GOURI RAO
CHILD HEALTH IN INDIA TODAY
India is the second most populous country in the world accounting for 16% of the worlds' people. However by land surface area it is the seventh and occupies 2.4% of the worlds land area. In 1993 the population of my country stood at 897 million with a growth rate of 2.1%. Its population density is 267/km2 . Only 26% of our people live in cities and my country is a predominantly rural, agriculture based economy. Around 40% of the population is below 15 years of age and 12% below 5 years of age. Women account for another 22% of our population.
I will now present to you a brief overview of the state of the health of Indian children which will include: (1) basic health indicators, (2) nutritional status, (3) common diseases, (4) educational status, (5) immunization coverage, (6) status of women which is closely linked with children's health and (7) the health delivery systems in our country.
Basic health indicators:
We have a birth rate of 29 versus 11 in Japan and a death rate of 10 versus 8 in Japan. While Japan has a growth rate of just 0.5%, ours stands at 2%. The life expectancy of an Indian is 61 years as against 76 for a Japanese. Seen in isolation these figures are not impressive. They fail to reveal the enormous strides India has made in the last few decades. In the past five years we are witnessing such a revolution in the economy of our country that even we are amazed. If one compares our statistics in 1960 to those in 1993, our death rate has been halved (22 versus 10), our birth rate has dropped from 43 to 29% and the life expectancy has risen from a mere 43 to 61 years.
However despite a few refreshing signs of change the overall picture of the health of our children, an easily neglected commodity, is grim. We have a lot to learn from Japan which has one of the worlds lowest under five mortality rates of just six, while ours stands at a whopping 122. The infant mortality rate is also very high, 81 as against a Japanese level of five. Poverty and illiteracy are probably the prime culprits for these dismal figures. The GNP (gross national product ) per capita is $310 in India versus $28190 in Japan and a third of out population is below the poverty line.
Nutritional status:
The average birth weight of an Indian baby is 2.7 kg in the lower socio-economic strata and 3.1 in the upper socio-economic strata. A third of these babies are low birth weight or below 2.5 kg and intra-uterine growth retardation accounts for two thirds of them. According to the National Survey in 1992 for the evaluation of one our national child health programmes called the ICDS (Integrated Child Development Schemes), severe malnutrition i.e. a weight less than 60% of expected for age was found in 6.8-8.6% of children between 0-3 years and 4-5.5% of those between 3-6 years of age. There has been a steady decline in severe malnutrition from 18-20% between 1969-75 to less than 8.5% after 1976. Besides protein energy malnutrition, other nutritional problems which beset our children are vitamin A deficiency, anemia and iodine deficiency. Ten percent of our preschool children have bitots spots, while a figure of more than 2% is considered to indicate that vitamin A deficiency is a problem. Two thirds of our women and children are anemic and 9% of 6-11 years olds have a goiter. Though very few countries have taken action to eliminate iron deficiency anemia on a national scale, India is a major exception. The UNICEF's report on the state of the world's children, 1995, says that more than 70% of pregnant women in India are getting at least three months of ferrous sulphate tablets and the goal of one third reduction of anemia by 2000 AD seems feasible.
Common diseases:
Acute respiratory tract infections (accounting for 20% of the under five mortality), diarrhoeal diseases and vaccine preventable diseases such as measles, whooping cough and diphtheria are common causes of morbidity and mortality in our children. Lameness surveys have shown that post polio residual paralysis is in the range of 4-5/1000 population. The prevalence of infection of tuberculosis as determined by mantoux positivity is 30% and of disease is 4/1000. The whole country is under malaria risk and though the number of cases reported each year is declining there are still epidemics of falciparum malaria. The commonest causes of perinatal mortality are low birth weight (30%) and asphyxia (20%).
Education:
Literacy, defined as ability to read and write is 62% in males and 34% in females. About 60% of primary school children reach grade five and 54% of boys and 32% of girls enroll into secondary school.
Immunization;
We have an excellent immunization coverage with 92% of children under one year immunized with BCG and 90% with DPT and OPV. Measles immunization coverage is 82% and 77% of pregnant women have received tetanus toxoid.
Status of Women:
Women play a key role in the growth, development and health of children. Hence the relevance of women's status here. While on one hand women are treated with great respect and we have been governed for several years by a woman Prime Minister, health statistics of women in our country are not impressive. The female male ratio in our population is 929, only 34% of women as against 62% of men are literate, contraceptive prevalence is 43% and maternal mortality is 4/1000 live births.
Health delivery systems:
It is a three tiered structure. Primary health care is provided by a network of subcenters and primary health centers. At the village level there is a band of voluntary, trained health workers called village health guides and trained birth attendants. In the primary health centers we have male and female health workers who provide basic health services, immunization, family planning and do disease surveillance. Secondary health care is delivered by community health workers and district hospitals which have medical specialists and laboratory services. Tertiary health care is provided by teaching hospitals, medical colleges and apex institutions. A large number of voluntary organizations are also existing side by side to deliver health care.
The Central Government also sponsors certain welfare schemes such as the Universal Immunization Programme, the Oral Rehydration Therapy Programme, the prophylaxis programmes against anemia and blindness and Child Survival and Safe Motherhood Programme (CSSM).
The Immunization Programme is concerned with production and delivery of the vaccines (BCG, OPV, DPT and measles) to children. The Oral Rehydration programme is concerned with education of the masses of appropriate therapy in diarrhoea. All pregnant women are eligible to receive iron and folate and all under fives iron, folate and vitamin A under the prophylaxis programmes. The CSSM programme is an ambitious attempt to control acute respiratory infections, improve newborn and maternal care and strengthen existing programmes.
As regards the health manpower there are 148 medical colleges, 106 nursing colleges and 500 training schools for health workers. There are 3.94 lakhs allopathic and 5.34 lakh non allopathic doctors.
The Kerala paradox:
So far I have been presenting the national averages of all parameters. But my country is a study in contrasts. At the southern most extreme of my country is the state of Kerala, lined with coconut trees, dense tropical forests and a long coastline indented with inumerable backwaters. In wealth it falls below the average for India as a whole. But astounding fact is that it has an infant mortality rate of just 17 against a national figure of 80 and life expectancy of women is 74 years which is 15 more than the national average. The major reason is considered near universal education, especially of women. We all have a lesson to learn from Kerala, that educating women is the best investment for healthy children.
In conclusion, India is a big country with big challenges facing it on the health front. We have made encouraging gains in improving our immunization coverage and providing a health infrastructure to the rural people. But a large population with high fertility, a low literacy level and a significant section of people below the poverty level means we have miles to go before we sleep.
