Smith - Public Policy and Maternal Mortality in India

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ABSTRACT

This study began with an interesting empirical puzzle concerning a pressing

public health issue in the developing world. More than half a million women die related

to pregnancy and childbirth each year. One in four maternal deaths worldwide occur in

India. This study asks, given two Indian states with comparable socio-cultural contexts

and economic indicators, what explains differing progress for maternal mortality

reduction? Comparative analysis of the policy processes in each state provides insights to

the research question and suggests the need for more holistic frameworks for analyzing

policy processes than currently exist.

Comparative case studies draw on more than 140 interviews with health policy

experts, managers and service delivery personnel in the two Indian states, as well as with

representatives of domestic and international NGOs and donor agencies over three

months in 2007; numerous national and state government reports; policy and program

documents; and reports and documents from international donor and nongovernmental

organizations to triangulate data relevant to answering the research question.

The findings suggest that differing social historical influences in each state;

worldviews, priorities and degrees of power among major political parties; strength and

ideas of key policy actors; and capacity and norms in the concerned public health

bureaucracies shaped variation in availability and access to publicly provided safe

motherhood services in the two states, especially for more vulnerable groups (e.g. women

with lower economic, educational and social status).

The results suggest a need for more holistic frameworks for analyzing policy

processes frameworks that highlight the influence of such social historical influences as


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major social movements and other feats of social organization (e.g. colonialism) as they

shape conditions of the political environment, the power of policy actors and ideas, and

organizational structures that shape subsequent policy processes. In doing so, the study

identifies a neglected set of variables in historical social organization, refines our

understanding of how the political environment matters, and presents political-

bureaucratic actors and ideas as a category of factors that bridges policy and management

to better reflect the overall set of causal relationships that influence policy outcomes.


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UMI Number: 3381604

Copyright 2009 bySmith, Stephanie Lynette

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Copyright 2009 Stephanie Lynette Smith

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TABLE OF CONTENTS

Chapter 1 Policy processes & safe motherhood in South India 1

Introduction 2

Theorizing the policy process 6

Conclusion 15

Chapter 2 Safe motherhood: profile & public policy 19

Introduction 20

Safe motherhood: scope, causes & interventions 21

Health systems 27

The scope of Indias maternal mortality crisis 30

Public policy & maternal mortality in India 32

Karnataka 37

Tamil Nadu 40

Conclusion 43

Chapter 3 Methods 45

Methods of exploration 46

Case selection 47

Data 50

Primary data 50

Secondary data 56

Validity 56

Chapter 4 Socio-cultural dynamics & safe motherhood 58

Introduction 59


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vii

Economic status 60

Education & literacy 65

Geography 70

Caste, class, religion & gender 75

Conclusion 82

Chapter 5 Politics & safe motherhood 84

Introduction 85

Politics & health policy in Tamil Nadu 86

Politics & health policy in Karnataka 98

Local & regional political dynamics 112

Conclusion 117

Chapter 6 The public health bureaucracy & safe motherhood 120

Introduction 121

The public health bureaucracy in Tamil Nadu 122

The public health bureaucracy in Karnataka 139

Conclusion 147

Chapter 7 Toward a more holistic framework for analyzing policy processes 149

Introduction 150

Summary of findings 151

Implications of findings for analyzing the policy process 152

Linking policy processes & outcomes 153

At the intersection of policy & management 156

Political environments & policy change 158


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viii

Governance structures & policy processes 160

Social historical factors in policy processes 163

Study limitations 165

Conclusion 167

Appendix A Comparing frameworks for analyzing policy processes 172

References 174


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TABLES

2.1 Global maternal mortality ratios with confidence intervals 232.2 Summary data on India, Karnataka and Tamil Nadu 363.1 Key safe motherhood indicators for India and major states 49

4.1 Economic status and safe motherhood process indicators in Tamil Nadu and

Karnataka, 1998-9 62

4.2 Economic status and safe motherhood process indicators in Tamil Nadu and

Karnataka, 2005-6 63

4.3 Education levels and safe motherhood process indicators, 1998-9 67

4.4 Education levels and safe motherhood process indicators, 2005-6 68

4.5 Rural and urban institutional delivery rates in Tamil Nadu and Karnataka, 1992-3,

1998-9 and 2005-6 73

4.6 Rural and urban antenatal and postnatal care rates in Tamil Nadu and Karnataka,

2005-6 73

5.1 Share of health in revenue budget of select major states (%) 97

6.1 Translation of political priorities in the health bureaucracy 148

7.1 Proposed holistic framework for analyzing policy processes 171

A.1 Comparing frameworks for analyzing policy processes 172

FIGURES

6.1 Maternal death audit form, Karnataka excerpt 146


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CHAPTER 1

POLICY PROCESSES & SAFE MOTHERHOOD IN SOUTH INDIA


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INTRODUCTION

Few would argue that the staggering maternal mortality burden born by women

and families in the developing world more than half a million women die related to

pregnancy and childbirth every year (WHO 2007) is unaffected by material

socioeconomic factors, such as poverty, illiteracy and gender inequality. The magnitude

of these problems and their influence on access to maternal health care, especially for

vulnerable groups, would seem to explain much in developing country settings. But this

study presents an empirical puzzle in which material socioeconomic factors fail to fully

explain why women in one Indian state access safe motherhood services at a greater rate

than women in a state with historically comparable socioeconomic indicators. This study

examines how public policy processes contribute to that variation.

Looking more closely at the relationships between socioeconomic factors and safe

motherhood outcomes in the two comparative cases, a distinct difference emerges

between the South Indian states of Karnataka and Tamil Nadu. In Karnataka, the gap in

rates of access to maternal health services between more resourced and more vulnerable

groups is wide, dragging down state averages. In Tamil Nadu, the gap is narrower, with

women from more vulnerable groups accessing safe motherhood services at significantly

higher rates than their counterparts in Karnataka. That is, women in Tamil Nadu access

safe motherhood services at greater rates than women in Karnataka across income

groups, levels of education and other socio-cultural categories. Why?

Another distinct difference between the states is the rate at which women access

safe motherhood services in the public sector. Women from more vulnerable groups

reported accessing safe motherhood services in the public sector at greater rates than the


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private sector in both states in a 1998-9 national health survey (IIPS 2001a and b). In

Tamil Nadu, they accessed maternal health services in the public sector at nearly twice

the rate of their counterparts in Karnataka, making up a substantial portion of the gap in

rates of access between the states. What explains this difference?

In Tamil Nadu, strong leadership and a policy community emerged surrounding

efforts to reduce maternal mortality in the mid-1990s. These policy actors effectively

integrated safe motherhood services among other service delivery priorities. They

developed new agency procedures, systems for training, monitoring and evaluation to

increase the availability and accessibility of safe motherhood services in the public

sector, with special attention to reaching groups with less access. Norms and expectations

that supported public health and social welfare policy, as well as the relatively robust

capacity of the health bureaucracy in terms of human and financial resources facilitated

their course of action. A significant social movement in the past century was an important

factor shaping operative norms and expectations for social welfare policy benefiting

vulnerable groups in the state. Tamil Nadus system of competitive party politics

profoundly shaped by this social movement reinforced these as priorities for the states

public health bureaucracy and provided opportunities for policy communities to promote

safer motherhood services. These forces worked over time to systematically shape policy

and action in ways that increased the availability and accessibility of safe motherhood

services in Tamil Nadus public sector.

