Block 2
Block 2
Block 2
Constraints
BLOCK 2
POPULATION AND HUMAN
DEVELOPMENT
67
Economic
Development since BLOCK INTRODUCTION
Independence
Block 2: Population and Human Development
Block 2 of this course is on ‘Population and Human Development’. This
block has three units. The units are devoted to the themes of demography,
education, health and nutrition. It thus deals with the social sector of
development.
Unit 5 is on ‘Demographic Features’. The unit discusses the growth in
population over the decades. Changing trends in fertility and mortality rates
are explained. The issue of demographic transition is then discussed in terms
of urbanisation, sex ratio, population pyramid and dependency ratio. The
concept of ‘population ageing’ with reference to demographic dividend and
National Population Policy is also presented in the unit.
Unit 6 is on ‘Education Sector’. The unit begins with a distinction on
‘human capital’ and ‘human development’. The status of ‘education sector’
in India is explained by ‘level of education’ and ‘gender and quality’
dimensions. The issue of ‘financing of education’ is discussed with reference
to ‘public expenditure on education’ and ‘alternative sources of funding’.
Unit 7 is on ‘Health and Nutrition’. The unit begins with an outline on the
concepts of ‘measurement of health and nutrition’. Issues of sources of
health expenditure, public healthcare system in India and the National Health
Policy are discussed in the unit.
68
UNIT 5 DEMOGRAPHIC FEATURES*
Structure
5.0 Objectives
5.1 Introduction
5.2 Population of India: Size and Growth
5.2.1 Growth of Population
5.0 OBJECTIVES
After going through this unit, you will be able to:
• define the concepts of ‘Density of Population’ (DoP) and ‘Growth of
Population’ (GoP);
• state the basic demographic equation of ‘Vital Statistics’ with a
specification of its main constituents;
• explain the different types of ‘fertility’ and ‘mortality’ rates along with
their merits and demerits;
• analyse the trends in ‘demographic transition’ in India;
• outline the concepts of ‘population ageing’ and ‘demographic dividend;
and
• indicate the objectives and achievements of NPP, 2000.
5.1 INTRODUCTION
Demography means ‘the scientific study of human population, with respect to
size, structure and development’. The study of Demography is important
*
Prof. Sumanash Dutta, Assam University.
69
Population and since human population in terms of its structure, composition and growth, has
Human
Development
significant bearing on economic growth and development. Population is the
only and ultimate source of labour supply for development activities. It is also
the ultimate beneficiary of development. Hence, population is both the means
and the end of economic development. In India, the Demographic data is
available in the Census Reports which is conducted every once in ten years.
The last such census was conducted in the year 2011. The present unit delves
into the important demographic features of India.
70
The population in India was 1028.5 million in 2001; it increased to 1210.6 Demographic
million in 2011. The Rate of Growth of Population over the period 2001 to Features
2011 is 17.7 (or 18) percent. However, when the decadal rate of population
growth is divided by 10, we get the average annual growth rate of population
which in the present case is 1.8 percent. The rate of decadal growth of India’s
population increased from 22 percent in 1951-61 to 25 percent in 1961-71.
After that, it has been declining steadily at a very slow pace at first but at an
accelerated rate since 1991. The growth rate of population, as per 2011
census, is not uniformly the same across the states of India. Some states have
exhibited higher average annual growth rate than the national growth rate. For
instance, Meghalaya (2.8 percent), Bihar (2.6 percent), Arunachal Pradesh
(2.6 percent), Jammu & Kashmir (2.4 percent), Rajasthan (2.2 percent), etc.
The lowest growth rate is in Nagaland (– 0.6 percent).
Merits and Demerits: TFR is the most frequently used index of birth rate. It
takes into account the entire fertility span of women population and at the
same time fertility of women belonging to particular age groups. TFR is less
precise because of the fact that not every woman shall start her reproductive
period at age 15 and some would not bear children.
TFR was estimated to be 5.2 for India in 1971 but is estimated to have come
down to 3.6 in 1991 and further to 3.0 in 2002. According to UNDP Human
Development Report 2001, TFR for the world population has dropped from
4.5 in 1975 to 2.8 in 1995-2000. In India, TFR has declined from 3.0 in 2002
to 2.4 in 2012. According to latest data available, TFR stands at 2.3 in 2013.
Such a high value for TFR means that at the current prevalent age-specific
fertility rates, a woman in India would add, on an average, 2.4 children to the
population before she completes her reproductive life. Although TFR has
been brought down to the level of 2.3 in 2013 over a period of more than 40
years, it is still high enough and 0.2 higher than Replacement Level Fertility
(i.e. TFR = 2.1) which is a matter of great concern.
