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 eyeonindia@livemint.com

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?

Himanshi Dhawan, TNN, Apr 11, 2010, 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.

India failing to curb MMR and IMR

India is failing its women and children and is crawling towards the Millennium Development Goal (MDG), which targets to cut child death rates by two-thirds and maternal mortality by three-quarters between 1990-2015.

According to a report that tracks the progress made by 68 priority countries, which account for 97% of maternal and child deaths worldwide, only 16 (24%) were on track to meet the MDG compared to 7 of 60 (12%) in 2005. India, however, is not one of them.

In fact, India's progress towards MDG target in child mortality, in the report 'The Countdown to 2015: Maternal, Newborn and Child Survival' published in the medical journal 'Lancet', has been found to be "insufficient" and its level of maternal mortality has been termed "high".

While India's target under the MDG for mortality of children under age 5 is 38 per 1,000 live births, the number of children who die before their fifth birthday stands at 76 at present.

Infant mortality rate in India stands at 57 per 1,000 live births while neonatal mortality rate - deaths in the first month of life - stands at 43 per 1,000 live births.

Early initiation of breastfeeding benefits both mother and newborns. Yet, only 46% infants under six months are being exclusively breastfed. Also, only 41% births have been registered.

Speaking to TOI from Cape Town, Dr Francisco Songane, director of WHO's partnership for maternal, newborn and child health, said: "India, along with Bangladesh, Pakistan and Indonesia, contribute over 50% of all maternal and child deaths globally. What's worse, India is not making sufficient progress. India's population is massive and even if the ratio of maternal and child mortality may not be high, the numbers are staggering."

Dr Songane added: "India is among the 26 countries in the list of 68 where progress has been found to be insufficient. India has to scale up its interventions. Coverage rate will also have to be increased drastically as at present, pockets of population are not reached."

According to the report, brought out by the International Partnership for Maternal, Newborn and Child Health (MNCH), an umbrella organisation comprising about 240 members such as Unicef, WHO and Save the Children, India's average annual rate of reduction of child deaths between 1990-2006 has been just 2.6%.

If India wants to achieve the agreed targets by 2015, the required rate to reduce child and maternal mortality will have to be 7.6% from 2007-2015.

The report also identifies a series of missed opportunities. It says only one-third of women in the 68 priority countries are using a modern contraceptive method - a proven means of boosting maternal and infant survival.

Only 50% women and newborns benefit from a skilled birth attendant at the time of birth globally. Only about one-third of children with pneumonia, the biggest single killer of children, get treatment while under nutrition has been the underlying cause of 3.5 million child deaths annually, and as many as 20% of maternal deaths.

source - Times of India

For better health, let's stick to the basics

The Economic Times, Gireesh Chandra Prasad, TNN

Given the state of affairs, the Economic Survey’s recommendations on healthcare might sound like truisms. But then, the truth does need to be oft-repeated. Not surprisingly, the Survey says that the central and state governments should make health insurance affordable to people and urgently improve the quality of basic services like drinking water and sanitation to address the poor health indicators of a nation of 112 crore.

Health insurance is critical in this scenario, given that it’s the poor service in state-run hospitals that forces people to seek expensive private treatment. It also is imperative that the delivery of public health services is improved. In fact, the Survey says a strategic focus on these areas should be the cornerstone of a successful policy framework for healthcare, given that state-funded healthcare for all still seems a distant dream.

India has one of the highest out-of-the-pocket household expenditures for healthcare. Then there’s the additional burden of user charges at state-run hospitals. Therefore, it is vital that innovative risk-pooling mechanisms are designed to improve access to healthcare, the Survey has said.

The data makes for depressing news. The latest figures on indicators like under-five mortality and maternal mortality rate shows that India fares worse than its more populous neighbour, China. Vector-borne diseases and epidemics are not under control.

In 2007, 940 deaths and about 10 lakh positive cases of malaria, filariasis, kala-azar, Japanese encephalitis, dengue and chikungunya were reported. Up to December 2007, 64 dengue deaths and over 5,000 positive cases have been reported while suspected chikungunya cases were more than half a lakh. Elimination of that old enemy, polio, is still not in sight with 471 reported cases last year.

Besides, there is a wide disparity among different states and urban and rural areas in access to healthcare. Life expectancy in Madhya Pradesh, Assam, Orissa, UP and Bihar, for instance, is noticeably lower than that in states like Kerala, Punjab, Maharashtra, Himachal Pradesh and Tamil Nadu.

This applies to infrastructure and medical staff too. Infant mortality rate is the highest in Madhya Pradesh while it is the lowest in Kerala. Most of the public health centres had operation theatres in Andhra Pradesh, Rajasthan and Maharashtra while the opposite was the case in UP, West Bengal and Chhattisgarh.

The Survey has recommended that there should be strategic focus on eliminating vector-borne and epidemic diseases, providing public health education, improving the urban and rural drainage system, providing clean drinking water and sanitation and a well organised garbage collection and disposal system. Mainstreaming traditional medicine would ease some burden on public health facilities.

Above all, good governance is very important in healthcare delivery. The 11th Five-year Plan envisages an investment of Rs 11.02 lakh crore at the central and state levels on social sectors. But greater allocation would not amount to much unless leakages in the system are plugged. Finance minister P Chidambaram had said on various occasions that outlay is not a constraint so long as it ensures outcomes. The government now needs to walk the talk.

Sick state of health in Madhya Pradesh!

View point Central Chronicle, Bhopal

Indore, Feb 16: Shivraj Singh government may receive laurels for his governance and pushing the state on the path of development, everything is not well as far as state of health in Madhya Pradesh is concerned. If one goes by the latest human development report of Madhya Pradesh, the state of health in Madhya Pradesh is far from satisfactory.

This is reflected from the latest estimate for longevity, measured as life expectancy at birth, which was 59 years for males and 58 years for females (corresponding to period 2002-06). As per the latest estimate on longevity as quoted in the Human Development Report 2007, the life expectancy for males and females in Madhya Pradesh was the lowest among all the major states in India and a good four to eight years lower than the national average.

States like Assam, Bihar, Gujarat, Haryana, Karnatakka and Kerala have better life expectancy at birth as compared to Madhya Pradesh. Even the state of Bihar which is counted among one of the most backward states in the country, life expectancy at birth for males and females (2001-06) stood at 65.66 years and 64.79 years respectively, much higher than that of Madhya Pradesh.

What has been found to be more surprising that while naturally female life expectancy should be more than male life expectancy, it is just the opposite in Madhya Pradesh, pointing towards discriminatory practices against both the girl child and women, leading to higher mortality rate.

Similarly, state's performance on the infant mortality rate (IMR) and the maternal mortality rate (MMR), is far below than the national average. IMR is related to combination of factors including poor nutrition for their mothers while pregnant, inadequate immunization of mothers from tetanus and lack of hemoglobin in their bodies, poor sanitary and health care conditions at birth, poor care during deliveries, etc.

The infant mortality in the state in 2004 was estimated at 79 (84 for rural areas and 56 for urban areas) as against national IMR of 58, the highest among all states in the country. Between 2000 and 2004, while the national IMR reduced from 68 to 58, the IMR of Madhya Pradesh dropped from 87 to just 79.

As far as maternal mortality rate is concerned, though the state had witnessed a significant reduction in MMR at 498/1000 (as per the National Family Health Survey - II) to 379/1000 as per the MMR data released in 2003, it was still far higher than the national MMR of 301/1000.

The public health infrastructure in the state is also far from satisfactory. As per the Human Development Report 2007, the state had a shortage of 26% in primary health centers, the very basis of primary health. The poor deliveries of primary health services in the state has primarily been attributed to doctors' unwillingness to serve in rural areas. Though the state has adopted an innovative approach of mobile health dispensaries through public private partnership and other health schemes, its impact on primary health is yet to be evaluated.

As per 2001 census, 22 per cent of the state population were directly at risk of water borne diseases as they did not have access to safe drinking water. As far as condition of sanitation is concerned, the state ranks far below than the national average. As per the survey carried out by the Ministry of Rural Development, Government of India, only 9.7% of rural households in Madhya Pradesh had a toilet in 2005, which is abysmally low even compared to the national average of 23.7%.

