Lund University

EASAS

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Panel No. 11

Panel Title: Education, health and demographic changes in South Asia

Convenor: Neelambar Hatti, Dept of Economic History, Lund University, Sweden
Co-convenor: T.V. Sekher, Population Research Center, Institute for Social and Economic Change, Bangalore, India.

    Wednesday 7 July, 8–12 & 13–17

Panel Abstract: In recent times, South Asia has experienced dramatic changes; lives at all levels have been profoundly affected by attempts at global integration. Phases of ongoing liberalisation have aimed at ‘structural adjustments’ in different areas of the societies. In almost all the countries, two sectors, health and education, crucial for human development, have been at the forefront of these efforts. The interventions seek to ‘reform’ these sectors from the perspectives of access, quality, productivity, community involvement, decentralisation, users choice, efficiency in resource allocation and use.
With poverty and illiteracy extensive, gender discriminations common, and deprivation widespread in the subcontinent, the reforms have brought about mixed but controversial results. Views on the impact of reforms tend to be largely polarised. Some have argued about the transitory nature of deprivation and emphasize the need for rapid and vigorous implementation of reforms. Others point to the growing social and economic disparity in the absence of public social safety nets.
Dimensions of concerns are broadly same in education and health sector issues which aid social capital formation. Rural and urban areas exhibit situations that are essentially similar in many ways among the countries. Insufficient public investment in health sector, private participation in the health care delivery services, urban bias, poor quality of services, lesser community control, etc are some core issues in the sphere of public health in south Asia. Similarly, poor state of public funded schools, rising illiteracy and drop-out rates, declining participation of women in schooling, mismatch between general and technical education, private control of quality education, low user’s charges in government sector, virtual free higher education, etc. are some critical areas that need greater attention in education. Inevitability of structural changes in these two sectors, with great direct social relevance, and primacy from the point of basic amenities make them singularly unique for greater evaluation in a contemporary and changing scenario. There is a need to examine existing policy options and programme implementations at micro-level. Better understanding of the ongoing changes, the process of social exclusion and community responses, witnessed in these two sectors as affecting and affected by the gender relations in south Asia is essential; it facilitates exploring new forms of discriminations and strengthening remedial measures in terms of community and institutional arrangements. Education and health juxtaposed with lower status of women are two significant determinants of demographic dynamics in south Asia that need attention. Demographic changes as reflected in fertility, mortality, migration, family planning etc, in the context of strong son preference in these societies also reveal some of the gender discriminatory patterns that have existed for long and have only recently begun to undergo changes.

Papers accepted for presentation in the panel:

Paper Giver 1: K. Srinivasan and S.K. Mohanty, International institute for Population sciences, Mumbai, India.

Paper 1 Title: Health care utilization by source and levels of deprivation in major states of India: Findings from NFHS-2

Paper Abstract: There is an increasing body of evidences, coming up in recent years, derived from analysis of data from the National Sample Survey and other sources that the public health services are being increasingly used by the relatively better off sections of the society, leaving the poor and deprived to the medical and health services from the private sector. We propose to check the validity of the above findings using an independent data source, i.e., National Family and Health Survey-2. Thus the paper has twin objectives, first of assessing the differential in use of general health care and family planning services by socioeconomic strata of the population in rural and urban areas for the major states of India and secondly, to compare the findings with those of 52n d round of NSSO.
The analysis has been presented in 5 sections. Initially, we construct a household deprivation index to measure the extent of deprivation and validate the same with nutritional status of women and food intake in the household. In section 2 we have examined the utilization of general health services and the patterns emerging from the analysis. In section 3, we studied the utilization of family planning services, with emphasis on limiting methods. In section 4, we compare our findings with that of NSSO findings. Finally, we have presented a few implications of our study.
Some of our findings differ significantly from those of the NSS though there are some agreements. Our analysis does not appear to validate the NSS findings widely circulated in national and international circles that the public health services is disproportionately used by better off section of the society, with the exception of undivided Bihar and Uttar Pradesh. In the state of Bihar and Uttar Pradesh, the public sector is almost non existent for general health services. In many other states public health system still continues to play an important role in treatment of illness and continues to be main provider of family planning services, particularly, limiting methods irrespective of level of deprivation. However both the NSS and NFHS data agree on the increasing use of private health services in the country.

      Full paper to be downloaded (as a pdf-file)


Paper Giver 2: Minna Saavala, University of Helsinki, Finland

Paper 2 Title: Familial Power Relations and Male Involvement in Reproductive Health in India

Paper Abstract: When reproductive health issues are addressed, it is generally taken for granted that reproduction is the sphere of women. Consequently, we know fairly little about the role and attitudes of men concerning childbearing, contraception, and sexually transmitted diseases in South Asia. We need to revise our approach to men both in academic and policy-oriented research, in order to involve males in HIV and STD prevention, improvements in child mortality, controlling unwanted pregnancies and other reproductive health issues. This paper explores familial power relations by using material from an anthropological field study in South India, and shows how families negotiate on reproductive issues. It is argued that improvement in male reproductive responsibility is related to the intensifying of conjugal communication in the context of extended family relations. This in turn reflects the rise in age at marriage, which is related to higher female school attendance, among other things. Understanding the male roles in reproductive decision-making helps us to find ways to involve them better in reproductive health policies.


