New Delhi: Most of the indicators of the Sustainable Develop Goals (SDGs) that India is projected to fall short of will have a direct or indirect bearing on the performance of the country’s health sector.
A study published in The Lancet Regional Health – South Asia journal said that India is not on-target to meet 19 of the 33 indicators employed by the United Nations to help understand whether or not the country can achieve the SDGs by 2030 – the deadline for most of the goals.
The study, published online on February 20, indicates that three of the said 19 indicators may never be achieved. These include halving anaemia among women (all women), women (pregnant) and women (non-pregnant). The SDG goals envisaged halving anaemia prevalence in women of reproductive age till 2030.
The authors believe anaemia among women may never be eliminated because prevalence has only increased between 2016-21 and if the trend continues, then the targets may become unachievable. Currently, more than half the women in this bracket are anaemic while the national target is to bring this share down to 23.57% by 2030.
Anaemia is associated with lower productivity. If it occurs during pregnancy, it increases the risk of maternal mortality and also contributes to low-birth weight in infants. In children, anaemia can lead to poor cognitive development. It is more prevalent in women.
The study has been conducted by S.V. Subramanian of Harvard Center for Population and Development Studies, and others.
Of the other 16 indicators that India is projected to miss the 2030 deadline, some may be achieved a few years later while others could take a few decades. Looking at the current rate of change between 2016-21, the authors projected that India would meet targets on improved water availability by 2031, hand washing facility by 2033, availability of clean fuel for cooking by 2035, reduction in teenage pregnancy among 15–19-year-olds by 2039, and reduction in partner violence (sexual) by 2040.
The other 11 off-target indicators are likely to be met between 2041-2162. They include access to basic services (2047), reduction in tobacco use among men (2050), reduction in partner violence – physical or sexual (2090) and decline in wasting and overweight (2162).
Distribution (count) of off-target districts when Sustainable Development Goal (SDG) indicators will be met post-2030. Source: The Lancet Regional Health – Southeast Asia
Programme implications
An important observation made by the authors is that most of these off-target indicators already have a special scheme or a dedicated programme. Despite that, they have not been able to show the desired progress.
“Programs such as Pradhan Mantri Awaas Yojana (to deliver affordable pucca housing to the poor), the Pradhan Mantri Sahaj Bijli Har Ghar (to provide universal household electrification), the Ujjawala Yojana (to provide clean cooking fuel to all poor households), and the Jal Jeevan Mission (to provide safe and adequate tapped drinking water to all rural households) are all relevant for SDG #1 to end poverty in all its forms everywhere,” the paper says.
The authors have contrasted this with the Swachh Bharat Mission, as according to them, India is well on target to provide universal sanitation to its citizens by 2030 in a majority of districts and by 2035 in the remaining ones. The authors say, “The political will and administrative focus that has supported the Swachh Bharat Mission at the highest levels would benefit other programmes aimed at providing basic services for the population of India.”
It may be mentioned here that NFHS-5 had pointed out that 19% of people in India practice open defecation and in some states like Odisha, Bihar and Jharkhand, 30% of people don’t have a toilet. (Although Prime Minister Narendra Modi had declared India open defecation free in October 2019).
For addressing the indicator of health insurance coverage, the authors call for “an appraisal” of the Pradhan Mantri Jan Arogya Yojana – a component of the Ayushman Bharat scheme – under which the government provides an insurance cover of Rs 5 lakh per family to those who qualify the eligibility criteria of income and other ones related to deprivation. This assumes importance as authors, quoting earlier studies, say 60% of expenditure on health is borne out-of-pocket in India.
The legislations and judicial processes related to gender violence and women empowerment as well as the schemes related to them like Beti Bachao Beti Padhao (to curb sex-selective abortion and promoting girls’ education), Mahila Shakti Kendra (to support skill development and employment of women), and Women Entrepreneurship Program (to encourage women to launch business ventures) also require more attention. For, the authors project India will not meet the SDG on gender equality by as late as 2090, and for nearly one-third of districts, this goal will never be met in the foreseeable future.
In the case of anaemia, there are dedicated programmes – Anaemia Mukt Bharat and Poshan Abhiyan – which were especially launched to address the nutritional indicators. Yet the NFHS-5 showed that anaemia levels only increased between 2016 and 2021. And, in this paper, the authors project that in more than 600 out of 707 districts studied, the deadline of anaemia reduction would not be met.
While reassessment of the policy implementation is needed, the authors also pitch for the development of better metrics at the district level to evaluate anaemia. The authors reasoned that while the prevalence of anaemia among all women was found to be 57%, according to the NFHS-5, severe anaemia was only 2% while moderate and mild were 28% and 25%, respectively.
Combining all these groups into one broad term to understand district prevalence, without understanding the degree of anaemia, into one group may not serve the purpose, the authors said, on the basis of a previous study that they had conducted and was published in 2022. They had called for more precise policy targeting taking into account the heterogeneities within districts, as far as anaemia outcomes were concerned.
Performance of districts
The maximum number of SDG indicators that have been achieved by any district is 13 – out of a possible 33. Lakshadweep and Ernakulam (Kerala) have achieved this milestone. The 61 districts that have achieved up to 13 indicators are largely located in the states of Kerala, Tamil Nadu, Arunachal Pradesh, and Punjab, the authors found.
About 94 districts have achieved seven to eight indicators distributed across the states of Karnataka, Andhra Pradesh, Telangana, Gujarat, Haryana, Punjab, and Uttarakhand.
Madhya Pradesh, Chhattisgarh, Assam, Odisha, and Jharkhand were among the worst performers as they comprised nearly 171 districts that have achieved their target for two or fewer indicators.
Percentage of Sustainable Development Goal (SDG) indicators that are “Off-Target” in 2021 for each district of India. Source: The Lancet Regional Health – Southeast Asia.
However, there are certain indicators which have already been achieved by a majority of districts of the country.
At the all-India level, the SDG pertaining to the reduction in adolescent pregnancy in the age of 10-14 years has been met. The other indicators that are on target include full childhood immunisation, opening of bank accounts for women, internet use, improved sanitation, birth registration, proportion of births assisted by skilled birth attendants (institutional delivery), reduction in multidimensional poverty, electricity access, reduction of tobacco consumption in women, reduction in child marriages, decline in mortality among children aged less than five years (under-5 mortality) and one month (neonatal mortality rate).