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Bihar State of Health in
POPULATION FOUNDATION OF INDIA
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State of Health in Bihar
Almas Ali
Sanjit Nayak
Sudipta Mukhopadhyay
Population Foundation of India
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© Population Foundation of India 2007
Design and Print
Impression Communications
2/8 A Ansari Road, Darya Ganj, New Delhi-110 002
9811116841, 65749684
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Acknowledgements
The idea of a comprehensive document on the State of Health in Bihar
germinated while developing the book India Socio-Demographic Development
Index, 2007 for policymakers and planners. This book looks substantially into
some of the important issues affecting the health status of the people in Bihar.
It views ‘health’ from a broader development perspective rather than purely
health indicators. It also explores the possibility of a more effective future
direction for healthcare in the state.
This book was made possible due to the effort of many people at various
levels. We extend our thanks to all of them. We are grateful to Mr A R Nanda
for giving us the opportunity to undertake this assignment and for providing
continuous guidance and motivation. We are grateful to our colleagues
Dr Kumudha Aruldas, Sona Sharma, Dr Sharmila Ghosh Neogi and
Dr Lalitendu Jagatdeb. We also greatly appreciate the support of our colleagues
Sanjay Kumar Singh, Matish Kumar, Amrit Kumar Rawat in Bihar and Nihar
Ranjan Mishra in Delhi. Our special thanks to the Registrar General of India
for providing the maps, the Government of Bihar and Population Foundation
of India documentation centre for providing us with relevant information.
We extend our sincere thanks to Shailender Singh Negi and Gajinder Pal Singh
Seerah for providing valuable technical assistance in data management and
Arthur Monteiro for editorial inputs. We are indebted to the David and Lucile
Packard Foundation for providing financial support for publishing this book.
Almas Ali
Sanjit Nayak
Sudipta Mukhopadhyay
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Foreword
The Population Foundation of India’s strategic focus is advocacy and action research on
critical issues of population. It advocates rights-based, gender-sensitive policies, programmes,
strategies and interventions for population stabilization, health and social development.
One of the features of this advocacy is to publish relevant information on states and districts
in the country. As part of its advocacy conference on Population, Health and Social
Development in 2002 in Bihar, PFI released the district profile for Bihar in 2002 based on
data from the Census of 2001 and District Rapid Household Survey 1998-99. The publication
was well received and created a large-scale demand for similar publications.
The linkage between health and development is an established concept. The need to integrate
these two has become an important concern for us today. Trying to change and improve the
health status of people in isolation is like chasing a mirage. It can happen only when all other
corresponding improvements are seen in related areas in social, economic and environmental
sectors. These efforts should also be based on evidence which reflects the reality and the
need. This publication brings out the current reality of the health and population scenario of
the state of Bihar based on reliable data. It reflects the current context of the health status, and
the gaps and priorities which need to be addressed in a development-oriented approach.
This document provides a holistic overview of Bihar, and includes the demographic and
socio-economic status in the state, assessment of its health situation, the current health delivery
system, and district profiles. It identifies areas of concern and explores policy options, which
may expedite improvement of human development in the state.
This publication is an endeavour to help policymakers, the state government, district
administrations, planners, programme managers and NGOs with information for improving
social conditions. We hope that the insights gained from it will help and motivate
governmental and non-governmental agencies to work towards creating a healthy population
in Bihar.
October 2007
New Delhi
A R Nanda
Executive Director, PFI
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Contents
List of Figures
viii
List of Tables
x
List of Maps
xiii
Glossary
xv
1 Introduction
1
2 Demographic and Socio-economic Scenario
5
3 Status of Health
19
I. Fertility
19
II. Mortality
25
III. Morbidity
38
IV. Nutrition
46
V. Reproductive and Child Health
51
4 District Health Profile and Ranking of Districts
67
I. District Health Profile
68
II. Ranking of Districts
143
III. Composite Socio-Demographic Development Index
165
5 Health Service Delivery
167