Paper Giver 3: Ismail Radwan, The world Bank, Washington DC, USA

Paper 3 Title: Private Sector Health Care for the Poor in India

Paper Abstract: Fertility, mortality and morbidity have slowly and steadily declined in India since independence but remain unacceptability high both compared with countries in the region and those at similar income levels. While the root causes are poverty and low levels of education, government stewardship of the health sector bears some responsibility. Since independence, public financing and provision of health care services has been the mainstream of health policy. Public sector health programs in India have faced well-recognized problems such as inadequate access by the most vulnerable groups, poor quality and coverage of primary and secondary facilities and until recently an excessive focus on sterilization and inadequate focus on maternal and child health.
At independence, according to the Bhore Committee report, less than 8% of all medical institutions in the country were maintained by wholly private agencies. By the early 1990s this figure had reached close to 60%. There is also mounting evidence that the poor are increasingly using the services of private sector health providers in India as the public sector is failing to reach and service such vulnerable groups in India. A recent assessment of the public subsidy to the sector has shown that the poorest 20% of the population capture only 10% of the subsidy less than a third that captured by the richest 20%.
Empirical studies have shown that the quality of primary public services provided by the public sector did not improve significantly between 1987 and 1996. Moreover, income, education and the overall quality of state administration are more important than specific public health interventions in explaining differences in demographic and health indicators during the period 1981-1991.
Despite the prevailing situation described above, government and international agencies have been slow to assess the role of the private sector in determining health outcomes for the poor in India. Previous studies have focused almost exclusively on the role of the public sector despite the fact that the private sector is an increasingly dominant or significant provider of a variety of primary health care services of importance to the poor.
Without effective government stewardship, private health care institutions in India have grown in the absence of an explicit policy to define their role. This has raised questions regarding the quality and legality of care as well as the exploitation of the poor. Although several studies have established the rapid expansion of the private sector in both the provisioning and financing of health care services in India there is little information on the manner in which different parts of the private health care system operate either alone or through interactions with the public sector. Moreover, studies that have been completed in this area have not gone as far as focusing on implementation.
This paper seeks to answer the following question: Given the importance of the private health care financing and provision of services, how can the Government of India better utilize the private sector in health services delivery to the poor? Within this broad framework, there are three policy objectives of particular focus;

Ý Increasing coverage: especially for essential health care priorities. It is assumed that the most important health goals both for the Government of India (GOI) and from the perspective of the poor are those captured by the Millennium Development Goals (Child mortality, maternal mortality and reproductive health, communicable diseases (especially Tuberculosis, Malaria, HIV/AIDs) and malnutrition).
Ý Improving the quality of care: A significant number of private health care providers in India (especially in the rural areas) are untrained practitioners. Although reliable data on their numbers are difficult to compile, it has been estimated that they number well over 1.25 million. These providers are not registered, qualified or regulated. There is evidence that the quality of care they provide is extremely low and can at times actually harm the health status of the patients. The Supreme Court has ruled their operations to be illegal and labeled them “quacks”. This highlights the need for prudent regulation of the sector.
Ý Reducing expenses for the poor: Due to well-known asymmetries of information, the poor are especially vulnerable to exploitative charging practices. Without access to affordable health insurance, they face the largest health care bills as a proportion of their income. Moreover, they face the largest out of pocket expenses that can often lead them into an unsustainable spiral of indebtedness and increasing poverty.

      Full paper to be downloaded (as a pdf-file)



Paper Giver 4: Mohammad Amirul Islam, Sabu S. Padmadas and Peter W.F. Smith,
Division of Social Statistics, University of Southampton, United Kingdom

Paper 4 Title: Degree and Determinants of Men’s Contraceptive Knowledge in Bangladesh

Paper Abstract: We examined the degree of men’s modern contraceptive knowledge in Bangladesh and the associated determinants using the 1999-2000 DHS. The reported number of modern methods known among men aged 15-59 years measured the degree of knowledge. Although contraceptive knowledge was universal in Bangladesh, the degree of knowledge differed among certain subgroups. About 19% of men reported having had heard of 4-5 modern methods (mean: 6.9). Results from multinomial regression analyses showed that older, educated and those who were currently using modern methods were more likely to have had reported a high degree of knowledge (p<0.001). We conclude that men who had a low degree of knowledge seem not properly informed about the wide range of contraceptive options. It is imperative that family planning intervention strategies in Bangladesh should focus on the degree of contraceptive knowledge to improve the uptake of more male-based modern methods.

      Full paper to be downloaded (as a pdf-file)



Paper Giver 5: Md.Shahid Perwez, Ford Foundation International Fellow, The University of Edinburgh, Edinburgh, UK

Paper 5 Title: Post-Colonial Understanding of Female Infanticide in North and South India

Paper Abstract: In the ongoing debate on the adverse sex ratios in India, the issues of female infanticide and female foeticide have acquired crucial importance in the eyes of officials, demographers and urban middle class. Gender selective deaths are known throughout human history and they could result into serious disproportion of women in a society. Despite several attempts to understand this practice from various perspectives e.g. anthropological and demographic, the subject of female infanticide and female foeticide remain comparatively partially understood due to its convolution and differentiation. In this paper, I address the question of why female infanticide, which was claimed to be effectively controlled in colonial India, has appeared in post- colonial India in communities and regions where it was previously unknown.
I will examine the subject of female infanticide in North and South India in the light of empirical data. Brief fieldwork conducted by the author in a North Indian population, inhabited by a Rajput clan, suggests that the practice is comparatively on decline in the wake of various developmental projects including transport, health and communications that resulted into some prosperity, though marginal, of the region. In the South, however, where there are increasing signs of female infanticide in some regions and some groups amidst development and prosperity. In the backdrop of these contradictions, this paper attempts to present and comprehend such complexities of female infanticide through an examination of kinship and marriage rules, changing forms of economic relationship, health infra-structure and education, son-preference/daughter neglect, overall prosperity and patriarchy. A major thrust of the paper would be on how the status of daughters and women are being shaped at the household level. The paper employs a cultural perspective based on ethnographic materials.


