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Analysis

Why India cannot follow new WHO guidelines to protect mothers

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India must double antenatal visits by health workers to pregnant women to reduce the risk of stillbirths and pregnancy complications, according to a new World Health Organisation (WHO) guideline released last November. Is India ready to implement this and other new guidelines to protect its mothers? It is not, an analysis of government data and research studies shows.

The new guidelines are important, given that, despite a 62 per cent reduction in child mortality between 1990 and 2015, more children (1.3 million) below five died in India in 2015 than anywhere in the world; the country had more stillborn babies than any other, 26 per cent of neonatal deaths, and close to a fifth of 303,000 maternal deaths in 2015.

The government, on February 15, joined a new network to improve the quality of care for maternal, newborn and child health, announced by the WHO and committed to halving preventable deaths of pregnant women and newborns in health facilities over the next five years.

The quality of antenatal care is vital to reduce the risk of stillbirths and pregnancy complications, and the absence of it explains why more women enrolling for hospital deliveries in India isn’t translating into fewer maternal deaths.

India’s maternal mortality rate (MMR) was 178 deaths per 100,000 live births in 2011-12, worse than Sri Lanka (30), Bhutan (148) and Cambodia (161), and worst among the BRICS countries: Russia (25), China (27), Brazil (44), and South Africa (138).

In November 2016, the government launched the Pradhan Mantri Surakshit Matritva Abhiyan, or the Prime Minister Safe Pregnancy Scheme, which aims to provide free and comprehensive care on the ninth day of every month during pregnancy. Pregnant women are provided special, free ante-natal checks in their second or third trimester at government health care facilities, including ultrasounds, blood and urine tests.

Yet, getting these facilities to women is a challenge, especially in poorer states. No more than 3.3 per cent of pregnant women in Bihar reported receiving full antenatal care, lowest among states. Full ANC refers to at least four antenatal visits, at least one tetanus toxoid (TT) injection and iron folic acid tablets or syrup taken for 100 or more days.

IndiaSpend looked at some of the WHO recommendations and evaluated India’s ability to implement them:

1. Minimum of eight antenatal contacts with pregnant women
A minimum of eight contacts for antenatal care can reduce perinatal deaths by up to eight per 1,000 births, compared to a minimum of four visits, said WHO.

Despite the emphasis to antenatal care under government health programmes, India is not close to universal antenatal care, according to a 2016 study, which analysed data from the National Sample Survey Office (NSSO).

The study found that women belonging to disadvantaged communities, particularly scheduled-caste (SC), scheduled-tribe (ST) and rural areas, received sparser ante-natal care. SC/ST women contribute to the highest proportion of pregnant women without antenatal care.

The proportion of mothers who had at least four antenatal visits varied considerably: While states such as Bihar, Madhya Pradesh and Uttarakhand reported four visits to 14.4 per cent, 35.7 per cent and 30.9 per cent, respectively, of mothers, richer states, such as Tamil Nadu (81.2 per cent), Maharashtra (72.2 per cent) and Andhra Pradesh (76 per cent), did better.

2. Daily oral iron, folic acid supplements
The WHO guidelines recommend daily oral iron and folic acid supplements with 30 mg to 60 mg of elemental iron and 400 µg (0.4 mg) of folic acid for pregnant women to prevent maternal anaemia, puerperal sepsis, low birth weight, and preterm birth.

Anaemia was the top cause of maternal deaths in India (50 per cent) and the associated cause in 20 per cent of maternal deaths, and India reported that 45 per cent of pregnant women were anaemic — the highest proportion in the world.

Only 9.7 per cent of mothers in Bihar consumed iron and folic acid for 100 or more days when they were pregnant, followed by Tripura (13.4 per cent) and Rajasthan (17.3 per cent), according to NFHS-4 data.

In the 2017-18 budget, the Indira Gandhi Matritva Sahyog Yojna (Maternal Benefit Scheme) saw an allocation increase from Rs 634 crore ($94.6 million) in 2016-17 to Rs 2,700 crore ($298 million).

This allocation, however, isn’t enough to cover all expectant mothers. The government itself had estimated that the the annual requirement for this maternity benefit scheme would be Rs 14,512 crore ($2.1 billion).

Since there isn’t enough funding, the ministry plans to provide maternity benefit only to first-borns.

3. Tetanus toxoid vaccination
The WHO guidelines recommend a tetanus toxoid vaccination for pregnant women to prevent neonatal mortality from tetanus.

India reduced neonatal tetanus mortality by 99.76 per cent over three decades in 2015, which was described as a “significant public health milestone” by the WHO, which declared the country free of neonatal tetanus in May 2015.