Karnataka, like neighboring Tamil Nadu, is a relatively wealthy state benefiting

from comparatively competent and stable governance in the broader Indian context,

affecting better than national averages for access to safe motherhood services in both


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states. Karnatakas performance lags next to Tamil Nadu, however. The state has had no

comparable program of action to increase the availability and accessibility of publicly

provided safe motherhood services and the most vulnerable groups are particularly

neglected. No strong policy community has formed surrounding the issue and leadership

for it is conspicuously absent. Institutional norms were less pro-poor and more oriented to

high-level hospital care than to the primary health approach that serves as a critical link

between women from more vulnerable groups and safe motherhood services. The states

political system serves to maintain the status quo distribution of resources for public

health services. Recent overtures from national leadership have not altered the equation

for priority attention to expanding access to rural health care, including maternal health

services, due to conflicts between parties at the state and national levels.

Comparative analysis of these cases has much to contribute to understanding our

empirical puzzle, as well as important factors and relationships in policy processes. The

same types of factors were at work in the policy processes in both states. Differing social

historical influences in each state; worldviews, priorities and degrees of power among

major political parties; strength and ideas of key policy actors; and capacity and norms in

the concerned public health bureaucracies shaped variation in availability and access to

publicly provided safe motherhood services in the two states.

The findings of this research depart from some of the more prominent frameworks

for analysis of policy processes in an important way. The findings emphasize connections

between policy and implementation or management, dimensions of policy processes that

tend to be treated as somehow distinct and amenable to separate analysis. The research

question in this study could not be sufficiently answered by focusing the analysis on


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agenda setting or public management factors and dynamics alone, however, suggesting

the need for a more holistic framework for analyzing policy processes.

This is not to suggest that scholars do not recognize the integral nature of various

stages, phases or dimensions of policy processes Sabatier and Jenkins-Smiths (1999)

advocacy coalition framework is highly developed in this regard. But existing

frameworks of analysis tend to be more geared toward understanding agenda setting or

policy change or organizational performance toward policy ends than toward

understanding the factors that connect them in a big picture sense. The results of this

study informed development of a more holistic framework of analysis that aims to

address this limitation of existing policy literature.

The results also suggest important refinements to our understanding of certain key

variables. Socio-economic and cultural variables are important to consider, but social

history referring to the historical organization of society and including such feats of

social organization as social movements, state formation and colonization is a neglected

factor that importantly shapes the more contemporary policy processes that are our most

common objects of study. Changes in governing coalitions or political leadership affect

policy agendas, but how is dependent on the worldviews, priorities and power of political

parties as revealed in this study. Lastly, policy actors need not be defined strictly in terms

of a particular phase of the policy process, but are more fruitfully conceived in terms of

multiple roles that may span the political-bureaucratic labyrinth in policy processes. This

understanding is crucial to overcoming analytic barriers between policy and

implementation in our frameworks of analysis.


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These points form some of the central contributions of this research to our

understanding of policy processes. The next section of this chapter discusses some of the

key ideas it draws on and responds to in public policy literatures.

THEORIZING THE POLICY PROCESS

Public policy processes are complex, involving a multitude of individual and

organizational actors, conflicting ideas, values and beliefs about how to define problems

and what to do about them, and various institutional, legal and societal norms, rules and

structures. This study is concerned with understanding how these factors and possibly

others affected the policy processes that led to differences in public sector performance

for safe motherhood in two Indian states. Existing approaches to policy analysis point to

a number of important factors and relationships some of which are well suited to

explaining our empirical puzzle and some of which this study suggests need refinement.

This promises to contribute to the development of better frameworks of analysis and to

further our understanding of their applications in different settings.

To begin, Baumgartner and Jones (1993) punctuated equilibrium model of

instability in American politics attempts to explain much of the policy process. It argues

that policy processes are characterized by lengthy periods of relative stability, of

incremental policymaking, that are occasionally disrupted by brief periods of wide-

ranging policy change. They explain that policy monopolies, stable sets of policy actors

supported by powerful structural arrangements and political understandings of an issue,

tend to exert significant influence on incremental policy processes within particular issue

areas or domains. These arrangements supporting policy ideas are generally

connected to core political values. The best are such things as progress, participation,


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patriotism, independence from foreign domination, fairness, economic growth things no

one taken seriously in the political system can contest (Baumgartner & Jones 1993, p.

7).

The main focus of their approach is to explain infrequent, short bursts of major

policy change that are characterized by the public attention-grabbing dynamics of agenda

setting that consumes officials time and resources. Competing ideas about the nature of a

policys contribution or impact or changes in central political values can create openings

for major change (Baumgartner & Jones 1993; Kingdon 1984; Sabatier & Jenkins-Smith

1999). According to Baumgartner and Jones (1993) model, changes to the structure of

political institutions and the way issues are understood by those institutions can

precipitate substantial policy change. For example, significant social movements, changes

in political leadership or shifting understanding of an issue from one of personal to

government responsibility could affect rapid policy change. As the authors suggest,

Public policymaking responds to the great cleavages of society, traditionally

organized by political parties (Baumgartner & Jones 1993, p. 21).

The approach to policy analysis presented by Baumgartner and Jones (1993) in

Agendas and Instability in American Politics draws attention to policy influences exerted

in the broader realm of macro politics, involving partisan political conflict. Major policy

change is set in motion by influences in the macro political environment and tends to

involve higher profile venues for authoritative decisions, such as those in the realm of

legislative or executive authority. Agenda setting in these arenas determines whether and

the extent to which certain issues receive attention and resources, as well as the operating

rules within which policy actors especially those representing the administrative state,


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but including technical experts and others with public and private policy interests

function within issue areas or policy domains, such as public health (Baumgartner &

Jones 1993; Redford 1969).

Baumgartner and Jones approach suggests that policy analyses need to account

for these larger cleavages, significant shifts in thinking about how to define and solve

public problems that are represented by political upheaval and changes of leadership, in

order to understand the ebb and flow of policy attention. It also suggests that these have

wide-ranging effects that can help to explain factors affecting decisions and actions in

policy domains. Their points are well taken, but require further inquiry to understand

their applicability to the Indian context. The focus on agenda setting is also limiting,

downplaying the power of policy entrepreneurs and communities that design and carry

out governmental programs of action that determine the availability and accessibility of

public services.

The advocacy coalition framework developed by Sabatier and Jenkins-Smith

(1999) suggests that major policy change is a function of power and conflict between

central groups of actors within policy subsystems. Drawing on Sabatier and Jenkins-

Smith (1999), the policy subsystem is an important concept used in this analysis to

refer to a subset of a larger socio-political system in which a fairly stable set of actors

influences government decisions and actions on issues within a policy domain in a given

jurisdiction, such as health policy in Tamil Nadu, over time. Like Baumgartner and Jones

(1993), the authors approach is sensitive to macro political influences, such as changes

in systemic governing coalitions (e.g. political leadership) and public opinion. These can

alter the terms of subsystem policymaking by shifting political support to different types


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of problems and solutions. Changes in socio-economic conditions, impacts from other

policy subsystems and other more stable factors such as basic constitutional and socio-

cultural structures, shape opportunities and constraints for advocacy coalitions to

influence authoritative government decisions.

The advocacy coalition framework features two central hypotheses concerning

policy change. It suggests that the central value- and belief-based commitments of a

governmental program of action are unlikely to be changed as long as the advocacy

coalition that instituted it retains power, unless change is imposed by a hierarchically

superior power or significant perturbations external to the subsystem (Sabatier & Jenkins-

Smith 1999). The latter are a necessary but not sufficient cause of change. While external

factors are important catalysts to change, the advocacy coalition framework is most

centrally concerned with attributes of and learning between groups of central actors in

policy subsystems as evidenced in its remaining seven hypotheses.