Paper Giver 6: Suresh Sharma, Institute of Economic Growth, Delhi, India

Paper 6 Title: Reproductive and Child Health Status in India: District Level Analysis

Paper Abstract: Paradigm shifts in India’s population policies since the International Conference on Population and Development (ICPD) in 1994 at Cairo have been brought forth with additional emphasis on a package of quality reproductive and child health (RCH) services geared towards an improvement in the quality of life. The Ministry of Health and Family Welfare sponsored district level Rapid Household Surveys in 504 districts of India for monitoring and evaluation of the RCH program. The study has elicited district level indices on RCH status, using factor analytical techniques. Thereby, the study highlights socioeconomic, cultural and infrastructural predictors of inter-district variations in the indices on RCH status. The study highlights the backward districts that are to be focused upon in the initial phase to bring about optimal results in terms of stated objectives of improvements in the quality of life and also the relative significance of alternate predictors to be emphasized for the purpose.

      Full paper to be downloaded (as a pdf-file)


Paper Giver 7: Girish Kumar, Centre de Sciences and Humaines, New Delhi, India

Paper 7 Title: Public Hospital Reforms in Madhya Pradesh (India): Perceptions and Trends

Paper Abstract: In the realm of the health sector, for a long period, people had suffered on account of various factors, including absence or near- absence of health delivery institutions and poor quality of services. With the progressive reduction in budgetary allocation in the health sector since the eighth five-year plan (1992-97), the matter was further aggravated. It is estimated that recurring expenditure on salary and establishment alone accounts for nearly three-fourths of the total health budget in most of the states. Although the low budgetary allocations have affected the healthcare facilities at all levels, the worst sufferers are the hospitals at tehsil (sub-district) level/ muffasil (rural) towns and health centres located in remote areas.
Caught in the quagmire of shrinking budget on the one hand and growing demands for catering to the health need of the ever-increasing number of people on the other, most state governments have resorted to alternative options. These options are based largely on the concept of public-private partnership (PPP). It is rooted in three fundamental assumptions: one, it will reduce the financial burden of the government; two, strengthen the capacity of the private sector to cater to the healthcare needs of the people; and three, create space for the participation of other stakeholders and community at large in improving the quality of healthcare through new management structures. During the past decade varying models of PPP have evolved across the provinces in India. The unfolding of 1991 economic reforms (leading to deregulation and privatization) and 73rd&74th constitutional amendments, 1992 (creating space for community participation at the local level) together provided necessary backdrop to this end.
The institutional structure developed for PPP in Indian province of Madhya Pradesh is known as the Rogi Kalyan Samiti (RKS), loosely translated as Patients Welfare Society. Apart from introducing the user’s fee, the new management has also created space for the community-centered actions. In fact, the RKS seeks partnership of all the concerned actors at the local level to raise funds for the upkeep of the public hospitals and, in turn, ensures their participation in the management of health services. This includes, administration at the local level, charitable organizations, donors, leading citizens of the area, people's elected representatives as well as the hospital staff. The Madhya Pradesh scheme of PPP is all the more unique in the sense that unlike in other provinces, where partnership has been sought mostly from market forces (excepting the areas where NGOs are being involved), the RKS seeks direct involvement of the users (community) and service providers (doctors, para-medicos) under the new management structure for running the public hospitals. Thus if the motivational factor in the case of former is profit, the latter instance is of meeting the social goal and, by extension, raising the social capital.
The paper proposed for the Conference is based on empirical data collected from nine hospitals (case study method) located at different levels in five selected districts of Madhya Pradesh. Apart from taking stock of on-going health sector reforms in the state, the paper critically examines the decision making process as well as sharing of responsibilities by different stakeholders under the aegis of RKS. It also aims at assessing the strength of institutional arrangements developed for ensuring transparency and accountability of the new management structure and above all, its reach and impact in terms of catering to the healthcare needs of the primary stakeholders, more specifically of the poor patients and their level of satisfaction.

      Full paper to be downloaded (as a pdf-file)


Paper Giver 8: Neelambar Hatti, Department of Economic History, Lund University, Sweden and T.V. Sekher, Institute for Social and Economic Change, Bangalore, India

Paper 8 Title: Lives at Risk: Declining Child Sex Ratios in India

Paper Abstract: In a seminal article in 1990, Amartya Sen suggested that world-wide, particularly in Asia, millions of women were missing from the population totals of many countries. He also noted the alarming fact that the sex ratio for female children in China, India and South Korea is actually deteriorating while the overall sex ratio for females in those countries has marginally improved. In India, the widening gap in the ratio of girls to boys is brought to light in the census of 2001, confirming a trend that has been in place since 1901. This is most pronounced in the youngest age group, thus indicating the scale of injustice as well as the long-term social and economic consequences implied.
While the 2001 census shows that the overall male-female sex ratio has marginally improved from 927 women per 1000 men to 933 per 1000 during the last decade, the number of girls to boys in the youngest age group fell from 945/1000 to 927/1000. The regional disparities also appear to have increased; the northern states generally exhibit a worsening trend in male-female sex ratio as compared to the southern states. The Census evidence suggests a clear cultural preference for male children, particularly among north Indians. The sharpest decline for the age group 0-6 years is observed in the northern states, particularly in Haryana (820/1000) and in Punjab (793/1000). Even in South India, with relatively better social development indicators, there are districts and taluks showing alarming trends in child sex- ratio. The census lists ‘sex-selective female abortions’, ‘female infanticide’, and ‘‘female neglect’ – typically through giving girls less food and medical care than boys- as “important reason commonly put forward” for this shocking anomaly. The new figures point to the use of new technologies to determine the gender composition. Furthermore, as social norms are changing toward smaller families, the availability of and access to new technologies provide an easy way for parents to achieve such goals.
The precarious situation of female children in modern India before birth (their chances of being born at all), at birth and during the first six years of childhood needs to be addressed. This paper provides a macro-level analysis of the trends in sex- ratio for the age group 0-6 years using the Decennial census data from 1901 to 2001 and other secondary sources. The paper also discusses issues related to sex-selective abortion, female infanticide (still prevalent in some parts of India) and discrimination and neglect of girl child. It is important to examine the nexus of economic, social and cultural factors that underlie daughter discrimination, thus shifting the focus from 'son preference' to 'daughter discrimination'.