However, to mitigate the threat of a resurgence, experts recommend that at least 80 per cent of expectant mothers must be immunised and at least 70 per cent of births must take place in hygienic conditions. Institutional deliveries rose by 15 per cent over a decade from 2004 to 2014, but the rise isn’t translating into fewer maternal deaths.

4. One ultrasound scan before 24 weeks’ gestation
An early ultrasound is recommended for pregnant women to estimate gestational age, improve detection of foetal anomalies and multiple pregnancies, reduce induction of labour for post-term pregnancy, and improve a woman’s pregnancy experience.

Ultrasounds should be done by radiographers at community health centres (CHCs) in rural areas. But CHCs nationwide are 66 per cent short of radiographers, and as many as 13 states and Union Territories are 75 per cent short, according to the Rural Health Statistics (RHS) 2016.

5. Counselling about healthy eating and keeping physically active during pregnancy
The role of gynaecologists and paediatricians is critical in counselling pregnant women. However, there is a 77 per cent shortage of obstetricians and gynaecologists and 80 per cent shortage of paediatricians in CHCs nationwide. Nearly 62 per cent of government hospitals — which include CHCs, district hospitals and sub-district hospitals — don’t have a gynaecologist on staff.

6. Health-care providers should ask all pregnant women about use of alcohol and other substances at every antenatal visit
Gynaecologists and auxiliary nurse midwives (ANMs) are the frontline of the battle against infant and maternal mortality. In 30 per cent of districts, sub-centres with ANMs serve double the patients they are meant to and an estimated 22 per cent of sub-centres are short of ANMs.

(In arrangement with IndiaSpend.org, a data-driven, non-profit, public interest journalism platform. Devanik Saha is with the University of Sussex. The views expressed are those of IndiaSpend. Feedback at [email protected])

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Analysis

Modi’s momentum under attack as opposition gears up for offensive

Congress President Rahul Gandhi is also now a more formidable opponent of Modi than he was in 2014 and his attacks are sharper and unrelenting.

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Vishwashghaat

New Delhi, May 26 (IANS) With his party ‘stopped’ in Karnataka and bracing to face crucial Assembly elections in three major states in the north this year end, Prime Minister Narendra Modi takes his government into the last year in office with the political momentum slightly shaken against the mounting burden of fulfilling expectations on numerous election promises.

Political analysts say that many of the promises of the Modi government have been rhetoric and it needs course correction by being more accommodative over the next year if BJP’s prospects are to improve.

They said the outcome of 2019 elections will largely depend on opposition parties coming together to pose a common challenge to the BJP.

Kumaraswamy's swearing-in ceremony

The BJP’s inability to form the government in Karnataka, despite being the single largest party, has come as a damper to the party. It had suffered jolts earlier this year in defeats in prestigious parliamentary by-elections in Gorakhpur and Phulpur as also Ajmer and Alwar.

“Intolerance has been a major drawback in the last four years,” says political analyst and senior journalist H.K. Dua adding that the idea of India as a plural polity had suffered due to incidents like ‘love jihad’ and lynchings.

“Every incident fouls the atmosphere. India is a composite society and Prime Minister himself said ‘Sabka saath, sabka vikas’ which did not happen. That’s why Dalits have been very angry, tribals have been very angry, farmers have been very angry. Caste divisions are sharper than before. That does not speak well,” he said.

Dua said constitutional institutions “have not been shown the respect they deserve.” He said consensus between the ruling and opposition parties for running parliamentary democracy has been ignored. “The initiative had to come from Prime Minister but that has not come,” he said, adding there is doubt how deep is the faith of government in democratic practices.

“I don’t think in 2019 there will be Modi wave. Opposition will be able to present a formidable challenge if they unite. So the unity is very, very important.

Kumaraswamy swearing-in ceremony

But even as efforts to forge understanding among opposition parties continue at various levels, Modi continues to have a cross-country appeal as the prime vote-catcher of the BJP.

As Prime Minister, he has sought to bring speed to decision-making by cutting red tape, set ambitious targets, launched some imaginative schemes, focused on delivery, simplified norms and shaken off lethargy in the official machinery.

The BJP-led National Democratic Alliance government is seen to be more focused and target-oriented but there is little visible impact of some of its initiatives such as the Swachh Bharat Campaign.

Subrata Mukherjee, a political analyst who taught at Delhi University, said there have been more promises than delivery in the past four years and projects like Start Up India and Make in India have not progressed the way they were made out to.

“The economic record of the government is not very good and they are now postponing everything to 2022. That is beyond their mandate. So it is politics of postponement,” he said.

