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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
-
independence India’s oft repeated claim of being a socialist welfare state, The State of the World’s Children 2005, a United Nations Children’s Fund (Unicef) global survey highlights this country’s utter neglect of child rights and abysmal welfare record. According to SWC 2005, a staggering 175 million children (below 18 years of age) in contemporary India are suffering utter poverty and deprivation. Of every 100 children born in India, only 35 births are registered, seven won’t make it to their first birthday (of whom five will die of malnutrition), 47 will remain underweight and only 53 will complete primary school. Girl children suffer more. An estimated 43 percent of adolescent girls are anaemic and an alarming 31 percent drop out of school every year.

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
Unfortunately for India’s 118 million child (under five years) citizens, the country is seriously off track in achieving any of the MDGs. According to a report Investing in Development: A Practical Plan to Achieve the Millennium Development Goals authored and released by UN millennium director Dr. Jefferey Sachs in New Delhi in early February, India is very likely to miss at least four MDGs — reduced child mortality, improved maternal health, improved access to sanitation facilities and eradication of extreme poverty and hunger. "A continuation of rapid private sector-led growth combined with public sector investment in health, education and environmental capital is required to achieve the MDGs. I don’t see this happening in India to the extent required. You need dramatic investment in health for example, but you only put in 1 percent of the GDP. This amounts to $5 per person annually and is far too little. You need to make critical investments in safe water and power in rural areas. So the full package has not happened," says Sachs also director of the Earth Institute, Columbia University and special adviser to UN secretary-general Kofi Annan on the Millennium Development Goals.

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
Indeed in the manifestos of political parties the issue of children’s health and deprivation seldom finds mention, simply because India’s 415 million children below 18 don’t vote on E-Day. In the rogue democracy into which high-potential post-independence India has mutated, children’s rights to shelter, health, nutrition and education are routinely ignored creating severe sociological and psychological problems within a society which has little time or inclination to nurture its massive population of 118 million children below the age of five years (see cover story ‘Coming of age in the republic of chronic injustice’ EW January).

Box 1

Deprivation definitions

To measure the extent of deprivation suffered by children in developing countries, where 1.9 billion children live, Unicef commissioned teams from Bristol University and London School of Economics, to research and compile data which strongly impact children’s lives. The research teams identified and defined the major indicators of child deprivation as under:

Nutrition. When children’s height and weight for their age are more than three standard deviations below the median of the international reference population

Water. When children have access only to surface water for drinking or who live in households where the nearest source of water is more than 15 minutes away

Sanitation. When children have no access to a toilet of any kind in the vicinity of their dwellings

Health. When children are not immunised against any diseases or young children afflicted by diarrhoea have not received any medical advice or treatment

Shelter. When children live in dwellings with more than five people per room or in homes without flooring material

Education. When children aged between seven and 18 years have never been to school

Information. When children aged between three and 18 years are without radio, television, telephone or newspapers at home

Source: The State of the World’s Children 2005

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
It is hardly a coincidence that
the BIMARU states of the Indian Union which sport rock-bottom child healthcare, nutrition (and education) statistics, are also the poorest, most lawless and most economically backward in the country. For instance the western state of Goa where per capita public spending on healthcare (Rs.382 per year) and on education is a multiple of several times more than in Uttar Pradesh, enjoys a per capita income of Rs.32,000 per annum, more than four times the per capita income in the Hindi hinterland.

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
Torres strongly believes that the deprivation of children flows from the deprivation and poverty of their parents, particularly mothers. This is why instead of highlighting healthcare or education per se, Unicef’s SWC 2005 makes a strong case for poverty eradication and higher standards of living for socially disadvantaged majorities in third world countries. The need is for a frontal attack on poverty which entails the provision of adequate shelter, safe drinking water and sanitation, food security and education. Somewhat belatedly development economists worldwide seem to have discovered that piecemeal attention to education, healthcare or nutrition while important, is insufficient to promote human development.

