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Mainstream, Vol XLIX No 17, April 16, 2011

Demographic Dividend and Health Concerns in India

Thursday 21 April 2011

by M Benson Thomas

A major dimension of the ongoing discourse on the population spurt in India is the significant question whether the country can attain the benefits of ‘demographic dividend’. By demo-graphic dividend we mean a rise in the rate of economic growth due to a rising share of the working age population. It is understood that the dividend occurs when a decline of birth and death within a short span of time creates an excessive shift in the age structure of the population towards the adult working ages. According to the latest statistics, the adults constituted 57.7 per cent of the total population of India in 2001 and their share is projected to grow to 64.2 per cent in 2021. (Registrar General of India 2001) However, the current discussions on this advantage seem to focus on education, employment opportunities and economic growth while avoiding the health status of adults in India.

Examining the Adult Mortality Rates (AMR) and the prevailing morbidity pattern in the country are the two ways in which the health of adults can be assessed. According to the World Health Organisation (WHO 2009), the Adult Mortality Rate (AMR) is a better indicator and is defined as the probability that a 15-year- old person will die before reaching his/her 60th birthday. The WHO report says that the AMR in India is 215, which is higher than those of the lower middle income countries (168) for 1000 population in 2007. It means that more than 20 per cent of Indian adults are dying in adult ages. This vulnerability is higher among males (25 per cent) than females (17.7 per cent) in India.

It is a point of concern that demographically advanced and backward States have no signifi-cant disparities in adult death rates especially among males. It defies the popular notion that those States that have controlled the mortality rates for infants, children and young mothers (advanced states) have also controlled their adult deaths. States like Kerala, Tamil Nadu, Andhra Pradesh and Punjab show advanced demographic features while Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh are backward States in demographic features. The advanced States boast of lower infant mortality rates which varies from 14 to 54 and a high life expectancy (66 to 73.9 years) while the backward States have higher infant mortality rates ranging from 61 to 73 and lower life expectancy (57.7 to 61.7 years). The all India average of infant deaths is 58 per 1000 births and Life Expectancy is 63.2 years at birth. But the mortality rate of adults portrays a different picture. The AMR in advanced States (except Kerala) is high and even comes close to the AMR of the backward States.

The high AMR, especially in the case of males, has two implications. Firstly, those States, which have a significant proportion of their population in the adult category, have failed to reduce the number of adult deaths, and therefore have been unsuccessful to reap the optimum benefits of the demographic dividend. Secondly, if the same syndrome spreads to the backward States (currently 52 to 55 per cent of their population are adults and this may shoot up in the near future) the situation will become more critical. Notably, these backward States account for a major chunk of the Indian population and can expect a proportionate growth of adults in the near future.

Another concern of adult health in India is related to its morbidity pattern. According to the NSSO’s 52nd Round Survey Report, 33 persons out of a thousand people in the age-group of 15-65 in the rural areas are chronically morbid while the same figure is 35 for urban India. Similarly, 77 (rural) and 71 (urban) persons per thousand population are morbid by acute diseases in India. The report also indicates that the adults in the advanced States have more acute and chronic morbidity in both the rural and urban areas, compared to the backward States. For example, it can be seen that though Kerala has a low death rate of adults, it has relatively higher morbidity. Perhaps, this could be due to the extension of adult life beyond the adult age using advanced healthcare. This phenomenon has to be understood in the context of the soaring healthcare burden in recent decades.

BOTH the AMR and high morbidity among the adult population in India can be attributed to the changing disease pattern and the policy mismatches in dealing with it. According to the WHO, most of the developing countries are going through an epidemiological transition which brings more deaths from non-communi-cable diseases and injuries than infectious and maternal deaths. Since adults are more vulnerable to these diseases, a high healthcare burden can be expected in the near future. The Indian health scenario is also not an exception to this phenomenon. Reports of Medically Certified Cause of Death Survey (MCCD), which is focused on the urban population and Cause of Death Survey-Rural (CDS-R), which is focused on the rural population, support this argument. These reports show the increasing trend in non-communicable diseases, especially in diseases related to the circulatory system, as a major cause of death. This trend is noticed more in the demographically advanced States.

Among the adult population, males are more vulnerable to death than females. It can lead to high incidence of orphanhood and widowhood. Since males are, in general, the breadwinners in families, their untimely death may have negative consequences for families and the society as a whole. Therefore the high prevalence of the AMR even in the advanced States in India need be taken seriously.

So far, there are no specific programmes or health policies, focusing on the demographic dividend, for adults in the country. Though we have national policies like the National Health Policy (2002), National Population Policy (2000), and programmes including the National Rural Health Mission (NRHM), they are not fully capable of solving or improving the adult health. It is also pertinent to mention that while the NRHM deals mainly with the primary healthcare issues of 18 highly focused States (backward States in the demographic transition) by spending crores of rupees, it conveniently ignores the needs of advanced States. However, in reality neither the advanced nor the backward States have so far concentrated their attention on adult healthcare.

Though a reduction in the AMR is possible by medical and therapeutic care, it requires more resources including high medical expenditures. A prolonged duration of non-communicable diseases and a highly expensive privatised healthcare etc. can translate into a miserable experience for the common people. A viable way to tackle this puzzle is to strengthen the preventive and promotive methods focusing on better lifestyle of the people. In a nutshell, it can be stated that to reduce ill-health and increase the health care services, the immediate solution is identification of the causes of such diseases. This needs to be complemented with a review of the appropriateness of the current medical technologies and the health services available to the general public.

The author is a doctoral scholar in the Population Research Centre at the Institute for Social and Economic Change (ISEC), Bangalore.

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