The United Nations Sustainable Development Goals comprise of 17 measures to attain sustainability across various platforms. 169 targets have been set that aspire to tackle a wide range of world issues that were earlier left out by the narrowed down vision of the Millennial Development Goals. These goals are a call to act to protect the planet through a global framework.
Among these goals lies the goal of Good Health and Well-Being. Thirteen targets have been set to promote this goal. They aim to ensure healthy lives and promote well-being at all ages which are important to build prosperous societies. In order to address this one needs to look at affordability and access to healthcare.
Despite the incredible achievements since the creation of Millennial Development Goals inequalities exist in health care access and children are vastly affected by this. This calls for recognizing the interdependence of health and development with prime focus on what these goals and targets mean for children. Internationally child health has been approved as the most important indicator for the development of the world. In every country, the respective governments have made every possible effort to tackle down the issues of child healthcare. Placing children at the heart of the vison for the future can be the starting point of the action plan. The SDGs, primarily goal no. 3 will have a significant impact on today's children and tomorrow's adults. The specific commitments for children include ending preventable deaths and hunger, ensuring children's access to nutrition that will help them thrive, promoting educational outcomes for all children and ensuring that they live without the fear of violence. Out of the 230 indicators used under the SDG targets, 50 are directly linked with children out of which 14 fall under good health and well-being. This indicates how good health of children can be the key to achieving development.
In highlight of the above details, this study is focused on conducting a comparative economic development analysis between India and China based on the SDG: Good Health and Well-Being, for children.
India and China have shared similar economic history from the time when they lagged behind the West and later took reforming steps to develop their economies. While the average income in India and China remains low, their impressive economic growth and enormous populations have made them two world powers of extraordinary importance. Such vast nations with a tight grasp on global economic progress makes them the ideal subject of this study.
India's national development goals are mirrored in the SDGs, making India effectively committed to achieving them. The Government of India has even released a Three-Year Action Agenda for the years 2017-18 to 2019-20 to fast track the action plan. On the other hand, China always places development as its first priority. The 13th Fiver Year Plan which was reviewed and approved in March 2016 attaches great importance to the implementation of the 2030 Agenda. In the context of child health and well-being, both nations have achieved major improvements in the past 20 years but disparities in regard to coverage and quality of healthcare still exist. This report aims to study the differences in healthcare achievements, public health innovations, governance and leadership and future scope of healthcare facilities and challenges between the two nations. It is hypothesised that although both countries are on a similar growth trajectory, China is more rapidly achieving these goals that India.
This paper reviews the existing literature on child healthcare in order to assess the health status and morbidity pattern of Indian and Chinese children, and to discuss issues relating to their health care needs.
To aid in a systematic analysis and synthesis of the selected literature, a conceptual framework was developed that consisted of six potential aspects:
• (1) Limitations in the MDG implementation and enforcement.
• (2) Need for SDG
• (3) Programs implemented under SDG
• (4) Success/Failures of SDG
• (5) Policy Comparison
• (6) Learning Outcomes
The study is based on the secondary data collected from various government reports such as NFHS reports, Surveys by Ministry of Women and Child Development (Gov. of India), Ministry of Health and Family Welfare (Gov. of India), World Health Organization, UNICEF…
India is the second most populous country after China, both with alarmingly high rates of population growth. India is listed as the country with disturbingly high rates of malnutrition and child mortality, whereas, China too suffers from high rates of infant mortality and child stunting.
In October 1975, India launched Integrated Child's Development Services (ICDS) programme for promoting the health and development of mothers and their children. The beneficiaries of the program are children below the age of 6 and their mothers. Under this program benefits are administered from anganwadis (village courtyard) by workers and their helpers. By 2017 the ICDS covered 78.6 million children and 18.6 million pregnant and lactating mothers.
Several aspects of the program have been analysed by researchers and some studies (Mander and Kumaran 2006; Thorat and Sadana 2009) have shown an “exclusionary bias” in the delivery of the benefits. Major findings from these studies show that eligible and impoverished children were unable to reap the benefits of the scheme and some discrimination was in fact not random rather than based on caste, gender and disability. They even demonstrated that there was a lack of anganwadi set ups in areas populated by backward classes, therefore indicating that upper castes held significant influence in the setting up of ICDS service centres.
Even in China, large disparities persist between different regions and Chinese ethnic groups in the field of health. It has been noted that people from rural and poor areas, and those from ethnic minorities, more rarely have access to a doctor for treatment.
Access to healthcare services remains limited, making Tibet the worst place to live in China in terms of health. Hospitals are concentrated in urban areas, while almost 40% of the Tibetan population is still nomadic or semi-nomadic. The infant mortality rate is one of the highest in the world here. A study (Huang et al. 2018) showed the discrepancy in maternal and child health outcome based on ethnicity. It concluded that ethnic minority women have poorer access to antenatal care use and their children had higher mortality and lower immunization.
