INDIA AND ROADMAP TOWARDS SUSTAINABLE DEVELOPMENT GOAL 3 : ACHIEVEMENTS AND CHALLENGES

Suresh Sharma and Manisha Bothra. 1. Associate Professor & Head, Population Research Centre, Institute of Economic Growth, Delhi. 2. Assistant Professor, Department of Economics and Public Policy, IILM Institute for Higher Education, New Delhi. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

India is witnessing high rates of economic growth consistently in past few years and is emerging as a strong contender in the global economy, however despite an impressive economic growth India"s public healthcare system is mediocre and this is reflected in the fact that India still ranks 130 out of 188 countries on human development index (HDR 2015). The healthcare infrastructure including modernized hospitals and world-class healthcare facilities though has developed in the past few years but the benefits of expanding healthcare sector are highly skewed in favour of the richer sections of the society while the lower strata of the population which constitute the majority of the population have little or no access to good quality healthcare services. The prime objective of this paper is to trace historical trends of the key health indicators and review the impact of policy programmes like NHM, JSY etc. in reducing the mortality. Further, this study also focuses upon the burden of out-of-pocket expenditure on health incurred by the population belonging to different stratified groups based on their socioeconomic background despite launching free health services. The study incorporates the pace of progress made under Millennium Development Goals and recommends policies/initiatives and the challenges towards achieving Sustainable Development Goals in the future. The data source includes World Bank dataset, NSSO, SRS, NFHS, DLHS, CES, HMIS and other statistical reports. The data is tabulated and analyzed using statistical packages and graphical tools. Spectrum software has been used for predictions. The results are expected to unveil that although the progress has been made over the years, but the pace has been slow and nearly stagnant and India needs to focus more on strengthening its health infrastructure and expand its human resource in health.

…………………………………………………………………………………………………….... Introduction:-
India is witnessing high rates of economic growth consistently in past few years and is emerging as a strong contender in the global economy, however despite an impressive economic growth India"s public healthcare system is mediocre and this is reflected in the fact that India still ranks 130 out of 188 countries on human development Owing to high rates of mortality and morbidity specifically amongst women and young children particularly the ones residing in rural areas facing a lot of difficulties in accessing the healthcare services the Government of India has launched "National Rural Health Mission" which later merged with National Urban Health Mission to form National Health Mission, with a prime focus on improving maternal and child health in India particularly in the rural areas. Despite noting an improvement in the maternal and child health indicators post its launch, more substantial efforts are needed to meet the targets of zero child death from preventable diseases and stark reduction in maternal death by 2030. (United Nations Report, 2015 1 )