6 Concerns, Challenges and Strategies for Change
175
References
189
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Figures
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13a
3.13b
3.14
3.15
3.16a
3.16b
3.17
3.18
3.19
Absolute increase in the population of Bihar, Census 1901–2001
Decadal growth rate of Bihar Compared with that of India, Census
Population density, Bihar and India, Census 1951–2001
Child sex ratio in Bihar, Census 1991
Child sex ratio in Bihar, Census 2001
Age Pyramid (a) Bihar, 2001 (b) India, Census 2001
Projected population composition in Bihar by age groups, RGI
Scheduled Caste and Scheduled Tribe population of Bihar, Census 2001
HDI according to social groups for Bihar and India, 2006
Development indicators, Bihar, 2001
Literacy rate in Bihar, Census 1951–2001
Literacy rates for Scheduled Castes and Scheduled Tribes, Bihar, Census 2001
CBR for Bihar and India, SRS 1981–2005
CBR for Bihar, Rural and Urban, SRS 1981–2005
GFR for Bihar and India, SRS 1996–2005
GFR, Bihar and India by residence, SRS 2005
ASFR, Bihar and India, SRS 2005
ASFR for rural and urban Bihar for SRS 2005
GRR for Bihar and India, SRS 1981–2005
GRR for Bihar and India, SRS 2005, by residence
TFR for Bihar and India as per NFHS data
Life expectancy in Bihar and India, 2000, by gender and residence
CDR for Bihar and India, SRS 1981–2005
CDR for Bihar, SRS 1981–2005, by residence
ASDR for Bihar and India, SRS 2005
ASDR for Bihar, SRS 2005, by residence
Distribution of deaths by broad age groups, Bihar and India, SRS 2005
Child mortality rate in Bihar and India, SRS 1995–2005
Child mortality rate for Bihar and India, SRS 1995–2005
Child mortality rate for Bihar, SRS 1995–2005, by residence
Infant deaths as percentage of total deaths by residence, Bihar, SRS 1995–2005
Infant mortality rate by residence, Bihar, SRS 1981–2005
Neo-natal mortality rate by residence, Bihar, SRS 1995–2005
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3.20
3.21
3.22
3.23
3.24a
3.24b
3.25
3.26
3.27
3.28
3.29
3.30
3.31
3.32
3.33
3.34
3.35
3.36
3.37
3.38
3.39
3.40
3.41
5.1
5.2
5.3
5.4
5.5
6.1
Share of neo-natal deaths to infant deaths by residence, Bihar, SRS 1995–2005
Causes of maternal death, Bihar, 2003-04
Various estimates of MMR for Bihar
HIV/AIDS prevalence in Bihar, PFI-PRB 2003–06
Nutrition levels in boys in rural Bihar, 1998
Nutrition levels in girls in rural Bihar, 1998
Severe under-nutrition levels in boys and girls in Bihar, 1998
Severe under-nutrition levels in children 1–5 years in India, 1998
Nutritional status of children in Bihar, NFHS III and NFHS II
Nutritional status of married adults in Bihar, NFHS III and NFHS II
Anaemia prevalence in Bihar, NFHS III and NFHS II
Use of iodized and non-iodized salt in (a) Bihar, (b) India
Women married by age 18, NFHS Bihar
Age at first birth for women, NFHS Bihar and India
Birth order 3 and above, NFHS Bihar and India
Spacing methods of contraception, NFHS and RCH Bihar and India
Contraception prevalence rate, NFHS and RCH Bihar and India
Limiting methods of contraception, NFHS and RCH Bihar and India
Unmet need of contraception, NFHS and RCH Bihar and India
Achievement in family planning, Bihar, 2006
Achivement in CPR all methods, Bihar, 2001–05
Any ANC, Bihar and India , NFHS and RCH data
Immunization coverage in Bihar: (a) progress; (b) compared with all-India level;
(c) by residence; (d) among SC/ST
Organogram of Health and Family Welfare Department, Government of Bihar
Concentration curve of public spending on curative health care
Visit to health facility for health or family planning services, rural Bihar
Visit to health facilities, public vs. private, rural areas
Change in utilization of health facility: NFHS II vs. Follow-up
Positioning family planning
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Tables
1.1 Reorganization of Districts in Bihar
2.1 Population Growth in Bihar Compared to that of India, Census 1901–2001
2.2 Population Density in Bihar Compared with that of India, Census 1951–2001
2.3 Change in Sex Ratio in Bihar and India, Census 1901–2001
2.4 Change in Child Sex Ratio in Bihar and India, Census 1951–2001
2.5 Age-wise Population Distribution in Bihar, Census 2001
2.6 Projected Population Characteristics of Bihar, Census 2006–2026
2.7 Scheduled Caste and Scheduled Tribe Population of Bihar, Census 2001
2.8 HDI according to Social Groups for Bihar and India, 2006
2.9 Social Development Index according to Residence for Bihar,
1991 and 2001
2.10 Literacy Rate in Bihar, Census 1951–2001
2.11 Literacy Rates for Scheduled Castes and Scheduled Tribes, Bihar, Census 2001
2.12 Crop Yield and Yield Gap in Bihar
2.13 Poverty Indices for Bihar and India, 1993-94 to 1999-2000
2.14 Selected Socio-economic Indicators of Bihar
2.15 Selected Millennium Development Goals Indicators for Bihar
3.1 CBR for Bihar and India Compared, SRS 1981–2005
3.2 GFR, Bihar and India, SRS 1981–2005
3.3 GFR, Bihar and India, SRS 2005