Krishna K Jha

Helping hands

Women and men helping pregnant women at Guna's district hospital to get her down from trolley on which she came to the hospital to show to the medical doctor. (pic courtesy - anil gulati)

Concern over delivery deaths

Editorial, Central Chronicle, Nov 30, 2007

Despite of spending crores of rupees for improving the health of women, the continuing deaths of women, in the State, during delivery is a cause of concern. Answering a question in the State Vidhan Sabha, the Public Health Minister himself admitted that there were 3359 cases of mother-child death between the period January 1, 2006 and October 2007. Of these maximum 224 cases pertain to Shahdol. It may be noted that for publicity of National Rural Health Mission and RCH a whopping sum of Rs 8.36 crore was spent during the last two years. At the same time an amount of Rs 620.36 crore was allotted under National Rural Health Mission and RCH for the years 2006-07 and 2007-08. The break-up of deaths of women/kids at other places is- Guna 145, Shivpuri 105, Sidhi 169, Sagar 137, Jhabua 149, Dindori 138, Balaghat 135, Chhindwara 101 and Mandla 101. It is learnt that awareness is even now lacking in these places for performing deliveries at health centres. It is a matter of grave concern that even after spending Rs 8.5 crores in publicity of National Rural Health Mission and RCH during the years 2006-07 and 2007-08 the death rate could not be brought down. Hence it is essential that awareness be created in right earnest among the intended class to curb mother-child deaths. For this purpose, participation of literate people of villages and youths could be sought for. With rapid advancement in communication technologies and opening of health centres in rural areas, the maternal mortality could be minimised.

Madhya Pradesh’s IMR and MMR still very high

Despite the figures of institutional deliveries for the current year in the state being quite impressive, Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR) do not show the corresponding improvement. Furthermore, utter unavailability of specialist gynecologists and pediatricians in Community Health Centers (CHCs) and Primary Health Centers (PHCs) puts a question mark on the very figures of institutional delivery.

In the current year, the rate of institutional delivery is 58 % as against 50.3% of 2006-07. The figures have constantly shown an improvement from year 2000-01 when it was a mere 26.2%. Cleary, the rate of institutional delivery has more than doubled since, if figures are anything to go by. Nonetheless, the IMR is 70 per thousand (improved from 88 in 1997) and MMR 397 per lakh (improved from 498). These figures certainly do not show corresponding amelioration. "We have annual records of institutional delivery but IMR and MMR are not surveyed every year, so here is this difference." says Dr Archana Mishra, Consultant, National Rural Health Mission (NHRM) and Reproductive and Child Health (RCH). Her argument might look genuine at the first sight but it has flaws.

The figures do not show the institutional delivery in urban and rural areas separately and insiders say most of the institutional deliveries giving push to the figure are being done in urban areas. Second thing they reveal is that government has included private sector hospitals in its schemes to enhance institutional deliveries among below poverty line (BPL) mothers and pay them for each delivery. Most of these hospitals are in urban and semi-urban areas. "It's not necessary the data of institutional delivery provided by a certified hospital conducting free delivery of BPL mothers under a government scheme and receiving the due money from government is true," says an insider. "It might be exaggerated by certain means to claim more money from government."

Needless to mention, under the arrangement certified private hospitals are extending facilities of Janani Express Yojana, Janan Sahayogi Yojana and other health welfare schemes to card holders. Talking of rural areas, state is short of 478 PHCs and 188 CHCs as per a report of Ministry of Health and Family Welfare of Government of India released on March 2006. To add to this, just 13 gynecologists and 12 pediatricians are working in 229 existing CHCs of the state.Around 216 gynecologists and 217 pediatricians are required in these health centers. State government's attempts to post specialists in rural areas have met with failure over the years and dais conducting traditional deliveries has been banned around a year ago, leaving villagers with no option but to go for totally unsafe, unprofessional delivery at home.

Let men do their bit

The Pioneer, Sunday November 11, 2007

Shailaja Chandra

For 30 years, vasectomy has been a political taboo, and the entire burden of family planning has been on women. But modern vasectomy techniques are a success in the West. India needs to try them

According to the projection of the Registrar General of India, India's most populous State, Uttar Pradesh, will account for 22 per cent of India's population by 2026. Half of India's demographic growth will occur in Uttar Pradesh and Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Rajasthan - certainly a huge jump. Fertility rates here are destined to take decades to reach replacement levels. In contrast, the south (Andhra Pradesh, Karnataka, Kerala and Tamil Nadu) is forecast to jointly account for only 13 per cent of the population increase during the same period, having already achieved the target fertility rate of 2.1 optimally projected for 2010 for the country.

Currently, 42 per cent of India's population produces three or more children. Of 188 million couples requiring contraceptive coverage, only 53 per cent are using contraceptives. The percentage of women having more than three children is 57 per cent in Uttar Pradesh, 54 per cent in Bihar and 49 per cent in Madhya Pradesh. Almost half the girls there are under 18 at marriage and soon become mothers.

With half the population in the reproductive group using no contraceptives, there is urgent need to push up the age of marriage, delay the birth of the first child and widen the scope for spacing and limiting families. Vasectomy is a feasible way of enlarging services for a simple, safe and effective terminal method.

Unfortunately, any large-scale efforts to limit population are attacked by critics as an invasion of "human rights". Added to this, given the cultural ethos of the northern States, such goals are dumped as "unacceptable" and "impossible" and invariably shunned by many politicians who thrive on the continued ignorance of populations.

The Millennium Development Goals do not envision family planning strategies as the direct route to improving maternal and child health. This acts as a deterrent to do-gooder international or national organisations from getting involved overtly.

Concentration on maternal and child health services has unwittingly excluded men. Counselling on vasectomy is just not their business. In India, men have ceased to be the direct object of the family planning programme ever since eight million male sterilisations were conducted -- six times more than in a normal year -- coercively and haphazardly during the draconian Emergency.

Even now horror stories of three decades gone by give shudders to politicians, especially in the Hindi belt. With no other terminal option available, millions of women have perforce to undergo tubal ligations having already borne the brunt of unwanted pregnancies and repeated childbirths, not to speak of often dangerous induced abortions.

Against this background, the recent resurrection of the vasectomy programme comes as a welcome surprise. Madhya Pradesh has doubled vasectomies in the span of just one year from 7,000 operations in 2003-04 to over 15,000 the year after. An orthodox State like Haryana has steadily shown higher and higher performance each passing year. Its neighbour Punjab has quadrupled the number of vasectomies in a matter of one year. Likewise conservative Rajasthan has upped the vasectomy performance from just 1,700 during 2003-04 by almost five-times.

During a recent visit to Gujarat, I noted how vasectomy operations had increased six-fold in one year with 6,200 operations conducted in just two months inviting the headline, "Vasectomy with a Vengeance", from a national newspaper. On October 6, in a single district, Vadodara, nearly 900 vasectomies were performed and hundreds of men had clearly come willingly for this outpatient procedure.

At every health facility, ANMs in white saris and smart name tags, anganwadi workers and village women togged up in their best attire escorted the "acceptors" for vasectomy. Even the drivers and sweepers had jumped on the vasectomy bandwagon and motivated between five and 15 young men each. Surgeries progressed speedily and while the patients lounged on beds, waiting their turn, paranthas, enthusiastic counselling and a bag full of condoms were kept in readiness to complete the day's work.

Whether the carrot was the Rs 200 motivation money or the Rs 1,000 compensation for acceptors, an enormous response was clearly evident. But despite occasional peaks, India's annual vasectomy total remains less than a 10th of the pre-Emergency levels, despite hundreds of surgeons having acquired the Chinese non-scalpel skill taught largely by a veteran, Dr RM Kaza of Delhi's Maulana Azad Medical College.

In the United States, United Kingdom, Canada and New Zealand vasectomies are expensive and it is the more educated people who opt for the procedure, gently encouraged to do so by sophisticated advertisements. In India, as in Bangladesh, Sri Lanka, and Thailand, vasectomies are treated as the poor man's option. In some Latin American countries like Brazil, Colombia and Mexico, vasectomy has been presented as an alternative to female sterilisation, and by involving wives in decision-making the outturns improved.

What is needed is for decision-makers outside the health sector to stop worrying about resurrecting the ghost of 1975 and understand that our population growth is having a direct and detrimental effect on maternal and infant mortality, the birth of underweight children and their future growth and survival. In all fairness to women, it is time to revitalise vasectomy.

Mothers and children in MP: Survival questioned

Sachin K Jain
Source - www.merinews.com

In MP, of the 1000 children born, 70 perish before their first birthday and as many as 8.56 lakh childbirths in 2006-07 occurred at homes. The negligence of the government and society is the biggest reason for the deaths of mothers and children.