India missed the Millennium Development Goal (MDG) target for both Child and Maternal Health and thus the question arises "What is beyond MDG?"
What is beyond MDG? India"s poor healthcare system is reflected in high maternal and child mortality rates, high prevalence of diseases, lack of access to healthcare services, high financial health cost to poor people and inequitable distribution in providing healthcare facilities and services. The focus on reducing child and maternal mortality rates gained significant attention when it became apart of the eight MDGs. MDG 4 is to reduce child mortality specifically the under-five Mortality Rate (U5MR) by two-thirds, between 1990 and 2015 and MDG 5 is to reduce the Maternal Morality Ratio (MMR) by three-quarters between 1990 and 2015. India"s progress towards Child health is moderately on track due to the sharp decline in Child mortality over the years however its progress in improving maternal health has been slow paced. (MDG Report 2015 2 ) MDGs has faced various constraints at the implementation level such as the goals were not designed for developed countries, no country could be forced to follow the MDGs, level of international aid have been minimum and targets for Overseas Development Assistance (ODA) were not time-bound, among other factors not specified here can pave a way for working towards the post 2015 Development agenda i.e. SDGs.
The important point arises that how should SDGs overcome the shortcomings of MDGs? There is a consensus building among member countries to approach the limitations faced while working towards achieving the MDGs and the way ahead of MDG that is SDG and thus creates a common set of goals.
Unlike MDGs, the SDG agenda includes only one health goal (SDG 3) which is to promote physical and mental health well-being. Universal Health coverage ensuring easy and equal access to quality health care services will eventually reciprocate into increasing life expectancy. Further Universal access to health care includes access to sexual and reproductive health care services such as family planning and other relevant health information as well. SDG 3 also aims to focus on accelerating progress to fight against malaria, HIV/AIDS, tuberculosis, other communicable as well as non-communicable diseases. In order to properly implement these goals, every country must commit to accelerating progress in reducing maternal, newborn and child mortality before the year 2030. (Transforming our world: the 2030 Agenda for Sustainable Development , 2015) 1 India and the MDGs Towards a sustainable future for all (2015), United Nations Economic and Social Commission for Asia and the Pacific 2 http://mospi.nic.in/mospi_new/upload/mdg_26feb15.pdf 171 Thus beyond MDG stands a paradigm shift to SDGs involving a holistic approach to providing solutions for all global problems such as international migration, climate change, conflict, barriers to development by focussingon people, environment, prosperity and global partnership among developed as well as developing countries and according to Jan Eliasson, U.N Deputy Secretary-General, the globalization will help in implementing the Sustainable Development Goals (SDGs) to improve the lives of citizens of the countries participating in this global partnership to reduce extreme poverty. (VOA, 2016) In order to experience sustainable development, the main focus should be on strengthening components like social, economic and environmental factors and then integrate these three components in each of the goals schemed in the form of SDGs. Few countries prefer having separate social, economic and environmental goals, others talk about the integration of every goal to be achieved. (TERI Policy Brief).
If the question of the significance of these approaches arises for India, then India should consider adopting the approach of interlinking social, economic and environmental components in each goal for sustainable development. However, it is suggested that SDGs should be aligned with the Five-Year Plan goals. India can move towards pursuing sustainable development in health if it can give high priority to health care which asks for more commitment on the part of ministries by ensuring increased public health expenditure, proper implementation and monitoring of health policies and programmes is essential.
Literature Review:-According to World Bank factsheet on maternal mortality there is a high risk of women dying during pregnancy and childbirth in the rural areas and poor communities in the developing countries as compared to their developed counterparts. 3 This discrepancy is due to the fact that maternal deaths are not uniform across the countries and within its regions owing to specific socioeconomic characteristics of a country and its states as mentioned by Radar &Parasurman (2007) there is a strong linkage between socioeconomic background and maternal deaths, Lower a women ranks in socioeconomic hierarchy more the chance of her dying from maternity related causes. Under-five Mortality declined more quickly than neonatal mortality. Their projections described that more than one-third of the countries examined in the study will not be able to achieve the 2030 target. Progress at the global level does not necessitate progress at national level implying MDG 4 will not be achieved in most countries in 2015 .
Thus the strategies for reducing maternal and child mortality should include availability of affordable and costeffective health care services. This could be established by targeting premature deaths whose effects will continue even after 2030. For India, estimated premature deaths in year 2030 were 1.49 million and a reduction of 30 percent per decade. .
In a projected report towards SDG, assuming if the current trends continue where the progress path will lead to 15 years down the line, it was found that South Asia is likely to have a maternal mortality rate double than the global targets. . However in India, births are projected to fall from 27 million in the year 1990 to 24 million in 2015, contributing to a 9 percent fall in maternal deaths. The evidence suggests that 75 per cent reduction in Maternal Mortality Ratio target is achievable within 25 years" time frame  172 SDGs are expected to be more ambitious than MDGs due to the intertwining of economic, environment and social goals. The implementation of SDGs will require every country to make an efficient use of resources to adopt goals and targets in accordance with the local challenges it faces. The Third International Conference on Financing for Development which was held in July 2015 in Addis Ababa resulted into a consensus among world leaders that countries need to consider setting spending targets for quality based public investments including health, education, energy, water and sanitation consistent with sustainable development strategies (United Nations, 2015).
In order to pursue SDGs, every country requires sound public policies, the mobilization and effective use of national resources along with strong international financial support. Financing SDG is beyond the capacity of any one organisation and demands a strong partnership among governments, private sectors and development organisations. Total investment spending for basic infrastructure, food security, climate change, health and education in developing countries are estimated to be $3.3 trillion to $4.5 trillion per year (United Nations Conference on Trade and Development , 2014).
Literature suggests that achievement of the goals for various countries differ from each other. Progress can be felt in India if India is able to remove disparities and inequalities in social, economic and environmental aspects within its states. To ensure this, the active involvement of public and private sector is crucial.
Objectives:-India has recorded a highly skewed and lagged performance in achieving the Millennium Development Goals related to maternal and child health. While some states were close to achieving the targets of its preceding agenda, others simply missed out on it. The year 2016 is the moment to reflect on the achievements, failures and lessons learnt from the MDG era. An important issue to be raised here is that whether the achieved levels for India are sustainable in the upcoming years or not. Also, what are the probable significant changes to be made in future in order to achieve SDG targets? How faster is the progress needed to deliver the goals?
The study aims to trace both historical trends of health indicators like Maternal Mortality Ratio, Infant and Child mortality rates, immunization coverage and proportions of live births attended by professional health personnel and review the impact of policy programmes like NHM, JSY etc. in reducing the mortality. Further this study focuses upon the burden of out-of pocket expenditure on health incurred by the population belonging to different stratified groups based on their socioeconomic background despite launching free health services. The study incorporates the pace of progress made under Millennium Development Goals and recommends policies/initiatives and the challenges towards achieving Sustainable Development Goals in the future with the help of various statistical tools, theoretical discussions and recommendations

