Special Report

Ticking child healthcare time bomb

Far from being the worker bees of a rapidly ageing global population, india’s children may well mature into sickly low productivity adults requiring life-long medical care — a scenario which has global doomsday implications. Summiya Yasmeen reports

In perhaps the most damning indictment of post-

The indicators of child deprivation as defined by the report, are lack of shelter, unsafe drinking water and sanitation, health and food insecurity, lack of access to a school, low infant mortality, malnutrition, child labour and child abuse (see box). India fares badly on each of these indicators of deprivation. For instance only 33.9 percent of its child population has proper shelter and 30 percent has access to sanitation facilities. Moreover only one in four of the 26.2 million children suffering chronic diarrhoea receive basic oral rehydration treatment resulting in millions of weak and malnutritioned children who metamorphose into physically and mentally stunted adults entering the national work force annually.

With the Union and state governments combined spending a mere 0.9 percent of GDP (cf. USA’s 6.2 percent, Britain’s 6.3 percent and China’s 2 percent) on the nation’s ramshackle, corruption-ruined public healthcare system with children at the end of the receiving line, the oft-trumpeted advantage of India harbouring the world’s youngest population (415 million citizens are below the age of 18) is likely to be frittered away. Far from being the worker bees of a rapidly ageing global population, India’s children may well mature into sickly, low productivity adults requiring life-long medical care — a scenario which has global doomsday implications.

SWC 2005 warns that the lives of 1.9 billion children living in developing countries of whom 415 million live in India, are under severe threat unless third world governments accelerate the processes required to achieve the Millennium Development Goals (MDGs). In September 2000, 187 nations, including India, adopted the Millennium Declaration and identified a set of seven MDGs to be attained by all nations by 2015. The seven MDGs are: eradication of extreme poverty and hunger; achievement of universal primary education; gender equality and empowerment of women; reduced child mortality; improved maternal health; a global plan to combat HIV/ AIDS, malaria and other diseases, and environmental sustainability.

Says SWC 2005: "Failure to achieve the MDGs will have tragic consequences for children, particularly those in developing countries. Millions will see their childhood violated through ill health or death from preventable diseases. Millions more will see their futures compromised because of governments’ failure to provide them with an education and the number of children orphaned or made vulnerable by HIV/ Aids will continue to rise."

Sachs: dramatic health investment need

Child rights campaigners and social activists working at the grassroots in the vast rural hinterland and in the nation’s multiplying urban slums warn that the magnitude of India’s child healthcare crisis is worse than Unicef statistical indicators. Says Jean Dreze, the Belgium-born honorary professor of economics at the Delhi School of Economics and member of the National Advisory Council (chaired by Congress Party president Sonia Gandhi) who is in the vanguard of the right to food campaign and the national campaign for the people’s right to information: "The neglect and deprivation that India’s children suffer everyday is far more disturbing than what social indicators of their well-being reveal. India has some of the highest levels of child under-nutrition in the world, on a par with Bangladesh and Nepal. About half of Indian children are underweight and half suffer from anaemia. This reflects a conspicuous failure of Indian democracy to bring children’s needs to the centre of the political agenda. Underprivileged children are twice removed from the field of public debate and democratic politics. Not only do they lack voice within the family, their parents themselves have little voice in the system due to economic, social and political disempowerment. This is the main reason why children’s needs count for so little in democratic politics and public policy," says Dreze.

Dreze: beyond statistics deprivation

Inevitably political and bureaucratic indifference to child health and nutrition is particularly glaring in the low-literacy Hindi heartland states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh (BIMARU). According to the India Development Report 2005 (Oxford University Press) more than three-fifths (1.3 million) of infant/ child deaths in India per year occur in these four states and if Orissa is included they account for two-thirds (1.5 million) of under-five mortality countrywide. The highest under-five mortality rate — 137.6 per 1,000 live births per year — was recorded in Madhya Pradesh as recently as 1999. Whereas Kerala has the lowest under-five child mortality rate of 19, Himachal Pradesh and Goa too have been able to reduce infant mortality to less than 50 by provision of better public health services and education. In these three states together with Tamil Nadu and Maharashtra, 80 percent of children are immunised against polio, TB, measles and DPT3.

"Of the 10.8 million under-five deaths in the world more than one-fifth — about 2.2 million are in India. Of this 1.5 million occur in the BIMARU states and Orissa. These states are the most insensitive to child health services and rights in the country. The more child caring are the southern states of Tamil Nadu, Karnataka, Kerala, Maharashtra and Goa which have established a modicum of public health services," says Dr. Srijit Mishra, assistant professor at the Indira Gandhi Institute of Development Research, Mumbai. An alumnus of Jawaharlal Nehru University, Delhi, Mishra has authored the chapter on ‘public health’ in the India Development Report 2005.

Mishra: BIMARU indictment

Nevertheless ameliorative child healthcare and support systems are necessary to supplement preventive healthcare (safe drinking water, sanitation, education) systems or the lack thereof. In India’s most populous state — Uttar Pradesh (pop.160 million) — infant mortality (below the age of one) is 83 per 1,000 and under-five mortality 123 compared to the all India figures of 63 and 87 (USA: 7 and 8; China: 37 and 30). Shockingly, a child dies every 50 seconds in Uttar Pradesh and 33 percent of newborns are underweight against the already disgraceful national average of 30 percent.