SANGRAM SINGH of Khatia-Narangi village in Baiga-tribal dominated Mandla district of Madhya Pradesh is not able to open his eyes despite many efforts. His eyelids collapse instantly and his eyes close. His skin is getting contracted. There are several questions about the chances of his survival. The weight of this 50-day child is just 2.2 kg. If such young children are capable of thinking, then Sangram Singh must be surely thinking about the unjust character of the society. He is still in critical situation and Government of Madhya Pradesh has ordered an enquiry in the Shivkali’s, his mother, death case. The term of reference of this enquiry does not contain any point to investigate the violation of child rights. They will only do a formality of investigation of death, not the violation of rights.

Sangram Singh is not just any child but a character of the story that is common for the 7700 children who are born every year in Madhya Pradesh. These are those children who do not have the good luck of receiving mother’s milk and the warmth and sensitivity of her lap. The tragic aspect is that the negligence of government and society becomes the biggest reason for the maternal deaths during childbirth.

If a woman dies within 42 days of childbirth, then the death is considered as maternal mortality. Shivkali died within 11 days of childbirth, yet the state government did not consider it as maternal mortality. As per the Health Department Mandla district did not record a single maternal death during April 2007, which means that along with life of Shivkali, the government is also denying her death. After the death of his mother, the life of Sangram is also in dire straits. At birth, his weight was 2.4 kg, which means that his development has been stunted. In such circumstances, the local health workers have refused to treat the child. Finally with the help of local social workers, Sangram was taken to a doctor Mukesh Rutela in Nainpur on May 22. Here it was diagnosed that Sangram was already entered in grade IV malnutrition category and is also suffering from various infections. At the time of birth he was not severely malnourished and if his treatment is not carried out very intensively, the chances of his survival are poor. The family is full of anger and sadness, but they are now not ready to go to government hospital.

Baiga tribal woman Shivkali had given birth to Sangram Singh on April 4 in her hutment. Local traditional midwife Jethibai assisted the childbirth. There is a primary health centre in this village. Interestingly, the village is not away from the mainstream of system. It is located just by the main gate of Kanha National Park. Ironically the objective of the Primary Health Centre located at the Khatiya village has been to take care of the national and international level tourists rather than the villagers. The PHC has now got a beautiful building, but only three to four villagers reach the PHC every day. When we reached the centre, out of the 15 member staff including four nurses, doctor, ANM and sanitary workers, only one nurse was present. Son Sai of Khatia village says that whenever one approached the centre, the message is that majority of staff have gone to block or district headquarters for some meeting. In such circumstances people are forced to go to Bicchia or Mandla. It is incomprehensible as to why the government is denying that the Baiga tribal (whom former Prime Minister Indira Gandhi had described as national people) live in a traditional setting. Because forest rights were taken away from them, they have also lost access to traditional medicines owing to which women and children are dying, but the modern medicine system is far out of their reach. If the future of the children is to be safeguarded then the government should have brought the Baigas close to modern treatment facilities in a sincere and sensitive manner.

The maternal and child mortality cannot be contained only by writing slogans on the walls or presenting unbelievable statistics. Isn’t it a serious fact that around 10 million children die every year before celebrating first birthday in Madhya Pradesh?

The effort for protection of life is also the responsibility of anganbadis, but it could only be called unfortunate that the name of Shivkali was not registered in the list of pregnant women in the local anganbadi. Naturally this pregnant woman from a poor family could not get enough nutrition to sustain herself and her foetus. However, after her death, the local anganbadi worker Shashikanta Thakur took possession of her mother-child card and filled up all details regarding completion of immunization doses. Similarly the district hospital took possession of all medical documents related to Shivkali and Sangram Singh. The amount of efforts taken to destroy evidence if taken previously could have saved lives of Shivkali and Sangram. Shashikanta waves off her responsibility saying that the tribal people do not want to get immunized or treated. “Khushiyal Singh (Shivkali’s husband) should have been more responsible. We cannot go home to home checking upon people,’’ she says. Thus the victim has been made the accused by the system. It is very unfortunate that the woman who could not even express her health problems or pains has been made responsible for her own death.

Ten per cent of the populace in MP is that of tribal communities including three primitive tribal – Baiga, Bharia and Saharia. But the state government does not have any work plan to change the innate behavioural patterns or gaining confidence of these communities. Not only this, but the 51000 odd traditional midwives (dais) who could have brought these people closer to modern medicine system have been banned from offering their services. On one hand the government is not able to provide proper health services and on the other hand it is scrapping the traditional and alternative systems.

The situation in Khatia is very unusual. Shivkali never received even a single health check up during her pregnancy period and did not get a single immunization dose. During last two years, the state government started as many as seven schemes to prevent maternal and child morbidity and mortality, of which the Vijayaraje Janani Bima Kalyan Yojana was closed down on May 11, 2007. The logic given was that the women were getting enough benefits under other schemes and thus this was not necessary. The truth is that during last year, 56 women and 807 kids perished in Mandla. Government touts that institutional childbirth is the best way to safe motherhood and that the responsibility to encourage community for this falls on health administration.

The sub-health centers and the primary health centers have to ensure that every pregnant woman should be registered within 12 weeks of pregnancy so that the regular health check up, immunization, nutritional needs and emergency treatment facilities could be ensured for her. The basic thing is that government will have to take care that health services and health workers should reach the needy people like Shivkali and Sangram. It should not be expected that women and children bearing pain and burdened by exploitation would reach the health centers and demand services.

As per the guidelines of the Government of India, all the primary health centers should have refrigerator and deep freezer to store the medicines, but at the Khatia PHC, the medicines and equipments were lying openly at temperature of 43 degrees. There are no standard arrangements of storing medicines in the 7300 sub-health centers in MP, owing to which the treatment of patients becomes risky in itself.

The issue of health demands sensitive behaviour and attitude, which means that it should be ensured that the people suffering from pains could be provided humane touch. It is a well-proven fact that total cure of any pain is not possible only through medicines. For Shivkali and Sangram, this belief could not prove to be positive.
In MP, of the 1000 children born, 70 perish before their first birthday and as many as 8.56 lakh childbirths in 2006-07 occurred at homes. The negligence of the government and society is the biggest reason for the deaths of mothers and children.


Sangram was born into tattered unclean rags at home, but after this the health of Shivkali started deteriorating. Then Shivkali’s father Mangal Singh started looking for the ANM and the health worker. As it was evening time, Jagat Singh Pande and Subhadra Pande did not pay attention to the issue and asked that Shivkali be taken to Mandla, which is 65 kms from Khatia. Under one scheme of the government, financial assistance is provided to pregnant women facing problems for reaching the health services, but Shivkali did not receive any such assistance. Mangal Singh rented a private vehicle for Rs 1200 and took her to district hospital, Mandla. They had the Deendayal Antyodaya Treatment Card, but the doctors did not pay attention to it. The lady doctor in the hospital asked for Rs 3000 from Mangal Singh for the treatment. Since it was matter of life and death for his daughter and grandson, Mangal Singh requested the doctor to start the treatment, although he had only Rs 30 left with him after paying the rent of the vehicle. Even this Rs 30 was taken away by the doctor. Mangal is also the chief of the Baiga Adiwasi Sangathan of Mandla and thus he lodged a complaint with the District Collector regarding this exploitation. Inquiry was conducted and pressure was created on the hospital administration.

But the inhumane face of the doctors came to the fore. As soon as the district administration official left the hospital, the hospital authorities refused to treat Shivkali and referred her to Jabalpur. Doctor said to Mangal Singh that, “you are a leader and only your leadership can save your daughter.” Thus Shivkali had to pay for her poverty as well as for demanding her rights, although indirectly. Left with no option, Mangal Singh decided to take Shivkali back to village, but she succumbed even before reaching the village.

Now Mangal Singh is facing a debt of Rs 5500, which he would have to repay at the interest rate of 10 per cent per month. Leave aside treatment and medicine; the family did not even receive any consolation. It is natural that no sacrifice is expected from the health workers, but could not they be expected to at least fulfill the responsibilities allotted to them.

Health worker Jagat Singh says that it is compulsory to attend meetings every month. Since targets are fixed, thus information has to be provided regularly, even if it means that there is no time left for fulfilling the targets. The health workers also have their limits; Jagat Singh says adding that what would have happened if Shivkali had died while the nurse was trying to treat her. If there are no doctors available permanently, how women like Shivkali could be saved.