Data and Methods:-
In order to conduct this study, data from various Statistical Reports has been used. Other secondary data source includes Sample Registration System (SRS) reports, NFHS, DLHS, CES and HMIS etc. Data for variables like IMR, U5MR and MMR for time period 1990-2013 was sourced from SRS, NFHS and DLHS reports. Immunisation against measles data for the time period 1990-2009 was sourced from NFHS and CES. Other data was sourced from HMIS portal. Data of Southern and Empowered Actions Group has been used for the analytical purpose to show the prevalence of significant inter and intra-state differences in India. The data has been tabulated, analyzed using Excel and Tableau software.

Results:-Key Health Indicators and their historical trends: Child Health
India along with Nigeria accounts for 33% of total child deaths in the world (Eric Zuehlke, 2000). Thus in lieu of large numbers of child deaths in India, MDG laid a strong focus upon key indicators related to Child Mortality such as Infant Mortality Rate, Under-Five Mortality Rate and Proportion of one-year-old children immunised against measles.
Infant Mortality rate (IMR): IMR comprises of pre-natal, post-natal and neo-natal child deaths out of which neonatal deaths were 68% of the total infant deaths in the year 2013. Kumar and Datta (1982) has highlighted in their study that "cute respiratory infections, acute diarrheal disease, low birth weight, protein energy malnutrition, tetanus neonatorum, and communicable diseases like measles, whooping cough, and typhoid" are the major reasons 173 behind infant deaths in India and further the authors added that India needs to design medium term or long term plans focusing upon improvement in female literacy rate and increment in GNP should be adopted to leap indirect benefits in form of better maternal and neo-natal care in the long run.
The national level figures stood at 28 and 40 per 1000 live births for neo-natal and infant mortality rate respectively in 2013. Since 1990, IMR has declined from 80 to 40 per 1000 live births in 2013. Despite a steep reduction since 1990 India was not able to reach MDG target of 27 infant deaths per 1000 live births. However owing to steep decline in the recent years, the gap between the likely achievement and the target was expected to be narrowed. 178

Proportion of births attended by skilled health personnel:
Deliveries with the help of skilled birth attendants can help in preventing both maternal and neonatal deaths. Most women in Rural areas choose deliveries at home due to poor or lack of access to healthcare system, low quality of maternity centres, lack of health personnel, barriers due to financial, social and cultural factors. MDG target is to achieve 100% coverage. As per the data of SRS, 2013, percentage of live births attended by skilled health personnel (Government hospitals, Private hospital, qualified professional) is 87.1%. Kerala, Goa and Tamil Nadu have already achieved nearly 100 per cent coverage of births attended by skilled health personnel. States which are likely to reach the target include Jammu & Kashmir, Karnataka, Odisha, Rajasthan and Sikkim as illustrated in Figure 11.

