Colourful posters of smiling, playing children decorate the nursery at the district hospital in Kurukshetra in Haryana. Situated next to the maternity ward, it has all the equipment newborns with breathing trouble, low weight, jaundice and other illnesses need.
“My sister had a premature delivery,” said Daljeet Kaur, a resident of the main town of Kurukshetra. “The child was kept in a baby-warmer for four days, which was crucial to save his life.”
Kaur said the mother and child were in hospital for over a week. “There was regular cleaning of the floors. Bed sheets were also washed regularly,” she said.
All of this seems to be an indicator of the improvement in maternal and child care in Haryana in the last few years. The infant mortality rate in the state declined to 36 per 1,000 live births in 2014 from 44 per 1,000 live births in 2011. This has been one of the fastest declines among Indian states. The maternal mortality ratio declined from 146 deaths per 100,000 live births in 2012 to 127 deaths per 100,000 live births in 2013. The state also registered a rise in institutional deliveries from 89% in 2015 to 91% till March this year.
But in stark contrast to the district hospital in Kurukshetra is the Government Medical College and Hospital in the state’s Mewat district. It does not have a nursery – which is important for infection control – while its maternity ward lacks some of the equipment necessary for newborn care. Clean sheets are also missing here.
As expected, data on maternal and child care in these two districts is starkly different. A study by the Postgraduate Institute of Medical Education and Research in Chandigarh showed that health coverage is 71% in Kurukshetra, the highest in Haryana, while it is just 12% in Mewat, the lowest in the state.
The indicators for health coverage for maternal and child care, are antenatal check-ups, iron and folic acid tablets, and institutional delivery as well as financial risk protection.
“A state has the same set of policies for all its districts,” said Shankar Prinja, health economist at PGI Chandigarh and lead author of the study, which aims to develop a method to achieve universal health coverage. “Therefore, ranking districts of the same state helps in evaluating implementation and utilisation of services while other factors remain similar. The difference in districts was huge.”
Apart from Kurukshetra, the districts of Jhajjar and Kaithal provide good access to health services. But Palwal and Fatehabad, along with Mewat, had less than one-third of population seeking government services. Prinja attributes the disparity to differences in health infrastructure.
A March 2015 research paper from the Government Post Graduate College in Mahendergarh showed that while Kurukshetra had 32 beds per lakh of population, Mewat had half that number for the same population. The total number of medical staff in Kurukshetra was 506 against 449 in Mewat.
The difference in facilities carried over into health services. In Kurukshetra, 67.8% of children were immunised against 11% in Mewat. There was a similar discrepancy in terms of institutional deliveries at 64.2% and 14.8%, respectively.
Doctors in Kurukshetra credited community health workers for the good results in the district.
“We have been able to achieve good level in maternal and child healthcare through the work of accredited social health activists and auxiliary nurse midwife,” said Dr NP Singh, a deputy civil surgeon. “We have a two-tier system of training them. The district health department has a separate training module while the National Health Mission also trains them regarding maternal and child care. That is why the coverage is wide.”
Accredited social health activists, also known as ASHA workers, said facilities at primary health centres and the district hospital were satisfactory, which made their work easy. “I bring pregnant women to primary health centres for delivery and the care is usually appropriate,” said Surjit Kaur, one of 32 ASHA workers in the town of Pipli. “All the complicated cases are referred to the district hospital, where too the facilities are decent.”
However, she cautioned that the fruits of intensive training and effort put in by health workers like her would diminish if the authorities did not treat them well. “ASHAs in the district have not been paid their salary for the past four months,” she said. “The dues run into lakhs for all the ASHAs, nearly 600 in Kurukshetra. This is bound to affect their quality of work.”
She also complained that stocks of iron and folic acid tablets ran out intermittently.
In this district, ASHA workers seem less aware about maternal and child care. And unlike their counterparts in Kurukshetra, they refer complicated deliveries to private clinics rather than to the district hospital.
“Many women have more faith in private hospitals than the public sector,” said Saima Meo, one such worker from Nuh town. “They go to clinics near their homes rather than to the district hospital.”
The infant mortality rate in Mewat is 52, compared to 44 in Kurukshetra.
“There are social and economic reasons for these disparities,” said Dr Kamal Mehra, deputy chief surgeon with the National Health Mission in Mewat. “Being a minority-dominated area, immunisation rates are low in the district,” he said. “We have started engaging religious leaders to convince the population to give the required vaccines to infants.”
Meo thinks it is more of a systemic problem. “It is a widely held belief that Islam does not permit vaccination,” she said. “But it is also related to minimal awareness about side-effects. When children get fever or rashes after taking vaccine, people think it is bad for their health and start to doubt the vaccination drive. The government needs to counsel parents about these things.”
A pregnant woman sitting next to Meo pointed to another problem. “I have never found a doctor in a government health facility,” she said. “Why will I go there? How can I depend on them in case of a complicated situation?”
Mehra blamed low education levels for the lack of awareness. “Not only common people, even our ASHAs and ANMs are less literate than most of Haryana,” he alleged. “It is very difficult to create demand for public health facilities in them.”
According to the 2011 Census of India, the literacy rate in Mewat is 54%, way below the 75.5% average for Haryana.
While the improvements in maternal and child care in Haryana are encouraging, it still needs to catch up to other states that are performing better.
The northern state recorded the highest drop in infant mortality rate among all states, going from 41 deaths per 1,000 live births in 2013 to 36 deaths per 1,000 live births in 2014, according to the Census data.
However, the infant mortality rate in Karnataka, for instance, was already much lower at 31 in 2013 and improved to 29 the year after. Similarly, in Jharkhand, it dropped from 37 to 34, and in Punjab from 26 to 24. Kerala has maintained an infant mortality rate at 12 since 2008.
“Haryana might have reduced its IMR, but it still has to improve a lot,” said Ranbir Singh Dahiya, a retired doctor from PGI Rohtak. “There are many states where women and children get better care.”
Dahiya added that the disparity among districts was another cause for concern. “Some districts can be relatively better within the state, but the overall situation is not great,” he said. “The districts that are lagging have more poverty and worse health services. That has to be looked into by the government."