The advocacy coalition framework contains both a broader framework that

identifies several types of variables that should be considered in analyses of policy

processes and a theory of policy change and changes to core policy beliefs of actors

within subsystems. The framework and theory were developed based on the U.S. system

of policy and politics, containing implied assumptions about well-organized interest

groups, mission-oriented agencies, weak political parties, multiple decisionmaking

venues, and the need for supermajorities to enact and implement major policy change

(Sabatier & Weible 2007, p. 199). Sabatier (1998) and Sabatier and Weible (2007)

responded to criticisms of the models shortcomings in explaining policy processes in

European corporatist regimes and less democratic societies. They adapted the model to


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consider the degree of consensus needed for major policy change and the accessibility

and number of venues actors must navigate to reach a decision point on a policy proposal.

The framework, perhaps best suited to analysis of more open pluralist regimes, is quite

adaptable to analysis of a range of regime types including those requiring greater and

lesser degrees of consensus and more and less open political systems (Sabatier & Weible

2007). Indias political system certainly falls within these ranges.

The advocacy coalition framework is useful in terms of identifying variables and

suggesting causal relationships that might be important to this analysis. However, this

study is less concerned with the dependent variable major policy change change that

is broad in topic and scope (Sabatier 1998) and more concerned with the aspects of

public service provision that affect achievement of policy goals (e.g. equitable access to

maternal health services). The advocacy coalition framework implies that policy change

is the primary objective of policy communities, that their struggle is waged at a political

level that draws public attention and incites negotiation between political leaders in

prominent forums. The struggle to influence higher-level political agendas and policy

change has important implications for government decisions, actions and results, but this

study suggests that it does not adequately capture the roles of policy actors in connecting

policy agendas to public performance outcomes.

Kingdons streams model (1984, 1995) is another important theory of the policy

process. Its primary relevance here is to recognize the significance and roles of actors in

policy processes. According to Kingdons approach, policy entrepreneurs and other

members of policy communities frame ideas about problems and solutions, looking for

windows of opportunity to advance issues on policy agendas so that they receive serious


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attention from authoritative government actors. Kingdon emphasizes legislative and

executive actors in his agenda setting model, but suggests policy entrepreneurs and

communities may include those inside or outside government, in elected or appointed

positions, interest group representatives, academics, consultants, and representatives of

civil society organizations. Their power derives from different bases of influence, such as

expertise, a position of leadership or political connections, and collective action

surrounding shared concern about a particular policy issue or arena (Kingdon 1984,

1995).

Kingdon is primarily concerned with major legislative policy change and suggests

that administrative actors individuals and agencies are more instrumental in

specifying policy alternatives or choices than agenda setting, though this formulation

downplays administrative discretion as an important source of policymaking power

(Appleby 1949; Meier 1979; Rourke 1984; Walt 1994). As Rourke (1984) suggests in

Bureaucracy, Politics and Public Policy, The scope of administrative discretion is

vast in all societies both in the everyday routine decisions of government agencies and

the major innovative or trend-setting decisions of public policy (p. 37). Agents of the

administrative state have the authority to establish and pursue their own priorities within

broader mandates determined by constitutional structures and macro political institutions

and should not be overlooked (Meier 1979).

Indeed, in their advocacy coalition approach to policy analysis, Sabatier and

Jenkins-Smith (1999) propose that actors engaged in policy subsystems be defined

inclusively, with implementation actors as influential shapers of policy and action.

Advocacy coalitions, equivalent to policy communities, serve important functions in


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defining problems, generating and vetting policy solutions, and helping issues rise on

decision agendas. They can also play important roles in shaping plans, programs and

implementation as they often include the experts that inform and authorities that carry out

policy points cogently made by such scholars of policy implementation as Elmore

(1979), Lester and Goggin (1998), Lipsky (1980), Maynard-Moody (2000), and Vinzant

and Crothers (1998), and supported by the findings of this research.

Theories of the policy process also accord an important role to such factors as

core values, beliefs and ideas that contribute to the identification of problems, solutions,

and their importance relative to other societal issues. They motivate actors and define the

structures of political institutions and government programs (Baumgartner & Jones 1993;

Kingdon 1984, 1995; Sabatier & Jenkins-Smith 1999). Actors form collective action

efforts to advance their beliefs and ideas to points of authoritative decision, action and

institutionalization (Sabatier & Jenkins-Smith 1999), suggesting their interaction as

another defining aspect of policy processes.

Stones (2002) concept of causal stories is useful for understanding the

importance of framing ideas in policymaking processes. Actors use causal stories to

define problems in ways that assign responsibility, point to solutions and inspire

collective action on their behalf (Snow et al. 1986; Stone 2002). Stone (2002) offers two

useful and well known examples in which causal framing had these effects: in Silent

SpringRachel Carson (1978) persuasively reframed environmental degradation as a

consequence of human activity rather than a natural occurrence, inspiring environmental

activism; and in Unsafe at Any SpeedRalph Nader (1966) reframed injuries and deaths

from motor vehicle crashes not as a result of accidental factors but manufacturers


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inattention to safety features, inspiring organized consumer protection efforts. When

responsibility for problems can be assigned, especially through a short and clear causal

chain, policy communities are more likely to unite, to elevate issues on policy agendas

and to alter institutional structures to support them (Keck & Sikkink 1998; Snow et al.

1986; Stone 2002).

Ideas are a medium of exchange and a mode of influence even more powerful

than money and votes and guns. Shared meanings motivate people to action and meld

individual striving into collective action. Ideas are at the center of all political conflict.

Policy making, in turn, is a constant struggle over the criteria for classification, the

boundaries of categories, and the definition of ideals that guide the way people behave

(Stone 2002, p. 11). Indeed, the advocacy coalition framework and policy streams models

suggest that though policy communities are centered around interest in a given issue, that

does not imply agreement about how to define a problem or what should be done about it

(Kingdon 1995; Sabatier & Jenkins-Smith 1999). Conflicting ideas contribute to

fragmentation and reduced power of policy communities (Kingdon 1995; Shiffman &

Smith 2007). By the same token, the more ideas resonate and have salience within

existing political agendas and institutions, the more influence policy actors are likely to

have on decisions and action (Berman 2001; Keck & Sikkink 1998; Shiffman & Smith

2007; Stone 2002).

The institutional analysis approach also makes a relevant contribution to our

understanding of policy processes, suggesting that rules, norms and strategies structure

the incentives that shape the behavior of policy actors (Ostrom 2007). The term

institution, Ostrom (2007) explains, refers not to organizational units but to shared


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understandings of prescriptions for behavior that are subject to more and less formal

monitoring and sanction as organizations or society dictate (see also Crawford & Ostrom

2005). In other words, the shoulds and should nots contained in organizational rules

and societal norms shape the behavior of policy actors, and in turn the programs of action

they design and carry out. This analysis uses the term institution in the same sense,

drawing on the concept to contribute to our understanding of factors that shape decisions

and actions of actors in relevant policy subsystems and agencies.

Drawing on broader social theories of culture, the organizational culture

perspective speaks to the power of institutions and ideas. It suggests that shared values,

beliefs, assumptions and understandings shape the rules, policies, strategies, goals and

practices of organizations and their members (Martin 2002; Ott 1989; Schein 1992;

Smircich 1983; Wilson 1989). And, by extension, the rules and practices of societies and

their members are shaped by shared values, beliefs and understandings, as evidenced by

the influence of class, caste and gender dynamics and flowing over into the formal

institutions of the state.

The organizational culture perspective assumes that many organizational

behaviors and decisions are almost predetermined by the patterns of basic assumptions

existing in the organization. They become the underlying, unquestioned but virtually

forgotten reasons for the way we do things here, even when the ways are no longer

appropriate (Ott 1989, pp. 2-3). Organizational culture is a lens through which new ideas

are filtered in the administrative state to determine whether they fit with existing goals

and practices. The more ideas resonate with the institutions operating in central state

agencies and political organizations, the more likely they are to be integrated into the


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sense of mission that guides their behavior. Wilson (1989) suggests how high the stakes

can be on this point, stating, Tasks that are not defined as central to the mission are often

performed poorly or starved for resources (p. 110).

