If you haven’t read first four chapters, read them here first,  Chapter two, Chapter three, chapter four

Despite the high economic growth during the last two decades, India has not been able to improve it’s maternal and child health indicators at the desired pace. We failed to achieve health goals related to Millennium Development Goals(MDGs) and our maternal and infant mortality remains unacceptably high.

India is in the middle of a demographic dividend which is going to last till about 2035-2040 (25 more years or one more generation) and it’s imperative that we invest in human capital to reap the fruits of demographic dividend. This will raise our long run economic growth potential.<What is demographic dividend? How does it help raise long run growth potential? Answer in the comments below.>

In this context, economic survey argues that given fiscal constraint <we can only spend as much as we tax plus some borrowing, never behave like arm chair pundits asking to raise budgetary allocation for everything without raising any taxes or train fares or bus fares> and state’s limited capacity to deliver public services <we know how state i.e. govts mess up almost every sector they get into, just see the performance of public schools i.e. state should not take tasks beyond it’s capacity; first improve capacity and then take additional tasks; just passing RTE or establishing 5 more AIIMS or IITs is not enough>, state should invest in relatively low cost maternal and early life health and nutrition programmes.

What’s the rationale behind investing in mother and child?

Intrinsic reasons– it improves quality of life directly and expands possibilities for the individual <if someone is not born healthy, chances are he would be unhealthy in later life as well>

Narrow economic logic

1. Research has shown that countries with better maternal and infant health “at takeoff” grew faster over the subsequent 20 years. <takeoff stages is similar to takeoff of an airplane, slow growing economy suddenly starts to grow very fast. For instance, China post economic reforms in 1979>
2. Tomorrow’s worker is today’s child or foetus and  events which occur while a child is in the womb i.e inside pregnant mother or very young (<2 yrs) affect cognitive development and health status even in adulthood i.e. if today’s child is weak, chances are tomorrow’s worker would be less productive.

Why does health of new born affects outcome much beyond the childhood?

1. the most rapid period of physical and cognitive development in a person’s life occurs in the womb <rapid development phases are most susceptible to environmental insults>
2. Dynamic complementarities in human capital accumulation- it simply means one human capital for instance health would affect accumulation of other human capital for instance education and training/skill in a dynamic way and vice versa. For instance healthy mother # healthy baby # learns better <cognitive development better in the womb as mother is healthy> and stays on in school longer. Or consider # unhealthy mother # weak baby # learns less and stays in schools for shorter period # less skilled and competent 

• research has shown that low birth-weight children benefit less from early-life cognitive stimulus programs i.e. early we intervene the better i.e. investment in mother and fetus. very young children
• success of subsequent interventions—schooling and training—are influenced by early-life development
• programs targeting younger children also appear relatively cheap in comparison to investments made in older children. For instance, iodine supplementation is way more cheaper compared to improving teacher quality or re-designing institutions to raise school accountability <good for fiscally constrained govt.>, also requires less service delivery capacity from the state, for instance, improving teacher quality would require teacher training, monitoring that they actually show up and teach in schools <investing in mother and child good for capacity constrained govt.>

The Dismal State of (Child’s) Play in India

Height is a good proxy for early life conditions and height is determined by early life environment and net nutrition.

“net nutrition” is defined as the sum total of (i) the nutrition available from the mother in the womb and during breastfeeding, (ii) the quantity and quality of the food that complements breast milk from 6-24 months, and (iii) energy losses due to disease and infection, and poor absorption of nutrients. <part 3 is an important cause of malnutrition in India due to open defecation and subsequent infections resulting in reduced absorption and increased losses in feces as well as due to high metabolism during infections>

Quick statistics

1. 48% of under 5 children are stunted (low height) compared to 39% in Sub Saharan Africa
2. 43% are underweight compared to 20% in Sub Saharan Africa
3. 28% are born low birth weight compared to 13% in Sub Saharan Africa

This data is taken from Amartya Sen’s book An Uncertain Glory which took data from UNICEF(2012). This condition of poor nutrition indicators comapred to much poorer and war torn Sub Saharan Africa is known as South Asian Enigma or The Indian Paradox and the low status of women is cited as one of the explanation.

3 quick points about height for age in India

1. there has been improvement over time in both urban and rural India
2. there is a persistent rural-urban height gap which has not closed over the past decade
3. despite the progress made, India remains a negative outlier—our children are on avg shorter than healthy children

Consequences-height-cognitive development gradient

Greater the height, greater the cognitive development (of course corrected for genetic potential for height not that because Chinese are short they are less smart then tall Caribbeans)

• taller Indian children are considerably better readers than shorter ones (height proxy for nutrition which affects cognitive development)
• absolute reading ability has not increased over time i.e we have not made much progress in addressing the nutrition and education challenge

Clearly much more needs to be done to improve the nutrition situation in India.

The Dismal State of Maternal Health

As we have already discussed first 1000 days of life (nine month in womb plus 2 years) are most critical for a child’s development. They depend critically on maternal health (esp 9 months in the womb)

70% of infant mortality (children who die before reaching their 1st birthday) is due to neonatal mortality(dying before 1 month). A leading cause of this is low birth weight which is clearly due to poor maternal health and nutrition.