5.3.2 Mortality Rates
We shall discuss four mortality rates viz. CDR, ASDR, IMR and expectation
of life at birth. The Crude Death Rate (CDR) or the Crude Mortality Rate
(CMR) in any year in an area is defined as the number of deaths in the year
�
per thousand population i.e. CDR = � × 1000, where D refers to the total
number of deaths from all causes registered in a defined geographical area (or
a social group) within a time frame (usually a calendar year) and P is the mid-
year population in the defined space and time.
Merits and Demerits: This is the most frequently used and most easily
calculated and understood index of mortality. It gives a general picture of
mortality situation prevailing in the entire population under consideration.
However, it is based on the assumption that the risk of dying for every
individual (P) is the same. It is not desirable to compare death rates of two
countries, two regions or two communities on the basis of CDR because of
this limitation. CDR in India has declined from a high rate of 49 per annum
per thousand during 1911-21 to 9 in 2001, 8 in 2006 and further to 7 in 2012.
73
Population and Age-Specific Death Rate (ASDR): Death occurs at all ages and the risk of
Human
Development
mortality varies with age. It is therefore necessary to analyse death rates for
populations at different ages (or age groups) by calculating age-specific death
���
rates (ASDR). This is calculated as: ASDR = ��� × 1000 where nDx is the
number of deaths recorded for persons in the ages x to x+n–1 and nPx is the
mid-year population size for this age group. When n=1, the ASDR becomes
�
annual age specific death rate and is given by: AASDR = �� × 1000.
�
5.4.1 Urbanisation
Urbanisation is a process by which societies become more urban. It refers to a
population shift from rural to urban areas. Thus, it is a case in which the rate
of growth of urban population is more than the rate of growth of rural
population. Two simple measures to gauge the degree of urbanisation are the
following.
i) Percentage of Population in Urban areas (PU):
���� �� ����� ����������
PU = ���� �� ����� ����������
× 100
Higher the value of the ratio UR, higher is the degree of urbanisation.
The share of urban population in India (PU) has increased from about 11
percent in 1901 to about 17 percent in 1951 and further to 31 percent in 2011.
There has been a gradual increase in the trend of urbanisation in India over
the period. The Urban-Rural ratio (UR), on the other hand, has increased
from 21 percent in 1951 to 45 percent in 2011. The rate of urbanisation has,
however, been uneven across the states. For instance, the NCT of Delhi is the
most urbanised with as much as 98 percent of its population living in urban
areas. Goa is the most urbanised among the states with 62 percent of its
population living in urban areas. The least urbanised states are Himachal
Pradesh (10 percent) and Bihar (11 percent). Census classification treats areas
with population above a certain level as Urban Areas. Thus, every census has
a potential for reclassification certain areas into 'urban', though people in
those areas continue to live in the same place.
Still urbanisation is considered beneficial because of better opportunity for
earning higher incomes, better infrastructure and better awareness and
response of people to social issues in general. Urbanisation therefore
contributes to modernisation and social change, the latter through lower birth
rate, lower death rate, lower IMR and lower fertility rates. These are mainly
due to higher levels of education and healthcare facilities which are much
better in urban areas than in rural areas.
The pattern of urbanisation in India is characterised by continuous
concentration of population in large cities without adequate expansion of
resource base and amenities. As a result, it has generated problems in the
77
Population and areas of housing, transport, water supply and sanitation, water, air and noise
Human
Development
pollution, social infrastructure (schools, hospitals etc), urban poverty and
unemployment and growth of slum areas.
5.4.2 Sex Ratio
The gender composition of the population is measured by the sex ratio,
defined as the number of females per thousand males. It has been observed
that females outnumber males in developed countries. India’s sex ratio,
however, shows that the society is masculine in respect of this demographic
feature. The sex ratio in India has declined from 972 in 1901 to 933 in 2001
which slightly increased to 943 in 2011. It varies widely across states: from
1084 in Kerala to 879 in Haryana and among Union Territories, from 1037 in
Pondicherry to 618 in Daman & Diu (as per 2011 census). The declining
trend in the sex ratio in India has been due to a number of factors like: high
Maternal Mortality Rate (MMR), high IMR among the girls, high Child
Mortality rate among the girls, strong son preference prevalent among the
parents, female illiteracy and low level of education, illegal female infanticide
and female foeticide, etc. Efforts to promote gender equality through
emphasis on education of girls, empowerment of women, legislation to
prevent domestic violence against women and ban on the use of pre-delivery
sex determining technology have been scaled up to tackle these issues in the
recent years in India. The latest initiative launched viz. ‘Beti Bachhao, Beti
Padao’ is worth noting in this context.