He said most of the schemes are a rehash of Congress schemes.

Mukherjee said Modi government needs to practice a more “accommodative politics.”

“They will have to work out accommodative politics, bring new segments. The scheduled castes, Muslims are angry. If they want to retain power, they will have to go for drastic course correction,” he said.

He said opposition unity was important for good politics and the proposed federal front cannot do without congress. “BJP will also have to understand that 2019 will be coalition government whether led by it or the Congress,” he said.

Unlike the 2014 elections, when he was the challenger, Modi will be the incumbent in 2019 and the opposition has a plethora of issues to queer the pitch including jobs, price rise, problems of farmers, multi-crore banking frauds, non-performing assets of banks, “write-offs” of corporate houses, and “atrocities” against weaker sections including Dalits.

Congress President Rahul Gandhi is also now a more formidable opponent of Modi than he was in 2014 and his attacks are sharper and unrelenting.

Congress General Secretary Ashok Gehlot said people had trusted Modi but he “betrayed” them. As a member of the opposition, he sees an all-round failure in the government.

“Farmers, youth, traders, women, everyone now feels betrayed. There is sense of fear and mistrust among people. Fuel prices are sky-rocketing. This is a loot. The situation in the country is such and all sections of society are so unhappy that the people will force every party in the country to come together to defeat Modi and the BJP,” he said.

BJP Spokesperson G.V.L. Narsimha Rao, however, as expected, termed the last four years as “epoch-making.”

“These will be best remembered for ushering in a New India Era with corruption-free governance, inclusive economic growth with special focus on farmers, women and marginalised sections,” Rao told IANS.

He said that Prime Minister Narendra Modi’s government has fulfilled long neglected basic needs of the common citizens with innovative schemes like Ujjwala.

The Ayushman Bharat scheme, announced in this year’s budget which aims to provide health insurance cover of Rs 5 lakh to around 10 crore families is an ambitious move to connect with the poor and, if successful, can help BJP earn goodwill in run up to 2019 Lok Sabha polls.

The elections in Madhya Pradesh, Rajasthan and Chhattisgarh later this year are expected to set the tempo for the Lok Sabha polls and the BJP is the incumbent in all three states facing tough contests.

(Prashant Sood can be contacted at [email protected])

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Analysis

Four years of Modi failed to deliver crore of jobs: Swaraj India

Prime Minister Modi had promised to deliver one crore jobs every year but the number of jobs have decreased in reality.

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Yogendra Yadav

New Delhi, May 26 (IANS) As the Narendra Modi-led NDA government completed four years on Saturday, Swaraj India alleged although it has provided some evocative slogans like ‘Make in India’, ‘Skill India’, ‘Beti Bachao, Beti Padhao’, but scored a near zero score in performance, especially in its promise to deliver one crore jobs every year.

“The Modi government only made an onslaught on the Constitution and democracy, and saw jobless growth, increasing communal tension, rural distress and overarching insecurity among Dalits, minorities and women in country. All the key promises of the BJP government have turned out to be hollow.

“Prime Minister Modi had promised to deliver one crore jobs every year but the number of jobs have decreased in reality,” said Swaraj India national spokesperson Anupam.

Swaraj India chief Yogendra Yadav said that the violence against religious minorities, especially Muslims, is spreading openly.

“The country is unsafe because despite the claims of surgical strike, incidents of encroachment and terror attack from Pakistan have increased. Relations with neighbouring countries and even old friends are seeing a challenging phase and China’s movements have become more aggressive,” he said.

Senior party leader Prashant Bhushan meanwhile decried the rise of corruption, eroding authority of anti-corruption bodies, shielding of corrupt officers are being shielded, the “disaster” of demonetization, no change in the black money situation and putting of the Lokpal issue in cold storage.

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Analysis

After 1,460 days of Modi rule, ‘achhe din’ yet to come

I do not blame this government for not being able to deliver ‘achhe din’. Which government since Independence has?

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Narendra-Modi

New Delhi: There’s only one year more to go for the BJP-led regime before another test at the hustings. But is the country any nearer to Prime Minister Narendra Modi’s promised ‘acche din‘ (good days)? Four years ago, the country had voted the present regime to power on hopes of better days in all socio-economic-political spheres. But despite some strong structural reforms like GST, and gut-wrenching changes like demonetisation, the jury may still be out on how good it has been, according to economists and others experts.

Despite India’s GDP growth of 7.2 per cent in the third quarter (October-December) of 2017-18, some economists feel that the demonetisation drive, avowedly taken to “cleanse the system” of black money, had ended up damaging the country’s economy instead.

