live a life with dignity by not being discriminated
against or harassed.
Important provisions:
• Rights of persons with mental illness: This provision states that every person will have the
right to access mental healthcare from services which are operated or funded by the
government.
• Advance Directive: This provision empowers a mentally-ill person to have the right to make
an advance directive that explains how she/he wants to be treated for the requisite illness
and who her/his nominated representative shall be.
• Mental Health Establishments: This provision states that every mental health establishment
has to be registered with the respective Central or State Mental Health Authority.
• Decriminalizing suicide and prohibiting electro-convulsive therapy: The most notable of all is
this provision effectively decriminalizes suicide attempt under the Indian Penal Code by
mentally ill persons by making it non-punishable. Electro-convulsive therapy, which is
allowed only with the use of anesthesia, is however out of bounds for minors.

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