5.4.3 Population Pyramid
Population Pyramid or age-sex pyramids are an elegant and useful way of
graphically presenting the age-sex distribution of population. A pyramid
comprises of two ordinary histograms placed on their sides. The rules of
drawing pyramids are generally the same as those for plotting histograms, but
there are certain conventions and special features. These are:
first, pyramids are always drawn showing the male population on the left
hand side and the female population on the right hand side. The young are
always at the bottom and the old at the top. It is conventional to use single
year or 5-year age groups, though other groupings are also possible.
second, the last open ended age-group is normally omitted, but in some cases
it is shown.
third, the vertical scale shows the age groups and the horizontal scale shows
the percentage of population or absolute number of population of each group.
In case of percentages, the percentages are to be calculated using the total
population of both sexes combined as the base.
fourth, the horizontal scale must be uniform for both the sides of the pyramid.
The vertical scale must also be uniform for both the sides while drawing the
histograms.
The population pyramids of India for 2001, 2016 and 2026 (projected) are
shown in Fig. 5.1. They reveal that the shape of the population pyramid has
been changing gradually. In 2001, it had a much broader base than that in
78
2016 and 2026 implying larger proportion of young children in the population Demographic
in 2001 compared to 2016 and 2026. The proportion of elderly has also Features
grown over the period as revealed by the slightly bigger size of histograms at
the top of population pyramid-2026 (Projected). The latter is because of
population ageing. The pyramids of developed countries are almost
rectangular in shape indicating lower proportion of children and a higher
proportion of the adults and the elderly in the population. The larger
proportion of working age population in India particularly belonging to age
groups 20-24 to 55-59 in pyramids 2016 and 2026 point out towards the
country’s entering the phase of demographic dividend.
As per the above, the values of (A) and (B) for India in 2015 were 44 and 9
respectively. The corresponding ratios for a developed country like USA are
29 and 22. In less developed countries, dependency ratio is generally high. In
India, the ‘dependency ratio’ is measured by taking both the 0-14 and 60+
population as follows.
���������� �� �������� (����)� ���������� �� ������� (���)
(C) Dependency Ratio = ���������� ���� ( �����)
Children and elders i.e. those in the age groups of 0–14 and 60+ are expected
to be taken care of by the working age population 15-59. The Dependency
ratio at (C) above indicates the responsibility of dependents per member of
the working age group population. A favourable dependency ratio tends to
boost savings. This is possible only if the working age population is
productively employed. The Dependency Ratio for India has come down
from 0.92 to 0.56 between 1951 and 2001.
has increased to about 7.5 percent in 2001 and further to 8.6 percent in 2011.
It is projected that the number of elderly population would be about 17
percent of the total population in India by 2051.
5.5.1 Demographic Dividend
The recent rapid fertility decline in some parts of the world has opened up a
new window of opportunity for achieving faster growth rate in economic and
human development. With steady decline in fertility, there will be fewer and
fewer children in the age group 0-14. The past high fertility ensures the
growth of the present workforce and the present low fertility implies smaller
size of dependent child population in future. This feature of population trend
is called ‘demographic window or dividend’. More specifically, the dividends
that accrue are: (i) higher labour supply for larger economic activities; (ii)
fewer children with better health for women’s health, education and
opportunity to join work force (iii) larger size of working age adults with
larger earnings and larger savings i.e. improved capital supply for economic
activities; (iv) less investment will be required on children at both micro and
macro level as less number of children will be there to look after in the
country; (v) better human development due to larger earnings, more
investment in higher education and better health for women and children
(China improved its ranking in HDI by resorting to one-child family planning
norm); and (vi) because of fertility decline and increase in the population of
working age people, the dependency ratio will decline. Low dependency ratio
is helpful in economic development.
Typically, this window of opportunity, or the availability of the demographic
dividend, lasts for 30 to 40 years, depending upon the country. India reached
the point of demographic window in 2011. The proportion of those aged less
than 15 years is still above 30 percent and the proportion of those aged 65 and
above is below 15 percent. The share of the working age population is rising
(almost 60.3 percent in 2011) in India. On the other hand, Work Participation
Rate (WPR) is low at 39.8 percent in 2011. Urgent steps are, therefore,
required to: (i) generate employment opportunities on a scale sufficient to
eradicate unemployment and underemployment; and (ii) prioritise skill
development among the youths to utilise new avenues of self employment;
and (iii) extend the reach of the modern educational and training system so as
to enable larger sections of the population to benefit and thereby participate in
the development process. Only then can India reap the benefits of
‘demographic dividend’.
5.5.2 National Population Policy (NPP)
The National Population Policy, 2000 (NPP 2000) reiterates the commitment
of the government towards voluntary approach in administering family
planning services. It provides a policy framework to meet the reproductive
and child health needs of the people to achieve the net replacement levels in
terms of TFR. The immediate objective of the NPP 2000 is to address the
unmet needs for contraception, healthcare infrastructure and to provide
81
Population and integrated service delivery for basic reproductive and child health care. The
Human
Development
medium term objective is to bring the TFR to replacement level by 2010
through the implementation of inter-sector operational strategies. The long
term objective of NPP 2000 is to achieve a stable population by 2045 in
conformity with requirements of the country to ensure sustainable economic
development. The government has already taken several steps and initiatives
under the immediate objectives of NPP 2000. As a result, TFR has declined
from 3.0 in 2002 to 2.3 in 2013. As per latest data available, 24 states/UTs
have achieved replacement level of fertility of TFR =2.1 by 2013.