Every year about 17 lakh childbirths are carried out in the State and of them 53 per cent are in BPL, tribal and dalit families. In such situation, 99 out of 137 posts of obstetricians and gynecologists are vacant. About 648 out of 4607 posts of doctors are vacant and of the rest 3133 medical officers are posted in urban and semi-urban areas. Shivkali needed blood, but although getting blood is easy for people of higher economic classes, she could not get blood. There was hospital, medicine, anganbadi as well as motorable road, yet Shivkali had to die and little Sangram is struggling for survival.

In Madhya Pradesh out of the 1000 children born, 70 perish before their first birthday. According to this rate, in year 2006-07 as many as 1.19 lakh infants could not be saved. This proved that still at the societal, political and governmental level, the right to honorable life right is a much neglected issue.

Despite efforts by the government, as many as 8.56 lakh childbirths in MP in 2006-07 occurred at homes. There are certainly efforts to rid the society of evil of maternal death through institutional childbirth. But the situation of the health centers and the inhumane behaviour meted out there is still a big challenge. In Indore, a nurse physically assaulted a pregnant woman while in Mandsaur a woman had to undergo childbirth on the road as she could not pay bribe to health workers. In Ashok Nagar, Nevabai became a victim to negligence of doctors and when the community demanded inquiry of the incident, the health administration boycotted Nevabai’s village Nidanpur. Due to this boycott, Phoolkunwar died on the road. Seems to me that the bigger reasons for maternal and infant deaths are selfishness and ego of the expert medical practitioners.

Fategarh health centre in Guna, MP helps save lives

Anil Gulati

Through UNICEF’s support, this primary healthcare centre has become a round the clock maternal and childcare service delivery centre. The Fategarh model has inspired and has been replicated in six more institutions in Guna.

PRIMARY HEALTH CENTRE, Fategarh village, District Guna, Madhya Pradesh, India: Fategarh is a panchayat village about two hours drive on make shift road from the district headquarters of Guna. The panchayat village lies in Madhya Pradesh but borders districts of Rajasthan, an Indian state.

The village has a sector sub health centre. Ninty deliveries, took place in this health centre, in June 2007, almost all of them are from this nearby villages. This was not the case a year and half before (before December 4, 2006, the day when this centre was revitalised). Before this date, all deliveries used to happen at home and there were number of maternal deaths in the area, which was revealed by Maternal and Prenatal Death Inquiry and Response or the social audit of maternal deaths in the Bamori block, which includes Fategarh panchayat.

Before December 2006, the centre offered only immunisation services like any other sub health centre in the state. Heath facilities like labour room facility for pregnant women of Fategarh and nearby villages was quite far and accessibility to health services was an issue. This was one of the reasons for maternal deaths in the area. It is here that UNICEF (United Nations Children’s Fund) came in and supported the District administration of Guna, Madhya Pradesh, to help make this centre a round the clock mother and child care service delivery centre. UNICEF not only supported the district by providing them with skilled birth attendants, but also trained them in integrated management of newborn and childhood illness.

The centre, as of now, caters for eleven villages. Niranjana and Kamlsa, auxiliary nurses midwives at the centre feel elated when they see the progress, but they sometimes get exhausted when they have to undertake seven to eight deliveries a day; thanks to the increased awareness and schemes by the state.

The centre also undertakes awareness programmes in remote areas and shares information on various schemes, like Janani Suraksha Yojana, initiated by the state government to promote institutional delivery with the community members. This has helped in creating awareness and demand for the need of the institutional deliveries.

“I felt much protected and secure when I came here for my delivery” says Shravani, a mother of three. Her first two deliveries were at home, but for the third one the village ‘dai’ got her to the sub health centre.

Dr Hamid El Bashir, State Representative, UNICEF office for Madhya Pradesh, adds that children and women’ lives can be saved and this can happen with improvement in both access and quality of health services through such interventions. Fategarh model of revitalisation of the sub centre to provide basic health care services, including conducting deliveries, has inspired and has been replicated in six more institutions in Guna.

Fategarh health centre in Guna, MP helps save lives

Anil Gulati

Through UNICEF’s support, this primary healthcare centre has become a round the clock maternal and childcare service delivery centre. The Fategarh model has inspired and has been replicated in six more institutions in Guna.

PRIMARY HEALTH CENTRE, Fategarh village, District Guna, Madhya Pradesh, India: Fategarh is a panchayat village about two hours drive on make shift road from the district headquarters of Guna. The panchayat village lies in Madhya Pradesh but borders districts of Rajasthan, an Indian state.

The village has a sector sub health centre. Ninty deliveries, took place in this health centre, in June 2007, almost all of them are from this nearby villages. This was not the case a year and half before (before December 4, 2006, the day when this centre was revitalised). Before this date, all deliveries used to happen at home and there were number of maternal deaths in the area, which was revealed by Maternal and Prenatal Death Inquiry and Response or the social audit of maternal deaths in the Bamori block, which includes Fategarh panchayat.

Before December 2006, the centre offered only immunisation services like any other sub health centre in the state. Heath facilities like labour room facility for pregnant women of Fategarh and nearby villages was quite far and accessibility to health services was an issue. This was one of the reasons for maternal deaths in the area. It is here that UNICEF (United Nations Children’s Fund) came in and supported the District administration of Guna, Madhya Pradesh, to help make this centre a round the clock mother and child care service delivery centre. UNICEF not only supported the district by providing them with skilled birth attendants, but also trained them in integrated management of newborn and childhood illness.

The centre, as of now, caters for eleven villages. Niranjana and Kamlsa, auxiliary nurses midwives at the centre feel elated when they see the progress, but they sometimes get exhausted when they have to undertake seven to eight deliveries a day; thanks to the increased awareness and schemes by the state.

The centre also undertakes awareness programmes in remote areas and shares information on various schemes, like Janani Suraksha Yojana, initiated by the state government to promote institutional delivery with the community members. This has helped in creating awareness and demand for the need of the institutional deliveries.

“I felt much protected and secure when I came here for my delivery” says Shravani, a mother of three. Her first two deliveries were at home, but for the third one the village ‘dai’ got her to the sub health centre.

Dr Hamid El Bashir, State Representative, UNICEF office for Madhya Pradesh, adds that children and women’ lives can be saved and this can happen with improvement in both access and quality of health services through such interventions. Fategarh model of revitalisation of the sub centre to provide basic health care services, including conducting deliveries, has inspired and has been replicated in six more institutions in Guna.

Empowering Women

By M V Kamath, The Organiser, Sept 30, 2007

Irrespective of whether a woman is elected President or not, there are certain things that not just a woman President but all political parties should attend to—and it is the rights of women. Not just in India, but all over the world women have been the greatest sufferers. About three quarters of the world’s 20 million refugees are women and their dependents. Women and children account for more than 80 per cent of those living in refugee camps and that is seldom acknowledged. Things are no better, specifically in India.

According to The Indian National Crimes Records Bureau (NCRB) quoted by a distinguished human rights expert, D.R. Kaarthikeyan, there were 9,518 cases of rape in India in 1990 which rose to 9,793 in 1991 and to 15,468 cases in 1999. Similarly, there were 4,836 dowry deaths cases in 1990, which rose to 5,157 in 1991 and to an all-time high of 6,699 in 1999. Cases of torture of women have to be enumerated to be believed. There were 13,450 cases in 1990, as many as 15,949 in 1991 and an unbelievable 43,823 cases in 1999.

In his book on human rights, Mr Kaarthikeyan writes: “Research has shown that for millions of women, their homes are dens of terror and that a huge chunk of violence that is perpetrated against women is committed by their own family members.” Not only that, but such violence cuts across income, class and culture and these incidents are rarely reported and even if they are reported “they are reported when it is too late to change the situation”.

It is frightening to think that every 26 minutes a women is molested, every 34 minutes a rape takes place, every 42 minutes a sexual harassment incident occurs, every 43 minutes a woman is kidnapped and almost every hour a woman is burnt to death over dowry, 25 per cent of rapes involving girls in the age of 16. This is India. The spiral of violence against women is apparently rising “at an alarming rate”—and this is where just not a woman president, not just a government in power, but all political parties irrespective of their ideology must come in, to fight for social reform, for enlightenment of people and for raising our ancient culture to higher levels. Gender violence comes in many forms with which most of us are familiar. They include foeticide, food deprivation, emotional abuse, forced marriage, sati, rape, sexual assault, harassment of all sorts, trafficking, forced sterilisation, torture and finally dowry deaths, the cruellest of all.

