population explosion

Socio-economic factors, not religion, influence India's fertility rate and population growth

States that are more developed, have a higher per-capita income and better access to healthcare have a lower total fertility rate

Fertility rates in India are more closely related to education levels and the socio-economic development within a state, than to religious beliefs, according to an IndiaSpend analysis of government data and research evidence.

The evidence IndiaSpend looked at shows that richer families and states with better health facilities and higher female literacy have lower fertility rates in India. Globally, there is little evidence to link religion and fertility rates, with poorer, conflict-ridden states and countries with lower female empowerment reporting higher population growth rates.

When the office of the Registrar General and Census Commissioner of India released fertility rates for the Indian population last year, the conversation was hijacked by the difference in population growth rates across religions. Several newspapers emphasised that the data showed that Muslim women had higher fertility rates than non-Muslims, and that the percentage of Muslims in the population was steadily growing.

The numbers showed that the proportion of Muslims in India had grown to 14.2% of the total population in 2011, up from 13.4% in 2001, while the proportion of Hindus had reduced to 79.8% from 80.5%. The percentage of Christians and Jains did not significantly change at 2.3% and 0.4%, respectively, while the proportion of Buddhists decreased from 0.8% to 0.7%, and that of Sikhs reduced from 1.9% to 1.7%.

This implicit suggestion that Muslims have more children than other religious communities, missed data that shows how population growth rates and the total fertility rate – or the average number of children a woman has over her childbearing years – vary widely between India’s states. The total fertility rate seems more closely related to per-capita income, healthcare and other basic facilities in that state.

Development and fertility

Compare, for instance, Kerala and Uttar Pradesh. In 2011, the total fertility rate of Uttar Pradesh, at 3.3, was higher than the Indian average of 2.4, and higher than the rate in Kerala, at 1.8, according to census data.

The Muslim population in Uttar Pradesh increased 25.19%, while the Muslim population in Kerala increased 12.83% between 2001 and 2011. Over the same period, the Hindu population increased 18.9% in Uttar Pradesh and 2.8% in Kerala.

The higher growth rates of Muslims in northern states are “more or less part of a northern culture than a Muslim culture”, NC Saxena, the former secretary of the Planning Commission of India, said in an interview to The Wire, a nonprofit journalism portal.

This is in sync with higher average total fertility rates in northern and central states, such as Uttar Pradesh (3.3), Bihar (3.5), Chhattisgarh (2.7), and Madhya Pradesh (2.9), as compared to southern states like Andhra Pradesh (1.8), Karnataka (1.9), Kerala (1.8), and Tamil Nadu (1.7), according to 2011 census data.

The states with the highest fertility rates in India are all in north and central India – Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan (which has a total fertility rate of 2.9), Jharkhand (2.8), and Chhattisgarh.

These overall fertility rates seem more related to the state’s development. For instance, Kerala has a literacy rate of 93.9%, compared to 69.7% in Uttar Pradesh in 2011. In the same year, 99.7% of mothers in Kerala received medical attention at delivery compared to 48.4% of mothers in Uttar Pradesh. 74.9% of women were above the age of 21 in Kerala at marriage, compared to only 47.6% in Uttar Pradesh.

Another way to interpret population growth rates is through the difference in poor and rich states. Empowered Action Group states, which include the poorest in India – Rajasthan, Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, and Chhattisgarh – have higher population growth. Between 2001 and 2011, the population of Empowered Action Group states grew at a rate of 21%, compared to 15% for the rest of India. Still, decadal population growth rates even in these states has fallen when compared to the decadal growth rate of 24.99% between 1991 and 2001.

Differences within states

Still, there are differences within states in total fertility rates between religious groups. In 2005-2006, according to data from the third National Family Health Survey, Uttar Pradesh had a total fertility rate of 3.3, higher than the all-India average of 2.4.

Kerala had a total fertility rate of 1.93. In 2005-2006, Muslims in Kerala had a total fertility rate of 2.46, higher than that of Hindus in Kerala, at 1.53. But the Muslim total fertility rate in Kerala was lower than that of Hindus in Uttar Pradesh, at 3.73. The total fertility rate of Muslims in UP was 4.33.

One reason for the higher Muslim fertility within a state could be wealth-related factors.

Survey information showed that families in the lower wealth quintiles have more children than richer families. For instance, in Bihar, women in the lowest wealth quintile have a total fertility rate of 5.08, while women in the highest quintile have a total fertility rate of 2.12. The same holds true for a richer state, like Maharashtra, where the lowest wealth quintile has a total fertility rate of 2.78, compared to the richest wealth quintile with a total fertility rate of 1.74.