Systems of beliefs, values and ideas are represented in the structures of political

and administrative institutions the stated goals, policies and standard operating

procedures that guide the ways individuals and groups process information and act on it.

As Sikkink suggests, "New ideas do not enter an ideological vacuum. They are inserted

into a political space already occupied by historically formed ideologies. Whether or not

consolidation occurs often depends on the degree to which the new model fits with

existing ideologies (Sikkink quoted in Berman 2001, p. 236). Ideas gain power through

their institutionalization in social, political and administrative structures (Finnemore &

Sikkink 2001; Martin 2002; Ott 1989; Schein 1992). Ideas and structures are shaped by

the power of actors to reinforce them or influence change over time (Keck & Sikkink

1998; Snow et al. 1986; Stone 2002). This is the stuff of policymaking from the setting

of agendas to authoritative decisions and goal pursuit.

CONCLUSION

This dissertation draws upon these theories of the policy process in order to

examine its empirical puzzle more and less equitable rates of access to safe motherhood

services among women in two South Indian states and the policy process contribution to

that variation.

This study departs from existing frameworks of analysis in two important ways.

First, it is less concerned with major policy change as the dependent variable. It is

difficult to form a direct link between major policy change as conceptualized in the


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policy streams, punctuated equilibrium and advocacy coalition frameworks of analysis

and changes in safe motherhood policies, programs and outcomes in our cases. There is

very little evidence to support a model in which policy communities waged high profile,

conflict-ridden campaigns targeting legislative or executive venues to affect major policy

change and even less to indicate that major policy change directly resulted in differences

in availability of and access to safe motherhood services in either case.

Rather, differences in the capacity of the health systems, the institutional norms,

and the actors and ideas operating in the health policy arena in each case shaped varying

degrees of availability and access to safe motherhood services, the latter particularly in

recent years. Importantly, the policy community that affected change in Tamil Nadu in

the past twelve to fifteen years was rather insulated. Its primary support came from

bureaucratic leaders. These leaders championed the cause, networking with other

members of the policy community, framing ideas about maternal mortality reduction in

ways that appealed to political principals and exercising their discretion to integrate

priority for the cause into the states vast public health service delivery network. This

finding suggests that organizational structures, as well as political-bureaucratic actors and

ideas, importantly shape the relationship between policy processes and outcomes a

central concern of this study.

But differences in the political environments and social history of the two states

also made important contributions to shaping policy processes and outcomes in the cases.

Existing frameworks of analysis point to change in governing coalitions as an important

factor affecting policy agendas, but in Tamil Nadu this did not make a difference on its

own. It was consistencies in the nature of the worldview, priorities and strength of Tamil


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Nadus governing coalitions and their opposition that provided continuous opportunities

for the safe motherhood policy community to promote their cause. In Karnataka, these

conditions had the opposite effect, providing few opportunities for strong advocacy to

emerge and take hold. There was also variable consistency in Karnatakas political

priorities as weak governing coalitions fell from and ascended to power. Differences in

political environments, although both featured competitive multi-party politics, affected

systematic differences in policy processes, performance and outcomes in the states. In

addition, differences in the states social histories Tamil Nadus widespread social

movement and Karnatakas formation of disparate regions lacking a cohesive political

identity were instrumental in shaping these varying political environments and

subsequent policy processes. This factor is neglected in existing frameworks of analysis.

To summarize, this study is interested in more than what it takes for items to rise

on policy agendas, to come to points of decision or to achieve successful implementation

it is interested in understanding holistically which types of factors and what types of

relationships in policy processes affect varying policy outcomes. This is a tall order and

one that comes with costs in terms of specificity and certainty. But it is an order that

comes with the rewards of identifying neglected factors, refining under-specified

variables and pushing the boundaries of our frameworks of analysis so that we can better

understand the range of factors and relationships that affect policy outcomes on pressing

social issues.

These are a few of the contributions this study makes to our understanding of

policy processes. To conclude, this chapter has set out the theoretical questions examined

in this dissertation and discussed relevant conceptual and theoretical contributions from


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public policy literatures. Chapter 2 discusses the policy and country contexts for the

study, providing background information on the global safe motherhood crisis, linking

safe motherhood with broader health systems policy issues, and profiling the Indian cases

that inform this study. Chapter 3 provides further discussion of the study design, data and

measures taken to support validity. Chapters 4 through 6 present the case evidence in

comparative perspective. The first empirical chapter examines the relationship between

social conditions and safe motherhood outcomes; the second, political influences; and the

third, bureaucratic influences on the programs of action that shape access to safe

motherhood services in Tamil Nadu and Karnataka. The concluding chapter summarizes

the results and draws implications for public policy scholarship.


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CHAPTER 2

SAFE MOTHERHOOD: PROFILE & PUBLIC POLICY


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INTRODUCTION

Safe motherhood first gained international attention as a significant problem, one

primarily affecting the developing world, two decades ago when the World Health

Organization released the first estimates of the global maternal mortality burden. Since

then, global advocates have mobilized research efforts to improve understanding of the

scope and nature of the problem, organized technical conferences to promote particular

interventions and raised global awareness of the problem at international meetings and

events. Published work by such scholars as AbouZahr (2001, 2003), Campbell (2001)

and Shiffman and Smith (2007) chronicle policy developments pertaining to the global

safe motherhood initiative. Shiffmans work contributes to our understanding of how safe

motherhood rose on policy agendas in Guatemala, Honduras, India, Indonesia and

Nigeria (Shiffman 2007; Shiffman & Garces del Valle 2006; Shiffman & Ved 2007). But

there is very little understanding of how policy processes affect outcomes on this issue in

high burden countries beyond this work.

Knowledge of safe motherhood tends to be developed based on a more narrow

technical perspective rather than lenses of analysis that facilitate understanding of the

political tides that affect investment in broader health and social policies, and maternal

health in turn. The first section of this chapter draws on that more technically oriented

literature to describe the scope of the global maternal mortality crisis that takes the lives

of more than half a million women annually (WHO 2007). It elucidates key safe

motherhood indicators, causes of death and interventions recommended by the global

policy community concerned with the issue. This is intended to provide readers with

background on the state of knowledge and current thinking on the issue. It also describes


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the context for safe motherhood policy and implementation in the developing world. The

tone of this section reflects the technical tone and narrow focus of much scholarship on

the matter up until it was more recently linked with the influence of the strength of

broader health systems. Relevant health systems literature is briefly discussed because it

enhances our understanding of the linkages between the technical issues surrounding safe

motherhood and related health policy and system issues that play into policy processes.

The latter part of this chapter turns to the Indian context and cases examined in

this study. India accounts for a quarter of the global maternal mortality burden (WHO

2007). Safe motherhood recently gained agenda status at the national level in India

(Shiffman & Ved 2007), but that does not explain historical policy developments and

outcomes or guarantee impacts at the sub-national level. Largely decentralized authority

for health policy and implementation to the state level and varying outcomes at the sub-

national level beg the question of how policy processes make a difference for access to

maternal health care at this level. This study responds to that need through comparative

case studies that provide insights to the empirical puzzle and further our knowledge of

important factors and relationships in policy processes.

SAFE MOTHERHOOD: SCOPE, CAUSES & INTERVENTIONS

A maternal death is defined as the death of a woman while pregnant or within 42

days of termination of pregnancy (WHO 2004, p. 3). More than half a million women

die related to pregnancy and childbirth every year worldwide, a figure that has held

steady for twenty years (WHO 2007). Further, ninety-nine percent of maternal deaths

occur in the developing world with Sub-Saharan Africa and South Asia accounting for 86


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percent of global maternal deaths (WHO 2007). One in four maternal deaths occur in

India.