There are, of course, legal provisions to fight gender violence but none of these have truly been effective. Jawaharlal Nehru once said: “You can tell the condition of a nation by looking at the status of its women.” On the one hand, India has the world’s largest number of professionally qualified women which may come as a surprise to many to know. India reportedly has more women doctors, surgeons, scientists and professors than even the United States of America. Similarly, India has more working women than any other country in the world and they are notable for their skills whether as surgeons, airline pilots or even bus conductors and menial workers. That should be a legitimate matter of pride.

But then think of this: India has the largest population of non-school going working girls, maternal mortality rates in rural areas are among the world’s highest and of the 15 million baby girls born in India each year, nearly 25 per cent of them do not live to see their 15th birthday.

Compared to baby boys, they get less food, less care and less attention, which is a disgrace to the country. Indians who boast of the panch kanyas, Ahalya, Draupadi, Sita, Tara and Mandodari, and insist that if these are smare nityam, maha pathaka nashanam (the greatest sins are destroyed if they are daily remembered), have no hesitation in resorting to foeticide if the foetus shows that it is that of a girl. What can be more shameful?

In India, female foeticide, sex selective abortion and child prostitution are only too common and few voices are raised against them. Laws are for textbooks, not for application. The Dowry Prohibition Act has been in existence for over 33 years, but how effective has it ever been? Domestic violence is recognised by existing civil law, according to Kaarthikeyan, but only in the context of dissolution of a marriage, and as being conduct amounting to cruelty, and therefore, ground for divorce. Is that all we want? With female foeticide becoming almost routine, we are coming to a stage when young men in some states, especially in the north and west, will have to search for brides elsewhere in the country. In the latest Census, the number of female child births has come down to 93.7 for every hundred male children. The anti-girl child bias has to be fought at the ground level and this is not a party issue: It is a national issue. We need a new set of Raja Ram Mohan Roys to act as social reformers who have the courage to speak out and speak persuasively. Sadly, we don’t have them. We only have cheap politicians for ever dwelling on secularism as their moola mantra which is an easy way to attain political applause.

When did any member of the present UPA government ever speak about these matters? When one realises that women form half of that world’s population—as indeed half of the population in almost any given state—it is shocking to learn that women perform two-third of the world’s work and receive only one-tenth of its income and less than one hundredth of its property. In reality, this is a man’s world. And men are notorious for the ways they treat women—not outsiders—but those in their own homes. In India, the states most notorious for the ill-treatment of women are Rajasthan, Madhya Pradesh and Delhi. Female foeticide is most rampant in Haryana and Punjab. Does anybody care? Trafficking in women and children, according to Kaarthikeyan, is one of the worst and most brazen abuses of human rights. According to him, at least 25,000 children are engaged in prostitution in India’s metropolitan cities, which is a low figure compared to other sources which put the figure as high as 500,000 girl children below the age of 18 years.

These are issues for our political parties lacking vision to give their attention to. But what can a parliament do which reportedly has some 119 MPs with criminal charges against them? What vision can one expect from them? We are not only a wild nation, but additionally we are also a blind nation. Our only national interest is politics, not people and politics, too, of the blindest variety. We speak about the common man, but it would be nice if we occasionally hear about the travails of the ordinary woman who is the lifeline of our society.

Madhya Pradesh nowhere near reaching key development goals

The authors of the Triple 7 report said the picture in the field of primary education was equally bleak, due to lack of trained teachers and of basic facilities such as drinking water and toilets in the schools.

By S Sharma, IANS - Madhya Pradesh is nowhere near reaching the UN Millennium Development Goals - by the 2015 deadline, if a mid-term evaluation report prepared by voluntary groups is anything to go by.

And this in a state where a world record 3.3 million people across 42 districts took part in a government-sponsored 'Stand Up Against Poverty' campaign in October to achieve the MDGs - reducing poverty, achieving universal primary education, promoting gender equality, reducing child mortality, improving maternal health and ensuring environmental sustainability.

Now voluntary groups in the state have prepared what they call the 'Triple 7 Report' - after a mid-term evaluation of how far the state is from achieving the MDGs.

The report says Madhya Pradesh - where 4.5 million families live below the poverty line - has been found wanting on all fronts.

'Malnutrition is a problem that has always been brushed under the carpet by politicians but the dire conditions in Madhya Pradesh now definitely call for some mandated moves', says Sachin Jain of Vikas Samvad, one of the groups behind the report.

In Madhya Pradesh 82.6 percent of all children under the age of three are anaemic, according to the government's own recent National Family Health Survey - III. The corresponding figure for 1998-99, when NFHS II was carried out, was a low 54 percent.

Sixty percent of all children under the age of three in the state are underweight, 51 percent are stunted and 20 percent are wasted, says the Triple 7 report.

Data collected during the state government's recent growth monitoring drive and Bal Sanjeevni Abhiyaan shows that 80,000 children are suffering from most severe malnutrition and are on the verge of death, the authors of the report say.

According to NFHS III, only 22.4 percent of the children below the age of two have full immunisation coverage.

The Triple 7 report says only 23 percent of the children are registered in Anganwadis -.

In a state where 24 women die in childbirth every day, the maternal mortality rate is 379 per 100,000 live births - third highest in the country.

The infant mortality rate - which counts children who die before the first birthday - stands at 76 per 1,000 live births.

'Though the state has introduced many schemes to help combat maternal and infant deaths, they are not yielding the desired results due to bureaucratic hassles and corruption,' say activists responsible for the Triple 7 report.

The activists refer to a recent report of the Comptroller and Auditor General of India that benefits of the schemes do not reach 52-62 percent of the children and 46-59 percent of the pregnant and lactating mothers.

And it is not as if private healthcare is stepping into the breach. The activists point out that expenditure on health has declined from 5.1 percent of total expenditure in 2000-01 to 3.4 percent in 2004-05.

This is a state where 38 percent of the rural population do not have access to safe drinking water. Madhya Pradesh accounts for 40 percent falciparum malaria cases in the country.

The authors of the Triple 7 report said the picture in the field of primary education was equally bleak, due to lack of trained teachers and of basic facilities such as drinking water and toilets in the schools.

The authorities also had to address issues such as the distance to the nearest school, midday meals and scholarships, the activists added.

Engaging India: A matter of national shame

Amy Yee, Financial Times

At a health centre in India’s Madhya Pradesh state, three-year-old Rajkumar clings to his mother, a woman named Anita whose youth is hinted at only when a smile cracks her weathered face. Rajkumar wails when his mother moves away slightly, standing by himself on the cot where she sits.

I am unsure whether he is crying for his mother or because it is painful to stand: his legs are matchstick thin – merely the width of two of my fingers. Rajkumar weights only 5.9 kg (13 pounds) when he should weigh 12 kg. His hair is brittle, light brown – another tell-tale sign of malnourishment.

Nearby, another mother looks on from amid the rows of cots lined up across the large room. She cradles her baby, whose head dwarfs his frail, doll-like body.
Severely malnourished children like Rajkumar and their mothers are sent to health centres like this one by government health workers who work, with assistance from Unicef, in surrounding villages at ”anganwadi” – half-day pre-schools where children are fed, immunised, weighed, and monitored. If left untreated, children at this stage are likely to die from infections that plague their weakened bodies. Indeed, more than half of all deaths among under-fives are linked to malnutrition, says the World Health Organisation. At the health centres, launched by Unicef and the Madhya Pradesh state government a few years ago, mothers are counseled on nutrition and hygiene. At this town clinic in Shivpuri district, about five hours from Delhi by train, children and their mothers are fed and monitored for two weeks.

At an anganwadi in a small hamlet miles from the health centre, children sing cheerful songs and crowd the floor of a simple shack. There they eat a daily lunch prepared from local ingredients on a wood-burning hearth. Today it is a meal of soy, groundnuts, rice, potato, onion, mint, oil and salt. The anganwadi also acts as a resource centre for mothers: its walls bear posters with bright cartoons that warn of polio and anemia.

Government-run anganwadi have been in place for three decades. The network has been expanded as part of a national plan to improve children’s health. In recent years Unicef has stepped up its presence in landlocked Madhya Pradesh, or ”Middle State”, which has some of the worst levels of malnutrition among already alarming national numbers.
An astonishing 46.3 per cent of all children under the age of three in India are malnourished, and nearly 80 per cent are anemic, according to the government’s National Health and Family Survey of 2005-06. There has been marginal improvement since 1992-93, when 51 per cent of under-threes were underweight. But in Madhya Pradesh, figures have worsened from 55 per cent in 1998-1999 to 60 per cent in 2005-2006.

