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Role of good health care in holistic development: A comparative study of

two States in India

Moutrisha Ganguly1, Koustab Majumdar2

Abstract

Rural India is the real face of our country as it represents 68.84 per cent of population. We need

continuous efforts to accelerate the development trajectory to maintain the rural landscape of

India. Health is an important indicator of quality of life and various health indicators, like –

crude birth rate, crude death rate, infant mortality rate, maternal mortality rate etc. are

intimately related with holistic development of an area. The concept of holistic development

works at multiple levels which are deeply enmeshed with each other. A high quality healthcare

system can support economic and development initiatives. Health care is essential for holistic

development and this calls for greater investment. In recent trends health investment is a great

factor intended for direct implications for health outcomes. Kerala is supposed to be a socialist

paradise with the best social and gender indicators, glowering on health issues, economic

growth and globalisation and ranked in 1st position in the Human Development Index (0.790)

in India while West Bengal ranked in 13th position (0.492). Kerala's mortality level has been

lower than West Bengal's at least since the early 20th century. The difference became sharper

in the 1970s. The empirical evidence from various surveys shows that the differences between

the states in nutritional standard, per capita income, distribution of income and assets,

industrialisation and urbanisation. The wider distribution of health facilities in the rural areas

of Kerala and their greater utilisation are found to be significant factors. Two important reasons

why the health facilities are used more in Kerala have been identified. First, the proportion of

literates, particularly among females, is much higher in Kerala. Historically there has always

been greater emphasis in Kerala on education and public health. Secondly, the rural poor in

Kerala are more aware of their rights to use health and other public facilities than those in West

Bengal. The decadal population growth of Kerala presents a conducive scenario for

development. As per the market price of 2009-10 Rs.499/- has been spent as per capita health

1 Masters in Rural Development and Management, Department of Rural Development Management, University of Kalyani, Kalyani, Nadia, West Bengal, email: moutrisha.ganguly @gamil.com, Mobile no: +91-9836239038 2 Masters in Rural Development and Management, Department of Rural Development Management, University of Kalyani, Kalyani, Nadia, West Bengal, email: koustab3662@gamil.com, Mobile no: +91-9647274605

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investment in Kerala which was Rs.330/- only in West Bengal. In general, West Bengal has

always been characterised by a higher level of economic development and Kerala by a higher

level of social development. The lower mortality level in Kerala can be attributed mostly to its

higher social development and social mobilization.

This paper seeks to find out a comparative analysis between the two State i.e. Kerala and West

Bengal specially focus on health related issues and basically based on different sources of

secondary sources of data related with health.

Keywords: Good Health Care, Health Care System, Holistic Development, Kerala, West

Bengal.

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Introduction

The nations of the world have agreed that enjoying the highest attainable standard of health is

one of the fundamental rights of every human being without distinction of race, religion,

political belief and economic or social condition. Beyond its intrinsic value for individuals,

improving and protecting health is also central to overall human development and to the

reduction of poverty.

The twentieth century has seen remarkable gains in health. Average life expectancy in

developing countries was only 40 years in 1950 but had increased to 63 years by 1990 (World

Bank, 1993). Factors such as improved nutrition, better sanitation, innovations in medical

technologies, and public health infrastructure have gradually increased the human life span.

The relative contribution of these factors depends on the level of economic development; there

are synergisms between the underlying factors operating in complex ways. More generally,

economic development depends on the level of skills acquired by the population and on capital

formation. The former is influenced by child nutrition, educational infrastructure, and

households’ resources, including parents’ physical health and cognitive attainment (e.g. Fogel,

1994, Scrimshaw, 1996, Bhargava, 1998a, 1999a). Capital accumulation depends on the

savings rate that is also influenced by adult health.

India is far away from achieving the Millennium Development Goals (MDGs) of UN and the

situation in West Bengal, though generally better than the Indian average, but worse than

Kerala, also requires substantial improvement.

Methodology

The health status of a population depends on nutrition, access to safe drinking water and

sanitation facilities, environment, type of shelter, awareness about health and health care. We

choose West Bengal as it is our home state and Kerala which represents the “shining India”.