"The child healthcare crisis is deplorable in Uttar Pradesh where children are vulnerable to even easily treated ailments like diarrhoea. Children are weak and susceptible to disease because 55 percent of them in the state are malnourished, of whom 15.9 percent are severely malnourished. The state is at the bottom on almost every indicator of child health and development. Education and health have traditionally been low on the list of priorities of the state government and local MLAs, but given the size and population of UP, its child development crisis has deep national implications," says Ray Torres, Unicef’s director for Uttar Pradesh.

Torres: deep national implications

Down south in peninsular India where education systems are better and adult literacy is higher, healthcare administration and delivery receive greater priority. The southern states of Karnataka, Goa, Tamil Nadu and Kerala have a relatively better record of running and staffing PHCs, giving mothers and children access to healthcare, ensuring that India ranks marginally above Sub-Saharan African countries in the UNDP’s annual Human Development Report. In Tamil Nadu and Maharashtra 80 percent of children are immunised against common children’s diseases and 90 percent of women in these four states receive some form of antenatal care.

The southern state of Tamil Nadu (pop. 62 million) is widely acknowledged as a pioneer in providing services such as anganwadi centres, mid-day meals, vaccination and health check-ups for children. It was the first state in the Indian Union to introduce mid-day meals in all government run schools way back in 1982. Much criticised when it was started by India’s first film-star-turned-politician, the late M.G. Ramachandran, the free mid-day meal scheme dramatically improved school enrollment and transformed Tamil Nadu into one of the most literate (73.5 percent) and educated states of the Indian Union.

Today 23 years after the scheme was introduced in government primary schools in the state, Tamil Nadu is widely acknowledged as one of the country’s most literate, industrialised and well administered states with an annual per capita income of Rs.21,000 against the national average of Rs.12,414. All this despite the corruption and misrule of a succession of filmstars and scriptwriters turned politicians who have proved unworthy successors of MGR. And now with India having become a hub of the new global knowledge economy, Tamil Nadu with its relatively healthy and well-educated populace and a large number of engineering colleges is set to emerge as the most attractive destination for the huge inflows of foreign investment into India.

Ananthalakshmi

Unfortunately this quantum of investment in children is the exception rather than the rule. With public, i.e Central and state government expenditure on health never having exceeded 1 percent of the GDP (cf. 2.5 percent spent on defence), healthcare spending has become a major overhead in already low household budgets. As a result private expenditure on healthcare in India is the highest worldwide — more than in China, Germany, the UK, USA or other SAARC countries.

"Public expenditure on healthcare as a percentage of total government spending has been declining over the years. In addition there is a serious mismatch between urban and rural allocations. Nearly three-fourths of the population receives a mere one-tenth of the annual healthcare outlay. A major share of the total allocation is absorbed by the family welfare i.e family planning and other national programmes. Even within that more than 80 percent is absorbed by salaries. This leaves hardly any scope for expenditure on infrastructure, equipment and supplies necessary for providing basic healthcare. The rural population has no option but to rely on quacks and the fee-for-service medical practitioners leading to sickness-triggered indebtedness. In fact after dowry, the most important cause of rural indebtedness is healthcare expenditure," says Dr. Srijit Mishra, assistant professor at the Indira Gandhi Institute of Development Research, Mumbai.

Against this depressing backdrop, the best official response is the Central government’s Integrated Child Development Services (ICDS) programme administered by the Union ministry of human resource development. Quite clearly the ministry takes great pride in its ICDS initiative. According to a ministry spokesperson, the programme which provides healthcare to pre-school children, pregnant women and nursing mothers through a package of services including supplementary nutrition, pre-school education, immunisation, health check-ups, referral services and health education, covers "more than 75 percent of India’s community development blocks through a network of 5,80,621 anganwadi (child care) centres". However what it doesn’t highlight is that the ICDS package is available to only 26.8 million children, a mere 23 percent of the 118 million (under five years) who need coverage.

Zachariah (right): ICDS universalisation plea

However as evidenced by the broader perspective taken by SWC 2005, educationists and child development professionals are veering around to the viewpoint that children’s healthcare programmes need focused attention and interventions in housing, sanitation, safe drinking water, nutrition, immunisation and school access — in short, a broad spectrum attack on child poverty. They are beginning to discern that all these deprivations impact children’s health, their capacity to study and future as adults. For example poorly housed, sickly and malnutritioned children in school are unable to learn. With 30 percent of newborn children in India recording low birth weight, 40 million children under-5 not immunised, and 46 percent (54 million) suffering moderate to severe stunting (cf. third world average of 16.1 percent), it’s hardly surprising that only 53 percent of children who enroll in primary school make it to secondary school. And one-fifth of India’s children i.e almost 83 million never make it to school at all.

Parikrma Foundation’s Bose (centre): multi-dimensional approach crusader

Likewise the authors of SWC 2005 have discerned that issues of nutrition, shelter, sanitation, quality education and healthcare — grouped under the umbrella term child poverty — need to be addressed simultaneously rather than serially, to promote national development. "Poverty in childhood is a root cause of poverty in adulthood. Impoverished children often grow up to be impoverished parents who in turn bring up their own children in poverty. In order to break the generational cycle, poverty reduction must begin with children," says SWC 2005.

This argument is endorsed by Anjali Sakhuja, deputy director of the Mamta Health Institute for Mother & Child, a Delhi-based NGO. "Investing in children is never wasteful. If children are given access to healthcare, quality education, safe water and adequate nutrition, they are more likely to realise their physical and cognitive potential. And such children grow up to be economically productive citizens who are an asset to the nation," says Sakhuja.

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