Globally, the maternal mortality ratio (MMR) is the most widely used indicator to

denote the extent of the problem. The maternal mortality ratio the number of maternal

deaths per 100,000 live births within a specified time period indicates the probability of

a woman dying once she is pregnant. The ratio controls for fertility rates.1 World MMR

was estimated at 400 for 2005 (WHO 2007). To give a sense of variation in maternal

mortality ratios globally in 2005, Sierra Leone featured the highest MMR in the world at

2,100; Nigerias MMR was 1,100; Indias 450; and Irelands, the lowest MMR in the

world, 1 (WHO 2007). Table 2.1 shows select maternal mortality ratios estimated for

2005, along with lower and upper estimates as reported by the World Health

Organization (2007). Some of Indias south Asian neighbors are included to give a sense

of the scope of the problem in that region. Sri Lanka is a successful anomaly among

South Asian nations, benefiting from government investment in the health system and

strategic efforts to expand access to maternal health care (Pathmanathan et al. 2003).

Although a tremendous gap in this important maternal health indicator is readily

observed between developed and developing nations, caution should be exercised in

using individual country estimates to compare across countries or time periods (Stanton

et al. 2000; WHO 2007). There are differences in data sources across countries, data

reliability is a problem and different methods have been used to develop estimates over

1 The maternal mortality rate, based a ratio of the number of maternal deaths to thenumber of women of reproductive age during a given time period, is another indicatorsometimes used. It does not control for fertility rates and is not reported on further in thisstudy. For deeper analysis of safe motherhood indicators and measurement methods, seeGraham et al. 1989, Stanton et al. 2000 and WHO 2007.


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time. In addition, confidence intervals that are used to indicate the statistical reliability of

maternal mortality estimates are large, due to the limited numbers of maternal deaths in

short time periods and sample sizes of surveys used to produce estimates (Graham et al.

1989; Stanton et al. 2000).

Table 2.1 Global maternal mortality ratios with confidence intervals

MMR Lower Estimate Upper Estimate

World 400 220 650

Sierra Leone 2100 880 3700

Nigeria 1100 440 2000

Bangladesh 570 380 760

India 450 300 600

Pakistan 320 99 810

Sri Lanka 58 39 77

Ireland 1 1 2

Source: WHO 2007

The issue of data limitations is an important one. In their study assessing maternal

mortality indicators in 13 countries based on Demographic and Health Survey data

commonly used by developing country governments and international donor agencies,

Stanton, Abderrahim and Hill (2000) found severe limits to data quality on time of death

recorded relative to pregnancy, childbirth, and the postpartum period and suggested

maternal mortality is under-reported though likely to a greater extent in the more distant

than recent past (p. 120). Graham and colleagues (1989) and Ronsmans and colleagues

(1997) issued similar cautions regarding the reliability and use of estimates. Despite


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measurement difficulties, the maternal mortality ratio offers an important window onto

the problem and has become a key indicator for assessing the state of maternal health

globally and nationally.

What causes maternal mortality? Leading direct causes of maternal death include

hemorrhage, hypertensive diseases, sepsis/infection, obstructed labor and complications

of abortion (Khan et al. 2006; Ronsmans & Graham 2006). Scholars suggest the means

of averting maternal deaths have long been available (Campbell 2001; Maine &

Rosenfield 1999, p. 480). But access to and availability of life-saving interventions are

not necessarily so straightforward. Thaddeus and Maines three delays framework is

useful for understanding this (1994). Through a review of maternal health research,

Thaddeus and Maine identified the time that elapses after the development of an obstetric

complication as crucial to determining obstetric outcomes. Three types of delays

emerged: delays in the decision to seek care, delays in reaching a health facility and

delays in provision of adequate care at health facilities.

It is important to understand that it is common practice for women in the

developing world to deliver in the home contrasting with Western bio-medical

childbirth norms of the modern era. The three delays are based in recognition that home

deliveries in developing countries are commonly attended by unskilled family members

or lay birth attendants that are not trained to recognize or manage obstetric complications;

that women and their families often lack access to financial resources and transportation,

resulting in delays in reaching health facilities; and that provision of adequate care is not

guaranteed in health systems that lack capacity in terms of human, technical and financial

resources. This framework facilitates understanding of macro-level health systems


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limitations, as well as social barriers that play out at the micro level, such as gender and

cultural dynamics that influence family decisions about maternal health care. Maternal

mortality reduction is about more than a set of direct causes and technical interventions; it

is about constraints and opportunities to addressing these barriers within relevant policy

subsystems, and in macro political and social spheres of influence thus helping to

inform the research questions of interest to this dissertation.

The safe motherhood policy community has developed a number of maternal

mortality reduction strategies taking social conditions and the state of health care systems

in developing countries into account over the past twenty years. Some of the more

prominent have been increasing training of traditional birth attendants, provision of

antenatal care and risk screening, attendance of skilled health professionals at births and

availability of emergency obstetric care (AbouZahr 2001, 2003; Campbell 2001; Hussein

et al. 2005; Maine & Rosenfield 1999; Miller et al. 2003; Paxton et al. 2005). Skilled

birth attendance, institutional delivery rates and antenatal care use are key safe

motherhood indicators in addition to the maternal mortality ratio.

It should be noted that the three delays model, safe motherhood indicators and

maternal mortality reduction strategies and recommendations discussed in the paragraphs

above and below are tailored to developing country contexts. Emergency obstetric care in

the event of life-threatening complications tends to not be readily available outside urban

areas and accessing it is cost prohibitive for many families. There are also significant

gaps in identification of high-risk pregnancies that should be referred for delivery with

the assistance of medical professionals in developing country settings. There is a body of

research demonstrating that planned home deliveries for low risk pregnancies result in


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similar outcomes, often with fewer medical interventions, as hospital deliveries attended

by medical professionals in industrialized North American and European settings. See

(OConnor 1993) for background on the home birth movement in the United States and

large-N studies by Duran (1992), Olsen (1997) and Johnson and Daviss (2005) for

additional information on this research. The global safe motherhood policy community

focuses on issues affecting women in the developing world an entirely different set of

circumstances from those women face in industrialized nations. They recommend skilled

care for women during pregnancy and childbirth and access to emergency care. These

criteria are difficult to meet outside of institutional settings and in many cases not even

then. Recognizing that institutional delivery rates are an imperfect indicator of maternal

health outcomes, this study nonetheless uses it as a key indicator of the state of maternal

health care in conformance with the global safe motherhood policy communitys

recommendations for developing country contexts.

In October 2007, a special issue ofThe Lancetdedicated to safe motherhood

reported on three key recommendations for maternal mortality reduction that were agreed

upon in the global safe motherhood policy community:

First, comprehensive reproductive health care, including family planning and safe

abortion, or where necessary, postabortion care. Second, skilled care for all pregnant

women by a qualified midwife, nurse, or doctor during pregnancy and especially

during childbirth. Third, emergency care for all women and infants with life-

threatening complications (Starrs 2007).

In the same issue, Freedman (2007) discussed the strength of health systems as integral to

the effectiveness of these strategies (Starrs 2007), an approach consistent with the World


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Health Organizations World Health Report 2000 and a recent report from the United

Nations Millennium Project Task Force (2005).

This understanding of safe motherhood problems, solutions and outcomes

specific to the issue as importantly shaped by broader health systems and the social,

political and administrative dynamics that shape them is important to the model of the

policy process developed in this thesis. This helps us to understand the influence of other

priorities in decision venues and how their impacts on programs of action might facilitate

or hinder progress for safe motherhood. It also reveals several practical health system

constraints and challenges to improving access to safe motherhood services.