Along with this in West Bengal and Kerala 68.13% and 52.30% of total population respectively

still lives in rural area according to 2011 Census. This study provides an assessment on the

health and health care situation in West Bengal in comparison with Kerala and all-India. The

major focus is on providing exhaustive and comprehensive accounts of different aspects of

health status and health care scenario than providing analytical insights on select issues. This

study is primarily based on the data from National Sample Surveys, National Family Health

Surveys, World Health Survey (for West Bengal), Sample Registration System, Census, State

Bureau of Health Intelligence (Government of West Bengal), Central Bureau of Health

Intelligence and Reserve Bank of India.

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Health Status

The health status of a population is usually measured in terms of indicators of mortality and

morbidity. The commonly used mortality indicators are crude death rate, infant mortality rate,

child mortality rate and maternal mortality rate. The last three indicators are important as they

reflect crucial aspects of health of a society, that is, the health status of mothers and children.

Also life expectancy at birth depends largely on infant mortality rate (IMR). The recent Sample

Registration System estimates of IMR show that West Bengal is in the fourth position (38),

after Kerala (14), Maharashtra (36) and Tamil Nadu (37).

Although India accounts for 16.5% of the global population, the country contributes to a fifth

of the world's share of diseases; a third of the diarrhoeal diseases, TB, respiratory, and other

infections and parasitic infestations, peri-natal conditions; a quarter of maternal ill health; a

fifth of nutritional deficiencies, diabetes, Cardio Vascular Diseases, and second largest number

of HIV/AIDS cases after South Africa.

Improvement of health requires more public spending. Yet, India is one of the five countries in

the world where public spending is lesser than 0.9% of GDP and one of the fifteen where

households account for more than 80% of total health spending. The need to increase spending

on health is well recognized. The Common Minimum Programme of the UPA Government had

committed itself to raise public health spending to 2%-3% of GDP. Such an increase would be

required for strengthening the regulatory aspects of governance, expanding the scope and

institutional capacity for intensive health education and dissemination of public information,

disease surveillance and research. In addition, there is need to strengthen delivery of health

services, decentralize systems for monitoring and oversight by involving local governments

and establishing systems for ensuring accountability and providing financial risk protection.

Poor public health outcome in the country can be appreciated from the table below, which

shows a few important health indicators for India as well as some other countries.

Health and Development

Investment in health is increasingly recognised as an important – and previously under-

estimated – means of economic development. As the Commission on Macroeconomics and

Health (CMH) of the World Health Organization (WHO) has shown, substantially improved

health outcomes are a prerequisite if developing countries are to break out of the cycle of

poverty. Good health contributes to development through a number of pathways, which partly

overlap but in each case add to the total impact as mentioned below:

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● Improved human capital - Healthy children have better cognitive potential. As health

improves, rates of absenteeism and early school drop-outs fall, and children learn better,

leading to growth in the human capital base.

● Higher labour productivity - Healthier workers are more productive, earn higher wages,

and miss fewer days of work than those who are ill. This increases output, reduces turnover in

the workforce, and increases enterprise profitability and agricultural production.

● Higher rates of national savings - Healthy people have more resources to devote to savings,

and people who live longer save for retirement. These savings in turn provide funds for capital

investment.

● Demographic changes - Improvements in both health and education contribute to lower

rates of fertility and mortality. After a delay, fertility falls faster than mortality, slowing

population growth and reducing the “dependency ratio” (the ratio of active workers to

dependants). This “demographic dividend” has been shown to be an important source of growth

in per capita income for many low-income countries.

Table 1: Changing Rural Population from 2001 Census to 2011 Census

State % of Rural Population 2001

Census

% of Rural Population 2011

Census

Kerala 74 52.3

West Bengal 72 68.1

All-India 72.2 68.8

Source3

Fig: 1 Changing Rural Population among overall India, Kerala and West Bengal

3 Report on Rural Health Statistics, April 2013, Statistics Division, Ministry of Health and Family Welfare, GOI,

New Delhi

74 72 72.2

52.3

68.1 68.8

0

20

40

60

80

Kerala West Bengal All-India

Per

cen

tag

e of

Ru

ral

Pop

ula

tion

Decrease in Percentage of Rural Population from 2001 Census to 2011

Census

% of Rural Population 2001 Census % of Rural Population 2011 Census

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This table 1 shows the changing rural population in the overall India, Kerala and West Bengal.