“Demonetisation was a terrible mistake by the government, for which the common people paid the price. It has reduced people’s trust in the banking system, as they were denied their own money during the period of cash crunch. It takes so much time and work to build institutions and policies — it is so much easier and faster to break things,” Jayati Ghosh, Economics Professor at Jawaharlal Nehru University (JNU), told IANS.

The government decided to ban 1,000 rupee and 500-rupee notes on November 8, 2016, taking away 86 per cent of the total currency in circulation. “May be this move had served the government’s purpose politically, but economically it was a bad one,” Ghosh added.

Echoing similar views, Arun Kumar, former professor of economics at the JNU, told IANS that when the NDA government came in, the Indian economy was already on an upward trajectory. The quarter, in which the government took over, the growth climbed to eight per cent. In October 2016, India was the fastest growing economy in the world when China slowed down a bit.

“But then the government administered a shock to the system with demonetisation. It had a negative impact on the unorganised sector that comprise 45 per cent of production and 93 per cent of employment in the country. According to some estimation, 50-80 per cent of that got damaged,” he said.

Kumar, who is now Chair-Professor with the Institute of Social Sciences, added: “Government did no survey at that time and hence no data is available. Even data from International Monetary Fund and World Bank, which rely on government data, do not show any estimates (on impact).”

After demonetisation, credit off-take in the country declined sharply. “Between November-December 2016, it was at historic low of 60 years. Investment into the country also took a big hit,” he said. However, Ranen Banerjee, Partner & Leader, Public Finance and Economics, at PricewaterhouseCoopers (PwC) has a different take on some of the benefits flowing from the action.

“Demonetisation had positive impact as far as digital payments were concerned. It shot up sharply during that period but came down subsequently. The level is still higher earlier. But demonetisation as a measure did not deliver all the results that it was supposed to deliver,” Banerjee said.

The government’s other major thrust, though, on Goods and Services Tax (GST) — rolled out on July 1 last year, got better billing. Economists are hopeful that it will bring in beneficial changes once the hiccups are over. Banerjee says GST would change the entire landscape of tax compliance in the country by creating a multiplier effect. “GST was a bold move which is showing positive results,” he added.

Ghosh, though, thinks GST goes against the grain of federalism. “A unified system is not so necessary in a federal structure — for example, the US does not have it and still has a very modern economy. In a federal structure you have to allow states to have some money raising power. Further, GST implementation has been really bad.”

Kumar said: “Introduction of GST has hit the unorganised sector badly. Even in Malaysia where GST was introduced in 2015-16 at 26 per cent, government decided to scrap it. The organised sector is rising at the expense of unorganised sector. Disparity is rising.”

Industry chambers have by and large welcomed government initiatives, especially the decision on GST. “The overall economy is strong with GST having settled down and reforms firmly on the right path,” Chandrajit Banerjee, Director-General of Confederation of Indian Industries (CII), told IANS.

Over the last four years, according to him, the government had systematically addressed major “pain points” for the economy such as ease of doing business, non-performing assets of banks, foreign direct investment rules, infrastructure construction and exit of failing enterprises.

“The government’s mission-mode development campaigns have delivered notable results, adding to overall growth multipliers. The firm level and sectoral level numbers look promising for the next year in terms of orders booked and capacity utilisation,” said CII’s Banerjee.

Former economics professor at Indian Statistical Institute, Dipankar Dasgupta, who holds that the economy was yet to recover from the hit it took because of demonetisation, says that on GST he was hopeful that with time it will stabilise. “In the other countries where it was introduced there were teething problems too,” he said.

The government also took up the job to cleanse bad loans of banks. It is pumping in Rs 2.11 lakh crore as capitalisation, spread over two years. But a number of banking scandals and rising non-performing assets (NPA) may have reduced the faith of people in the bank system, after the shock of demonetisation. “We have declining deposits in the banking system due to people’s rising mistrust,” says Ghosh. Dasgupta says recapitalisation should be followed with caution so that it does not widen the fiscal deficit.

The government, though, has got support in its effort to tackle the issue of NPAs. The bankruptcy law has put everyone on notice. “People are taking the issue of NPAs seriously trying to resolve it. Companies are opting for out of court settlement. Propensity to comply has increased as borrowers know that there will be consequences on not servicing a loan,” Banerjee of PriceWaterhouseCoopers said.

Yet, overall the promise of the golden pot at the end of the five-year rainbow, as promised by Modi in his of speeches — where he had painted the BJP rule in attractive hues — has not materialised in four years. BJP’s best salesman may have oversold the hope. “I do not blame this government for not being able to deliver ‘achhe din’. Which government since Independence has?” asks Dasgupta rhetorically.

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