Health systems

Recent scholarship on health systems defined as all the activities whose primary

purpose is to promote, restore or maintain health by the World Health Organization

(2000, p. 5) draws attention to the significance of the overall organization, resources

and responsiveness required to provide for the health needs of populations. This is in

contrast to programmatic and policy emphasis on narrowly defined health issues, such as

HIV/AIDS, malaria, family planning or safe motherhood, that tend to be the foci around

which policy communities form in the global health arena and which subsystem policy

analysis tends to emphasize. According to the World Health Organization and others,

health systems encompass the institutions and individuals engaged in formal health

services, such as professional medical care, traditional healers, home care, health

promotion and prevention of ill-health, as well as mechanisms for its provision (e.g.

insurance) and regulation (Reich et al. 2008; UN Millennium Project Task Force 2005;

WHO 2000).


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In its The World Health Report 2000 Health Systems: Improving Performance , The

World Health Organization stated:

Combating disease epidemics, striving to reduce infant mortality, and fighting for

safer pregnancy are all WHO priorities. But the Organization will have very little

impact in these and other battlegrounds unless it is equally concerned to strengthen

the health systems through which the ammunition of life-saving and life-enhancing

interventions are delivered to the front line (2000, p. xii).

After years of channeling attention and resources to vertical disease-specific

programming designed for cost-efficiency and to bypass the shortcomings of health

systems, global health policy communities are increasingly recognizing the importance of

broader systems of health care delivery for shaping outcomes. This represents a

significant shift in thinking about how to alleviate health problems, particularly in low-

and middle-income countries a shift reminiscent of the primary health care movement

linked with the Alma Ata Health for All declaration of 1978 (Campbell 2001).

To this point, Gilson (2003) has importantly observed that health systems are

complex socio-political institutions and are part of the social fabric of every country

(p. 1461). Freedman (2005) shares this view, observing, Societal values and norms are

signaled and enforced not only through interpersonal relationships, but also in the very

structure of a health system (p. 21). Like Gwatkin and colleagues (2004), they call

attention to how health systems tend to reflect and produce social inequities such as those

defined by caste, class and gender relations in societies, linking institutional rules and

norms in social, political and administrative spheres of influence to more and less

equitable health outcomes a phenomena of interest to the present research.


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Central health systems constraints and strategies to overcome them have received

a good deal of attention from health policy scholars. In a 2004 article in The Lancet,

Travis and colleagues stated, there is growing consensus that a primary bottleneck to

achieving the MDGs [Millennium Development Goals2 which include maternal

mortality reduction] in low-income countries is health systems that are too fragile and

fragmented to deliver the volume and quality of services to those in need (p. 900). Major

health systems constraints include shortfalls in health human resources, financing,3

information systems, equipment and drug supply, infrastructure, weak management and

poor regulation (Hanson et al. 2003; Murray & Frenk 2000; Oliveira et al. 2003; Reich et

al. 2008; Travis et al. 2004; WHO 2000).

Drawing on the World Health Organization report of the Commission on

Macroeconomics and Health (2001), Hanson and colleagues (2003) suggested infusion of

additional financial resources could reduce constraints to taking up priority interventions

that would strengthen health systems and promote specific health goals: for example, at

the community level lack of demand and barriers to use; and at the health services level,

shortages and distribution of staff, weak supervision and technical guidance, inadequate

drug, medical and equipment supply, and infrastructure. However, health sector policy

and strategic management constraints affecting these and other weaknesses would depend

2 The Millennium Development Goals set a target date of 2015 to alleviate a number ofpressing social problems, including poverty, education and health goals, that UnitedNations member states agreed to at the turn of the century. Goal five aims to improvematernal health by reducing the global maternal mortality ratio by 75 percent from 1990levels.3 For a comprehensive assessment of health systems finance needs and issues, see theWorld Health Organization report of the Commission on Macroeconomics and Health(2001). Hongoro and McPake (2004) provide an overview of global health humanresources constraints.


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more upon support from political actors, the context for reform (e.g. corruption), and

inter-sectoral policies such as civil service rules and budgeting and planning frameworks

(Hanson et al. 2003). The authors suggest political factors and certain types of policies

are important to strengthening health systems, but the dynamics of policy processes and

how they matter remains neglected in this literature. This study addresses this gap.

THE SCOPE OF INDIAS MATERNAL MORTALITY CRISIS

This section presents an outline of the problem nationally using key indicators in

order to provide context for the subsequent discussion of public policy and safe

motherhood in India, as well as case selection and profiles. The scope of Indias safe

motherhood problem is substantial with the country accounting for far more maternal

deaths than any other nation. This is partly a function of the size of Indias population.

The status of Indias maternal mortality ratio was on par with the average for other

developing nations in 2005 (WHO 2007). As reported by the World Health Organization

(2007), Indias maternal mortality ratio was fifty times the average for developed regions

of the world (450 compared to 9 maternal deaths per 100,000 live births).

Not comparable with the estimates developed by the World Health Organization,

UNICEF and UNFPA reported above due to differing methodologies, the Registrar

General of India estimated the nations maternal mortality ratio at 301 (95% Confidence

Interval 285-317) for 2001-3, a reduction of nearly 25 percent from 1997-8 (Registrar

General of India 2006). This survey provides the most reliable source of data on maternal

mortality ratios at the sub-national level in India. The Registrar General also reported that

less than thirty percent of all births in India took place in a public or private health care


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institution in 2003.4 Leading causes of death included haemorrhage (38%), sepsis (11%),

and unsafe abortion (8%) (Registrar General of India 2006).

As noted in the previous chapter, safe motherhood indicators tend to vary among

Indian states along the lines of socio-cultural and development indicators. Women in the

Empowered Action Group states of Bihar and Jharkand, Orissa, Madhya Pradesh and

Chattisgarh, Rajasthan, Uttar Pradesh and Uttaranchal, and Assam suffered maternal

mortality at rates disproportionate to their representation in the female population overall,

while women in the southern states of Andhra Pradesh, Karnataka, Kerala and Tamil

Nadu were under-represented in this figure (Registrar General of India 2006). The

Empowered Action Group is a set of states in northern India thus designated for their

relatively low socio-economic indicators among Indian states. In contrast, South Indian

states are known for their relatively advanced socio-economic indicators and, in the

Indian context, somewhat more advanced ideas about gender equity.

The maternal mortality ratio for the Empowered Action Group states in 2001-3

was 438 (95% Confidence Interval 410-467) compared to 173 (95% Confidence Interval

144-202) for the southern states. Other major states, including Gujarat, Haryana,

Maharashtra, Punjab and West Bengal, featured an MMR of 199 (95% Confidence

Interval 178-220) during the same time period. We do not have reliable, comparable

estimates of MMR at the state level for historical comparison. As discussed earlier in the

4 It should be noted that what constitutes an institutional delivery varies substantially.Deliveries are counted as institutional regardless of the level of health facility ortraining of staff in attendance. Quality of facilities and equipment also variessignificantly. The empirical chapters of this thesis elaborate upon some of the variation inpublic sector institutional delivery services. Limited though this measure is, it is one ofthe best available indicators of the state of maternal health services and access in India.Quality of care related to institutional delivery and other safe motherhood services is animportant and neglected issue.


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chapter, the figures reported on this indicator should be approached with caution due to

large confidence intervals that make inter-state comparisons difficult. Other key safe

motherhood indicators should be consulted to gain a better understanding of relative

progress among states.

Institutional delivery rates reflected similar disparities among these groups at 16

percent in the Empowered Action Group states and Assam, 64 percent in the southern

states, and 34 percent in the other major states (Registrar General of India SRS 2006).

The Registrar Generals report (2006), Maternal Mortality in India: 1997-2003,

concluded that attendance of skilled health professionals at births and institutional

deliveries needed to be expanded to reduce maternal mortality in India further, especially

in the Empowered Action Group states and Assam. This is consistent with global safe

motherhood recommendations cited previously (Starrs 2007).