It reveals that rural population is decreasing with shifting of trends of year. Major changes is

recorded in rural population (In, 2001 74% and 52.3% in 2011) in Kerala while the rural

population is recorded in West Bengal (In, 2001 72% and 68.1% in 2011), more or less same

at the national average (In, 2001 72.2% and 68.8% in 2011)

Important Health Indicators

Public health outcome is measured by certain key indicators such as Infant Mortality Rate or

IMR (no of children dying within one year after birth out of 1,000 live birth); Child Mortality

Rate or CMR (no of children dying within five years after birth out of 1,000 live birth);

Neonatal Mortality Rate or NMR (no of children dying within four weeks after birth out of

1,000 live birth); Maternal Mortality Rate or MMR (no of death of women while pregnant or

within 42 days of termination of pregnancy out of one lakh live birth); Birth Rate (no of child

birth per 1,000 population per year), Death Rate (deaths per 1000 population per year); Total

Fertility Rate or TFR (average number of children that would be born to a woman over her

lifetime if (1) she were to experience the exact current age-specific fertility rates through her

lifetime, and (2) she were to survive from birth through the end of her reproductive life), Life

expectancy at birth (which is the statistically expected number of years of life remaining at

birth) etc.

Table 2: Data of Birth Rates and Death Rates as on March 2012

State Crude Birth Rate Crude Death Rate

Total Rural Urban Total Rural Urban

Kerala 15.2 15.4 14.4 7 7.1 6.6

West Bengal 16.3 18.1 11.5 6.2 6.1 6.5

All-India 21.8 23.3 17.6 7.1 7.6 5.7

Source4

4 Report on Rural Health Statistics, April 2013, Statistics Division, Ministry of Health and Family Welfare, GOI,

New Delhi

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Fig: 2 Crude Birth Rates and Crude death Rates in between Rural and Urban areas among

overall India, Kerala and West Bengal

The following table: 2 shows the CBR and CDR in between rural and urban areas of overall

India, Kerala and West Bengal. It shows that there are a substantial difference in the CBR as

well as CDR in between the rural and urban areas and it is prominent due to service of health

treatment, per capita income, nutritional status and awareness about good health practice. The

difference is more-high in West Bengal as compared to Kerala but significantly less as

compared to national average.

Table 3: Infant Mortality Rate Infant Mortality (IMR) Rate in overall India, Kerala

and West Bengal

State Infant Mortality Rate

Total Rural Urban

Kerala 12 13 9

West Bengal 32 33 26

All-India 44 48 29

Source5

5 Bulletin on Rural Health Statistics 2011

15.216.3

21.8

15.4

18.1

23.3

14.4

11.5

17.6

76.2

7.17.16.1

7.66.6 6.5

5.7

0

5

10

15

20

25

Kerala West Bengal All-India

Bir

th R

ate

s a

nd

Dea

th R

ate

s Crude Birth Rates and Crude Death Rates as on March 2012

Crude Birth Rate Total Crude Birth Rate Rural Crude Birth Rate Urban

Crude Death Rate Total Crude Death Rate Rural Crude Death Rate Urban

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Fig: 3 Infant Mortality (IMR) Rate in overall India, Kerala and West Bengal

The table: 3 depicts the Infant Mortality Rate (IMR) among overall India, Kerala and West

Bengal. IMR is important measurement of health. A lower rate of IMR express a better health

care service as an important component of holistic development which is recorded in Kerala

(Total= 12, Rural= 13, Urban= 9) as much lower than West Bengal (Total= 32, Rural= 33,

Urban= 26) and overall India (Total= 44, Rural= 48, Urban= 29). It reveals that health care

delivery system is too much poor especially in rural areas and in West Bengal and other state

except in Kerala.

