|Year : 2015 | Volume
| Issue : 2 | Page : 335-339
Health-related Millennium Development Goals: How much India has progressed?
Harshal Tukaram Pandve
Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune, Maharashtra, India
|Date of Web Publication||16-Dec-2015|
Harshal Tukaram Pandve
Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune - 411 041, Maharashtra
Source of Support: None, Conflict of Interest: None
Millennium Development Goals (MDGs) have to be achieved by 2015. This review article discussed India's progress toward health-related MDGs of reducing child mortality (Goal 4), improving maternal health (Goal 5), and combating HIV/AIDS, malaria, and other diseases (Goal 6). This review article assesses India's progress toward these goals as well as focuses on major but neglected road blocks in progress such as deficiencies in public health infrastructure and public health man power of India.
Keywords: Millenium development goals, health related, india, progress
|How to cite this article:|
Pandve HT. Health-related Millennium Development Goals: How much India has progressed?. Arch Med Health Sci 2015;3:335-9
| Introduction|| |
In 2000, 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge became the eight Millennium Development Goals (MDGs) to be achieved by 2015. The eight MDGs are to:
This article discussed India's progress toward health related MDGs of reducing the child mortality (Goal 4), improving maternal health (Goal 5), and combating HIV/AIDS, malaria, and other diseases. The article focuses on major but neglected road blocks such as deficiencies in public health infrastructure and public health man power of India.
- Eradicate extreme poverty and hunger;
- Achieve universal basic education;
- Promote gender equality and empower women;
- Reduce child mortality;
- Improve maternal health;
- Combat HIV/AIDS, malaria, and other diseases;
- Ensure the environmental sustainability;
- Develop a global partnership for development. 
A search strategy for this review article involved a detailed literature review on the subject of India's progress toward achievement of health-related MDGs and major road blocks in the achievement of health related MDGs with special reference to public health infrastructure and public health man power in India. Indexed and nonindexed journals, websites of important organizations, national programs in the field were identified and searched for key words. The most relevant publications were reviewed in details and included in the present review.
Health constitutes the prime focus of the MDGs. While three out of eight goals are directly related to health, the other goals are related to factors which have a significant influence on health. Hence, the goals and targets are inter-related in many ways. In India, considerable progress has been made in the field of basic universal education, gender equality in education, and global economic growth. However, there is a slow progress in the improvement of health indicators related to mortality, morbidity, and various environmental factors contributing to poor health conditions. 
According to World Health Organization (WHO), India will fail to achieve some of the most important MDG targets such as reduction in maternal and child deaths, and increase in child immunization rates by 2015. WHO has for the first time aired its views that India will miss its targets, some by a big margin? WHO admits that India has been effectively reducing its infant and maternal mortality figures mainly due to National Rural Health Mission. As per experts the pace has not been satisfactory enough, especially when it comes to infant and maternal deaths. 
| Progress Toward Goal 4|| |
According to report "Towards Achieving MDGs India 2013" the target of reducing infant mortality rate (IMR) which is important for Goal 4 of reducing child mortality is likely to miss the 2015 target. Target of IMR to achieve is 27/1,000 live births by 2015, but as per the historical trend IMR is likely to be 41. Similarly, under five morality rate as per historical trend will be 50/1,000 live births by 2015 and target to be achieved is 42, thereby missing the target by 8 points. The proportion of 1-year-old (12-23 months) children immunized against measles is at 74.1% in 2009 (UNICEF and Government of India - Coverage Evaluation Survey 2009) and as per the historical trend, India is expected cover about 89% children in the age group 12-23 months for immunization against measles by 2015 and thus likely to fall short of universal immunization by about 11% points.  As per District Level Household and Facility Survey (DLHS-3) Report which is based on data collected from 7,20,320 households from 28 States and 6 Union Territories of India during 2007-08, at the national level 87, 63, 66, and 69% of the children (aged 12-23 months) received bacille Calmette-Guerin (BCG) vaccine, three doses of DPT, three doses of polio, and measles vaccine, respectively. There is a considerable drop from BCG to measles vaccine coverage. It means that large number of children who had initial contact with service providers is missed out of subsequent services. The complete schedule of immunization including BCG, three doses of DPT and polio each, and measles was received by 54% of the children. Nearly 5% of the children did not receive a single recommended vaccine. About 57% of the children (aged 12-35 months) received supplementation of at least one dose of Vitamin A and only 19% children received 3-5 doses of Vitamin A. 
