Abstract
Healthcare is crucial to the survival, physical growth and meaningful active life of young children (WHO et al., 2018). India continues to face challenges in improving the quality of life of its residents due to the extremely high prevalence of poor health and nutritional outcomes among young children and women of reproductive age. Despite recent improvements in health and nutritional outcomes, India stands very low in various global health rankings; the major contributing factors for this low ranking are the high level of mortality among young children and the prevalence of various types of undernutrition. In India, some states (mostly in the northern and eastern regions) lag far behind the global values of these indicators, whereas some states, mostly from the southern region, have outcomes comparable to those of any developed country. The Empowered Action Group (EAG) states comprises the eight states of Bihar, Madhya Pradesh, Uttar Pradesh, Uttarakhand, Chhattisgarh, Jharkhand, Odisha and Rajasthan from the northern and eastern regions of the country, which are of particular concern regarding health outcomes (NITI Aayog & World Bank, 2021). As these states contribute highly to the total population of the country and due to their higher fertility levels than that of many other states, these states have a higher proportion of children than other states, thus affecting national health outcomes in general and that of young children in particular. It is evident that without improving the health outcomes in these eight states, the health outcomes of the country could not be improved. Thus, issues that are common across these states and state-specific challenges, both need to be analysed (ICMR et al., 2017; Sharma et al., 2018; Venkateswaran & Singh, 2021).
This book deals with a specific issue in child health, i.e., newborn survival (first 28 days of life), in one of the EAG states, Bihar. Bihar is known for its higher socio-economic backwardness than major Indian states. It is the third most populous state in India, with around 90% population living in rural areas. According to the multidimensional poverty index, it is the highest-ranked state in terms of poverty. In addition, its literacy rate is one of the lowest in the country; early marriage and child marriage are quite common; and the prevalence of various forms of undernourishment and mortality among children and women is higher than in most of the other states, with a low social status for women (p. 39). Further, Bihar has the highest total fertility rate (TFR) in the country at 3.0. Hence, improving newborn survival is crucial for attaining the replacement level fertility (p. 3). Against this backdrop, the book explores the status of newborn healthcare in Bihar, the response of the state health system to the challenges in newborn healthcare, and the factors affecting newborn healthcare, including health infrastructure, human resources and financing of newborn healthcare programmes, thus drawing some inferences for policymakers.
Chapter 1 outlines the need for the study in the context of Bihar, identifying research gaps in the existing literature on newborn healthcare, explaining the research methodology adopted and drawing the study sample. Chapter 2 provides detailed insights into existing studies on neonatal healthcare in other countries and other Indian states. Chapter 3 elaborates on the scenario of neonatal healthcare in Bihar prior to the study, along with the availability of healthcare infrastructure in general and that of newborns in particular. Chapter 4 outlines the antenatal care-seeking behaviour and access to safe delivery services in the study area, focusing on state-specific socio-cultural barriers from the perspective of users. Chapter 5 assesses the quality and adequacy of services received at public and private facilities, which helps identify the gaps in current service provision. Chapter 6 analyses newborn healthcare practices (demand side factors) emerging from the interplay of individual-, household- and community-level factors that determine the health-seeking behaviour of newborns. In this chapter, Sandhya Mahapatro highlights the need for strengthening home-based newborn care (HBNC) programmes and the role of community workers. Chapter 7 discusses the availability of specific public health infrastructure in the state, such as sick newborn care units (SNCUs), to address the health emergencies of newborns. Chapter 8 evaluates the role of direct benefit transfer (DBT) schemes, such as Janani Evam Baal Suraksha Yojana (JBSY) and Pradhan Mantri Matru Vandana Yojana (PMMVY), in improving the current level of institutional delivery and survival and healthcare of newborns and providing economically weaker sections with a social safety net against catastrophic healthcare expenditure arising out of treating newborns. Chapter 9 summarises the findings of the study and suggests policy insights to strengthen the newborn healthcare system in Bihar.
The findings of this study underscore both demand-side and supply-side issues in newborn healthcare in Bihar. They show that the current level of availability of infrastructure is inadequate for a state like Bihar with a high TFR. Sandhya Mahapatro shows that poor and marginalised households are in fact spending a higher proportion of their annual household budget on delivery and newborn healthcare than their economically well-off counterparts (p. 62); this forces the former to reach out for distress financing. There is not much difference in costs incurred between delivery at home and delivery at a public institution. Due to the lack of an adequate number of public-run SNCUs, poor households are forced to visit private institutions, resulting in high out-of-pocket expenditures and distress financing. Although DBT schemes such as PMMVY and JBSY provide a cushion, a high proportion of sample respondents are either not aware of these schemes or do not know the procedures to claim these benefits. Sandhya Mahapatro highlights that users have to make under-the-table payments for faster and adequate care for their newborns (p. 133). The poor status of women often prevents them from taking care of their health needs and that of their newborns, given the prevailing hierarchy levels at both household and community spheres. Sandhya Mahapatro also emphasises the need for improving HBNC interventions, which play an important role in improving postnatal education. In the case of pregnancy, the number of home visits by health workers stands at 1.3, which is much lower than that prescribed by the HBNC guidelines, 5 and 6 times respectively, for delivery in a health facility and home delivery. Improving women’s education, strengthening their economic conditions and empowering them to take care of their health are crucial to improve the state of neonatal health in Bihar. In conclusion, Sandhya Mahapatro has reiterated the need for improving physical health infrastructure with a focus on the quality of services delivered. By applying the Mosley–Chen (1984) theoretical framework on newborn survival, which integrates various socio-economic factors, institutional factors and prevailing health beliefs, this study has provided rich insights into newborn survival in Bihar, triangulating information from secondary sources, household-level surveys and selected case studies. One of the likely limitations of the current approach is that it overlooks the health-seeking behaviour of respondent households for the healthcare needs of other morbidities and how it could be related to newborn healthcare in such households. Nevertheless, this book is an ideal reference for researchers, health activists and policymakers who work on various aspects of child healthcare in India and elsewhere.