Table 4: Present status of Antenatal Check-up Camp (ANC) in Indian States6

State Status of State's ANC

Facilities (%)

Kerala 99.8

West Bengal 96.1

Source7

6 District Level Health Survey 2012

7 Bulletin on Rural Health Statistics 2011

12

32

44

13

33

48

9

26

29

0 20 40 60 80 100 120 140

Kerala

West Bengal

All-India

Infant Mortality rate

Infant Mortality Rate (As on March 2012)

Infant Mortality Rate Total Infant Mortality Rate RuralInfant Mortality Rate Urban

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Fig: 4 Antenatal Check-up Camp in Kerala and West Bengal

Here table 4 depicts that Antenatal Check-up Camp in Kerala and West Bengal. Out of total

sub-centres there are 99.8% and 96.1% sub-centres in Kerala and West Bengal respectively

which having the facility to provide the Antenatal Check-up facilities. Proper antenatal and

postnatal check-up is very important for reducing morbidity and avoiding mortality of the

mother as well as the infant. Full ANC includes three check-up and consumption of 100 iron

tablets, percentage of completing the course is even less. Delivery of services at the Sub-centre

which provides ANC services such as examination of the mother including weight gain by the

mother, measuring blood pressure, estimating haemoglobin, checking presence of albumin in

mother’s urine (for knowing the risk of suffering from eclampsia) has to improve for

identifying the risk of pregnancy and to ensure checking of such expecting mothers by doctors

and appropriate interventions for mitigating the risks. Conducting postnatal check-up for

assessing complication of the mother after delivery and illness of the infant is also very crucial

but more neglected than the ANC. It reveals that the better Antenatal providing health sub-

centres are more in Kerala which reflect a better health care service and lead to lower MMR

(Maternal Mortality Rate), IMR (Infant mortality Rate) as well as health status.

Table 5: Maternal Mortality Rate (as per 2011 Census)

State MMR

Kerala 81

West Bengal 145

99.8

96.1

94 95 96 97 98 99 100 101

Kerala

West Bengal

Percentage

Present Status of State's ANC Facilities

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Fig: 4 Present status of Maternal Mortality Rate (MMR) in Kerala and West Bengal

Source8

MMR is an important component to measuring the current status of health. Here, the following

table: 4 shows a significant difference in MMR in Kerala and West Bengal. MMR is recorded

81 while it is 145 in West Bengal. Thus it reveals a strong health care system is exist in Kerala

while it is too poor in West Bengal.

Table 5: Average Monthly Per Capita Expenditure of overall India, Kerala and West

Bengal

State Average MPCE (Rs.)

Rural Urban

Kerala 1383 1941

West Bengal 702 1452

All-India 772 1472

Source9

8 Registrar General, India, Ministry of Home Affairs, Govt. of India, Census and Vital Statistics, January

2011http://www.censusindia.gov.in

9 Report on Rural Health Statistics, April 2013, Statistics Division, Ministry of Health and Family Welfare, GOI,

New Delhi

Kerala, 81

West Bengal, 145

0

20

40

60

80

100

120

140

160

KERALA WEST BENGAL

Present status of MMR

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Fig: 5 Average Monthly Per Capita Expenditure of overall India, Kerala and West Bengal

The following table 5 represents the Average Rural and Urban Monthly Per Capita Expenditure

(MPCE) in overall India, Kerala and West Bengal. It shows a substantial variation in MPCE

between the rural and urban areas which is much high in overall India (Rural= Rs. 772/- and

Urban= Rs. 1472/-) and West Bengal (Rural= Rs. 702/- and Urban= Rs. 1452/-) while relative

difference is recorded in Kerala (Rural= Rs. 1383/- and Urban= Rs. 1941/-). It reflects well

economic growth and relatively higher per capita income and quality life-style in Kerala’s

people than any other States in India.

Public Health Infrastructures of the State and Delivery of Related Services

The public health infrastructure comprises of the health institutions, health professionals and

other personnel and the overall arrangement for delivery of various health related services.

Preventive and curative services are mostly delivered in the public sector. In rural areas such

services are provided by the Sub-centres (SC), the Primary Health Centres (PHC) and the Block

Primary Health Centres (BPHC). The BPHCs with at least 30 beds are generally declared as

Rural Hospitals (RH) and have facilities better than the BPHCs. The BPHC and the RH have

otherwise similar functions and are headed by the Block Medical Officer of Health (BMOH).

