Sunday, April 18, 2010

Saving India’s women

Livemint, April 4, 2010 : Analyses of social factors, which determine the impact of central programmes, can shape policies to save women’s live

Nirvikar Singh

Gendercide. That was how a recent Economist magazine cover story described the problem of 100 million girls and female foetuses being killed around the world, with population giants India and China being among the worst offenders. Changing this state of affairs will be a huge task, involving changing attitudes as well as incentives, working throughout the web of economic and social relationships that devalue women in many societies. Dowry practices, women’s access to the labour market and entitlement to inheritances, psychological biases and hurts that get passed on through generations, and many other factors come into play.

In India, the National Rural Health Mission includes specific efforts to tackle problems such as high maternal mortality ratios. This may not be the worst problem area for women, but it represents a place where specific, tangible public policy interventions can be designed and implemented. One such intervention is the Janani Suraksha Yojana (JSY), literally, the mothers’ protection plan. The scheme is narrower than this name might suggest, though the spirit embodied in the programme title is welcome. JSY provides monetary incentives for pregnant women to go to health facilities such as government-run community health centres for delivering their babies. Institutional deliveries reduce maternal mortality to the extent that complications can be tackled immediately and adequately, and there is better overall hygiene in such environments.

An important link in the chain are accredited social health activists (ASHAs), who are also given monetary rewards for bringing pregnant women to healthcare facilities for their deliveries. Other facets include counselling, antenatal care, and some post-natal monitoring. It will take time to see how exactly the scheme is changing health outcomes, but there is already evidence that institutional deliveries have increased. Over 10 million women have availed of JSY, and though it is hard to say how many of these would have gone to a health centre anyway, even in those cases, the scheme provides a timely and targeted income supplement.

Government reports tend to give percentages and numbers—they do not typically sort out causes and effects. That can only be done unambiguously through controlled experiments. However, examining patterns across India’s vastness can be revealing. Ambrish Dongre, at my university, has been looking at precisely this issue. He begins by asking the question, “What factors influence a woman’s benefiting from the JSY?” Do caste, wealth and education matter? Does it matter how big the village is, or how developed it is? Do ASHAs really make a difference? And how does distance from the nearest health facility affect the woman’s choice?

To answer these questions, Dongre looks separately at two groups of states. Those with low institutional delivery rates (such as Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan and Jammu and Kashmir) provide JSY benefits to all women going to government health centres. High-performing states (which include middle-income states) have some age, poverty status and caste restrictions on who is eligible: Hence, they must be analysed separately. Interestingly, in the low-performing states, scheduled caste women appear to be more likely to be beneficiaries than other castes, but in the other states, the benefits are somewhat more widely spread. In both groups of states, the benefits are spread across different wealth classes. A strong result in both types of states is that lack of education reduces the likelihood of a woman benefiting from JSY. This illustrates the complexity of even targeted interventions—if tackling maternal mortality requires educating women, a much broader and deeper intervention is required. But, of course, educating women ought to be a prime social goal in its own right.

In the low-performing states (but not the other group), having an illiterate husband also reduces the likelihood of the woman benefiting from JSY. Some other external or social effects are also striking. Developmental characteristics such as greater village size, or presence of a bank or post office, have positive effects. Importantly, local governments that are engaged in health-related decisions overall seem to be good for women’s choices with respect to JSY. The presence of other beneficiaries of the scheme matters positively, as does the presence of an ASHA. Distance from a health facility acts as a deterrent. Much of this is not surprising, but it confirms an approach to development and policy intervention that has been gaining steam. Even if targeting is not ideal, money, new ideas and institutional innovations can shake things up and begin processes of change.

Increasing institutional deliveries will reduce maternal deaths, but it will not directly reduce gendercide. Dongre’s analysis of which factors affect whether women benefit from JSY shows us how policy interventions interact with initial social and economic conditions. Studies such as Dongre’s can give us insights into designing future policies to save far more Indian women and girls.

Nirvikar Singh is a professor of economics at the University of California, Santa Cruz. Your comments are welcome at

India - a study in health contrasts

By Prashant K. Nanda, New Delhi, April 7 (IANS)

From becoming a hub of medical tourism to having a sizable population deprived of basic healthcare, from bulging bellies in urban areas to stunted growth among kids across rural belts — the country remains a study in health contrasts. India now stands at the cross-roads of improving health indicators and achieving the Millennium Development Goals (MDGs).