Consider this data-

1. 42.2% of Indian women are underweight at the beginning of pregnancy
2. 50% of pregnant ladies are anemic(low hemoglobin in blood) <data from An Uncertain Glory>
3. Women from richer households in India start pregnancy heavier,suggesting that resources are at least part of the reason for low pre-pregnancy weight <poor #less to spend on nutritious food #low pre pregnancy weight>

No surprises then that women in India gain only about 7 kgs during pregnancy, substantially less than the 12.5- 18 kg gain that the WHO recommends for underweight women.

Very very important sociological insights

Use these observations in paper 1 (society) and essay. They will certainly add value to your answers.

1. reason for poor maternal health is that social norms accord young women low status in joint households. <When compared across the same ages, till about age 35, fraction of underweight women exceeds that of men by at least 5 percentage points. > within-household nutritional differentials are stark
2. lower status of younger daughter-inlaws in families. <children of younger brothers in joint family households are significantly more likely to be born underweight than children of their older brother> Chacha’s children more likely to be born low birth weight than Tau’s<Tijori ki Key Badi bahu ke haath mein>
3. Indian firstborn sons are found to have a height advantage over African firstborn sons, and the height disadvantage appears first in second-born children, increasing for subsequent births<preference for healthy male heir>

Improving Maternal Health in India

Clearly much more needs to be done to improve maternal health.

Govt response-. The National Food Security Act of 2013 legislated a universal cash entitlement for pregnant women of at least 6,000 rupees.

But it will only be successful if families convert these payments into more, higher-quality food and more rest for pregnant women and to make sure it happens, the cash transfer could be paired with education about how much weight a woman should gain during pregnancy and why weight gain during pregnancy is important. <cash transfer plus health education>

You can follow the whole women empowerment story, click here

Universal v/s conditional cash transfers

Should cash transfer be universal i.e given to every pregnant women regardless of what she does with that money or conditional on women performing certain tasks such as visit hospital regularly, getting delivered in hospital, vaccinating her child etc as in Indira Gandhi Matritva Sahiyog Yojana (IGMSY)?

Conditional cash transfer seems better but it entails high administrative costs, delays and often lead to significant exclusion. Hence survey suggests the cash transfer should be given in a single, lump-sum payment early in pregnancy to avoid delays, reduce administrative costs, and ensure that it is possible for the household to spend the money on better food during pregnancy.

Case for going universal and problems with conditional cash transfer

With careful design and significant investment of state capacity, maternal health could be significantly improved during pregnancy.

The problem of open defecation

Facts-open defecation in India is much more common than in even much poorer countries <61% in rural India v/s 37 % Nepal, 32% rural Sub Saharan Africa, just 1.8% B’Desh>

Only lack of toilets or income constraints is not the reason, but there are sociological reasons

Fact- many people in rural India who live in households that contain working latrines that are in use by other household members nevertheless defecate in the open.

Research suggests that rural Indian households reject the types of latrines promoted by the WHO and the Indian government partly because their pits needed to be emptied every few years and empty the latrine pit is associated with the strong notion of purity and pollution <history of untouchability- work of disposing of human faeces is associated with severe forms of social exclusion and oppression>

Consequences- disease, diarrhoea, environmental enteropathy (reduced absorption of food) resulting in less amount of net nutrition available to kids as we discussed above.

Building toilets and ensuring people defecate in the open is an example of public good as even those who don’t defecate in the open get sick due to germs from people who defecate in the open.

Addressing open defecation

Govt. response- swatch Bharat Abhiyan

• In the last year alone, the government built over 80 lakh toilets
• UN’s Sustainable Development Goals commit to ending open defecation worldwide by 2030

Historically, open defecation in India has declined by about 1 % per year  <about 50 years before India becomes open defecation free>. We need to more than triple the rate of reduction to achieve SDG. For that, it is important to understand barriers to toilet adoption in rural India and promote latrine use <as we just learnt, it;s much of a sociological, behavioral problem>

Influencing social norms to make investment yield better return

A big challenge is deeply entrenched norms and facilitating behavioural change. One can build clinics in villages or transfer money to pregnant mothers or build latrines, but how does one bring out the right usage of all this physical capital ?

Govt has a progressive role to play in changing norms, and thus the importance of high pitch campaigns such as Swatch Bharat Abhiyans.

The government has recognised the importance of influencing social norms in a wide variety of sectors—

• persuading the rich to give up subsidies they do not need (give up lpg subsidy campaign)
• reducing social prejudices against girls (selfie with daughter)
• educating people about the health externalities of defecating in the open (swatch bharat)
• and encouraging citizens to keep public spaces clean (swatch Bharat)

Way forward-

• Invest more resources in understanding the behavioral patterns and how to change them
• Create a Nudge unit within government for behavior change communication as other countries have done
  

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You might want to read- Blog from CD published on The Better India

7 Rights Every Pregnant Woman in India Should Know About (govt schemes for pregnant women in short, imp for exam)

Open all the hyperlinks. Learn, understand and revise

Ask all your doubts in the comment section below or in doubts clearing forum . All your suggestions, criticism and feedback are most welcome.

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