Check Your Progress 2 [answer within the space given in 50-100 words]
1) What is urbanisation? How is it measured? What has been the trend in
India’s urbanisation process as per these indicators?
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2) What does the population pyramid depict? How does it differ between
the developing and the developed countries?
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3) When does a country signifies to have entered a phase of ‘demographic
dividend’? What are its implications for economic planning?
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82
5.6 LET US SUM UP Demographic
Features
84
UNIT 6 EDUCATION SECTOR*
Structure
6.0 Objectives
6.1 Introduction
6.2 Human Capital and Human Development: Distinction
6.3 Education Sector in India
6.3.1 Elementary Education
6.3.2 Secondary Education
6.3.3 Higher Education
6.0 OBJECTIVES
After reading this unit, you will be able to:
• distinguish between the terms ‘human capital’ and ‘human
development’;
• describe the growth in the Education Sector (ES) in India;
• analyse the adequacy of expansion in the ES in terms of its quantitative
and qualitative dimensions;
• critique the performance of ES with the educational attainment in terms
of its gender and quality dimensions;
• discuss the trend in Public Expenditure on ES in India with a
comparative profile of the same in other countries; and
• explain the role of ‘state’ versus ‘market’ in financing education with
an outline of alternative sources of financing the ES.
6.1 INTRODUCTION
Education contributes to building up what has come to be known as ‘human
capital’. Human capital is distinct from ‘physical capital’ but is
complementary to the latter. Physical capital facilitates economic growth
which, in turn, creates conditions which demand better education facilities.
*
Prof. Sebak Jana, Vidyasagar University
85
Population and This results in human capital formation in the economy. Human capital
Human
Development
formation, in turn, spurs economic growth. Thus, these social aspects of
development invariably attract the attention of both policy-planners and
political leaders albeit with differing motivations for each. In this context, the
present unit discusses the issues relating to one of the two specific sub-
sectors of social sector development viz. education sector in the Indian
economy (the other one being health).
terms, therefore, only in ‘upper primary’ level of education the dropout rate
for girls is higher for girls (4.5) as compared to boys (3.1) [2013-14].
Considering that the dropout rate in 1960-61 was as high as 65 percent, there
is a major improvement in this respect. One aspect on which the achievement
of improving girls’ enrolment could depend is the ‘number of female teachers
per 100 male teachers’. This figure was as low as around 20 (for each of the
three school levels) in 1951. This has gradually risen to the level of 65-80 for
different levels of education by 2011-12. Thus, while there is improvement in
this respect, there is scope for increasing the number of female teachers at all
levels of education both towards achieving greater gender parity as also to
minimise dropout rates of female children from schools.
6.4.2 Quality
A nationwide survey of children’s reading and arithmetic capabilities in rural
India is conducted every year by the NGO Pratham. Given its scale and
comprehensive coverage, its Annual Status of Education Report (ASER) is a
path-breaking initiative, being the only Indian nationwide survey for
assessing the learning achievement of children between classes I and VIII.
There are four basic tests of increasing difficulty to gauge the arithmetic
competence and the students are asked to perform each only after clearing the
lower level. These are: (i) recognition of randomly chosen numbers from one
to nine, (ii) recognition of randomly chosen numbers between 11 to 99, (iii)
subtraction of two-digit numerical problems with borrowing and (iv) division
of three-digit by one-digit numerical problems. The survey results in 2010
reveal that only 37 percent of the children in class III could recognise
numbers up to 100. Furthermore, just 27 percent of the students could reach
the next level i.e. subtraction. What is even more worrying is that the
proportion of children reaching the highest test level has consistently
declined since 2005, when the survey was first conducted. In 2005, at least 15
percent of the children in class III could perform all the tests, while in 2010
only 9 percent of the children could do so. Also, in 2010, 67 percent of the
children in class VIII could reach the highest level, while the corresponding
figure in 2005 was 70 percent. Clearly, pushing enrolment is not
automatically translating into improved learning.