| Progress Toward Goal 5|| |
Goal 5 is related to improving maternal health. To reduce maternal mortality ratio by three quarters, between 1990 and 2015 is an important target. At the historical pace of decrease, India tends to reach maternal mortality ratio of 139/1,00,000 live births by 2015, against the target of 109. However, the bright line in the trend is the sharper decline that is 17% during 2006-09 and 16% during 2003-06 as compared to 8% decline during 2001-2003. With the existing rate of increase in deliveries by skilled personnel, the achievement for 2015 is likely to be 62% only, which is far short of the targeted universal coverage. 
According to DLHS-3 Report utilization of Antenatal Care (ANC) services for the women who had their last live/still birth during the 3 years prior to the survey showed that at the national level 75% of the women received at least one ANC visit during pregnancy. About 55% of women received ANC from government health facilities. Though 75% of the women in India received any ANC, only 49, 46, and 50% of the women had checkup of weight, blood pressure, and abdomen, respectively. Forty-seven percentage of women received iron and folic acid (IFA) tablets/syrup and 73% got at least one tetanus (TT) injection. A full package of ANC (including minimum of three ANC visits, at least one TT injection and 100 or more IFA tablets/syrup) was received by only 18% of women. Minimum of three ANC visits and timing of first antenatal checkup is crucial for maternal and child care. In India, 45% of women got ANC in the first trimester of pregnancy and about half of the women had minimum of three antenatal checkup. The coverage of ANC in first trimester varies from 24% in Bihar to 96% in Kerala. At the national level, nearly half of the deliveries (47%) took place in health institutions. Seventy percentage of the deliveries in urban areas took place in health institutions whereas it is only 38% in rural areas.  In India, 61 and 35% of the women experienced delivery and postdelivery complications, respectively. About 55% of the women sought treatment for pregnancy complications and 57% for postdelivery complications.  The practice of breastfeeding is universal in the country, but the initiation of early breastfeeding within 1-h of the birth of the child is not common. Two-fifth of women started breastfeeding within 1-h of birth and 71% breastfed within 1-day of birth. However, 29% of mothers started breastfeeding only after 24 h.
Evaluation shows that India is slow/almost off track or moderately/almost nearly on track considering all indicators regarding goal of reducing child mortality and improving maternal health. 
| Progress Toward Goal 6|| |
Goal 6 is combat HIV/AIDS, malaria, and other diseases. India has made significant strides in reducing the prevalence of HIV and AIDS across different types of high risk categories. Based on the HIV estimation 2012, India has demonstrated an overall reduction of 57% in the annual new HIV infections among adult population from 2.74 lakhs in 2000 to 1.16 lakhs in 2011. The adult HIV prevalence has decreased from 0.41% in 2001 to 0.27% in 2011. Furthermore, the estimated number of people living with HIV has decreased from 24.1 lakhs in 2000 to 20.9 lakhs in 2011. Wider access to antiretroviral therapy (ART) has resulted in 29% reduction in estimated annual deaths due to AIDS related causes between 2007 and 2011. It is estimated that around 1.5 lakhs lives have been saved due to ART till 2011.  The evaluation commented that India is moderately/almost nearly on track considering all indicators. 
Malaria is a public health problem in several parts of the country. About 95% of population in the country resides in malaria endemic areas and 80% of malaria reported in the country is confined to areas consisting 20% of population residing in tribal, hilly, difficult, and inaccessible areas. Malaria, both in terms of prevalence and death has declined. Malaria diagnosis has declined from 1.745% in 2005 to 1.52% in 2009. The Plasmodium falciparum malaria percentage has gradually increased from 39% in 1995 to 50.01% in 2012. As per the World Malaria Report 2012, the South-East Asian region bears the second largest burden of malaria (13%), only being next to African region (81%). In the South-East Asia region, India shares two-thirds of the burden (66%). ,
India accounts for one-fifth of the global incidence of tuberculosis (TB), but India has made progress in halting its prevalence. Treatment success rates have remained steady at 86-87% over the last 5 years and prevalence of TB has steadily declined. However, rise of multi-drug resistant TB is posing as new challenge for India. According to Revised National TB Control Programme Annual Status Report 2013 (TB India 2013) and central internal evaluations in 2012, involvement of the general health system in TB control continues to remain inadequate and this was observed in the majority of the states and the districts visited by the evaluation team. 