SDG related schemes and interventions:-
A national coordinating agency is essential for effective implementation of SDGs given the interlinked objectives and targets. In India, for achieving SDG 3 the nodal agency is Ministry of Health and Family Welfare which has  Figure  12 and with increased GDP the funds allotted under Health has increased manifolds. The principal strategies included "decentralized village and district level health planning and management, appointment of Accredited Social Health Activist (ASHA) to facilitate access to health services, strengthening the public health service delivery infrastructure, particularly at village, primary and secondary levels, mainstreaming AYUSH, improved management capacity to organize health systems and services in public health, emphasizing evidence based planning and implementation through improved capacity and infrastructure, promoting the non-180 profit sector to increase social participation and community empowerment, promoting healthy behaviours and improving inter-sectional convergence."  NHM also aimed at reconstruction of the Indian health system by augmenting public health expenditure, promoting innovative policies to strengthen public health management and service delivery, increasing human resources, decentralizing health programmes and action planning, popularizing AYUSH into the public health system, among others. It is expected that such efforts could help in achieving the core goal of "improving access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare." To promote community participation in improving access to health care at household level, thus MahilaArogyaSamiti (MAS) came into being. MAS is a group of around 50-100 households, who are responsible for promoting behavioural change towards health and hygiene and facilitate community risk pooling mechanism in their coverage area. This encouragement among MASs for saving to meet emergency health needs was proposed to bring down high out-of-pocket expenditure which often leading to indebtedness among urban poor. Under National Health Mission, two major policy initiatives JSY and JSSK were introduced with an objective to reduce the number of maternal deaths and ensure provision of cashless services with monetary incentives to pregnant women to opt for institutional deliveries where she is regular monitored from first ANC till 48 hours of PNC.
Despite that, India alone accounted for 17 per cent of total maternal deaths in the year 2013 5 and is classified as one of the country with highest cohorts of unvaccinated children. 6  Overall there has been an enhancement of the health outcomes post the introduction of the scheme but the gaps and constraints of ineffective health infrastructure and the degrading role of other socio-economic factors like patriarchy, low female literacy rate, early marriage higher total fertility rate, lack of awareness etc. remains and thus constraints the effectiveness of the scheme.
The two major determinants of effectiveness of Health Delivery Services are Human Resources and Infrastructure in Health Sector:

Human Resource in the Health Sector:
Human Resource is the most significant part of building a strong foundation for public health. Availability of adequate number of skilled health personnel at different tiers of health care system are needed for providing efficient health care services to people in need of. It is also important to emphasize that information related to human resource in Health sector is usually incomplete and at times unreliable as well.
There It is a matter of concern that there are shortages in human resources in government health institutions that serve poor sections of the society living in urban slums, rural and tribal areas. To ensure the availability of health professionals in rural areas on a regular basis, a large number of health professionals need to be trained to meet health care needs of people. "Provision of doctors with adequate incentives, both monetary as well as non-monetary benefits, such as improved infrastructure facilities of health care institutions, suitable accommodation, preferential school admissions for their children, increase in the age of retirement from 60 to 65 years, permission for private practice/pay clinics/evening clinics, posting spouses at same place etc. are certain important issues to be considered". Over the next few years, changing trends like increase in phenomenon of insurance services, increase in awareness among people regarding health and changing demographics will result in more health spending. Healthcare spending in India stands at a less than 5 percent of GDP and a major share of these spending is private. In India, private healthcare comprises of about 75 percent of the country"s total healthcare expenditure and thus raising the issue of affordability of health care services. Further there is a large gap between requirement and availability of workforce and as per KPMG projections presently there is only half of health personnel"s working than their expected demand in the year 2022 as shown in Figure  Since inception of NHM, there has been a significant improvement in terms of assistance released to States/UTs to increase public health spending, health infrastructure, human resources, streamlining AYUSH and ASHAs into the public health system, free drugs, Mobile Medical Units (MMUs), Emergency services, patient transport system, community participation, among others.  Figure 16 illustrates that there has been a substantial increase in the health infrastructure comprising of District Hospitals, Primary Health Centres, Community Health Centres and Sub Centres in India over the past five years but despite that there is a gap in the effective functioning of health infrastructure owing to lack of sufficient space, maintenance and other specific factors thus India needs to focus upon technological advancement and design a health infrastructure which is able to meet the requirements of general public.