      Full paper to be downloaded (as a pdf-file)


Paper Giver 9: Saswata Ghosh, Council for Social Development (CSD), New Delhi, India

Paper 9 Title: Gender Differences in Treatment-seeking Behaviour during Common Childhood Illnesses in India: Does Maternal Education Matter?

Paper Abstract: Gender inequalities, in one form or the other, with considerable contextual differences, are ubiquitous and all pervasive in South Asia. In health, these are manifested in differences in mortality (observed by overall sex ratio) in almost every country in this region. India is no exception in this regard. Discrimination and gender gaps have been observed even in early years of life. Beside other factors, discriminatory treatment-seeking practices among children during the post-neonatal and later childhood period probably contribute to this. There are numerous studies, which have established the positive effect of maternal education on child health and survival. But there are contradictory evidences that whether maternal education reduces gender bias in treatment-seeking behaviour or not and the debate over it remains inconclusive. By using National Family and Health Survey (NFHS-2), 1998-99, the present study observed that the gender bias in treatment seeking behaviour does exist among illiterate and middle school educated women when child is affected by acute respiratory infections and reduces considerably among higher educated mother. In case of diarrhoea no evidence of gender differences in treatment seeking behaviour has been found statistically irrespective of the level of maternal education, even after controlling all other spatial, demographic and socioeconomic factors.

      Full paper to be downloaded (as a pdf-file)


Paper Giver 10: Damodar Sahu, Institute for Research in Medical Statistics, New Delhi and V. Jayachandran, UNICEF, New Delhi, India

Paper 10 Title: Why immunization Level fails to catch-up in India: A community based analysis?

Paper Abstract: In spite of Government of India initiative to improve immunization coverage in India over time, it continues to be very low in certain parts of the country particularly in the rural area where two-third of the population lives. A number of studies have been examined correlates of immunization coverage in India and other countries, mostly on individual level information. However, recent research emphasized the importance of community level variables. The present study used multilevel analysis to know the effectiveness of community level indicators and their linkages with individual level indicators to guide program managers to achieve the convergence.
Objective:
1. To examine the linkages of various demographic, socio-economic, maternal care (level-I: individual level variables of children and parents) and community-level factors (level-II) that may affect immunization coverage in rural India.
2. To assess the effectiveness of the community level variables like health services and infrastructures available at the community level on immunization coverage, by controlling the effects of other individual level factors in rural India.
Study design: We propose to use two--level model to examine the linkages of various socio-economic and programme factors that may affect infant survival. Accordingly we shall be incorporating variables at two levels- level-I: individual level variables of children and parents; and level-II: community level variables; from data collected under National Family Health Survey, 1998-99, India. The main focus of the analysis will be on assessing the effectiveness of the community level variables like health services and infrastructures available at the community (or cluster) level on immunization coverage, by controlling the effects of other individual level factors in rural India.
Hypothesis: There is a strong positive relationship between immunization coverage and the availability of health services in the community. (Whether there was a health centre facility i.e. primary health centre or community health centre/rural hospital, or government hospital/dispensary or private hospital/clinic within 2km of the sample cluster, weather all-weather road within the cluster, whether opportunity of higher education (middle school or above) within 2 km of the sample, whether health or family welfare film show organized at community in the past one year) in the community (or cluster).
Data and Methodology: The India’s National Family Health Survey, 1998-99 (NFHS-2) data used for this paper. A child-based file is created to include selected child-specific information from birth history, and mother and household characteristics. The present study will be based on most recent births born three years preceding the survey because the desired data on immunization coverage in NFHS-2 were collected only for these births. Two-level logistic model where children (level I) are nested within a cluster (level II) has been estimated using iterative generalized least squares (IGLS).
Preliminary findings: The findings of the present study have positive impact immunization coverage on some of the individual level variables such as demographic (male children), socioeconomic (literate mother’s, mothers from high socio-economic status), and maternal care variables (mothers who have received ANC, received TT, and delivered in institute). In addition, community levels variables, availability of all-weather road in community was noticed to be more important for immunization coverage. In order to increase the immunization coverage in rural areas in developing countries like India, infrastructure facility such as availability of all-weather road to the community, which is basic need of commutation, is to be facilitated.