As per evaluation, India is slow/almost off track or moderately/almost nearly on track considering all indicators regarding goal related to malaria and other major communicable diseases. 
| Status of Public Health Infrastructure in India|| |
It is important to explore the reasons behind India's slow progress toward health related MDGs. Foremost roadblock is related to lack health infrastructure and health manpower in India. Rural Health Statistics of India 2013 Report, as on March, 2012, there were 1,48,366 sub centers, 24,049 primary health centers (PHCs), and 4833 community health centers (CHCs) functioning in the country. As on March, 2012, 64.4% of sub centers, 90.2% of PHCs, and 97% of CHCs are located in the government buildings. The rest are located either in rented building or rent free panchayat/voluntary society buildings. It means that almost 35% of the sub centers are not having own buildings. Around 10% of the PHCs are without own infrastructure. Most surprisingly 3% CHCs are not having own building, which is the first referral unit (FRU) for PHCs.  Rented or rent free buildings are not supposed to have recommended structure as per guidelines for building of sub centers, PHCs, and CHCs. Due to lack of proper buildings the services provided are definitely affected adversely.
According to DLHS-3 Report, the average population covered by a sub center is 8,372 and for PHC, it is 49,193 while the population norm for sub center is 3000-5000 and for PHC is 20000-30000. The percentage of sub centers having basic infrastructure such as water (73%), toilet (65%), and regular electricity (23%) vary considerably. Thirty-seven percentage have functioning vehicles and 36% have regular electricity supply. The functional operation theatre (OT) is available in 61% of the PHCs and new born care equipment are available in 28% of the PHCs. Sixty-seven percentage of the CHCs have functional OT (surgery carried out in OT) and 76% of the CHCs have new born care services. However, the blood storage facility is available only in 9% of the CHCs which are designated as FRUs. 
| Status of Public Health Manpower in India|| |
The availability of manpower is one of the important prerequisites for the efficient functioning of the health services. As on March, 2012 the overall shortfall (which excludes the existing surplus in some of the states) in the posts of health worker (female)/auxiliary nurse midwife was 3.8% of the total requirement as per the norm of one HW (F)/ANM per sub center and PHC. In case of health worker (male), there was a shortfall of 65.2% of the requirement.  HW (F)/ANM is backbone of maternal and child health in rural areas. Health worker (male) is essentially responsible for vector borne disease surveillance especially of malaria, distribution of treatment of malaria. He is also responsible for TB and leprosy control, blindness control, condom distribution, health education, water monitoring, reporting, etc. In such drastic shortfall of HW (M) all these activities are affected tremendously.
PHC is the first point of contact for the patients in the community. Shortfall of the PHC staff is also considerable. For doctors at PHC, there was a shortfall of 10.3% of the total requirement.  Doctor is said to be the captain of PHC team. Due to shortfall of doctors at PHC level there is lack of leadership for other staff of PHC leading to adversely affecting PHC's performance in all the designated activities.
For health assistant (female)/lady health visitors, the shortfall was 38.2% and that of health assistant (male) was 52.6%.  Due to shortfall of health assistant (female)/lady health visitors and health assistant (male) supervisory and monitoring activities definitely get affected.
36.5% PHCs were without laboratory technicians and 23.1% PHCs were without pharmacist affecting smooth functioning of PHCs. 