PUBLIC POLICY & MATERNAL MORTALITY IN INDIA

Indias safe motherhood crisis is an interesting and important context in which to

study policy processes. To begin, though Indias safe motherhood problem is significant

and general goals for maternal mortality reduction are documented in national health

policies since the early 1980s, the issue received little meaningful attention or resources

from Indias national government until the 2004 national election (Shiffman & Ved

2007). A new government that promised attention to social equity goals rose to power in

2004 with a mandate to expand access to health services in rural areas. Attention from

prominent national figures and unprecedented resources dedicated to maternal mortality

reduction goals followed in the Government of Indias sweeping National Rural Health

Mission policy introduced in 2006. As promising as this increase in attention and


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resources was, it remains unclear whether national priority for maternal mortality

reduction forms a sufficient basis for alleviation of the problem in India. It certainly did

not play a substantial role in Tamil Nadus early policy attention to the issue. Shiffman

and Ved (2006) noted the generation of state level commitment for the issue as a key

challenge to achieving progress.

The structural devolution of health policy to the sub-national level in India is an

important consideration in designing and conducting this analysis. Constitutionally,

health policy is on Indias concurrent list a responsibility shared by the national and

state governments. The federal government has some influence as it sets national health

policy goals, develops programs and funds a portion of states health activities. In

practice, Indias states are largely responsible for health policy and implementation,

including a significant role in service delivery. States fund the greater proportion of

public health services and activities (Government of India 2005), giving local political

priorities substantial influence over the sector. The National Rural Health Mission

strengthens the influence of priorities determined through state-level political processes

with its emphasis on devolution of this responsibility to the local level. The structure of

responsibility for health policy and implementation in India suggests states are an

important level to analyze policy processes affecting safe motherhood. Further, scholars

of public policy processes suggest that diverse outcomes are common at the sub-national

level, especially in less centralized systems (Baumgartner & Jones 1993; Walt 1994),

suggesting this as an important level of analysis.

The cases selected for analysis in this study feature varying safe motherhood

outcomes and relatively comparable socio-cultural and economic indicators. This latter


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feature helps to control to the extent possible for social influences on safe motherhood

outcomes so that the affects of and relationships between macro political and subsystem

policy dynamics may be more readily observed. Case studies of the south Indian states of

Tamil Nadu and Karnataka, states historically comparable on the bases of similar socio-

cultural and economic indicators, raise important questions about what explains varying

outcomes. Their comparable social structures and location within the same federal

structure of government positions the cases well to help answer our empirical question

about how policy processes have contributed to varying rates of access to safe

motherhood services in the two states, as well as to reveal important factors and

relationships in policy processes.

Table 2.2 below summarizes key data on both states and India to examine further

the comparability of Karnataka and Tamil Nadu on select social and economic indicators

and show their relationship to key health indicators. It should be noted that both states

compare favorably to Indias averages and the states historical figures are crucial to

establishing the bases for their comparison. The Government of India (2002) reported

that the per capita net domestic product, incidence of poverty and level of human

development in Karnataka compared favorably to Tamil Nadu dating to the early 1980s.

The poverty rate in Karnataka was, in fact, quite a bit lower than in Tamil Nadu (38

versus 52 percent). On another important indicator, female literacy, Tamil Nadu led

Karnataka by seven to eight percentage points in the early 1990s on into the early 2000s.

Importantly, these social and economic indicators were associated with closely

comparable fertility and infant mortality rates, key public health indicators, between the

states in the early and late 1990s as reported in the National Family Health Surveys (IIPS


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2007). Total fertility rates continued to be comparable in the 2005-6 surveys, while infant

mortality rates declined to a greater extent in Tamil Nadu than in Karnataka (IIPS 2007).

Significantly, institutional delivery rates (the best historically comparable maternal health

data we have) show disparities between the states dating to the first National Family

Health Survey in the early 1990s while other key health indicators remained closely

comparable. In other words, Karnataka and Tamil Nadu are historically comparable on

key economic, social and health indicators with the exception of maternal health and this

presents an interesting puzzle for investigation. If social and economic indicators do not

fully explain the disparities, then what can help us to explain this variation?

This chapter continues with a brief introduction to the states to familiarize the

reader with their general geographic, socio-economic and health profiles. Chapter 4

compares relationships between key socio-economic indicators and safe motherhood

outcomes in the two states in much greater detail and further discusses their relevance to

answering the research questions.


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Table: 2.2 Summary data on India, Karnataka and Tamil Nadu

India Karnataka Tamil Nadu

Past Recent Past Recent Past Recent

Per capita net

domestic product,

1981-2/1997-8

1,671 2,840 1,584 2,866 1,570 3,141

Below poverty line

(%), 1983/1999-200044 26 38 20 52 21

Human development

index (HDI),

1981/1991

0.302 0.381 0.346 0.412 0.343 0.466

Female literacy rate,

1991/200139 54 44 57 51 65

Total fertility rate,

1992-3/2005-63.4 2.7 2.9 2.1 2.5 1.8

Infant mortality rate,

1992-3/2005-6

79 57 65 43 68 31

Institutional delivery

rate, 1992-3/2005-626 41 39 67 64 90

Sources: India National Human Development Report 2001(Government of India 2002)

for population figures, per capita net domestic product, poverty line, human development,

and female literacy rate; IIPS (2007) National Family Health Survey data for fertility,

infant mortality and institutional delivery rates


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Note: The infant mortality rate indicates the probability of a child dying before her first

birthday; the fertility rate indicates the average number of births per woman

Karnataka

Karnataka is located in south India. It borders Kerala and Tamil Nadu to the

south, Andhra Pradesh to the east, Maharashtra to the north and Goa tucked in at the

northern tip of the states western coastline along the Arabian Sea. In 1956, Karnataka

state (called Mysore until 1973) was formed along linguistic lines of Kannada-speaking

areas of five territories, including Bombay, Hyderabad, Madras, the former princely state

of Mysore and the independent state of Coorg (Government of Karnataka 2006). The

states 191,791 square kilometers encompass mountains, plateaus and coastal areas

(Government of Karnataka 2006). Karnatakas population numbered 52.7 million in

2001, sixty-six percent residing in rural areas (Government of India 2001). In 1999-2000,

per capita net state domestic product stood at 16,343 Rupees (about $413 US), leading

Indias average of 15,562 Rupees (about $390 US) (Government of India 2002).

Agriculture made up a third of net state domestic product in 2000 while industry (16

percent) and services (54 percent) accounted for the remainder (Government of India

2001). Fifty-six percent of workforce labor was agricultural (Government of India 2001).

The proportion of the population living below the poverty line decreased from 38 percent

in 1983 to 33 percent in 1993-4 to 20 percent in 1999-2000 (Government of India 2002).

Among major religions, Hindus made up 84 percent of the population, Muslims 12

percent and Christians 2 percent in 2000 (Government of India 2001).

Karnatakas standard human development indicators have improved over time

and compare favorably with Indias, just leading nationwide averages on several


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measures. In 2001, the state led the all-India average on the Human Development Index5

(0.478 to 0.302) and Gender Development Index (0.637 to 0.609) (Government of

Karnataka 2006). Literacy rates were at 67 percent compared to 65 percent and reflected

similar male-female gaps: male literacy rates stood at 76 percent in both settings and

female literacy at 57 percent in Karnataka and 54 percent in India overall (Government of

India 2001). On the sex ratio, an important indicator of the status of women in society,

Karnataka led the national average at 964 compared to 933 females per 1,000 males

still reflecting a significant gender gap, though not as wide as nationally (Government of

India 2001).