Paper Giver 11: M. Niaz Asadullah, Oxford University, UK

Paper 11 Title: The Effectiveness of Private and Public Schools in Bangladesh and Pakistan

Paper Abstract: Using labor market earnings data from Bangladesh Household Income and Expenditure Survey (HIES) 2000 data, this paper empirically tests the effectiveness of private and public schools in Bangladesh. Earnings gap of private and public school graduates are decomposed following Oaxaca-Ransom (1994) approach to see whether there is any earnings advantage for individuals educated in private schools over public school graduates. For Bangladesh we do not find any evidence of superiority of private schools over public schools. Attendance of private schools has negative returns in wage work, which is primarily because of differences in returns to individual characteristics among private and public school graduates. The finding is also true for publicly funded private schools.
In addition, we use Pakistan Integrated Household Survey (PIHS) 2001 data to provide a cross-country perspective to our analysis. For Pakistan, the raw data suggests existence of a private school attendance premium. However, once private school premium is fully decomposed following the Oaxaca technique, we find that most of the premium is attributable to differential human capital endowments of the individual, not to the differences in returns to these endowments. The finding that private schools in Pakistan, instead of those in Bangladesh, are at least as effective as their public school counterparts perhaps reflects the differential public policy towards private schools in the two countries.


Paper Giver 12: N. Ajith Kumar, Center for Socio-Economic and Environmental Studies, Cochin, India

Paper 12 Title: Entry Barriers to Medical Education in Kerala, India

Paper Abstract: Kerala, the southernmost state in India, stands apart from other states in the country in terms of its achievements in providing access to schools and Arts & Science colleges irrespective of gender and socio-economic background of the students. But the present study, which examines the financial and non-financial barriers to enter medical courses, finds that there are innumerable barriers before children from unfavorable socio-economic background to access medical courses much sought after now for its job potential. The study uses a representative sample of students in the medical education institutions in the government sector.
The study finds that the present system of subsidizing only the fee component of the private cost has placed an undue burden on the students or their families as fees constitute only a small component of the educational expenses of the students in the government run institutions. The educational grants and scholarships provided by the government and universities do not cover even a fraction of the non-fee academic expenses. The student loans were not found attractive to the students as educational loans are not subsidized in India and the interest repayments do not wait for the completion of the course. It is found that access to medical education is mostly limited to the upper middle income and high income groups which forms less than ten percent of the population. If the State wants to bring down the entry barriers, it must think of providing larger number of scholarships and the quantum of scholarships should be enhanced to meet the non-fee academic and maintenance expenditure. There is also a need for changing the student loan scheme.
Finance is not the only barrier for entry. The medical education in the State is heavily biased against the rural population. Students of government schools and rural schools find it difficult to get admission to these courses. There is also gender bias. First generation students whose parental education is low are not finding it easy to get admission. Thus, the system leaves very little scope for social and occupational mobility. The academic implications of narrowing the range of students admitted to medical courses are also important. The medical courses are not able to access the latent talents from 90 percent of the households in Kerala. As a result, almost all students come from more or less the same socio-economic background. The lack of diversity in the background of the students has some serious academic and professional implications. It becomes difficult for these students to communicate and empathize with patients who come from diverse and lower backgrounds. The urban elite students may also be not willing to work in rural areas. The gender bias in admissions also has implications on the health of women and children especially in the rural areas.
The study finds that the present method of entrance tests adds to the difficulties of the disadvantaged groups as the success in these tests largely depends on the special coaching provided in costly coaching institutions located in cities. The study suggests that better mobility through higher education can be attained only if the huge disparities in school education are brought down considerably.

      Full paper to be downloaded (as a pdf-file)


Paper Giver 13: T. Nirmala Devi, Andhra University, Visakhapatnam, India

Paper 13 Title: Changing Profile of Education, Health and Demographic Sectors in South Asia

Paper Abstract: The macroeconomic policies of the South Asian countries during the last five decades following their independence have not facilitated the creation of sound social infrastructure. The paper delineates the factors responsible for the region’s low levels of development. The marginal improvement in literacy levels in the1980s and 1990s continues to impede the development process and adversely affect the quality of life in the region with the exception of one or two countries. The slow rise in female literacy levels and the presence of sizeable number of dropouts' point to the gaps in the policy implementation in regard to strengthening the primary education and empowering women. Sri Lanka with an impressive enrolment rate at both primary and secondary levels and Maldives with nearly cent percent enrolment at primary level stood as exceptions to the general trend. Incidentally, gender disparity is least in these countries. The fact that the infant mortality rate and the maternal mortality rate in the region did not register significant decline, in spite of considerable improvement in the overall health status, testifies the inadequate health services and low nutrition levels among the people in general and women in particular. Access to safe water, sanitation, medical care, nutrition and the overall calorie consumption per person in the region are not satisfactory.
South Asia experiences rapid population growth notwithstanding the decline in the decadal growth rates. The deceleration in the population growth rate during the 1980s and 1990s was appreciable only in Bangladesh and to a certain extent in India, while the ineffective implementation of population policies in Nepal and Pakistan had resulted in marginal fall. Over population has obviously hindered the developmental process in South Asia, whereas the East Asia’s relatively higher population growth rates could not deter the region’s socio-economic development.
Gender bias in the South Asian region impedes the access of women to education, health and sufficient nutrition. In this regard, except Sri Lanka, Kerala State in India and to some extent Maldives, where positive changes in the sectors of education, health and demography took place, the situation in South Asia is not encouraging. It is felt that the governments in the region need to display strong will and embark on capacity building exercises and increase social spending to ensure a better quality of life.