All primary health care services in rural areas are delivered by the RH/BPHC, PHC and the

SC. In urban areas such services are provided by the municipalities and coverage of such

services varies with the capacity of the urban local government and is not as well structured as

1383

702

772

1941

1452

1472

KERALA

WEST BENGAL

ALL-INDIA

Average Rural and Urban MPCE - Kerala, West Bengal and

all-India

Average MPCE (Rs.) Rural Average MPCE (Rs.) Urban

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it exists in the rural areas. RH/BPHC or even higher level hospitals located within

municipalities provide some of those services to the urban population. There should be one

Auxiliary Nurse-cum-Midwives (ANMs) and one male Health Workers (known as Multi-

Purpose Worker (Male) or simply MPW) for looking after preventive healthcare other than

those related to Reproductive & Child Health (RCH).

Table 6: Number of Sub Centres, PHCs & CHCs functioning in India, West Bengal and

Kerala

State 2005 2012

Sub-centers PHCs CHCs Sub-centers PHCs CHCs

Kerala 5094 911 106 4575 809 217

West Bengal 10356 1173 1173 1056 909 348

All-India 146026 23236 3346 148366 24049 4833

Source10

Fig: 6 Number of Sub Centres, PHCs & CHCs Functioning in India, West Bengal and

Kerala

The table 6 depicts number of Sub Centres, PHCs & CHCs functioning in India, West Bengal

and Kerala. It shows there is a reduction in number of Sub Centres and PHCs in Kerala due to

Standardization of Health Institutions during 2009 (as reported by the State Government) but

number of functioning Community Health Centre (CHC) become increase. While in West

10 Bulletin on rural health statistics in India 2012

0

20000

40000

60000

80000

100000

120000

140000

160000

Kerala West Bengal All-India

Table 6: Number of Sub Centres, PHCs & CHCs functioning in

India, West Bengal and Kerala

2005 Sub-centres 2005 PHCs 2005 CHCs 2012 Sub-centres 2012 PHCs 2012 CHCs

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Bengal PHCs upgraded to CHCs in 2005 and 2012 in West Bengal and in India the functioning

number of SC, PHC and CHC frequently increase in 2012.

Table 7: Distribution of Sub-centers on the basis of facilities not available at Sub-

centers (As on March 2012)

State

Number of

Sub-centres

Functioning

Without

Regular

Water Supply

Without

Electric Supply

Kerala 4575 607 (13.2%) 108 (2.30%)

West

Bengal 10356 7046 (68%) 3524 (34%)

All-India 148366 37855 (25.5%) 35845 (24.1%)

Source11

Fig: 7 Facilities not available at Sub-centers (As on March 2012)

Here the table represents Distribution of Sub-centers on the basis of facilities not available at

Sub-centers in overall India, Kerala and West Bengal. It shows that the number of functioning

sub-centers is much low in Kerala (4575) than West Bengal (607) but in those sub-centers there

are only 13.2 % of functioning sub-centers having no water supply facilities while it is recorded

as 68% in West Bengal and 25.5% in overall India. There are only 23% of SC functioning

without electric supply which is recorded in West Bengal and over all India is 34% and 24.1%

respectively.

11 Bulletin on rural health statistics in India 2012

0

20000

40000

60000

80000

100000

120000

140000

160000

Number of Sub-centres

Functioning

Without Regular Water

Supply

Without Electric Supply

Facilities not available at Sub-centers

Kerala West Bengal All-India

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Table 8: Changes in Public Expenditure in Health by State Government of Kerala &

West Bengal (in percentage)

States 2009-10 2010-11 2011-12

Kerala 3.71 % 3.83 % 4.13 %

West

Bengal 7.19 % 7.14 % 5.96 %

Source12

Fig: 8 Changes in Public Expenditure in Health by State Government of Kerala & West

Bengal (in percentage)

Here the table depicts that the changes in Public Expenditure in Health by State Government

of Kerala and West Bengal. It shows that out of total fund 3.71% is spent in health sector in

2009-10 by State Govt. of Kerala which is further rise to 3.83% and again extend up to 4.13%

while the expenditure in health sector is recorded in West Bengal 7.19% in 2009-10 and drop

down to 7.14% in 2010-11 and a significant level of reduction is recorded (5.96) in West

Bengal.