The CHCs as a FRU provide specialized medical care in the form of facilities of surgeons, obstetricians and gynecologists, physicians, and pediatricians. The current position of specialists manpower at CHCs reveal that as on March, 2012, out of the sanctioned posts, 51.8% of surgeons, 40.7% of obstetricians and gynecologists, 53.3% of physicians, and 43.1% of pediatricians were vacant. Overall 43.7% of the sanctioned posts of specialists at CHCs were vacant. Moreover, as compared to requirement for existing infrastructure, there was a shortfall of 74.9% of surgeons, 65.1% of obstetricians and gynecologists, 79.6% of physicians, and 79.8% of pediatricians. Overall, there was a shortfall of 69.7% specialists at the CHCs as compared to the requirement for existing CHCs. 
As per DLHS-3, about 91% of the sub centers have ANM in position and in 58% of the cases, ANM is residing in sub center quarter. The facility survey also observed that 76% of the PHCs have medical officer in position. However, the lady medical officer is available only in 24% and AYUSH doctor in 19% of the sampled PHCs. The extent of availability of the human resources at CHC level is not very encouraging. Only 25% of the CHCs have gynecologist in position. Only 19% of the CHCs have a pediatrician and 17% have an anesthetist. 
Revised National TB Control Programme Annual Status Report 2013 (TB India 2013), there is a total 692 reporting units as per district TB centers (DTCs)/district in India while there are 600 District tuberculosis Officers (DTOs) are in position. About 13% DTCs not having DTO who is nodal officer for Revised National TB Control Programme adversely affecting the program activities. Total 2732 tuberculosis units (TUs) are in place in the country. Each TU staffed with medical officer for TB Control (MO-TC) who is responsible for management of TB cases in that particular TU. TB India 2013 Report there are 2320 MO-TC are in place, about 15% TUs are without MO-TC. Senior treatment supervisor (STS) is responsible for monitoring of DOTS providers and treatment TB cases in the TU. According to TB India 2013 Report there is about 7% shortfall of STS. Senior Tuberculosis Laboratory Supervisor (STLS) is responsible for monitoring of Designated Microscopic Centers under the particular TU. TB India 2013 Report there is shortfall of about 7% of STLS.  Lack of supervisory manpower most of the program activities at ground level are affected adversely.
Of the total staff in position 78% of medical officers and 79% of paramedical staff is trained as per program guidelines. Still more than 20% of staff working under program is under trained as per the guidelines of the program. 
There are few critical observations as per central internal evaluations of RNTCP in 2012. Important of those are:
- Lack of full time State TB Officer at the state,
- Continued lack of a sanctioned post of District TB Officer (DTO) in the districts,
- DTOs if available are not full time,
- Lack of full complement of staff at State TB Training and Demonstration Center,
- Vacancies among contractual staff positions both at the state and the district level,
- Frequent transfers of state and district program managers,
- Untrained staff at all levels,
- Lack of appropriate monitoring of trainings in the state,
- Inadequate capacities to conduct trainings of staff,
- Lack of accountability among the general health staff,
- Lack of appropriate performance appraisals for the contractual staff. 
| Status of Urban Healthcare in India|| |
India also has among the world's largest urban population with below poverty line incomes and the world's largest population living in slums. Large disparities are observed in health, provision for healthcare, and housing conditions between the poorest quartile and the rest of the population in urban areas in India. In general, the urban poor in each state and city are in the most disadvantaged position regarding all the indicators.  The public health infrastructure in rural India is definitely well designed but in case of urban areas were almost 45% of the Indians are residing public health infrastructure is different at different places. At very few places public health infrastructure existent and functioning while at majority of urban areas public health infrastructure is either nonexistent or nonfunctional due which health urban population in particular of urban poor residing in slums is adversely affected.
| Conclusion|| |
To conclude, India's progress toward health related MDGs, the progress so far has been mixed. The nation has achieved the required trend reversal in the fight against HIV/AIDS. India is moderately on track, while considering the targets reducing child mortality as the sharp decline in the recent years in infant mortality and under five mortality rate are likely to take us very near to the target, trend reversal has achieved in the fight against malaria and TB, though there was some fluctuations in between. While country has to strive more to reduce the maternal mortality to reach the desired level. To achieve MDGs, we must address issues related to health infrastructure and health manpower. Unless and until we focus our attention to these important roadblocks in health of Indian we cannot achieve the health related MDGs in given time frame or even in future.
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Conflicts of interest
There are no conflicts of interest.
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