On average, Muslims across India are poorer than Hindus across India, with an average monthly household per capita expenditure of Rs 833, compared to Rs 888 for Hindus, Rs 1,296 for Christians and Rs 1,498 for Sikhs, according to a 2013 National Sample Survey report, based on data from 2009-2010.

Researcher Sriya Iyer, a professor at the University of Cambridge, said that religion does not have a statistically significant effect on fertility if other factors such as “access to education (quantity and quality), income, whether couples have help with childcare or not, local health care provision (quantity and quality) that lowers infant mortality and hence increases child survival, and the degree of urbanisation of the community” are taken into account.

Further, her 2002 study in a Karnataka taluka (an administrative sub-division of a district) found that both Hindus and Muslims had more children than Christians, but she argued that religion affects fertility and contraception through other socio-economic factors, such as a family’s decision to educate its children, rather than through the ideological tenets of a religion.

Socio-economic factors affect the fertility of religious groups in different ways. For instance, higher education for women, and secondary education for men, lowers the fertility of Muslims but not of Hindus or Christians, the study reported, suggesting that family planning programs might have to be designed keeping in mind these differences.

Further, Iyer said, evidence from India showed that, over the long term, “total fertility rate between religious groups are projected to converge, as women from all religious communities are having fewer children today than their mothers or grandmothers”.

Religion and fertility

There is little evidence internationally of the correlation between religion and fertility rates.

For instance, according to World Bank data, in 2014, Bangladesh, India’s Muslim-majority neighbor, had a total fertlity rate of 2.2. Iran, another Muslim country, has a total fertility rate of 1.7, below replacement level, which means the current population cannot be replaced at the prevailing population growth rate.

Similarly, Malaysia and Indonesia, both Muslim-majority countries, have fertility rates of 1.9 and 2.5, respectively. Other Muslim-majority countries, such as Saudi Arabia (2.8), and Egypt (3.3), have higher fertility rates. The Hindu and the Muslim populations in Pakistan have the same total fertility rate – 3.2 – according to data from the Pew Research Center.

Another neighboring country, Sri Lanka, with a Buddhist majority, had a total fertility rate of 2.1 in 2014. Its Buddhist population had a total fertility rate of 2.2 between 2010 and 2015, while both Hindus and Muslims had a higher total fertility rate, at 2.3 and 2.8, respectively.

Socio-economic factors

Fertility rates also depend on a number of factors unrelated to religious group. For instance, socio-economic factors, education, modernisation, access to contraceptives, and state policies for development, all affect fertility, according to P Arokiasamy, the head of the department of development studies, at Mumbai-based International Institute for Population Sciences.

In addition, population growth rates also depend on other factors such as work opportunities for women, access to contraception, age at marriage, and decision-making power within the household. For instance, a meta-analysis of studies, published in 2014, found a positive correlation between women’s empowerment and lower fertility, longer birth intervals, and lower rates of unintended pregnancy.

Population growth

Population projections by the Pew Research Center, a US-based think tank, estimates that by the year 2050, Muslims will make up 18.4% of India’s population, the largest population of Muslims in any county in the world. But India’s Hindu population will still be larger than the total Muslim population of India, Pakistan, Indonesia, Nigeria, and Bangladesh, five countries with the largest Muslim population in the world.

Overall, population growth is slowing down in India and the decadal growth rate fell from 21.54% between 1991 and 2001 to 17.64% between 2001 and 2011, which is in line with global trends that show that population growth rates fall as a country becomes more developed and literate.

In India, the Muslim growth rate is falling faster than the growth rate of Hindus.

The decadal population growth rate of Muslims fell 4.9 percentage points from 29.5% in 2001 to 24.6% in 2011, while that of Hindus fell 3.5 percentage points, from 20.3% to 16.8%. In 2001, 65.1% of all Hindus, above the age of 7 years, were literate, while 59.1% of Muslims were literate, according to census data. In 2011, the percentage of literate Hindus rose to 73.3%, while that of Muslims increased to 68.5%.

Fertility rates of populations that have higher fertility, such as low-income families and Muslims, are falling faster than other groups, as methods of contraception and education spread to these groups, explained Arokiasamy of International Institute for Population Sciences.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Putting the patient first - insights for hospitals to meet customer service expectations

These emerging solutions are a fine balance between technology and the human touch.

As customers become more vocal and assertive of their needs, their expectations are changing across industries. Consequently, customer service has gone from being a hygiene factor to actively influencing the customer’s choice of product or service. This trend is also being seen in the healthcare segment. Today good healthcare service is no longer defined by just qualified doctors and the quality of medical treatment offered. The overall ambience, convenience, hospitality and the warmth and friendliness of staff is becoming a crucial way for hospitals to differentiate themselves.