Conclusions and Recommendations:-
The results of the study clearly indicate that India was not able to achieve the predefined goals for achievement of targets related to specific indicators under MDG. Therefore, there is a need for SDGs to take forward what MDGs could not achieve. SDGs must be able to look beyond the path build by MDGs. In order to successfully implement SDGs, the support of Developed countries is much required. Assistance such as time-bound targets, quantitative benchmarks for all the targets, sound economic and trade policies, technological advancement and other resources are needed by developing countries like India. Further the inter-state and intra-state differentials are highly prevalent in case of India thus India needs to devise specific policy initiatives depending upon the specificities of a state to fill the vacuum.
The process of scheming SDGs should include participation of government, non-government organisations and the society as a whole especially the marginalised groups. Nicloai et al. in theirCountry level analysis found that faster growth is significant if governments and the civil society contribute their efforts to achieving the goals and targets thus health initiatives like NHM, JSY, JSSK and Mission Indradhanush has a key role in improving the health indicators. The focus should be upon having good governance that ensures equality and justice. Further other factors like transportation systems, agricultural system, migration, urbanisation etc. should be considered as priority areas by the policy makers Development progress is beneficial for all and hence there is a need to blur the line between national and international. SDGs will not only affect an individual"s wellbeing in form of poverty eradication, health and energy but also for the society as a whole in form of better living conditions, food and water security.
Pregnant women remain at the highest risk of dying between the third trimester and the first week after the end of pregnancy. Hemorrhage is the major cause of maternal mortality and this can be prevented by ensuring timely access to obstetric health care. The difficulty in capturing of maternal deaths owe to factors such as under-reporting of maternal deaths, misclassification of causes of maternal death, lack of large samples to produce current estimates, lack of reliable data. Liu et l. Suggested that Maternal and child nutrition need to be focused upon. Maternal 184 micronutrient supplementation reduces fetal growth restriction, preterm births, and neonatal mortality. Improved breastfeeding practices and nutrition interventions in early childhood would contribute in reducing child mortality.
As suggested by Nicloai et al. Better and reliable data is required to monitor progress over the upcoming years. It is important for countries to learn from each other"s experiences because their initial points of progress are different and its pace varies across the globe.
Achieving SDGs require investment contributions from both public and private sectors. However, an annual financial gap persists in SDG-related sectors and in sectors such as education and health care, the potential for increasing private sector participation is challenging because these are public services responsibilities which are sensitive to private sector"s business goals. For India to achieve SDG 3, it will firstly have to achieve Health Index, comprising of health status of population, quality of healthcare institutions and financial instruments for access to healthcare of 0.9. India will need approximately INR 55 lakh crores (USD 880 billion) till 2030 to achieve this value of health Index. A financial gap of around INR 19 lakh crores (USD 305 billion) is projected for public health expenditures (Technology and Action for Rural Advancement A Social Enterprise of Development Alternatives Group , 2015).
In the presence of gaps in healthcare infrastructure and inadequate skilled human resource apart from presence of wide-ranging inter and intra state disparities India has a long way to go to achieve a decent standard of health and healthcare which in turn depends upon the institutional interventions and innovations focusing upon health service delivery since These discrepancies in turn pose a huge challenge ahead of achieving MDG 5 and require an approach depending upon the specificities of a region. And as the MDG era ends and India heads towards adopting Sustainable Development Goals, a shift in the policy paradigm involving more focus up on implementation along with continuous monitoring and evaluation of existing programmes is essential and further policy paradigm involves a shift to interventions which ensures horizontal and vertical equity in health care. The government must focus upon the targeted groups and ensure that they get access to not only an effective healthcare system but also to basic education and nutrition and these factors in turn would ensure greater effectiveness of the National Health Mission as a scheme and would facilitate India to reach and sustain its health related goals.