Keeping in mind the above-mentioned disparities in child healthcare, one needs to look at the changes and achievements made under the millennial development goals program. Here we look at Goal 4: “Reduce Child Mortality”. Under goal 4, India more or less achieved the target of reducing the under-five mortality rate (U5MR) to two-thirds along with a marginal decline in the rural-urban gap in the indicator, during 2009-13. But, the urban U5MR continued to be lower than the rural U5MR by more than 40% of the corresponding level. Significant drop was noted in the infant mortality rate in both rural and urban areas, although the rural-urban gap in 2013 was still significant. India fell short on the universal coverage of immunization of one-year old children, although it made a remarkable improvement from 42% in 1992-93 to 74% in 2009. ICDS had a significant role in supplement role in aiding the country achieving these targets, but it could not significantly bridge the urban-rural divide. In the case of China, the country progressed smoothly in reducing U5MR and achieved its set target by 2007 itself. The wide disparities in child mortality rates across China decreased numerically, the rates remained high in poorer provinces than the wealthier counterparts. The progress lagged behind in the case of infant and children of migrant women. The immunization situation varies greatly across the country and the rural areas lagged far behind in attaining universal coverage.
Both nations recorded higher mortality rates for females than males, this can be attributed to the son preference that exist in both nations.
The partial fulfillment of the MDG goals and it's narrowed down approach lead to the formulation of SDGs. Under the Sustainable Development approach a wider scheme of things are brought into the picture. Since the SDGs aim to leave no one behind, they play an essential role for children. In the SDG era, in order to monitor the progress made for children UNICEF categorizes the goals under the following five children's rights: survive and thrive, learning, protection, environment and fair chance. Therefore, the goal of achieving good health and well-being plays a critical role in order to ensure these rights are protected and exercised.
As India and China are densely populated with large children's populations, such nations need to be active participants in order to protect the future, i.e. today's children. So far, both nations have shown high interest by formulating and releasing national plans that support the attainment of these goals.
India has launched a National Health Mission which is leading change in the area of national wellbeing. Under this mission the government has launched the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNC+A) approach in 2013. It focusses its resources on the vulnerable and disadvantaged groups in the country. Its objectives were even incorporated in the 12th Five Year Plan.
China on the other hand has action plans that are ahead of the SDG goals when it comes to targeting neonatal mortality rate, under-five mortality rate and ending preventable deaths of newborns. The country has set targets of much lower rates than the global goal to be achieved by 2020. It also aims to fully launch scientific child rearing and healthy youth initiative by 2020 with 70% satisfaction rate for services regarding adolescent development.
ADD HOW CHINA IS AHEAD OF INIDA (SUPPORT HYPOTHESIS)
There are lifelong benefits to breastfeeding, it lowers mortality and infectious morbidity, reduces dental malocclusions and leads to higher intelligence and bonding. It is also said to lower the risk of having allergies and babies that are exclusively breastfed for the first six months have lower risks of catching ear infections, respiratory illnesses and suffering from bouts of diarrhea. Poor feeding practices in India cause the burden of malnutrition and child mortality. Multi-centred studies conducted across India, Peru and Ghana showed that non-breastfed or partially breastfed infants had a higher risk of dying than those that had been pre-dominantly breastfed.
A study conducted in India estimates infant and child feeding indicators along with determinants of feeding practices (A. Patel et al. 2005-06). It was carried out with 20,108 children aged between 0-23 months and found that the rate of exclusive breastfeeding was 71% but declined rapidly with age to 14.2% at 6 months. It was also noted that trends of exclusive breastfeeding were high in uneducated mothers and mothers in the poorest wealth quantiles. On the other hand, the rates for complementary feeding showed opposite trends, i.e. they were higher for more educated mothers, residing in urban areas.
Since mid-1990s any breastfeeding rates in majority of Chinese cities including minority areas was above 80% at four months, but very few of those reached the national target of exclusive breastfeeding of 80%. A 30-month cohort study in Northwest China (P. Liu et al. 2007-10) found that shorter duration of breastfeeding was associated with several factors such as maternal age, illness, gestational age and employment. In 2013, China's exclusive breastfeeding rate fell to 20.8% suffering a decline of nearly 7% since 2008.
Such a decline in breastfeeding practice shows an increase in the market of breast-milk substitutes (BMS) with China having the largest market in the world. In 1981, WHO adopted the policy framework to promote breastfeeding through the implementation of International Code of Marketing Breast-Milk Substitutes. Under this code, India introduced the Infant Milk Substitutes (IMS) Act in 1992 that bans all forms of promotion of foods marketed for children up to 2 years of age. The legal status of the code in India has full provisions in law, whereas in China it has few provisions in law. In fact, the most recent legal measure with respect to the Code in China was taking in 1995, India amended the IMS Act to improve certain provisions in 2003. This shows that legislation's implementation and enforcement are weak throughout China, violation of the Code remains severe as 60.9% of the labels of formula products do not comply with the code's regulations. Although India has taken more recent legal measures, it still lacks behind when it comes to maintaining a comprehensive ban. Companies continue to aggressively market and promote BMS through conferences and conventions thus, further undermining breastfeeding rates. Several baby food companies in India say that they strictly adhere to Indian regulations and are committed to ethical marketing practices. The need for further improvement in enforcement has been recognized and the approach adopted by the Indian Government has led to a significant decline in the fraudulent promotion of BMS. These government led mechanisms are empowered to apply legal sanctions in case of violations. It will be extremely profitable if China followed suit in this case and led a multi-sectoral, comprehensive scheme with an updated enforcement strategy to tackle the upcoming marketing tactics.
