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Adam Roberts: The neglect of health in India

A survey of India's children highlights worrying trends in malnutrition, immunisation and access to health facilities. What is needed is a strong debate of India's health policy and, of course, greater spending on public health

Adam Roberts 

Adam Roberts

In July I published, in The Economist, leaked results of a remarkable survey of India's children. Carried out in 2013 and 2014 by the government and Unicef, the UN children's agency, the Rapid Survey of Children (RSOC) involved 210,000 interviews across India, plus the weighing and measuring of 90,000 children and 28,000 teenage girls. The results showed trends in malnutrition, immunisation rates, access to medical centres and more. The data were needed because India last completed a full National Family Health Survey (NFHS) in 2006, nearly a decade ago.

That new survey came with a political puzzle. The results were ready last October, but for months the government refused to publish them. Why? It was not because of doubts about quality. I asked if there were a political reason. Perhaps nobody wanted to embarrass the Prime Minister, Narendra Modi. The survey showed Gujarat, which he ran for a dozen years, had done poorly on public health despite rising incomes there.

The share of children, who are hungry in Gujarat, fell from 44.6 per cent to 33.5 per cent, from the NFHS study to the new one. However that result was worse than the new national average of just under 30 per cent. (That is still dreadfully high: only Africa is close to having a similar problem, with 21 per cent of kids underweight.) Gujarat also did worse than the national average for stunting, with 42 per cent of children unusually short for their age, and on other measures of malnutrition. Maharashtra, with similar incomes, did markedly better, as did some poorer states. The different outcomes appeared to rest on whether states tried hard to help the neediest, such as adivasis. Maharashtra did, Gujarat did not.

The government has now published summaries of the RSOC data. It would be better still if the raw data were also made public, so researchers, policy-makers and others could learn the most from the survey. In turn, there are two new puzzles. One is why the release of the report has not provoked more debate about ending hunger and chronic deprivation. Politicians, and much of the media, appear to be shy or bored of the topic. It is perhaps embarrassing to confront the fact that so many Indians remain desperately ill-fed. But you need not have a humanitarian bone in your body to care about this. For the economy to flourish it needs healthy, brainy workers - not growing masses of the unskilled. China ended hunger much earlier than India (only about three per cent of Chinese go hungry). Malnutrition hinders brain development and makes it harder for children to study. If nearly a third of India's future workers are not getting properly fed, that is a bad omen for future prosperity.

A second puzzle is why some data published by the government differ from the set I made available earlier. A partial comparison of the two sets appears to suggest somebody has adjusted figures selectively, improving some results for India as a whole, and for states including Gujarat, Uttar Pradesh and Bihar. Consider teenage girls with low body mass index (BMI measures your weight divided by the square of your height). That matters because low-weight mothers often produce malnourished babies. In my original leaked report, 53 per cent of Indian girls were shown to have low BMI. Now government-published results of the same survey suggest it is 44.7 per cent - a difference of over eight percentage points. The biggest change appears to have been made to the figure relating to girls in the Other Backward Classes category. Health officials, or the minister for women and child development, should explain how and why that figure changed - and many other discrepancies.

In general, more public discussion of India's health data is overdue. It is a pity, for example, there is not more detailed public analysis by experts, politicians, officials and commentators of India's efforts to reach various global targets for the Millennium Development Goals (MDG), for improving human welfare. To his credit, Modi mentioned the topic last week, after hosting a global summit on it. He offered to help other countries learn from India.

Health data in fact show a mixed story. One MDG that can be celebrated is for India to reduce mortality of children under five, to 42 deaths for every 1,000 live births (down from 126 deaths in 1990). Even if India does not quite reach the target this year, it should do so within a year or two. Less encouraging has been progress on cutting deaths of mothers (to 109 for every 100,000 live births) and of infants (to 27 per 1,000 live births). It is likely that these targets will be reached only after several more years, perhaps not until well into the next decade.

Overall India is making some progress on improving health, as any comparison with the situation in 1990 would show. What needs more debate is why gains have not come at the pace expected - and why they don't appear to match rates of improvement elsewhere, for example, in Bangladesh. I would suggest the answer is linked to the fact that India spends only about one per cent of gross domestic product on public health and the low quality of education and training. The latter helps explain why many newborns die when they could be resuscitated by nurses, or because of infections or hypothermia that could easily be prevented.

The worst performing states, as ever, are Uttar Pradesh and Bihar, where persistent poverty, dysfunction in government and poor quality private health facilities are just some chronic problems. The benefits from improving public health quicker in India would be immense. But for that to happen, India also needs strong debate of its health policy, and that in turn should rest on good quality, widely shared data.

The writer is South Asia bureau chief,
The Economist

First Published: Thu, September 03 2015. 21:46 IST