West Bengal’s health secret

For at least the past year, and probably more, media reports about West Bengal have generally been negative. There are many reasons for this, and the merits or demerits of those perceptions and arguments can be debated. But quite apart from the debates about land acquisition for industrialisation, there have been other accusations levelled by an increasingly strident and now more confident Opposition, about the various failures of the state government.
It is certainly true that despite some remarkable successes in land distribution, decentralisation and power to panchayats, and so on, various observers had identified lacklustre performance in health and education as major concerns.
The good news is that this picture has changed, especially for health in the past decade. Recent data from the office of the Registrar-General of India, using the Sample Registration System (SRS), shows that West Bengal is now one of the best-performing states in the country in terms of the most basic health indicators.
These show that the demographic transition in West Bengal has proceeded more rapidly than for India as a whole, and in a positive direction. In terms of both crude birth rates and crude death rates, the improvement has been significantly greater than for India as a whole, even though the state already had lower rates than the Indian average.
As a result, among the major states, West Bengal in 2008 had the fourth lowest birth rate (after Kerala, Tamil Nadu and Punjab) and the lowest death rate among the major states, even lower than that of Kerala. What is also noteworthy is that the state’s rural-urban gap appears to have been closing with respect to the death rate. In 2008, the rural death rate in West Bengal was 6.1 compared to the urban rate of 6.6 (a gap of 7.5 per cent), whereas for India as a whole it was eight in rural areas compared to 5.9 in urban areas (a gap of 26.2 per cent). Even Tamil Nadu, the state that has otherwise performed very well in health indicators, shows a rural-urban gap in the death rate of 23 per cent.
The infant mortality rate (IMR) — expressed as the ratio of the number of deaths of infants of one-year-old or less per 1,000 live births — is often regarded as the single most important indicator of overall health conditions in a particular area. The relatively rapid decline in IMRs in West Bengal (by 57 per cent, compared to the all-India average decline of 34 per cent) has made it one of the best performing among major states with respect to this indicator. The IMR in 2008 in West Bengal was 35, putting it in fourth position after Kerala, Maharashtra and Tamil Nadu. The rural-urban gap in the IMR has also improved, from 26 per cent in 1997 to 21 per cent in 2008, compared to the all-India gaps of 42 per cent in 1997 and 38 per cent in 2008.
Further, throughout this period West Bengal has had a very low gender gap in IMR, thereby making it very different from several other states of the country. This is also confirmed by other survey data — for example, the various rounds of the National Family Health Surveys (NFHS) have found the gender gap in IMR in West Bengal to be either the lowest or among the lowest in the country.
The maternal mortality ratio (MMR) is the rate of maternal deaths per 100,000 live births among women aged 15-49 years. MMRs have been declining faster and are now lower in West Bengal (141) than the national average (264). The lifetime risk of maternal death (the probability that at least one woman of reproductive age of 15-49 years will die during or just after childbirth) was only 0.3 per cent in West Bengal in 2004-06, compared to 0.7 per cent for all-India and 0.2 per cent in the best-performing state, Kerala.
Obviously, while these improvements are praiseworthy, there is still a long way to go in terms of improving even these basic health indicators. The differences between West Bengal and the best performing state Kerala remain substantial, suggesting that appropriate policy interventions can continue to make significant improvements in these indicators.
But the question remains: what accounts for this recent improvement in health indicators, especially in relation to the rest of the country other than Tamil Nadu? A number of possible explanations can be considered.
First, there has been a general improvement in institutional conditions, especially in the West Bengal countryside, in terms of the number of hospitals and health facilities and the increase in access of women to antenatal and post-natal services. This has been enabled not only by increased public expenditure in certain areas, but also by a programme of more decentralised public health delivery, with greater autonomy given to local and village health committees in terms of spending and care systems. Thus, the NFHS have found that there was a gradual increase in the percentage of mothers who made at least three antenatal visits during their last birth in West Bengal, from 50.3 per cent in 1992-93 to 62.4 per cent in 2005-06. This compares favourably with the national averages, which were significantly lower.
Second, since health is intimately related to both sanitation and nutrition, some improvement in both of these variables is also likely to have played a positive role. The extension of better sanitation facilities to rural areas has accelerated, even though overall these facilities still remain inadequate. It is likely that the improvement in both IMR and MMR has been most marked in those districts where the sanitation programme has been more successful. Similarly, targeted schemes for maternal nutrition, implemented through the Integrated Child Development Services and other programmes, are also likely to have had positive impact.
Clearly, therefore, there are signs of substantial progress in basic health indicators in West Bengal in recent years. The question of why these have gone largely unnoticed in both the national and the state-level media is of course an entirely different issue.