The statistics are stupefying given India’s ambition of becoming a global power. It is hard to take that aspiration seriously with almost half the country’s infants malnourished during critical years of cognitive and physical development. Even if Rajkumar lives to adulthood, he may be mentally and physically stunted. One wonders how India will reap the much-touted ”demographic dividend” of its youth where half of its 1.1bn population is under the age of 25.
Aid agencies say it is difficult to fund projects to combat the pervasive problem of malnutrition because of ’fatigue’ among donors. But India’s malnutrition ranks far worse than sub-Saharan Africa’s average rate of 27 per cent for children under the age of five, an ugly fact that rouses officials from complacency.
Manmohan Singh, India’s prime minister, condemned malnutrition as ”a matter of national shame” in his Independence Day address last week. Mr Singh ambitiously urged eradicating malnutrition in five years, and said communities must help ensure that corruption does not divert funds from the needy.

Of course, this is all much easier said then done. The challenges are starkly laid out during this visit to Madhya Pradesh. The state’s large population of 60m is scattered across thousands of villages with dirt roads and limited or no electricity, making them difficult and expensive for health workers to reach. Low literacy of 60 per cent makes it is hard to spread knowledge through pamphlets and posters.

Many mothers simply don’t know how to care for infants in the absence of adequate education. Only 55 per cent of mothers in Madhya Pradesh deliver in hospitals – though that’s an improvement from 26 per cent a few years ago – so most lack advice from healthcare professionals from the start. Anita, for example, says she didn’t know Rajkumar was malnourished in spite of his emaciated state.

Most rural diets are dominated by grain, which is inadequate for a growing child who needs protein, vitamins and minerals. Lunch at the anganwadi cannot compensate for a paltry diet at home.

But even if they have money, accessing better food is a major challenge for rural families. The nearest open-air markets are miles away and transport is not readily available. Supermarkets, so ubiquitous in the developed world, seem like a bizarre fantasy while standing among the low, mud-walled homes in this village in Shivapur. Superstitions and taboos also are deeply ingrained in local culture. Anita admits she did not breastfeed her son in the first critical days after her birth because her mother-in-law discouraged her.

Yet there are glimmers of hope. Back at the town health centre, a casual labourer named Papku sits with his 10-month old son who is stricken with diarrhea. Sleeping next to the infant on the cot is Papku’s three-year-old son, Krishna, who was admitted to the centre a year ago weighing just 6 kg. After his parents were counseled on proper nutrition, Krishna’s weight has doubled to 12 kg (26.5 pounds) in a year. The boy looks robust and meaty although his father earns only Rs60 ($1.50) a day to support his family of six, which includes his wife and three young daughters.

Given his modest means why did Papku have five children? Papku matter-of-factly states that even after his eldest son was born, he wanted two sons in case one died. It is a jarring explanation. But the pragmatic answer reflects life for Papku and his family – and hundreds of millions like them across India.

A women dies every 7 minutes in India

One woman dies every 7 minutes in the country due to complications related to pregnancy and childbirth, the government today admitted in the Rajya Sabha. In a written reply, Minister of State for Health Panabaka Lakshmi said estimates of the Registrar General of India has revealed that the maternal mortality ratio for India is 301 per 10,000 live births which translates into 77,000 per year or one woman dying every seven minutes. Both Uttar Pradesh and Uttaranchal have a maximum MMR of 517, followed by Assam 490, Rajasthan 445, Madhya Pradesh and Chhattisgarh 379, Bihar and Jharkhand have MMR of 371 and Orissa 358, she said. The reasons for such high level of maternal mortality in the country was hemorrhage (38 percent), sepsis 11 percent, abortion 8 percent, obstructed labour 5 percent, hypertensive disorders 5 percent and others 34 percent, she added. The centre has launched the National Rural Health Mission to increase the access of quality health care including services of safe motherhood in rural areas.

Under NRHM and RCH phase II, one of the goals was to achieve a reduction in MMR to 100 per 100,000 live births, she said. Services are being strengthened through Janani Suraksha Yojna which promotes institutional delivery for reducing MMR and infant mortality rate by providing quality maternal care during pregnancy, delivery period with appropriate referral transport system along with cash assistance to pregnant women with special focus on BPL women and SC/ST population. Moreover, ASHAs are being appointed and a number of other steps being taken to reduce maternal mortality, she added.

Bureau Report

Iron and Iodised Fortified Salt for Expectant Mothers in MP

Minister for Public Health and Family Welfare, Government of Madhya Pradesh, Ajay Vishnoi informed media yesterday state government has decided to supply fortified salt (Iron + Iodine) to all the expectant and nursing mothers of 23 tribal predominant districts of the state. The fortified salt would be distributed through 26 thousand 691 aaganbadis functioning in these districts.

The districts where fortified salt is to be distributed includes Dhar, Jhabua, Badwani, Khargone, Ratlam, Shahdol, Anuppur, Umaria, Betul, Mandla, Dindori, Balaghat, Chhindwara, Sheopur, Hoshangabad, Burhanpur, Seoni, Sidhi, Jabalpur, Dewas, Khandwa, Harda and Katni. Instructions have been issued by the government to all the district collectors, chief medical and health officers, district woman and child development officers in this regard. These officers will also ensure monitoring, storage, utilisation of the salt besides its proper distribution to the beneficiaries through aaganwadis and undertake reporting. The medicated salt will be distributed in ratio of one kilogram per beneficiaries per month as per the take home ration system, which can be utilised by the beneficiaries for her use and family as well.

Mothers and children in MP: Survival questioned

Sachin K Jain

In MP, of the 1000 children born, 70 perish before their first birthday and as many as 8.56 lakh childbirths in 2006-07 occurred at homes. The negligence of the government and society is the biggest reason for the deaths of mothers and children.

SANGRAM SINGH of Khatia-Narangi village in Baiga-tribal dominated Mandla district of Madhya Pradesh is not able to open his eyes despite many efforts. His eyelids collapse instantly and his eyes close. His skin is getting contracted. There are several questions about the chances of his survival. The weight of this 50-day child is just 2.2 kg. If such young children are capable of thinking, then Sangram Singh must be surely thinking about the unjust character of the society. He is still in critical situation and Government of Madhya Pradesh has ordered an enquiry in the Shivkali’s, his mother, death case. The term of reference of this enquiry does not contain any point to investigate the violation of child rights. They will only do a formality of investigation of death, not the violation of rights.

Sangram Singh is not just any child but a character of the story that is common for the 7700 children who are born every year in Madhya Pradesh. These are those children who do not have the good luck of receiving mother’s milk and the warmth and sensitivity of her lap. The tragic aspect is that the negligence of government and society becomes the biggest reason for the maternal deaths during childbirth.

If a woman dies within 42 days of childbirth, then the death is considered as maternal mortality. Shivkali died within 11 days of childbirth, yet the state government did not consider it as maternal mortality. As per the Health Department Mandla district did not record a single maternal death during April 2007, which means that along with life of Shivkali, the government is also denying her death. After the death of his mother, the life of Sangram is also in dire straits. At birth, his weight was 2.4 kg, which means that his development has been stunted. In such circumstances, the local health workers have refused to treat the child. Finally with the help of local social workers, Sangram was taken to a doctor Mukesh Rutela in Nainpur on May 22. Here it was diagnosed that Sangram was already entered in grade IV malnutrition category and is also suffering from various infections. At the time of birth he was not severely malnourished and if his treatment is not carried out very intensively, the chances of his survival are poor. The family is full of anger and sadness, but they are now not ready to go to government hospital.

Baiga tribal woman Shivkali had given birth to Sangram Singh on April 4 in her hutment. Local traditional midwife Jethibai assisted the childbirth. There is a primary health centre in this village. Interestingly, the village is not away from the mainstream of system. It is located just by the main gate of Kanha National Park. Ironically the objective of the Primary Health Centre located at the Khatiya village has been to take care of the national and international level tourists rather than the villagers. The PHC has now got a beautiful building, but only three to four villagers reach the PHC every day. When we reached the centre, out of the 15 member staff including four nurses, doctor, ANM and sanitary workers, only one nurse was present. Son Sai of Khatia village says that whenever one approached the centre, the message is that majority of staff have gone to block or district headquarters for some meeting. In such circumstances people are forced to go to Bicchia or Mandla. It is incomprehensible as to why the government is denying that the Baiga tribal (whom former Prime Minister Indira Gandhi had described as national people) live in a traditional setting. Because forest rights were taken away from them, they have also lost access to traditional medicines owing to which women and children are dying, but the modern medicine system is far out of their reach. If the future of the children is to be safeguarded then the government should have brought the Baigas close to modern treatment facilities in a sincere and sensitive manner.

