MacroScan - The Good News about Health in West Bengal

Media discussion about West Bengal has been largely negative in the past couple of years, for a variety of reasons. Whatever be the merits or demerits of those arguments, one problem with the conditions in the state that has been identified by a number of observers in the recent past has been the relatively poor performance in terms of human development, especially health and education, relative to other clear successes in land distribution, decentralization and power to panchayats, and so on. Indeed, the fact that health indicators in West Bengal generally lagged behind or at best kept pace with the national average was noted in the West Bengal Human Development Report 2004.

The good news is that this picture seems to have been changing, especially in the past decade. Recent data from the office of the Registrar General of India, using the Sample Registration System (SRS), show that West Bengal is now one of the best-performing states in the country in terms of the most basic health indicators. The SRS is a large-scale demographic survey of the Government of India, which is generally held to be providing the most reliable annual estimates of fertility and mortality indicators.

The charts here - which are all based on SRS data - 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 (Chart 1) and crude death rates (Chart 2), the improvement has been significantly greater than for India as a whole, even though the state already had lower rates than the Indian average. The crude birth rate (live birth per 1,000 people in a year) in West Bengal declined from 22.4 to 17.5 between 1997 and 2008 (or by 28 per cent), compared to a decline of 19.3 per cent for India as a whole. The death rate in West Bengal fell by 24.2 per cent over the same period, as compared to 20 per cent for India as a whole.

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 8.0 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.
Chart 1 >> Chart 2>>

One major - and positive - reason for the decline in death rates is the decline in infant mortality rates (IMR) in the state. The infant mortality rate - expressed as the ratio of the number of death of infant 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. This being the case, it is heartening to note that the improvement in this indicator in West Bengal actually accelerated in the most recent period, as compared to the Indian average where it decelerated slightly (Chart 3).

As Chart 4 shows, the decline in IMRs in West Bengal has made it one of the best performing among major states with respect to this indicator, placing 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. Chart 5 shows how the state has experienced the second largest decline in IMR among the major states over the period, after Tamil Nadu.
Chart 3 >>

What is worth noting is that West Bengal throughout this period 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 have found the gender gap in IMR to be either the lowest or among the lowest in the country.
Chart 4 >> Chart 5 >> Chart 6 >>

The other very important indictor of both health conditions and the status of women is the maternal mortality ratio (MMR), which is the rate of maternal deaths per 100,000 live births among women aged 15-49 years. Once again, MMRs are lower in West Bengal than the national average, and have been declining faster as well. The lifetime risk of maternal death (defined as the probability that at least one woman of reproductive age of 15-49 years will die during or just after childbirth assuming that the chance of death is uniformly distributed across the reproductive span) 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 still 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 ante-natal 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 surveys 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 ICDS 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.