Dark side of resurgent India by A.K. Shiva KumarThere has been considerable discussion in recent years about India‚s demographic advantage which accrues from the fact that the country has a very young population. Strategies to capitalise on this advantage have tended to concentrate on improving education and skills. Much less importance is being accorded to improving health conditions ‚ perhaps more important than education for building rich and productive lives. How has India fared in providing healthcare to its citizens in recent years? Useful insights can be obtained from an analysis of the recently released results of the third National Family Health Survey (2005-06). There is good news on the population front with a further slowing down in rates of population growth. India‚s total fertility rate (TFR) is down to 2.7 ‚ significantly lower than the TFR of least developed countries (5.0), Sub-Saharan Africa (5.5) and low human development countries (5.8). The TFR is at or below the replacement rate of 2.1 in ten states: Delhi, Himachal Pradesh, Punjab, Sikkim, Goa, Maharashtra, Andhra Pradesh, Karnataka, Kerala and Tamil Nadu. Urban TFR is down to the replacement level of 2.1 which is signi-ficant because almost one-third of India‚s population resides in urban habitats.At the same time, however, there are some disturbing trends that can adversely affect India‚s potential to cash in its demographic advantage. Improvements in healthcare for children have been agonisingly slow during the past seven years despite the hype surround-ing economic growth. India‚s infant mortality rate (IMR) is reported at 57 deaths per 1,000 live births ‚ down from 68 in NFHS-2 (1998-99). But it‚s still significantly higher than IMRs reported by China (26), Sri Lanka (12), Vietnam (17), Egypt (26), Indonesia (30) and even Bangladesh (56).Another area where progress and performance have been depressingly poor is child malnutrition which still remains among the highest in the world. According to NFHS-3, 43 percent of children under age three in India are malnourished (under-weight) ‚ down from 40 percent in 1998-99. Again, 79 percent of children aged between six-59 months are anaemic ‚ up from 74 percent in 1998-99The factors behind the poor health of India‚s children are not difficult to discern. First, there‚s been very limited increase in the coverage and reach of health services for children. For instance, the proportion of fully immunized children between 12-23 months inched up from 42 percent in 1998-99 to 43.5 percent in 2005-06 ‚ an increase of less than 2 percentage points over seven years. Similarly, three out of every five births still takes place at home, and the proportion of deliveries attended by trained birth attendants rose from 42 to 49 percent ‚ a mere 7 percentage points over seven years.The numbers offer important lessons for government and public health officials. First, India cannot afford to become complacent about its healthcare record. NFHS-3 reveals that even so-called good health and high-income states cannot afford to become complacent about public health issues. Between 1998-99 and 2005-06, immunization coverage slipped in ‚Ëœrich‚ states like Punjab, Maharashtra and Gujarat; and also in ‚Ëœgood health‚ states like Tamil Nadu and Kerala. But at the same time, trend statistics also reveal that states don‚t necessarily have to become income-rich to do well on the public health front. The proportion of fully immunized children in Orissa, Chhatisgarh and Uttarakhand is higher than in Andhra Pradesh and Gujarat.Secondly, the roots of health and fertility improvements extend beyond medical interventions. We need to understand the social, economic and behavioural determinants of health and fertility outcomes and acknowledge that modernisation and higher incomes are not sufficient to ensure good health outcomes. Despite progress, strong biases against the girl child endure in Indian society. Neither has there been any marked improvement in caring practices for new born children ‚ especially when it comes to breast-feeding or the introduction of solids at the end of six months ‚ so vital for healthy child nutrition. Third, public expenditure and investment in public healthcare has to experience a quantum jump. In countries that report the highest life expectancy at birth (80 years and above), public expenditure on health varies from 6.3-6.4 percent of GDP in Australia, Japan and Italy to 8 percent in Sweden and 8.8 percent in Iceland. In contrast, public expenditure in India aggregates barely 1-1.2 percent of GDP. Simultaneously the public-private spending mix on healthcare has to change dramatically. We need to reverse the current 25:75 public-private mix to 75:25 which is the norm in countries where health outcomes are positive.Finally, and perhaps most significantly, the Central and state governments ‚ indeed society ‚ need to evolve a consensus on the issue of providing universal, affordable and good quality healthcare to all. And all stops need to be pulled out to translate this consensus into a national priority.(Dr. A. K. Shiva Kumar is a Delhi-based advisor to Unicef and visiting professor at Harvard University)