The maternal and child mortality cannot be contained only by writing slogans on the walls or presenting unbelievable statistics. Isn’t it a serious fact that around 10 million children die every year before celebrating first birthday in Madhya Pradesh?

The effort for protection of life is also the responsibility of anganbadis, but it could only be called unfortunate that the name of Shivkali was not registered in the list of pregnant women in the local anganbadi. Naturally this pregnant woman from a poor family could not get enough nutrition to sustain herself and her foetus. However, after her death, the local anganbadi worker Shashikanta Thakur took possession of her mother-child card and filled up all details regarding completion of immunization doses. Similarly the district hospital took possession of all medical documents related to Shivkali and Sangram Singh. The amount of efforts taken to destroy evidence if taken previously could have saved lives of Shivkali and Sangram. Shashikanta waves off her responsibility saying that the tribal people do not want to get immunized or treated. “Khushiyal Singh (Shivkali’s husband) should have been more responsible. We cannot go home to home checking upon people,’’ she says. Thus the victim has been made the accused by the system. It is very unfortunate that the woman who could not even express her health problems or pains has been made responsible for her own death.

Ten per cent of the populace in MP is that of tribal communities including three primitive tribal – Baiga, Bharia and Saharia. But the state government does not have any work plan to change the innate behavioural patterns or gaining confidence of these communities. Not only this, but the 51000 odd traditional midwives (dais) who could have brought these people closer to modern medicine system have been banned from offering their services. On one hand the government is not able to provide proper health services and on the other hand it is scrapping the traditional and alternative systems.

The situation in Khatia is very unusual. Shivkali never received even a single health check up during her pregnancy period and did not get a single immunization dose. During last two years, the state government started as many as seven schemes to prevent maternal and child morbidity and mortality, of which the Vijayaraje Janani Bima Kalyan Yojana was closed down on May 11, 2007. The logic given was that the women were getting enough benefits under other schemes and thus this was not necessary. The truth is that during last year, 56 women and 807 kids perished in Mandla. Government touts that institutional childbirth is the best way to safe motherhood and that the responsibility to encourage community for this falls on health administration.

The sub-health centers and the primary health centers have to ensure that every pregnant woman should be registered within 12 weeks of pregnancy so that the regular health check up, immunization, nutritional needs and emergency treatment facilities could be ensured for her. The basic thing is that government will have to take care that health services and health workers should reach the needy people like Shivkali and Sangram. It should not be expected that women and children bearing pain and burdened by exploitation would reach the health centers and demand services.

As per the guidelines of the Government of India, all the primary health centers should have refrigerator and deep freezer to store the medicines, but at the Khatia PHC, the medicines and equipments were lying openly at temperature of 43 degrees. There are no standard arrangements of storing medicines in the 7300 sub-health centers in MP, owing to which the treatment of patients becomes risky in itself.

The issue of health demands sensitive behaviour and attitude, which means that it should be ensured that the people suffering from pains could be provided humane touch. It is a well-proven fact that total cure of any pain is not possible only through medicines. For Shivkali and Sangram, this belief could not prove to be positive.

Sangram was born into tattered unclean rags at home, but after this the health of Shivkali started deteriorating. Then Shivkali’s father Mangal Singh started looking for the ANM and the health worker. As it was evening time, Jagat Singh Pande and Subhadra Pande did not pay attention to the issue and asked that Shivkali be taken to Mandla, which is 65 kms from Khatia. Under one scheme of the government, financial assistance is provided to pregnant women facing problems for reaching the health services, but Shivkali did not receive any such assistance. Mangal Singh rented a private vehicle for Rs 1200 and took her to district hospital, Mandla. They had the Deendayal Antyodaya Treatment Card, but the doctors did not pay attention to it. The lady doctor in the hospital asked for Rs 3000 from Mangal Singh for the treatment. Since it was matter of life and death for his daughter and grandson, Mangal Singh requested the doctor to start the treatment, although he had only Rs 30 left with him after paying the rent of the vehicle. Even this Rs 30 was taken away by the doctor. Mangal is also the chief of the Baiga Adiwasi Sangathan of Mandla and thus he lodged a complaint with the District Collector regarding this exploitation. Inquiry was conducted and pressure was created on the hospital administration.

But the inhumane face of the doctors came to the fore. As soon as the district administration official left the hospital, the hospital authorities refused to treat Shivkali and referred her to Jabalpur. Doctor said to Mangal Singh that, “you are a leader and only your leadership can save your daughter.” Thus Shivkali had to pay for her poverty as well as for demanding her rights, although indirectly. Left with no option, Mangal Singh decided to take Shivkali back to village, but she succumbed even before reaching the village.

Now Mangal Singh is facing a debt of Rs 5500, which he would have to repay at the interest rate of 10 per cent per month. Leave aside treatment and medicine; the family did not even receive any consolation. It is natural that no sacrifice is expected from the health workers, but could not they be expected to at least fulfill the responsibilities allotted to them.

Health worker Jagat Singh says that it is compulsory to attend meetings every month. Since targets are fixed, thus information has to be provided regularly, even if it means that there is no time left for fulfilling the targets. The health workers also have their limits; Jagat Singh says adding that what would have happened if Shivkali had died while the nurse was trying to treat her. If there are no doctors available permanently, how women like Shivkali could be saved.

Every year about 17 lakh childbirths are carried out in the State and of them 53 per cent are in BPL, tribal and dalit families. In such situation, 99 out of 137 posts of obstetricians and gynecologists are vacant. About 648 out of 4607 posts of doctors are vacant and of the rest 3133 medical officers are posted in urban and semi-urban areas. Shivkali needed blood, but although getting blood is easy for people of higher economic classes, she could not get blood. There was hospital, medicine, anganbadi as well as motorable road, yet Shivkali had to die and little Sangram is struggling for survival.

In Madhya Pradesh out of the 1000 children born, 70 perish before their first birthday. According to this rate, in year 2006-07 as many as 1.19 lakh infants could not be saved. This proved that still at the societal, political and governmental level, the right to honorable life right is a much neglected issue.

Despite efforts by the government, as many as 8.56 lakh childbirths in MP in 2006-07 occurred at homes. There are certainly efforts to rid the society of evil of maternal death through institutional childbirth. But the situation of the health centers and the inhumane behaviour meted out there is still a big challenge. In Indore, a nurse physically assaulted a pregnant woman while in Mandsaur a woman had to undergo childbirth on the road as she could not pay bribe to health workers. In Ashok Nagar, Nevabai became a victim to negligence of doctors and when the community demanded inquiry of the incident, the health administration boycotted Nevabai’s village Nidanpur. Due to this boycott, Phoolkunwar died on the road. Seems to me that the bigger reasons for maternal and infant deaths are selfishness and ego of the expert medical practitioners.

`Woman in labour turned away from hospital'

Central Chronicle Bhopal, June 11

A woman in labour was turned away from a government hospital, tribal farmers were put in a debt trap by showing them as loanees for the lift irrigation pump that did not work even for a single day and electric supply was erratic in rural areas.

These were among a host of complaints found true after Chief Minister Shivraj Singh Chouhan ordered spot verification of the grievances raised by the common people during his 'Jan Darshan' programme in the tribal-dominated Jhabua district in the last two days. Chouhan ordered suspension of at least half a dozen officials, including engineers, and issuing of show cause notices to two executive engineers of Public Works and Water Resources departments, official sources said. A nurse was suspended following complaint that she did not admit a woman in labour who had turned up at the government hospital at Meghnagar for institutional delivery.
Jhabua block panchayat Chief Executive Officer S T Madhavacharya and Sub-Engineer Dinesh Lodhi were suspended for irregularities in the construction of water bodies in farmer's land at village Antarvelia. Two Sub-Engineers SN Chouhan and KK Saxena were suspended for irregularities in rural employment guarantee scheme, the sources said.

Chouhan had instructed the Indore Divisional Commissioner to scrutinise the tender system in all Works departments in the district and black-list the contractors who were found not up to the mark. ''Rural people were not satisfied with the electricity distribution system'', he said while reviewing the working of the Power Distribution Company (Discom) and suggested to improve the system to ensure that farmers got power supply on schedule.

Taking a serious note of the lift irrigation schemes, he stated that only 600 of the total 1100 LIS were functional. Many schemes did not function even for a single day and the farmers were labelled as loanees, the Chief Minister said.