Quality of higher education has also been a major concern in India. To rectify
this situation, some of the policy measures taken in this direction are: (i)
redesigning academic programme to synchronise with the market demands,
(ii) laying greater emphasis on interactive modes of learning, (iii) changes in
the assessment procedure and examinations, (iv) introduction of the semester
system, (v) teachers’ assessment, (vi) grading of institutions, (vii)
introduction of credit system to afford inter-institutional mobility, (viii)
faculty development programmes, (ix) maintenance of national database of
academic qualifications, etc. National Policy on Education in India has all
thorough laid special emphasis on improving the quality of higher education
in India by the establishment of accreditation agencies. Notwithstanding the
fact that we have 13 regulatory bodies of higher education, the quality of
91
Population and education is fairly low and content in the programmes less relevant to the
Human
Development
‘needs of the individual and the society’. Out of 3,674 colleges assessed by
NAAC, only 24.4 percent of colleges have been awarded the A grade. The
educational system suffers from what has been called ‘diploma disease’ i.e. it
does not aim at conveying knowledge and skills but is more concerned with
certification and credentialing. As such, its contribution to the growth of
human capital is minimal and is unable to meet the emerging demands for
skilled professionals.
when positive externalities are taken into account, the resulting social rate of
return far exceeds the private rate of return. This makes the role of state
crucial in funding education. Second, consumers are often ignorant of the
benefits that they would receive by investing in education. Besides, they
cannot take into account the positive spill-over effects of their education on
the society (like improving family health, productivity, reduction in poverty
rates, etc.). Since the government is considered wiser in making such
decisions, state funding in the provision of education is required for ensuring
equality of opportunity. Further, since not every household/individual has the
resources required to invest in education, in the absence of state subsidies,
only those who could afford to pay would enrol in schools and colleges. In
other words, those who are meritorious but lack resources would be left out.
In order to meet the ends of equity, market proponents argued that the access
to education loans could be improved. However, since the capital market
suffers from its own imperfections, such measures would not suffice.
Moreover, since the human capital is embodied in individuals, it cannot be
offered as liquid collateral. What about inclusion? Will a child from poor
family take education loans and at the end of college, begin with a debt
burden? Will it be progressive? There is also a long gestation period for the
repayment of such loans to commence due to the uncertainty of future
income opportunities. Such factors would constrain both the availing of such
loans by the individuals and also the institutions from advancing the loans.
Thus, the presence of imperfect capital market becomes a major reason due to
which the role of state to invest in education needs to continue. The other
view point is that educational loans to poor people do not serve the objectives
of inclusion and equity as these loans are available for selected
courses/institutions only and hence the objective of inclusivity is far from net.
6.5.2 Public Expenditure on Education
If we consider the spill-over effects in the form of positive externalities,
education at any level, not only at the elementary and secondary levels,
merits to be treated as a ‘public good’. In its strict sense, education is
considered as a ‘merit good’. By definition, a good like ‘education’ which is
regarded by society or government as deserving public finance, is treated as a
merit good. More generally, merit goods are treated as those goods (or
services) which the government does not want people to under-consume
merely because their consumption depends upon their ‘ability to pay’. To
prevent such under-consumption, the government chooses either to subsidise
such services or provide it totally free at its point of consumption. In view of
the mixed characteristics of education i.e. of both public as well as merit
good, education is also sometimes referred to as ‘public merit good’.
Impinging on investment for providing the educational services, i.e., a huge
establishment or fixed cost as well as a recurring operational cost, the
characteristics that impinge on investment considerations of the government
are: (i) consumer ignorance, (ii) technical economies of scale, (iii)
externalities in production and consumption and (iv) inherent imperfections
93
Population and in the market like absence of credit institutions. On the issue of public
Human
Development
investment in education, it is customary to express the total allocation or
expenditure as a percentage of GDP (Table 6.1). The trend in this respect for
India shows that over the years 1961-81, public expenditure on education
doubled from 1.5 percent to 3 percent. Thereafter, it increased marginally by
just another 1 percent between 1981 and 2001 (to touch 4.1 percent in 2001).
In the post-2000 years, the public expenditure on education has declined (e.g.
2005-06, 3.3%). Since 2005-06, it has ranged from 3.5 percent in 2007 to 4
percent in 2010. The stagnation of public expenditure in education at just
around 4.1 percent of GDP (in 2014) is in stark contrast with the comparative
profile with other countries (Nepal, 4.7 percent; Germany, 4.9 percent; USA,
5.2 percent; U.K., 5.7 percent and South Africa, 6.1 percent). As stated
before, the decline in public expenditure on education in India is for reasons
of fiscal constraints whereby for elementary and secondary level more
resources are allocated but for higher education, there is a shift towards cost
recovery.
Table 6.1: Public expenditure on education as percent of GDP
Year Percent
1960-61 1.5
1970-71 2.1
1980-81 3.0
1990-91 3.8
2000-01 4.1
2010-11 4.1
2010-11 4.1
discriminatory fee structure i.e. course fee linked to the income level of the
family or the ability to pay is suggested. Those from the lower socio-
economic strata are levied less burden and those from the upper income
groups are made to pay more. The ‘graduate tax’ method levies a tax on the
employers employing educated workforce. The case for the method is made
on the ground that while the employers get the benefit of such educated
persons, they themselves do not pay for their training. The method is
disadvantageous in that it may motivate the employers to go for less educated
workers thereby causing the problem of unemployment among the educated.