Paper Giver 14: A A Jayachandran, Population Foundation of India, New Delhi, India

Paper 14 Title: Better Understanding of Reproductive Characteristics of Adolescent Girls in Four Selected States and India

Paper Abstract: Adolescent populations constitute the largest proportion in the history of mankind and about 85% are living in the Developing world. Adolescents' share in India's population is currently one-fifth of the total population and any issues related to adolescents have rake up significant interest.
Adolescents' fertility poses a major concern in India as about 19% of the total fertility has taken among 15-19 age group (NFHS-II). This paper tries to feature some reproductive characteristics of the adolescent girls in selected states and India to have an insight into have an insight into the wide-varied profiles stages in various states. National Family Health Survey I and II data are used in this paper to find the changes occurred in the reproductive characteristics of Adolescent girls. States are selected to show how different characteristics are possessed by different states in India. Selected four sates are Kerala, Maharashtra, West Bengal and Uttar Pradesh to get the whole spectrum of picture.
Different reproductive characteristics would be analysed like, age at marriage, age at first pregnancy, knowledge and awareness about contraception, HIV-AIDS, RTI/STI and their contraceptive use and desire for children etc. The study would be an interesting one since adolescents shape the future course of fertility of any population and the use of excellent data set (NFHS-1 and 2) makes the study more important.
Paper would be using different statistical applications to draw conclusions and expected to draw useful policy measures.


Paper Giver 15: T.V.Sekher, Institute for Social and Economic Change, Bangalore, India

Paper 15 Title: Fertility Transition: The Case of Rural Communities in Karnataka, India

Paper Abstract: Most developing societies are now experiencing demographic transition at varying levels. In a vast country like India with high demographic diversity and heterogeneity, the levels and stages of fertility decline differ significantly from state to state. Given this situation, it is interesting to have a look at demographic transition in South India ( a population of 220 million in 2001), which has now entered its last phase with fertility rates registering significant decline during the last two decades well ahead of other parts of the country. However, in view of the average level of economic development in this part of the country, the South Indian experience has revived discussions on the determinants of fertility reduction, notably about the respective role played by endogenous (cultural and historical features) and exogenous (economic transformations and governmental interventions) factors in popularizing family planning.
The present paper has aimed at understanding the channels of fertility decline in the South Indian State of Karnataka through an analysis of socio- cultural and spatial differentials. It has also attempted to capture the self- sustaining nature of fertility reduction by bringing out the fact that fertility decline in one social group is fuelled by low fertility behaviour in other groups. For this purpose, employing focus group discussions and individual case studies to gather qualitative data from different social groups, three village studies were carried out during 2002-03. It was observed that villagers were trying to cope with new 'risk factors ' by modifying their behaviour, and one among them was the fertility behaviour. The varying fertility in the villages appeared to be the consequence of level of development in and around the village and the "risk perceptions" among the people. Though the diffusion mechanism and imitation factors were relevant to a great extent, their impact varied considerably across communities and geographical locations.

      Full paper to be downloaded (as a pdf-file)


Paper Giver 16: Binitha V Thampi, Institute for Social and Economic Change, Bangalore, India

Paper 16 Title: Determinants Female Autonomy and the impact of Autonomy on women’s well being in Kerala, India

Paper Abstract: Female autonomy has widely been acknowledged as a major factor that contributes to better demographic outcomes. Female autonomy is a multi-dimensional entity, which refers to different aspects of women’s life. The well quoted study of Dyson and Moore in the Indian context on ‘On Kinship Structures and Female Autonomy’ (1983) define Autonomy as ‘the capacity to manipulate one’s personal environment and the ability – technical, social and psychological to obtain information and to use it as the basis for making decisions about one’s private concerns and those of one’s intimates’. Female education and work participation are being considered as the two major proxy variables of women’s autonomy. Studies conducted in the context of developing countries have documented the relative significance of these two factors, particularly that of female education, in determining better demographic outcomes such as low fertility, child mortality and better health status of women etc. These studies have considered female autonomy as an intermediate variable in their conceptual framework. The National Family Health Survey (NFHS II), of India conducted during 1998-99 has measured female autonomy in terms of certain indicators on household decision making and mobility status.
The state of Kerala in India has drawn considerable attention in the recent past due to the paradoxical nature of its development with high level of achievements in the social sectors despite its relatively low per capita income, which is being known as ‘Kerala Model of development’. The achievements of Kerala in terms of better demographic outcomes such as low fertility rate, infant and maternal mortality rates etc. have largely been attributed to the high levels of educational attainment of women. Also, Kerala has low levels of female work participation rate compared to the rest of the states in India.
In this context, an attempt has been made to understand the factors determining female autonomy in Kerala and the relative significance of the two proxy variables of Autonomy. Again, more important is to understand the indicators of women’s, that are often expected as the outcome of women exercising their autonomy. Hence, the association between female autonomy and selected indicators of their well being such as incidence of domestic violence, contraceptive acceptance has also been analysed.
The Autonomy has been measured in the NFHS (II) in terms of household decision making power, mobility status and access to the resources. Using the scores assigned to the variables on these dimensions, a composite index of autonomy is constructed. In order to examine the factors determining women’s autonomy, a multivariate regression analysis has been carried out with autonomy index as the dependent variables and a set of explanatory variables have been employed. They are:

1. Age of women in five year age groups from 15-19 to 44 -49
2. Education (illiterate, literate, primary, secondary, higher)
3. Place of residence (urban/rural)
4. Family structure (extended/nuclear)
5. Religion (Hindu, Christian, Muslim)
6. Caste (scheduled caste, scheduled tribe, other backward caste, others)
7. Standard of living index (low, medium, high)
8. Work status (working, non-working)