Health indicators in Karnataka have improved steadily over time and lead Indias

averages. Life expectancy in Karnataka is more that two years longer than the countrys

average at 63.3 years (Government of India 2002). Fertility declined from nearly three

children per woman in the early 1990s to 2.1 in 2005-6 while the national average stood

at 2.7 (IIPS 2007). Infant mortality rates experienced a notable decline of approximately

one third over the same period with 43 deaths per 1,000 live births in Karnataka in 2005-

6 compared to 57 nationally (IIPS 2007).

Karnataka has also made progress on safe motherhood indicators. Between the

1992-3 and 2005-6 National Family Health Surveys, overall institutional delivery rates

increased from 39 to 67 percent (IIPS 2007). According to National Family Health

Survey figures, both rural and urban institutional delivery rates increased substantially.

5 The United Nations Development Programme has used the Human Development Indexsince 1990 as a broad measure of well being based on life expectancy, educational andeconomic indicators. India was ranked 126th of 177 countries in the 2006 report (UNDP2006). The Gender Development Index, introduced in 1995, is an adjusted measure ofhuman development that accounts for gender disparities. Scores on the indexes rangefrom 0 to 1, with higher scores indicating relatively higher levels of human development.


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Rural rates increased from 27 to 57 percent while urban rates increased from 68 to 85

percent (IIPS 2007). It should be noted, however, that the respected Sample Registration

System (Registrar General of India 2006), with its larger sample size and more rigorous

methods of data collection, reported overall institutional delivery figures more

conservatively at 41 percent in 1991 and 50 percent in 2003. Both reports show the state

leading Indias averages by more than one and a half times, suggesting the state of

maternal health is somewhat more advanced in the state than nationally. Assistance of a

skilled health professional (doctor, nurse or other) at deliveries, another important safe

motherhood indicator, increased from 47 to 71 percent between the 1992-93 and 2005-06

surveys (IIPS 2007).

That said state-level figures and rural-urban comparisons do not capture regional

differences in institutional delivery rates. The gap between the lowest performing

districts, Koppal and Raichur at 21 percent, and the highest performing districts, Udupi,

Dakshina Kannada and Bangalore Urban all in the ninetieth percentile, is wide

(Government of India 2004). All eleven of the states northern districts6 track at or below

the median (61 percent in Belgaum) among twenty-seven districts, suggesting regional

dynamics may be at work in determining safe motherhood outcomes in the state. There is

a precipitous drop in institutional delivery rates between the top performers in the

ninetieth percentile and the next tier of performers in the seventieth percentile (five

districts). So while the northern districts draw down state-level figures, this forms an

incomplete explanation for lagging safe motherhood performance in the state.

6 According to the Karnataka Human Development Report 2005, the northern districtsinclude Bidar, Gulbarga, Raichur, Koppal, Bellary, Bijapur, Bagalkot, Belgaum, Gadag,Dharwad and Haveri.


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Lastly, Karnatakas maternal mortality ratio compared favorably to Indias overall

ratio of 301 [95% Confidence Interval 285-317] in Sample Registration System reporting

for 2001-2003. The states maternal mortality ratios showed a decline from 266 [95%

Confidence Interval 202-331] to 228 [95% Confidence Interval 169-287] deaths per

100,000 live births between the 1999-2001 and 2001-2003 Sample Registration System

surveys (Registrar General of India 2006). Trends are not possible to assess with

certainty, however, because of the large overlap between confidence intervals and long-

term MMR data are not yet available at the state level. As noted previously, maternal

mortality ratios are best considered in relationship to other safe motherhood indicators.

Tamil Nadu

Tamil Nadu is Indias southernmost state occupying its eastern coastline. It

borders Kerala is to its west, Karnataka to the northwest and Andhra Pradesh to the north.

The states territory covers 130,000 square kilometers and includes coastal regions,

plains, valleys and mountainous areas. The modern era of the past 60 years saw Tamil

Nadu formed of the pre-independence territory of the Madras Presidency, but Tamil

language and history dates back nearly 6,000 years (Government of Tamil Nadu 2003).

With a population of over 62 million, Tamil Nadu is one of Indias most populous states.

Fifty-six percent of its population resides in rural areas (Government of India 2001). It is

also one of the most prosperous of Indias states with per capita net state domestic

product of 19,141 Rupees (about $470 US) in 1999-2000 compared to Indias average of

15,562 Rupees (about $382 US) (Government of India 2002). The high tech boom has

had an important on the economies of Tamil Nadu and Karnataka, especially in their

capital cities. Agriculture remains a significant sector in Tamil Nadu, accounting for 65


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percent of workforce labor and nearly 20 percent of net state domestic product

(Government of Tamil Nadu 2003). Services (58 percent) and industry (24 percent) make

up the remainder. The proportion of the population living below the poverty line declined

from 52 percent in 1983 to 35 percent in 1993-4 and 21 percent in 1999-2000

(Government of India 2002). The vast majority of the population is Hindu (88 percent),

but the state also features significant Christian (6 percent) and Muslim (5.6 percent)

populations (Government of India 2001).

Standard human development indicators depict Tamil Nadu as a fairly progressive

Indian state. Tamil Nadu leads the all-India average on the Human Development Index

(0.531 to 0.302 in 2001) and Gender Development Index (0.813 to 0.676 in 1991)

(Government of India 2002; Government of Tamil Nadu 2003). The state enjoys

relatively high literacy rates, 73 percent compared to Indias overall rate of 65 percent

(Government of India 2001). However, the gender gap in literacy nationally is also

reflected in Tamil Nadu. Female literacy is 65 percent compared to male literacy at 82

percent in the state while Indias rates are 54 percent and 76 percent respectively

(Government of India 2001). Although the status of women in Tamil Nadu may be

considered somewhat advanced relative to other parts of India (Basu 1990), the state is

not spared the phenomenon of Indias missing women (Sen 1992) as indicated by a sex

ratio of 986 females per 1,000 males (Government of India 2001). It is more equitable

than the all-India average of 933 females per 1,000 males, however. Lastly, it is

important to note that Tamil Nadus development indicators have also shown steady

improvement over time.


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Tamil Nadus health indicators are also relatively favorable and have improved

markedly in the past fifteen years. To begin, life expectancy, the infant mortality rate and

the fertility rate in Tamil Nadu are advanced compared to India overall. At 64.1 years,

life expectancy in the state is three years greater than the countrys average (Government

of India 2002). Fertility declined from 2.5 children per woman in the early 1990s to

below the replacement rate, 1.8 children in 2005-2006 in Tamil Nadu, while it hovers at

2.7 nationally (IIPS 2007). Tamil Nadu has also decreased its infant mortality rate to 31

deaths per 1,000 live births, more than halving its rate of fifteen years ago (IIPS 2007).

Indias overall infant mortality rate lags at 57 deaths per 1,000 live births, though down

from 79 in the early 1990s.

Turning to safe motherhood indicators, the state has made a good deal of

progress. According to Indias most recent National Family Health Survey, 90 percent of

deliveries took place in health care institutions in 2005-06 (IIPS 2007), reflecting an

increase from 64 percent during the 1992-93 survey. The most significant change is in the

rural institutional delivery rate. Rural institutional deliveries increased from 50 to 87

percent in the past fifteen years while urban rates increased from 91 to 95 percent (IIPS

2007). Indias respected Sample Registration System reports more conservative figures

with total institutional deliveries increasing from 57 to 65 percent in Tamil Nadu between

1991 and 2003 (Registrar General of India 2006). Either scenario puts Tamil Nadus

institutional delivery rate at more than double the countrys average. Another important

maternal health indicator, assistance of a skilled health professional (doctor, nurse or

other) at deliveries, incr

Documents

Smith - Public Policy and Maternal Mortality in India