However, since only educated workforce can undertake certain type of works
which are knowledge intensive, the substitution effect is expected to be less.
The method of ‘student loans’ targets the beneficiaries directly. While many
committees constituted by the government have favoured this approach, it is
also said to adversely impact equity considerations. For instance, the method
may lead to the promotion of those courses which are having higher
employment market neglecting the courses which may be important from a
societal angle. Another problem with this method is the issue of insufficiently
developed credit markets and the problem of recovery of loans which is
dependent on uncertain future employment markets.
For elementary and secondary level of education, a commonly practised
method is ‘earmarking’. This refers to a levy of a special cess for the
particular purpose. The programme of SSA generated a major part of its
funds by this method. Many countries, both developed and developing, have
successfully adopted this method. Another method which has successfully
been implemented for school level is the ‘direct benefit transfer’ (DBT)
method. A major problem of government schools is of accountability
impinging on quality of education. The method of DBT is said to deal with
this by transferring the power of selecting a school of their choice to the poor
household/parent. It is a voucher system in which a parent can admit a child
to the school which charges fees up to the amount of the voucher. Parents can
choose any type of institution (private, aided or government) where the fee
charged, if higher than the voucher amount, can be supplemented by the
family. With the value of the voucher being set ‘inverse to the family
income’ (i.e. poorer families getting higher valued vouchers), the method is
argued to afford the potential of being an instrument of greater equity. One
criticism of this method is that the method may not work in backward/rural
areas as private schools may not be popular in such areas. However, data
from NSSO for 2014-15 shows that the per month median fee charged by
private unaided elementary schools in rural areas was Rs. 292 while in urban
areas it was Rs. 542. In the light of this, it is argued that even a relatively low
voucher value of Rs. 500 per month would represent significant share of total
expense even in remote rural areas. Another concern about DBT is how to do
away with the present ‘grants-in-aid’ system which is kept equivalent to meet
the requirement of teachers’ salary. The grants method, thus, gives priority to
schools and not to pupils/students. Such a grant does not even take into
account the number of students. It is far from trying to address the attitude of
the teachers towards their accountability. With DBT, it is pointed out that 95
Population and teachers would have to focus more on attracting, retaining and then giving
Human
Development
quality education. Towards implementing DBT, the government is
contemplating ‘school consolidation’ where tiny schools are merged with
bigger schools nearby and redeploying teachers from over-enrolled schools to
under-enrolled schools. Many countries (e.g. Colombia, Chile, Netherlands,
New Zealand, US) have used the DBT method to good effect.
Check Your Progress 2 [answer within the space given in about 50-100
words]
1) What specific policies are needed to improve the sub-standard
performance in education?
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2) How is GPI defined?
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3) In what way, the ratio of female enrolment in schools can be improved?
To what extent, there is improvement in this regard over time?
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4) What is an indicator available to establish that the school level education
system has declined in quality in recent years?
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5) On what grounds, the public funding of education was defended in the
face of market proponents arguing against it?
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Sector
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6) Is education rightly a public good or a merit good? Give reasons for your
answer.
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UNIT 7 HEALTH AND NUTRITION*
Structure
7.0 Objectives
7.1 Introduction
7.2 Measurement of Health and Nutrition: Concepts
7.2.1 Malnutrition
7.2.2 QALY/DALY
7.0 OBJECTIVES
After reading this unit, you will be able to:
• define the concepts of health and nutrition;
• explain the status of health and nutrition in terms of major indicators;
• identify the factors contributing to increasing health expenditure;
• describe the structure of Indian Public Health System;
• distinguish between preventive and curative healthcare needs;
• discuss the trends in healthcare financing in India; and
• outline the features of different health policies introduced by the
government in India.
7.1 INTRODUCTION
There is a common saying that ‘Health is Wealth’. From a human
development perspective, good health and nutrition are invaluable in their
contribution to an individual’s physical and cognitive development.
Malnutrition increases the susceptibility to infection and delayed recovery,
making the burden of disease and morbidity very large for the country.
Malnutrition increases the incidence of non-communicable diseases adding to
*
Dr. Smritikan Ghosh, Asstt. Prof., Scottish College, Kolkata.
99
Population and a huge cost of healthcare. However, most of the developing and
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underdeveloped countries unfortunately have a chronic problem of ill health
with India being at a very low position in respect of its health and nutritional
ranking. Specifically, in case of children, the situation is more vulnerable as
according to World Bank, 22 percent disease burden of the Indian children is
because of malnutrition.