Table 9: Number of Government hospital beds available per 100,000 Population

State Number

Kerala 82

West Bengal 58

India 43

12 Annual Report to the People on Health, Ministry of Health and Family Welfare, GOI, New Delhi.

3.71

3.83

4.13

7.19

7.14

5.96

0 2 4 6 8 10 12

2009-10

2010-11

2011-12

Changes in Public Expenditure in Health by State

Government of Kerala & West Bengal (in percentage)

Kerala West Bengal

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Fig 9: Number of Government hospital beds available per 100,000 Population

Source13

The table 9 depicts that Number of Government hospital beds available per 100,000 Population.

It shows that the government hospitals beds are relatively high in Kerala (82) per 100,000

population which is quite low in West Bengal (58) while in overall India it is recorded lower

in Kerala and West Bengal.

Table 10: Number of Sub-divisional Hospital, District Hospital and Medical units

functioning in overall India, Kerala and West

State Sub Divisional

Hospital (SDH)

District Hospital

(DH)

Mobile Medical Units

(MMU)

Kerala 80 15 17

West

Bengal 45 16 0

All-India 987 722 2134

Source14

13 Registrar General, India, Ministry of Home Affairs, Govt. of India, Census and Vital Statistics, January

2011http://www.censusindia.gov.in

14 West Bengal Development Report, Planning Commission, GOI, New Delhi.

82

58

43

0

20

40

60

80

100

Nu

mb

er o

f G

overn

men

t h

osp

ita

l b

ed

s

ava

ila

ble

per 1

00

,00

0 P

op

ula

tio

n

Number of Government hospital beds available per

100,000 Population (As on 2009)

Kerala West Bengal India

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Fig: 10 Number of Sub-divisional Hospital, District Hospital and Medical units

functioning in overall India, Kerala and West

This table illustrates that Number of Sub-divisional Hospital, District Hospital and Medical

units functioning in overall India, Kerala and West Bengal. It shows the number of Sub-

Divisional Hospitals (SDH) in Kerala (80) is relatively high comparatively in West Bengal (45)

while in overall India it is recorded 987, but the DH is more or less same in Kerala (15) and

West Bengal (16) and it is recorded as 722 in overall India. Mobile Medical Unit is important

fact for good health care service which is recorded in Kerala as 17 while it is nil in West Bengal

and 2134 of numbers in overall India.

Conclusion

West Bengal is fast emerging as one of the faster growing state economies of the country. From

this comparative study we can say that West Bengal has to run a long way to reach the goal

that it require. The reduction of IMR is largely dependent on reduction of neonatal death. In

order to prevent neonatal death there is need for both improving more home-based neonatal

care through training of the ASHA and improving level of awareness of the mothers so that

they can assess the risk and take the baby to the hospital for which no cost has to be incurred.

The training package of ANM and ASHA workers should be developed for better management

of neonatal and childhood illness. The atmosphere of health centres should be upgraded. Poor

and people living in remote rural areas faced several constraints in receiving public health

services, which are normally provided free of cost. Lack of awareness and information related

to service offered, problem of access including cost of accessing the services and out of pocket

expenditure due to inadequate provision or inefficiency in the system as well as health seeking

0 500 1000 1500 2000 2500

Kerala

West Bengal

All-India

Number of Sub Divisionl Hospital, District Hospital &

Mobile Medical Units Funtioning As on March 2012

Mobile Medical Units (MMU) District Hospital (DH) Sub Divisional Hospital (SDH)

17 | P a g e

behaviour etc. are the important causes behind failure of services reaching the poor and those

living in remote areas. Health cannot be seen as a state at all but must be seen as a process of

continuous adjustment to the changing demand of living and of the changing meaning we give

to the life. The holistic perspective of health not only takes into account existing technologies

and their organisation, it also underlines the importance of social determinants such as food

availability and nutritional status of populations, drinking water supply, housing, transport,

education, employment that contribute to people’s well-being and, last but not the least, the

status of women. The health status of the people in the country is an important flag-post to

evaluate the success of the policies of government. Despite several growth-orientated policies

adopted by the government, the widening economic, regional, and gender disparities are posing

challenges for the health sector.

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