“We are at a difficult time. While millions of children are dying due to hunger and malnourishment, lifestyle diseases are on the upswing among urban populace,” said D.K. Gupta, president of the Federation of Association of Paediatric Surgeons in South Asia.

While states like Uttar Pradesh, Bihar, Madhya Pradesh, Chhattisgarh and Orissa are leading victims of malnourishment, more literate and rich states like Punjab, Kerala and Tamil Nadu are going the obese way.

According to the United Nation’s Children Fund (Unicef), nearly 2.1 million children die every year in India before reaching their fifth birthday. This accounts for 20 percent of children’s death across the globe, which means one out of every five children dying is an Indian.

The maternal mortality and infant mortality rate in India is even worse than in Sri Lanka and Thailand. According to an official data, 254 women die per 100,000 live births in India. A World Bank report puts the figure at 450.

Similarly, 46 percent of children in India are malnourished, a startling figure that has remained almost unchanged for the last seven years.

Tens of thousands of Indian kids are dying due to diarrhoea and pneumonia every year, which are largely preventable if water and hygiene conditions improve.

Even as it battles to control communicable diseases like Tuberculosis, India is increasingly falling in the trap of lifestyle diseases. With economic prosperity has come unhealthy lifestyle and poor eating and working habits. Cardiovascular diseases, several forms of cancer, diabetes and hypertension silently kill millions every year.

India has already earned the dubious distinction of being a diabetes capital. For record, India is home to over 30 million diabetic patients. The World Health Organisation (WHO) has also warned that more than 270 million people, mostly from China, India, Pakistan and Indonesia, are susceptible to diseases linked to unhealthy lifestyles.

“Earlier they (lifestyle and chronic diseases) were called western phenomena but today India is facing both. Patients of chronic diseases in India have overtaken the numbers of chronic patients in the west,” said Sandeep Bhudhiraja, director of internal medicine at Max Healthcare here.

The argument has been accepted by Health Minister Ghulam Nabi Azad many times. “We are battling both forms of problem,” he says. S. Sunder Raman, an independent advisor to the central government on health, said: “There are three major hindrances. Inadequate financial allocation, low level of priority to the sector and lack of due focus on fitness are the main culprits.”

Experts also said that there is another uneven field in medical human resources. According to Azad: “Eighty percent of medical work force serve just 20 percent of Indians living in cities”.

Now, citizens to audit govt's welfare schemes?

, New Delhi

Troubled by the quality of the mid-day meal or the continued absence of the anganwadi worker from the ICDS centre? You can make a call or just SMS your complaint. In a move that is likely to bring accountability and transparency in governance, and more importantly give power to the citizen, the United Nations Millennium Campaign (UNMC), in association with state governments and civil society partners, plans to introduce a "citizen's audit'' to assess delivery mechanisms of welfare programmes and the government's performance in achieving the millennium development goals (MDGs).

The audit is likely to begin in six districts of three states by September this year. UNMC regional director (Asia-Pacific) Minar Pimple said, "This will effectively mean real time tracking of the MDGs.'' The UNMC along with its partners is working at a software platform by which people will be able to call or SMS their complaint with the district collector's office. The data can then be used to take immediate action.

According to Pimple, India has been making progress in certain fields like enrolment of children in schools and halting the progress of HIV/AIDS. But there continue to be indices like infant mortality, gender empowerment, lack of access to safe drinking water and poverty where the country has not been able to make much headway. Studies have also shown that the problem rests with states like Bihar, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh that are the worst affected in all indicators.

Besides focusing on accelerated development of MDGs by pushing for higher allocation of government resources and citizen's monitoring, the UNMC also plans to work with parliamentarians. Grading parliamentarians according to the performance in their fulfilling goals like access to water, sanitation, roads will be the objective. "We would like to make it a constructive engagement with MPs,'' Pimple said.

The UNMC also plans to emphasise on local MDGs through its civil society partners. Gender empowerment is the key to make things work, says Pimple. Citing the example of Nepal and Bangladesh, Pimple said that the two countries had a lower growth rate than India but had succeeded in bringing down infant deaths and maternal mortality by encouraging greater participating of women. He said that in fact the women's reservation bill was an important step in this direction for India. UNMC's `Stand up & Make a Noise' campaign -- to be launched in September -- is an effort to create awareness amongst people about their rights.