Other initiatives to promote breastfeeding include the Baby-Friendly Hospital Initiative, jointly launched by WHO and UNICEF in 1991. It targets the promotion of breastfeeding through lactation support from health workers. In India, by 2002 Kerala was the first state to be declared Baby Friendly State. Even after the successful implementation of the program in the initial years there was a sharp decline in the percentage of implementation. Revamping of the initiative was carried out in the form of training programs launched in hospitals that included lectures/classes on aspects of breastfeeding. A study on effectiveness of BFHI concludes that its implementation has successfully improved breastfeeding practices. According to this study, the percentage of timely initiation of breastfeeding has increased from 39.4% to 80.6% after counselling. For China, the BFHI has been equally fruitful. By 2015, 31 of its provinces had at least one baby-friendly hospital, and 92% of babies born in these hospitals were exclusively breastfed during their stay there.
According to the “Asian Enigma”, the home of the malnourished child is not Sub-Saharan Africa but South Asia. It states that just over 30% of Africa's children are underweight but the corresponding figure for South Asia is over 50%. Bangladesh and India have malnutrition rates that are even higher than the poorest countries of Africa. An estimated 12.7 million children in China are stunted due to chronic malnutrition. (World Food Programme, 2016)
Despite rapid development in India and China, its fruits have been unable to secure a better nutritional status for its children. Poverty is the most significant underlying cause of malnutrition and of course there is poverty in the neighbouring countries.
The existence of socio-economic inequality of childhood malnutrition in India is supported by growing evidence. The pretext of malnutrition in India can be said to be based on the two-way causality between poverty and under nutrition. It was recorded in the National Family Health Survey (NFHS) – 3 (2005-06) that 48% of children were stunted and 42% were underweight, for those under 5 years of age. According to the Rapid Survey on Children conducted by the Government of India in 2013-14, about 38.7% of children were stunted and 29.4% of children were underweight in the country. The percentage change between the two surveys was only -0.14% for stunted children and for underweight children it was -0.27%. In the NFHS-4 (2015-16), which is the latest publication, the percentage further fell, recording 38.4% as stunted children and 35.7% as underweight children, aged below 5 years. Other than the overall statistics of the nation, the two states most afflicted with malnourishment, Bihar and Madhya Pradesh, have recorded substantive decline in the percentage of stunted and underweight children between NFHS-3 and NFHS-4. This improvement can be attributed to increased access to improved sanitation over the years. By tackling the adverse conditions in these two states it can be said that one aspect India's health condition is on the mend. A study on the nutritional status of children in India concluded that in spite of the declining trend of chronic malnutrition in India, the main concern is the burden it exerts on the poor.
Childhood malnutrition in China is more prevalent in poor rural areas than in rural and urban regions. WHO, Global Database on Child Growth and Malnutrition recorded that 20.8% of children under 5 years of age were stunted and 6.8% were underweight in the year 2002. This figure plummeted down to 8.1% for prevalence of stunting and 2.4% for prevalence of underweight children in that age group, in the year 2013. Four decades of rapid economic growth has fueled a dramatic reduction in China's undernourished population. China recorded a sharp decline of about half in child underweight and stunting between 1992 and 2002. But the poor continue to suffer and stunting is the most serious problem that was impeding child growth and development. So far, China has achieved this dramatic reduction due to food security throughout most of the country, making the problem of malnutrition relatively small. Another health issue crippling China is the growing prevalence of obesity in children mainly in the urban areas. Child obesity is a public health threat and the rising trends of overweight and obesity are apparent in both developed and developing countries. In the 1990s, over a six-year period, a survey conducted to study the prevalence of overweight children observed a modest shift from undernutrition to over nutrition. The shift in urban residences was attributed to improvement in diet and reduced physical activity. A recent study from 2015 concluded that prevalence of overweight and obesity in children aged 7-12 years was much greater than adolescents aged 13-17 years.
Even though stunting and underweight in China has declined, the problem of malnourishment is far from eliminated as now the overweight factor comes into play. But all indicators consulted show that India lags far behind. Hence, prevalence of child malnutrition is far more crippling in India than in China and with slower progress in India.
There is a body of evidence that children's health and nutritional status are enhanced by having more educated parents (Sandiford, Cassel, Montenegro and Sanchez, 1995; Desai and Alva, 1998; Chou, Liu, Grossman and Joyce, 2010). An analysis on the role of maternal literacy in reducing child malnutrition in India (Borooah, 2009) concludes that literate mothers make more effective use of health-care facilities and therefore real benefits flow to children in terms of reduced risk. Studies have also shown that mothers education does cause favorable infant health outcomes. Child malnutrition in China has seen improvements since then economic boom and the governments introduction of pro-rural policies. The Chinese Ministry of Health introduced a “nutrition intervention project” which aimed at providing supplements to children aged between six months to six years.
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