The descriptive statistics of the variables and regression output are not provided here. The significance of the explanatory variables is explained below.
The regression analysis shown that education is having a negative relationship with autonomy with a moderate (5%) level of significance. Also, the caste and the standard of living are found to be insignificant in determining female autonomy. The younger age groups have shown a very significant negative relationship with autonomy. Muslim women do have significantly less autonomy compared that of Hindu women. Also, living in the nuclear families and in the urban areas as well as participating in the work force significantly enhances the autonomy of women.
Multiple Classification Analysis (MCA) is performed in order to assess the gross and net effects of the explanatory variables on women’s autonomy. This analysis allows us a more accurate assessment of each factor under consideration, controlling the effect of other variables, with women’s autonomy. The results are summarized below.
The analysis carried out has shown that education per se does not have a very significant bearing on women’s autonomy, where as their age, family structure, religion and work status do have. The gross effect of family structure and area of residence remained same after making allowances to other factors and both are highly significant statistically indicates the independent influence of these two variables on women’s autonomy. Hence, living in nuclear families and in urban area significantly enhances the autonomy. The age of women does have large net effect on autonomy and in the younger age groups it is negatively significant and a threshold age group 35-39 above which the relationship has turned out to be positive. The threshold age of 35-39 implies that women are less autonomous during their reproductive career, which might adversely affect their reproductive decision making. However, their enhanced autonomy in the higher ages may influence positively the reproductive decisions of their daughters or daughter in laws.
Also, the impact of autonomy on two selected indicators of women’s well being such as contraceptive use and incidence of domestic violence are not unidirectional. Autonomy is having a significant positive association with contraceptive use where as education is not showing a similar significant relationship with contraceptive use. Religion is showing significance in terms of Muslim women having considerably low levels of contraceptive use compared that of Hindus or Christians. Also, the family structure is statistically significant and women belongs to nuclear family do have more contraceptive use.
Quite contrary to our expectation, it is found that autonomy index has a positive and significant relation with prevalence of domestic violence. Also, the household standard of living has a negative and significant relation with domestic violence. The work status also shows positive association and it is statistically significant too. These indicate that poor women who are working and are more autonomous are more likely to experience the violence within the family domain. It may also be true that the exercise of autonomy might leads to violence in any society under cultural transition. Hence, the increase in violence along with enhancement in autonomy that emerged out of our analysis has to be further probed with primary inquiry.


Paper Giver 17: Shanti Nandana Wijesinghe, University of Gothenburg, Sweden

Paper 17 Title: Reconstruction, Reconciliation and Mental Health: A Conceptual Analysis

Paper Abstract: Almost all conflicts can be seen as resulting from factors related to health and development in our contemporary world. Therefore, an understanding of issues on health is essential for reconstruction, reconciliation and resettlement of communities divided by conflict because it is imperative to improve their life styles as well as own social and cultural environments.
The number of people affected by wars has increased during last few decades. Conflicts cause individuals to violate human rights, and also on the other hand, civilians are vulnerable to greater psychological and physical pressure as a result of on going war-related violence and terror in contemporary world. These include refugees, internally displaced persons (IDPs), children, unaccompanied miners, and children heads of house hold, the physically and mentally disabled, the detainees, and prisoners of war. Moreover, Women are more increasingly vulnerable to physical and psychological pressure from conflicts. Therefore, the impact of increased mortality and morbidity due to psychological pressure must be addressed in reconstruction and reconciliation efforts both at the conceptual and practical spheres because these concepts are directly correlated with the aspects of peace and development in contemporary societies. To address mental health needs of these affected population groups the new approaches, management efforts are required.
This paper tries to understand the relationships between the concepts of reconstruction, reconciliation and mental health in order to provide conceptual ground for the ongoing peace building efforts in nationally, regionally and globally. The paper is also explained the nature and forms of concepts; reconstruction, reconciliation and mental health in terms of post conflicts situations in contemporary societies.


Paper Giver 18: J P Singh, Department of Sociology, Patna University, Patna, India

Paper 18 Title: Health for All in Rural India: Problems and Prospects

Paper Abstract: In the main the paper attempts to assess how far different governments of post-Independent India have been able to achieve what they have targeted during the successive plan periods in the field of health-care, especially in rural areas. The study is necessitated because rural areas tend to record a higher incidence of mortality than urban areas, showing a considerable contrast. In view of this objective the paper has sought to assess the availability of health infrastructure in rural areas of different states. A study of this kind would help us understand the differential patterns of population morbidity and mortality that obtain in the country and ultimately throw some light on the issues of varying patterns of health transition across the states. For the purpose of data the study heavily depends on the state level statistics derived from village directories of the 1991 census. But in course of arguments data from other secondary sources such as National Family Health Survey are also used to corroborate the arguments. It has been contended in the paper that the government has achieved a lot in the field of health-care, but it has to achieve a lot more, particularly in rural areas, in order to translate the lofty ideals of 'Health For All' into a reality.


Paper Giver 19: Dr. Fathima Kutty Kapil, Andhra University, Warzail, India

Paper 19 Title: Impact of Education on Social Customs and Practices in India

Paper Abstract: Dr. Radhakrishnan defines education as the instrument for social, economic and cultural change. For social and national integration, for fostering moral and spiritual values, and for increasing productivity, education should be properly utilized. The importance of education is not only in knowledge and skill, but it is to help us to live with others. The social implications of literature are as important as the economic. It is through education that we acquire the passion and the perspective to fight against caste prejudices, class privileges and group antagonisms. The most important aim of education is to help us to see the other world, the invisible and intangible world beyond space and time. Telugu literature gave us a second birth, to help us to realize what we have already in us. The meaning of literature is to emancipate the individual and we need the education of the whole man physical, vital, mental, intellectual and spiritual.
The most important problem, which attracted the attention of educated progressive leaders, was that of the marriage of children. In India, marriage was performed after the girl had attained puberty but gradually child marriages increased in the Indian society. Child marriage caused early widow-hood, stoppage of education of girls, early motherhood, weak progeny, maternal mortality, etc. In fact, it was a national malady, and all, irrespective of caste, colour, creed or religion, more or less suffered from it.
Due to education and through literature and Dramas under changing circumstances child marriages were eradicated. Kanyasulkam and Varasulkam were the two evils prevalent in Andhra. The spread of women's education, and the establishment of schools brought about some changes that helped in eradicating these practices. The practice of Sati and the eradication of the same are brought to light.