Infant Mortality is the probability of a newly born child’s death before its
first birthday. Numerically, it is the number of infant deaths per 1000 live
births in a year. Abbreviated as IMR, it is measured as: IMR = (Number of
resident infant deaths/Number of resident live births)*1000. For example, say
in 2016, among the State residents, number of infant death is 1300 and
number of live births in the State is 150000. Then IMR=
(1300/150000)*1000 = 8.7. According to World Health Organisation
(WHO), 75 percent of world’s under-five deaths is within first year of
infant’s life.
number of deaths per 1000 per year’. Empirically, it is measured as: Child
Mortality Rate (CMR) = (D/N)*1000 where D = deaths between 0-4 years
during the year of calculation and N = number of live births among the new
born during the year of calculation. For computational purposes, the data is to
be drawn from the registration of newborns. According to WHO, world-over
nearly 9 million children die before their 5th birthday. Main causes of this
type of death are pneumonia, diarrhoea and malnutrition.
The Indian health scenario with respect to the above indicators is indicated in
Table 7.1. It shows that except maternal mortality rate and crude death rate,
all other rates are falling. Crude death rate (defined as number of deaths per
year per 1000 people) is constant for first two National Family Health Survey
(NFHS) rounds and maternal mortality rate has increased for the same time
period.
7.2.1 Malnutrition
Malnutrition may be over-nutrition or under-nutrition. Under-nutrition is
measured by indicators like under-weight, stunting and wasting. Wasting
represents the failure to receive adequate nutrition in the period immediately
preceding the survey and is a sign of the extent of malnourishment. It may be
the result of inadequate food intake or a recent episode of illness causing loss
of weight and the onset of malnutrition. Persons whose ratio Z-score of
weight-for-height is below –3 SD (i.e. minus three standard deviation from
the median of the reference population) are considered ‘severely
malnourished’ and those below –2 SD as ‘malnourished’. Thus, if there are
10 individuals whose Z-scores as: –4.1 SD, –3.9 SD, –3.1 SD, –2.8 SD, –2.1
SD, –2.0 SD, –1.1 SD, 1.5 SD, 1.9 SD and 2.5 SD respectively then, the first
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Population and three individuals are severely malnourished, the next three individuals are
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Development
malnourished and the last four are nourished. Note that on the negative side,
up to –1 SD, a margin is given for not regarding a person in the malnourished
category. Similarly, the height-for-age is the ratio of ‘height in cms and age
in months’. The Z-score of this ratio is taken as an indicator of ‘linear growth
retardation’ and ‘cumulative growth deficits’. Linked to the extent of
malnourishment, persons whose Z-score of height-for-age is below –2 SD
from the median of the reference population are considered ‘stunted’ for their
age and are labelled ‘malnourished’. Likewise, when this Z-score is less than
–3 SD, the person is called ‘severely stunted’ or ‘chronically malnourished’.
Stunting reflects failure to receive adequate nutrition over a long period. Such
failures are also affected by recurrent and chronic illness. Weight-for-age is a
composite index of height-for-age and weight-for-height which takes into
account both the acute and chronic malnutrition. Persons whose weight-for-
age is below – 2SD from the median of the reference population are classified
as underweight. Sometimes, anaemia level is also taken as an indicator of
under-nutrition. In nutrition literature, adult malnutrition and child
malnutrition are separately distinguished as follows.
Adult malnutrition is measured by ‘body mass index’ (BMI), Aneamia level
and overweight. BMI is measured as ‘weight divided by height-square’ (i.e.
kg/m2 where weight is taken in kgs and height is expressed in meters). The
standard value of BMI is 18.5. Thus, when a person’s BMI is below this
standard value, he/she is called ‘malnourished’. On the other hand, when the
BMI value is more than 25, the individual is called ‘obese’. In case of
anaemic persons, the BMI level is taken as 12 for female and 13 for male. In
India, there is a decreasing trend of underweight women and men over time
(Table 7.2). However, the percentage of overweight women and men has
increased significantly over the last 15 to 20 years. This is very alarming.
Within the same time span, percentage of women and men with anaemia has
not fallen significantly. This is also a major concern. The trend for
underweight children in India is continuously falling (it has declined
7.2.2 QALY/DALY
Other than the above measures, there are two more popular measures to
assess the health standard of people. These are: Quality Adjusted Life Year
(QALY) and Disability Adjusted Life Year (DALY). QALY is a measure of
disease burden which includes both quality and quantity of life lived. One
QALY means one year of perfect health. DALY measures how many years
are lost due to ill health, disability or early death. Thus, DALY shows health
loss and QALY shows health gain (i.e. QALY is the inverse of DALY).
Thus, in practice, the difference between a DALY and a QALY depends on
whether the quality of life is expressed as a loss (DALY) or a gain (QALY).
Additional differences are taken into account by the way in which disease
weights are assigned.
