UP still BIMARU while other states progress

IN basic health indicators, Uttar Pradesh (UP) continues to lag behind not only India but even other BIMARU states according to the latest health statistics that recently became available. This is the conclusion we arrived at after analysing the National Family Health Survey (NFHS)1998-99, Annual Health Survey (AHS) 2012-13 and Rapid Survey on Children (RSOC) 2013-14.

The three surveys provide an insight into the performance of BIMARU states in health indicators over time. The recent RSOC was commissioned by the Ministry of Women and Child Development (MWCD) in 29 states during 2013-14 with technical and financial assistance from UNICEF India.

The Infant Mortality Rate (IMR) was 42 per 1,000 live births for India, but for UP the figure was 68 in 2012-13. The corresponding figures for Bihar, Madhya Pradesh and Rajasthan were 48, 62 and 55, respectively.

Downward trend

But was UP improving faster over time to catch up, at least with the other BIMARU states? Not really. In the other BIMARU states basic health indicators improved at a much faster rate than UP. The rate of change in Bihar is better.  During 1998-99 to 2012-13, the IMR came down from 89 in 1998-99 to 68 in 2012-13 for UP. The improvement is 21 points. The corresponding figure for Bihar is 30 points while MP and Rajasthan stand at 25 and 26 points, respectively.

 It is not just that the rate of improvement over a 15-year period has been much faster in all the poorer states of India than in UP. It is also that when the base level of the health indicator (i.e. the IMR) in the initial year is high, it is easier to reduce it than when it is lower. In other words, it was easier to reduce IMR in UP.

The Under-5 mortality ratio (U5MR) too has improved slowly in the state. The U5MR stood at 132 in UP in 1998-99 and came down to 90 in 2012-13. The corresponding figures for Bihar are 112 and 70, respectively. So the reduction is the same, 42 points, in both states. But it came down from a much higher level in UP.

Similarly, both Madhya Pradesh (MP) and Rajasthan have done much better than UP. The respective U5MR figures for MP are 145 and 83 and 125 and 74 for Rajasthan for the same period. The reduction for MP is 62 points and 51 points for Rajasthan.

Health in a shambles

The fact that the most important indicator of child health has remained consistently worse in UP across two decades than in the other poorest states of India shows beyond any doubt how little policy priority has been accorded to the health sector in the past two decades.

UP continues to lag behind the other states in other key Reproductive and Child Health (RCH) indicators as well. Ensuring safe motherhood and raising contraceptive prevalence rates (CPR) are considered the topmost priorities of an RCH programme. The percentage of women using any contraceptive method was 59 percent in UP in 2012-13 which was higher than Bihar but lower than MP and Rajasthan (in fact, the 2012-13 rate in UP is just marginally higher than the national figure of 56 in 2005-6).

The corresponding figure for Bihar is 41 percent while it is 63 and 70 percent for MP and Rajasthan, respectively. It is the responsibility of the public health system to bolster CPR, but a poorly functional public system is unable to cope with the unmet demand for family planning emanating from households.

The place of delivery offers an insight into how functional a public health delivery system is perceived to be by citizens. While those who can afford to pay can access private clinics, the vast majority cannot. However, the percentage of deliveries in a proper health facility for UP is about 57 percent while the corresponding figures for MP and Rajasthan are 83 and 78, respectively. For Bihar it is 55 percent.

However, what is significant is how the other states, MP and Rajasthan in particular, have improved their health system in a short span of time. The percentage of deliveries in a proper facility stood at 22 in UP in 1998-99, which was the same as in MP and Rajasthan nearly two decades ago. MP improved by 61 percentage points while Rajasthan gained by 57 percentage points between 1998-99 and 2012-13. Bihar too gained about 41 percentage points in the same period. But UP improved by just about 35 percentage points.

As an alternative to giving birth in a public health facility, delivery could be safe if assisted at home by a trained health professional. The percentage of deliveries assisted by health professionals too is lower in UP than other BIMARU states. The figure is 29 percent for UP in 2012-13 while for MP and Rajasthan it is 38 and 36, respectively.

Poor immunisation

But what happens to the child after birth? Generally, the nutrition status of a child depends on the quality of care he or she gets during the first two years of life. The child immunisation rate (or the share of children who receive full immunisation) is one such indicator of care. Among the BIMARU states, it is the lowest in UP. The number of children receiving full immunisation (which covers all preventable diseases) for UP stands at only 53 percent in 2012-13 while it is as high as 70 percent for Bihar.

The corresponding figures for MP and Rajasthan are 66 and 74 percent, respectively. Poor immunisation coverage means that the case load in hospitals for preventable diseases increases, since un-immunised children land up in hospitals after contracting a disease.

However, what is equally significant is the rate of improvement in the coverage. It improved by about 58 percentage points for Bihar during the period 1998-99 to 2012-13. The corresponding improvements for MP and Rajasthan are 44 and 57 percentage points, respectively. But UP gained just 33 percentage points in the same 15-year period.

Why is the situation in UP so distressing? The centre initiated the National Rural Health Mission (NRHM) in 2005, to address, among other issues, mother and child health concerns, particularly in the poorest states. Clearly, other poor states, where governance was better, did far better than UP in achieving the goals of the NRHM.

To make matters worse, only a third of the physician posts in the Provincial Medical Service get filled. Worst of all, Provincial Medical Service physicians continue to resist rural postings. Alongside, the shortage of para-medical staff with a modicum of competency remains an issue. Unsurprisingly, at least half of all public health facilities cannot function 24x7.  

Santosh Mehrotra is a professor of economics at Jawaharlal Nehru University, New Delhi, and author of Policies to Achieve Inclusive Growth in India (Cambridge University Press, 2016)