Paper Giver 20 : Shankpal Pramod, Health Alert Organization of India, Dhule, India

Paper 20 Title: Incorporating Peer Educators in Adolescent Reproductive Health Information Dissemination in Schools and Communities of Rural India

Paper Abstract:
Issues: Due to cultural implications/barriers, adolescents are forbidden from discussing HIV/AIDS issues in public. Due to this adolescents in post primary schools receive wrong information on HIV transmission in youths and sexuality health issues from their peers & other sources like pornographic material. HIV community leaders faced a long-standing demand to correct this wrong information received by adolescents. This is due to belief that adolescents are good listeners especially when it involves their peer. They also understand their likes better because they speak in same language.
Methodology: Between May-August 2003, our 10 year old NGO carried out community baseline survey in 6 Post-Primary Schools in rural constituency of Mah. State. The aim was to determine how post primary adolescents receive HIV/AIDS & sexuality information & how we can improvise on these issues. From these schools we formed 24 groups of peers. [Each group consisted 16 peers]. We trained these 16 selected peers over six sessions by NGO Team. The aim was instituting peer-counseling services in this selected target population of school children. Total 55 protocol interviews in 14 rural secondary schools in this tribal region with 3-4 interviews per school, with principal or deputy; biology, life skills or guidance teachers; plus others doing youth activities. NGO volunteers Focused group discussions with 4 school governing boards of teachers, parents and students.
Results: Adolescent’s activities were monitored over five month's period after which post intervention evaluation was done with questionnaire. These peer educators helped in disseminating correct information to their peers, additionally there was 70% improvement in level of their peers knowledge of sexuality & HIV/AIDS. This approach also increased leadership quality and general well being and self assertiveness of most of peer educators who were elected prefects/senior prefects in various schools.
Conclusion: For resource poor settings we need to encourage use of peer-educators counseling as a means of having better impact policy for sex education & HIV /AIDS control. NGO’s should concentrate on reaching school adolescents community in isolated population. Sex education & sexuality development will be at optimum level by using this model. This model will prove very effective for HIV prevention in resource poor developing nations.

      Full paper to be downloaded (as a pdf-file)


Paper Giver 21: Jos Mooij and Manabi Majumdar, Centre for Economic and Social Studies, Hyderabad, India

Paper 21 Title: Education, Decentralization and the Indian State

Paper Abstract: Despite a widespread and increasing acknowledgement of the importance of education for development in India, the actual progress made is far from satisfactory. More than fifty years after Independence, still more than thirty per cent of the children between 6 and 10 years do not attend school. There is an increasing dualism in the schooling system, where more well-to-do families send their children to private (and usually costly) schools, and those who cannot afford to do this send their children to government schools, if at all. The state has clearly failed, both in universalizing education and in providing sufficiently good quality education that would continue to attract the well-to-do. The outcome is a kind of deadlock: when the politically influential middle and upper classes lose their interest in good quality government schooling, the result is an overall neglect on the part of the state.
One of the recent policy initiatives that is potentially interesting in this context is decentralization. In the whole of India different kind of initiatives have been taken place to shift power from the central or state level to lower levels of politics and administration. This has also happened in the case of education. The question is whether and to what extent these developments have affected, or are going to affect, access, exclusion and interest in government schooling. Primarily based on a review of the literature, but also using some examples from West Bengal and Andhra Pradesh, this paper will discuss these questions.


Paper Giver 22: Mattias Larsen and Neelambar Hatti, Department of Economic History, Lund University, Sweden

Paper 22 Title: Joint Families and Son Preference: A Field Study on Declining child Sex Ratios in Karnataka state of India

Paper Abstract: Human population exhibits definitive characteristics in terms of its sex composition. In most parts of the globe fewer females are born, yet females, as compared to their male counterparts, typically survive longer to exceed the males numerically at any given point of time. However, this demographic attribute eludes India where males decisively out-number the females and women constitute less than half of the total population. Sex ratio is a direct indicator of women’s status and welfare. The sex ratio changes are usually analysed in a framework that underlies (relatively) greater deprivation and discrimination of females, as opposed to males, in the south Asian cultural set-up. A change in sex ratio of children, aged 0-6 years, reflects the sum total of intra-household gender relations.
While the 2001 Indian census shows that the overall male-female sex ratio has marginally improved from 927 women per 1000 men to 933 per 1000 during the last decade, the number of girls to boys in the youngest age group fell from 945/1000 to 927/1000. The regional disparities also appear to have increased; the northern states generally exhibit a worsening trend in male-female sex ratio as compared to the southern states. The Census evidence suggests a clear cultural preference for male children, particularly among north Indians. The sharpest decline for the age group 0-6 years is observed in the northern states, particularly in Haryana (820/1000) and in Punjab (793/1000).
Important factors in this process of change are; a decline in fertility, parents desire to plan the gender composition of the family, patrilineal inheritance patterns which links the importance of having a son with old age support, the existence of dowry, the cultural importance of sons as solely responsible for the performance of the parent’s funeral rituals, and a lower status of women. It is thus a combination of social, economic and cultural factors, which underlies the increasing discrimination against daughters. There is a need to analyse the factors at play themselves as well as how they combine to create a situation with negative changes in child sex ratio in the context of overall societal change. To examine these features, an attempt is made in this paper based on a field work carried out in selected villages of Karnataka State, India.

      Full paper to be downloaded (as a pdf-file)

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