The term BIMARU was an acronym coined by the late Indian demographer and Economist Dr Ashish Bose to describe the backwardness of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh relative to the best-performing states in terms of demographic indicators. The 'Performance in Health outcomes' index report (Health Index Report) published by the NITI Ayog earlier this month noted that Bihar, MP, Rajasthan and Uttar Pradesh are situated at the bottom of the health index displaying a worrying condition of public health in these states. Among the 21 larger states considered for the index, UP is ranked at 21st place, Rajasthan at 20th, Bihar at 19th and MP at 17th respectively. This article analyses the situation of the BIMARU states on some of the key Child and Maternal health indicators.
Child Mortality in the BIMARU States
The Health Index Report used the indicator Neonatal Mortality Rate (NNMR) and Under Five Mortality Rate (U5MR) to draw upon the health outcomes for children. The report noted that the Neonatal Mortality Rate or the number of neonatal deaths (occurring in the first 28 days of life) per 1000 live births during a specific year reflects the quality of prenatal, intrapartum, and neonatal care services. This is an important indicator as approximately 68 percent of infant deaths in India occur during the neonatal period. The BIMARU states have the highest NNMR among all the states/UTs in India and at the same time, the NNMR for BIMARU states is higher than the average NNMR for India. Among the BIMARU states, Uttar Pradesh and Madhya Pradesh have the highest NNMR at 45.1 and 36.9 respectively which means that out of every 100 live births 4.5 children in UP and 3.6 children in MP die before completing 28 days of life.
The U5MR reflects the probability of dying before attaining the age of 5. The U5MR or the number of deaths under the age of 5 per 1000 live births during a specific year reflects a combination of several factors, such as the nutritional status of children, health knowledge of mothers, level of immunization and oral rehydration therapy, access to maternal and child health services, income of the family, and availability of safe drinking water and basic sanitation services. The BIMARU states have one of the highest U5MR in India with Uttar Pradesh and Madhya Pradesh has the highest U5MR in India at 78.1 and 64.6 respectively. This means that out of every 100 live birth 8 children in UP and 6 children in MP die before their fifth birthday.
The horrifying factor is that the reduction in NNMR and U5MR among BIMARU states has been one of the lowest in the country in the last one decade (2005-06 to 2015-16). The reduction has been lowest for UP at 5 % in NNMR and 19% in U5MR as against 24% in NNMR and 33% in U5MR at all India level.
Nutritional Health of Children in the BIMARU States
The Health Index Report mentioned that the Low Birth Weight (≤2.5 kg) among new-borns is an important predictor of new-borns health and survival. There are several risk factors related to the mother that may contribute to low birth weight, such as poor nutrition, insufficient prenatal care etc. All the BIMARU states except Bihar has the highest proportion of LBW new-borns in India.
Source: NFHS 4
Similarly, BIMARU states have the highest proportion of Underweight and Stunted (too short for one's age) children in India with Bihar having the highest proportion of Underweight children at 43.9% and Stunted children at 48.3%.
Maternal Care Indicators in the BIMARU States
The Health Index Report noted that Institutional deliveries (public and private) can play a substantial role in addressing maternal and infant mortality and morbidity. Among the 21 larger states considered for the report, Bihar (63.8%) and UP (67.8%) figured at the bottom in institutional deliveries of the children at some health facility.
Health care services during pregnancy and childbirth and after delivery are important for the survival and well-being of both the mother and the infant. Antenatal care (ANC) can reduce the health risks for mothers and their babies by monitoring pregnancies and screening for complications. During Antenatal Care Pregnant women are more likely to have their weight measured, their blood pressure measured, and a blood sample taken, than to take iron and folic acid (IFA) tablets for at least 100 days or to take an intestinal parasite drug. The percentage of the mothers who received all recommended types of Antenatal Care is worst for BIMARU states. The percentage of mothers who received all recommended ANC at all India level is 21% while it is lowest for Bihar at 3.3% followed by UP at 5.9%, Rajasthan at 9.7% and Madhya Pradesh at 11.4%.
There is a direct correlation between the Maternal Mortality Ratio (MMR) and the ANC received by mothers. The MMR is the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births. Most maternal deaths are avoidable, as the health-care solutions to prevent or manage complications are well known. Improving access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth will reduce maternal deaths significantly. All the BIMARU states have MMR higher than MMR at all India level. The MMR for UP is second highest in the country at 285 as against just 167 for all India.
Total Fertility Rate (TFR)
The TFR represents the average number of children that would be born to a woman if she experiences the current age-specific fertility rate throughout her reproductive years (15-49 years). A high level of fertility is associated with extreme poverty, gender inequality, maternal mortality, and other dimensions of sustainable development. The BIMARU states have the highest TFR in the country with Bihar and UP having the highest TFR at 3.4 and 2.7 respectively as against the average TFR of 2.18 at all India level.
Source: NFHS 4
Sex Ratio at Birth
Sex Ratio at Birth (SRB) or the number of girls born for every 1000 boys born during a specific year is an important indicator and reflects the extent to which there is a reduction in the number of girl children born by sex-selective abortions. All the BIMARU states have SRB lower than SRB of 926 at all India level. The SRB for Rajasthan is 861 and is positioned among the bottom four states in terms of SRB among the 21 larger states considered for the Health Index Report by Niti Ayog.
Per Capita Health Expenditure in BIMARU states
Total Health Expenditure per capita indicates health expenditure per person in the country. According to National Health Accounts 2014-15, the BIMARU states have one of the lowest per capita health expenditure in India. Bihar, MP and Rajasthan figures among the bottom 5 states having lowest per capita health expenditure at Rs.2047, Rs.2511 and Rs.2943 respectively.
Source: National Health Accounts 2014-15
Along with lowest per capita health expenditure, the BIMARU states also have one of the highest Out of Pocket Expenditure (OOPE) on health. OOPE are expenditures directly made by households at the point of receiving health care. This indicates the extent of financial protection available for households towards healthcare payments. Bihar has the highest proportion of OOPE on health at 82.3% followed by UP at 78.3%. The situated is aggravated by the fact that Bihar has one of the highest poverty headcount ratio in the country with 33.7% of its population living below poverty line.
The analysis presented here demonstrates a grim situation of public health in the BIMARU states. The acronym BIMARU which was coined almost four decades back still holds true in meaning for the health situation of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. All these states depict worst health outcomes be it Child health, Maternal Health or per capita health expenditures.
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