Delivery in running bus

Shivpuri (MP), Jun 9, UNI reports :

A tribal woman gave birth to an infant in a running bus.After waiting for a vehicle, Ruby, wife of Mangilal, walked about 3 Km to reach the nearest bus stop to reach Shivpuri, 25 Km away.Her relatives said she gave birth to the child in the private bus itself before reaching Shivpuri hospital, where she was later admitted.Mangilal, a resident of Mohammadpur Khutela village, said they had information about the government schemes Janani Express and Janani Suraksha Yojana to promote institutional delivery and free transport facility.After contacting the office concerned, they waited for the elusive transport facility. Later, they mustered courage to take the woman in labour to the hospital by the first available bus.

Women's health on the AIRwaves

AIR’s 14 radio stations in Madhya Pradesh ran a 15 to 20 minute episode daily on the issue of women's health.

Anil Gulati in Bhopal

Ten percent of maternal deaths in India take place in the state of Madhya Pradesh. Maternal death audits as undertaken by the state reveal that how timely medical attention still is a challenge for many pregnant women. Lack of awareness on recognition of danger signs, issue of transport, access to proper medical facilities, poverty are still some of the many challenges which needed to be overcome. Though the Government of Madhya Pradesh has launched many schemes to promote institutional deliveries and to combat maternal mortality, with special focus for below the poverty line and those belonging to scheduled castes and tribes, but a lot remains to be done.

Media and civil society are helping to raise concern and create awareness on the issue. All India Radio with its vast network in the state particularly in rural Madhya Pradesh contributed its bit by using air waves for the cause by addressing issues of immediate concern to its audiences.

All India Radio in collaboration with the state government and UNICEF, supported by Department of International Development (DFID), strategically used its programme options to engage communities on the issue of safe motherhood and help voice their concern by its people - policy interface. It also used its news network to give voice to state and civil society on the issue. Content analysis of last few months i.e. June 2006 - Feb 2007 AIR news reports tell us that the issue has been in focus and is spread evenly. News pertaining to government proclamations, schemes, and events took the major share but the news network also relayed statements of various experts and people working on the issue, which is a positive trend.

AIR has a strong presence especially in rural areas vide its fourteen radio stations across the state. It ran a 15 to 20 minute episode daily in form of a series from its network of radio stations on the issue of women's health. 35 such programmes were aired. Each programme had a local expert, often a medical professional to answer the questions and issues that were raised by the people from the district. It also provided information on how to recognize danger signs in pregnancy, stressed on the need of institutional delivery, care including nutrition of women during pregnancy, and issues related to anaemia. The purpose was to provide information and answers to the questions to the community by a local expert.

In addition to the same, the radio network also aired a series of seven one-hour live-phone in programmes on its afternoon prime time slot each month. It was a 'people - policy maker interface'. As part of the same programme a political representative or a representative from the state department was present in the studio to answer questions raised by callers on the issue. For the first time the issue of maternal health was addressed in this forum. The initiative by its very nature strengthened the community - system interface.

In the first programme the State Health & Family Welfare Minister answered questions from various rural parts of the state. Callers from far off villages in districts like Rewa, Tikamgarh, Sagar and Hoshangabad, brought to the notice of Health Minister the problems they face when it comes to the functioning of the health delivery system at the primary health centre level. The common grievance was that the doctors and nurses were absent from the duty. Questions were also raised the benefits of schemes not accruing and the types of health schemes available. On similar lines representatives from State's Women Commission, Human Rights Commission, Women and Child development department, Rural Development and Public Relations department were involved. Fifteen to twenty questions were asked in each programme.

In the last of the series the Chief Minister of the state answered queries of people in the state on the issue. Though the programme focused on women's health and safe motherhood, issues of education especially of girls, grant of scholarships to girls as provided by the state and violence against women also came up. In turn the programme offered an opportunity for people to get answers to their grievances by their elected representative on issues which many times get neglected in the political process.

A comment on two years of NHRM

Dr Sanjit Nayak at One World South Asia

Health being a state subject, states have used their own discretion to interpret and implement the National Rural Health Mission (NRHM). While this has resulted in some activities being implemented the broader goal of the NHRM to empower local communities has been lost. This has lead to the dilution of the agenda of placing people's health in people's hands. The current government approach is to mandate community participation by issuing government orders to its functionaries at the district level. In rural areas, village and district action plans based on community need assessment have remained a non starter and in urban areas the poor remain marginalized from this process. The NRHM talks about health sector reforms but the specific objectives of the reforms appear unrealistic and unlikely to result in the improvement of the health status of the individual or the community. In effect the Mission remains more target oriented with a disproportionate emphasis on inputs rather than focused on output or performance. The concept of Accredited Social Health Activist (ASHA), which forms the core through which the NRHM will be operationalised, cannot be described as being an innovation but rather is old wine in a new bottle. In earlier versions of the health programme similar human resource mechanisms have been proposed - for example the community health worker, link worker, multi- purpose worker amongst other things. In India, the polices, plans and schemes have often been comprehensive but the implementation has remained poor and as a result the desired result as envisaged by policies and programmes has never been actualised. The ASHA as has been mentioned earlier forms the core implementation mechanism for NRHM, who will undertake the bulk of the activities at the community level.

Inspite of playing this critical role, women who are selected are seen to be volunteers and the programme itself does not define any type of financial compensation for the work they will undertake. Recent findings show that it is proving to be extremely difficult to motivate individuals to undertake the work where no remuneration is forthcoming. As part of the ASHA scheme an incentive system has been proposed under the supervision of Sarpanch and Auxiliary Nurse Midwife. This has lead to non-integration (architectural correction) of all the other health programmes at the community level. Furthermore, there is an extremely high expectation from ASHA whose envisaged work profile does little justice as a part time worker.

The ASHA work under severe constraints with regard to infrastructure as a result ASHAs often have to resort to referring their patients to private service providers. In addition, ASHA has replaced the male health worker. ASHA's work profile is different and primarily to support the ANM. The numbers of male MPWs is already reduced and it is likely that their role will soon be written out of health programmes. It is important to point out that MPWs have a key role to play in other programmes e.g. prevention of communicable diseases and undertaking surveillance, none of which can be undertaken by ASHA. As part of the reform process of the health sector, which remains an important component of NRHM, the strengthening of public-private partnership has been mooted.

However, many health activists feel this is the governments' way of shirking responsibility to provide health services in particular primary health care as has been envisaged in the Constitution. The government is now trying to even privatize primary health care and does not want to invest in improving the public health sector. Upgrading infrastructure, especially PHC to FRU/ UPHC in un- served and underserved areas with doctors unwilling to provide service will further privatise primary health care. Contracts to private practitioners will be the only solution to man these PHC. Indian Public Health Standards (IPHS) to provide quality health care in the public health system by ensuring minimum requirements of infrastructure, accountability of doctors, the need for standard treatment protocols and social audit through rogi kalyan samiti (RKS) has been a non- starter. This has been the scenario previously as such policy directions have not translated into action. T

he guidelines for IPHS do not address the real issue which requires an analysis of failure of previous schemes. An attempt was made by the National Commission of Health and Macro-economics but its recommendations are gathering dust. NRHM aim is to reduce infant mortality and maternal mortality by improving access through the ASHA and the Janani Suraksha Yojana (JSY) scheme by strengthening Community Health Centres. The emphasis is on technology alone. It has failed to address the correlates to nutrition and thus to poverty. The belief that reducing total fertility will reduce infant mortality ignores the links between the socio-economic status of the community especially that of women and health of an infant. It is important to note that access to care is also linked to discrimination as well. Additionally unskilled human resource and poor infrastructure in un-served and under-served areas compound the problem. Targets to reduce infant mortality rate (IMR) and maternal mortality ratio (MMR) by only increasing health sector expenditure needs to address issues of equitable distribution and resource allocation. Conceptual problems do exits in NRHM. Much of NRHM today depends on public- private partnership and not on strengthening the public health system. By outsourcing and contracting we have subscribed to privatisation of the health care delivery system. It is also difficult to comprehend how ASHA can bring about inter- sectoral coordination. In conclusion the link between poverty and ill-health are cursorily mentioned and are ignored in the actual implementation plan laid out as part of the NRHM. Based on the above analysis it might be fair to say that attainment of the goals envisaged by NRHM by 2012 remains wishful thinking.


The author is a public health specialist with the Population Foundation of India New Delhi. The views expressed are that of his owns as an activist and not that of the foundation