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
"Tamil Nadu has a long history of state intervention in education and healthcare. Health services for children are provided through a network of public health centres, health sub-centres and community health centres apart from post-partum, family welfare, mother and child health centres and hospitals in urban and rural areas. Consequently the state has a low infant mortality rate of 44/ 1000 births (cf. all India average of 63), a maternal mortality rate of 1.3/1,000 (cf. all India average of 4.07) and is ranked first for the vaccination status of children between 12-23 months. Moreover child health allocations from the state’s annual healthcare outlay computed over the past four years, is an impressive 42.27 percent. This is not expenditure, but investment in our young people which will pay huge dividends," says S. Ananthalakshmi, honorary director of IRDC (Information, Documentation & Research Centre), Indian Council for Child Welfare, Chennai.

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
That’s why while they admit
that the ICDS is the most comprehensive early child-hood development programme in South Asia, childcare activists stress that its "admirable objectives" should encompass at least three times the current number of children. "ICDS is the most comprehensive and proven early childhood care programme in the country. Unlike most government health programmes which are focused on family planning and immunisation, ICDS focuses on providing pregnant mothers and children below five years supplementary nutrition, early schooling, regular health check-ups and other referral services. We are part of a network of NGOs which believe that ICDS urgently needs to be universalised to cover all 118 million children below five years of age," says Dr. Veda Zachariah, programme manager of Sanjivini Trust, a Bangalore-based NGO which works with pregnant mothers and children below six years living in the city’s slums.

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
Shukla Bose, an alumna of IIM-Calcutta and formerly the high-flying chief executive of Resort Condominiums India, (the company which introduced the concept of holiday time share villas and apartments to India) and currently the promoter-CEO of the Bangalore-based Parikrma Foundation is a crusader for a multi-dimensional approach to children’s healthcare and education. "Children enrolled in government schools are from the poorest of poor families which can barely provide them one meal a day. In our schools we are convinced that however bright, children cannot study on empty stomachs. Therefore we not only provide our children a free mid-day meal, but breakfast and an evening protein drink as well. Our aim is to give children more than 88 percent of their daily calorie requirement in school itself. As a consequence all our children have gained weight, become healthier and don’t fall ill often. Therefore they are able to attend class regularly, concentrate on their studies, and participate in school activities more fully. If as a nation we want our children to actually learn in school and become productive citizens, we must ensure they receive adequate nutrition, preventive healthcare and encouragement in school," says Bose. Though promoted only in 2003 after Bose’s dramatic resignation from the Christel Foundation following a spat with founder trustee Christel de Haan, Parikrma runs three CISCE-affiliated, English medium free schools for slum children with an aggregate enrollment of 480 children.

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.

Stiglitz: painless option
Dr. Joseph E. Stiglitz professor of economics at Columbia University who was awarded the Nobel prize for economics last year, believes that it "costs very little" to eradicate child poverty and that the MDGs can be painlessly attained by a global cut in arms and armaments expenditure. "The additional cost of achieving universal primary education by 2015 — the second Millennium Development Goal agreed to by 187 countries in September 2000 — is estimated at $ 9.1 billion annually. Less than $100 billion will be required over the next 10 years to make this goal a reality. To put this number in perspective, global defence spending in 2003 amounted to over $ 956 billion. A 1 percent reduction in annual global military spending — which would only shave a fraction off the 11 percent spending increase that took place in 2003 alone — could provide primary education for all children around the world," writes Stiglitz in a special essay included in SWC 2005.

Back home in India where defence expenditure has crossed Rs.80,000 crore per year, fond hopes are being expressed that gifted the world’s youngest population 21st century India could become the back office and workshop of a rapidly ageing global — especially OECD — order. But the nation’s grim child healthcare time bomb prognosticates an alternative nightmare scenario. Suffering continuous neglect and disease, the nation’s high-potential child population could morph into sickly, low productivity citizens requiring continuous medical care and subsidisation. In which case a potential national asset could transform into a massive national liability.

With Mona Barbhaya (Mumbai); Vidya Pandit (Lucknow); Autar Nehru (Delhi) & Hemalatha Raghupathi (Chennai)