Check Your Progress 1 [answer within the space given in about 50-100
words]
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2) State the five major health indicators? Which of these has fallen
internationally by about 50 percent over the period 1990 and 2015?
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Population and 3) What are the three sub-components of under-nutrition? How are they
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Development
measured?
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4) How is ‘adult malnutrition’ measured? What is a notable trend in this
respect for India?
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7.3 HEALTH EXPENDITURE Health and
Nutrition
Demand factors:
a) Population Ageing: With increase in average age of the population,
demand for medical care is also increasing.
Supply factors:
a) Supplier-Induced Demand: Sometimes health service suppliers create
demand for healthcare facilities to increase their market share. This is
called supplier induced demand. This is done by adoption of new
medical technology, providing medicines and treatments not absolutely
related to patient’s condition, etc.
b) General Economic Growth: Economic growth of the country is
improving the living standard of the population which has also
increased the availability of improved medical technology. This induces
demand for healthcare expenditure.
Healthcare spending can be divided into public and private spending. Despite
several growth-orientated policies adopted by the government,
economic/regional/and-gender disparities have remained posing challenges
for health sector in India. For instance, nearly 75 percent of health
106 infrastructure, medical manpower, and other health resources are
concentrated in urban areas where only 27 percent of the population live. To Health and
reduce this disparity, public health has to focus on health promotion and Nutrition
disease prevention and control by taking into account the social determinants
of health. The focus of public health should be on bringing about changes not
only for preventing disease but also for promotion of health through
organised action at societal level.
India is the second most populous country of the world with a widely varied
socio-political-demographic and morbidity pattern. Most of the States in
India face severe healthy workforce shortage. A large number of health
service providers, managers and support workers are needed to fill this gap.
Many States are unable to provide even basic, minimum lifesaving services
in a consistent manner. The challenges of public healthcare system in India
may, therefore, be summarised as: (i) inadequate resource availability for
public healthcare; (ii) severe geographical and social disparity; (iii)
inadequate integration between health programmes; (iv) lack of community
focus; (v) fragmented functional responsibility; (vi) inadequate attention to
primary healthcare; (vii) inadequate public health orientation; etc.
Of the above, the first i.e. objective of public healthcare expenditure was
discussed briefly in Section 7.3. Regarding the second objective on efficient
use of the budget, government has recently rearranged its infrastructure
totally under the National Rural Health Mission (NRHM). Next comes the
objective related to providing financial assistance in meeting the rising
healthcare cost to the poor and the needy. This objective is at least, in part,
related to the institutional mechanisms of establishing a healthy health
insurance market in which the regulatory role of the government plays an
important part.
In the last two decades, Central and State governments have been providing
insurance premium for meeting the health costs of the underprivileged
sections of the society. Even with all these efforts, the current distribution of
main sources of health insurance premium is as follows: households (49.5
percent), government (27 percent) and others (employers) (23.5 percent).
Such health insurance coverage is mostly for in-patient care i.e. patients who
are admitted in the hospital. Comprehensive health insurance (i.e. covering
the out/in-patient, preventive, primary and post-hospitalisation care) is
offered by only select social health insurance schemes of the government like
ESI, CGHS, etc. which caters only to a small section of total population. Few
private insurance companies are providing the pre and post hospitalisation
follow-up service which only some of the more affluent section of the society
are able to avail. The goal of universal health coverage, therefore, continues
to remain a distant challenge for India’s policy makers and government.
Check Your Progress 2 [answer within the space given in about 50-100
words]
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108
..................................................................................................................... Health and
Nutrition
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2) Which three factors from the ‘Demand Side’ influences the
government’s decision to spend more on healthcare? Why?
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4) What are the two major sources of ‘health expenditure’? Which of these
dominates in Asian Countries? What is its current level in India?
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Population and 6) What are the major challenges faced by the public healthcare system in
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India?
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e) India Newborn Action Plan: This was also established in 2014 with
the main objectives of developing the health of newborn and reduces
cases of stillbirth.
Check Your Progress 3 [answer within the space given in about 50-100
words]
1) State the four specific goals of the National Health Mission: 2012-17.
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2) What are the two specific steps identified to achieve ‘universal health Health and
coverage’ under the National Health Policy, 2017? Nutrition
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3) State the five major aims of the National Mental Health Policy, 2014.
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4) On what fronts, is the National Health Policy, 2017, is critiqued?
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Population and
Human
7.7 SOME USEFUL BOOKS AND REFERENCES
Development
1) Neun and Santerre: Health Economics: Theories, Insights and Industry
Study.
4) PHE and OPE. For Asian countries, OPE is more than 80 percent. For
India, it is estimated as 89.2 percent in 2012.
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5) Yes because of high private out-of-pocket expenditure. An ideal Health and
healthcare system should be accessible to all with a fair distribution of Nutrition
financial cost between the public and the private healthcare spending.
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Population and
Human
Development
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