A study by the Deloitte Centre for Health Solutions in fact indicates that good patient experience is also excellent from a profitability point of view. The study, conducted in the US, analyzed the impact of hospital ratings by patients on overall margins and return on assets. It revealed that hospitals with high patient-reported experience scores have higher profitability. For instance, hospitals with ‘excellent’ consumer assessment scores between 2008 and 2014 had a net margin of 4.7 percent, on average, as compared to just 1.8 percent for hospitals with ‘low’ scores.

This clearly indicates that good customer service in hospitals boosts loyalty and goodwill as well as financial performance. Many healthcare service providers are thus putting their efforts behind: understanding constantly evolving customer expectations, solving long-standing problems in hospital management (such as long check-out times) and proactively offering a better experience by leveraging technology and human interface.

The evolving patient

Healthcare service customers, who comprise both the patient and his or her family and friends, are more exposed today to high standards of service across industries. As a result, hospitals are putting patient care right on top of their priorities. An example of this in action can be seen in the Sir Ganga Ram Hospital. In July 2015, the hospital launched a ‘Smart OPD’ system — an integrated mobile health system under which the entire medical ecosystem of the hospital was brought together on a digital app. Patients could use the app to book/reschedule doctor’s appointments and doctors could use it to access a patient’s medical history, write prescriptions and schedule appointments. To further aid the process, IT assistants were provided to help those uncomfortable with technology.

The need for such initiatives and the evolving nature of patient care were among the central themes of the recently concluded Abbott Hospital Leadership Summit. The speakers included pundits from marketing and customer relations along with leaders in the healthcare space.

Among them was the illustrious speaker Larry Hochman, a globally recognised name in customer service. According to Mr. Hochman, who has worked with British Airways and Air Miles, patients are rapidly evolving from passive recipients of treatment to active consumers who are evaluating their overall experience with a hospital on social media and creating a ‘word-of-mouth’ economy. He talks about this in the video below.

Play

As the video says, with social media and other public platforms being available today to share experiences, hospitals need to ensure that every customer walks away with a good experience.

The promise gap

In his address, Mr. Hochman also spoke at length about the ‘promise gap’ — the difference between what a company promises to deliver and what it actually delivers. In the video given below, he explains the concept in detail. As the gap grows wider, the potential for customer dissatisfaction increases.

Play

So how do hospitals differentiate themselves with this evolved set of customers? How do they ensure that the promise gap remains small? “You can create a unique value only through relationships, because that is something that is not manufactured. It is about people, it’s a human thing,” says Mr. Hochman in the video below.

Play

As Mr. Hochman and others in the discussion panel point out, the key to delivering a good customer experience is to instil a culture of empathy and hospitality across the organisation. Whether it is small things like smiling at patients, educating them at every step about their illness or listening to them to understand their fears, every action needs to be geared towards making the customer feel that they made the correct decision by getting treated at that hospital. This is also why, Dr. Nandkumar Jairam, Chairman and Group Medical Director, Columbia Asia, talked about the need for hospitals to train and hire people with soft skills and qualities such as empathy and the ability to listen.

Striking the balance

Bridging the promise gap also involves a balance between technology and the human touch. Dr. Robert Pearl, Executive Director and CEO of The Permanente Medical Group, who also spoke at the event, wrote about the example of Dr. Devi Shetty’s Narayana Health Hospitals. He writes that their team of surgeons typically performs about 900 procedures a month which is equivalent to what most U.S. university hospitals do in a year. The hospitals employ cutting edge technology and other simple innovations to improve efficiency and patient care.

The insights gained from Narayana’s model show that while technology increases efficiency of processes, what really makes a difference to customers are the human touch-points. As Mr. Hochman says, “Human touch points matter more because there are less and less of them today and are therefore crucial to the whole customer experience.”

Play

By putting customers at the core of their thinking, many hospitals have been able to apply innovative solutions to solve age old problems. For example, Max Healthcare, introduced paramedics on motorcycles to circumvent heavy traffic and respond faster to critical emergencies. While ambulances reach 30 minutes after a call, the motorcycles reach in just 17 minutes. In the first three months, two lives were saved because of this customer-centric innovation.

Hospitals are also looking at data and consumer research to identify consumer pain points. Rajit Mehta, the MD and CEO of Max Healthcare Institute, who was a panelist at the summit, spoke of the importance of data to understand patient needs. His organisation used consumer research to identify three critical areas that needed work - discharge and admission processes for IPD patients and wait-time for OPD patients. To improve wait-time, they incentivised people to book appointments online. They also installed digital kiosks where customers could punch in their details to get an appointment quickly.

These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.