3.4 ASFR, Bihar and India, SRS 2005
3.5 ASFR for Bihar and India, SRS 1981–2005
3.6 GRR, Bihar and India, SRS 1971–2005
3.7 GRR, Bihar and India, SRS 2005
3.8 TFR for Bihar and India, SRS 1981–2005
3.9 TFR Bihar and India as per NFHS data
3.10 Life Expectancy Figures for Bihar and India, SRS 1990 and 2000
3.11 CDR for Bihar and India Compared, SRS 1981–2005
3.12 ASDR for Bihar and India by Residence, SRS 2005
3.13 Distribution of Deaths by Broad Age Groups, Bihar and India, SRS 2005
3.14 Child Mortality Rate, Bihar and India, SRS 1995–2005
3.15 Proportion of under 5 Mortality to Total Deaths, Bihar and India, SRS 1995–2005
3.16 Infant Deaths as Percentage of Total Deaths in Bihar and India, SRS 1995–2005
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3.17 Infant Mortality Rate for Bihar and India by Residence, SRS 1981–2005
3.18 Infant Mortality Rates by Sex, Bihar and India, SRS 1995–2005
3.19 Percentage Change in IMR, Bihar and India, SRS
3.20 Disaggregated Neo-natal Mortality and Peri-natal Mortality Rates,
Bihar and India, SRS 1995–2005
3.21 Status of Maternal Mortality Ratio in Bihar and India
3.22 Projected Mortality and Fertility Characteristics of Bihar, SRS 2006–2025
3.23 Kala-azar Occurrence in Bihar and India, 2001–06
3.24 Malaria and Pf Cases in Bihar and India, 2001–06
3.25 TB Incidence, Prevalence and Treatment Rates in Bihar and India, 2005
3.26 Japanese Encephalitis Cases in Bihar and India, 2001–05
3.27 Leprosy Cases and Prevalence in Bihar, 2006
3.28 Estimated population exposed to risk of filariais and microfilaria carriers
and filaria cases, 2004-05
3.29 Knowledge of HIV/AIDS among Ever Married Adults (15–49 years) Bihar and India
3.30 Prevalence of HIV infection in Bihar and India, 2003–06
3.31 Nutritional Status of Children under 3 years in Bihar and India
3.32 Distribution of Nutritional Status of Children (1–5 years) According to
Weight for Age, in Percentage (Gomez Classification), 1998
3.33 Distribution of Severely Undernourished Children (1–5 years) in States/UTs,
Gomez Classification, 1998
3.34 Child Feeding Practices in Bihar and India
3.35 Breast-feeding and Colostrum Feeding Practices in Bihar and India, 2005
3.36 Nutritional Status of Children and Married Adults in Bihar
3.37 Households Reporting Use of Salt Types in Bihar and India, 2005
3.38 Marriage and Fertility Rates for Bihar and India
3.39 Current Use of Family Planning Methods, Bihar and India
3.40 Unmet Need for Family Planning, Bihar and India
3.41 Achievements of the State of Bihar in Family Planning, 2000-01 to 2005-06
3.42 Selected Family Planning Methods, Bihar 2001–05
3.43 Effective CPR due to all methods, Bihar, 2001–05
3.44 Status of Maternal Health Determinants in Bihar
3.45 Ante-natal Care, Bihar and India, 2005
3.46 Healthcare Received in Child Delivery
3.47 Immunization Coverage in Bihar
3.48 Immunization Status by Residence and among SC/ST in Bihar and India, 2005
3.49 Coverage of Type of Syringes used for Immunization and Method of Sterilization,
Bihar and India
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3.50 Child Immunization and Vitamin A Supplementation, Bihar and India
3.51 Achievement in Immunization
3.52 Treatment of Childhood Diseases
3.53 Knowledge of Diarrhoea Management and Treatment
3.54 District-wise Key RCH Indicator, Bihar
4.1 District-wise Key RCH Indicators, Bihar, RCH-2
4.2 Ranking of Districts According to Decadal Population Growth Rate
4.3 Ranking of Districts According to Density of Population
4.4 Ranking of Districts According to Sex Ratio
4.5 Ranking of Districts According to Child Sex Ratio
4.6 Ranking of Districts According to Female Literacy
4.7 Ranking of Districts According to Girls Marrying Below the Age of 18 Years
4.8 Ranking of Districts According to Birth Order 3 and Above
4.9 Ranking of Districts According to Any Antenatal Care
4.10 Ranking of Districts According to Institutional Delivery
4.11 Ranking of Districts According to Full Immunization
4.12 Ranking of Districts According to Contraceptive Prevalence Rate
4.13 Ranking of Districts According to Socio-demographic Development Index
5.1 Healthcare Infrastructure in Bihar as in March 2006
5.2 Availability of health personnel in Bihar, March 2006
5.3 Shortfall in Health Personnel in Bihar, March 2006
5.4 Shortfall of Specialists and Technicians in Health Facilities in Bihar, March 2006
5.5 Health Staff Position at PHCs and Sub-centres
5.6 Quality of Care Indicators for Bihar and India
6.1 Projected Population and Fertility, Bihar and India, 2001–2101
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Maps
1.1 Position of Bihar in India, 2001
1.2 Bihar Administrative Divisions, 2001
4.1 District Map of Araria
4.2 District Map of Aurangabad
4.3 District Map of Banka
4.4 District Map of Begusari
4.5 District Map of Bhagalpur
4.6 District Map of Bhojpur
4.7 District Map of Buxar
4.8 District Map of Darbhanga
4.9 District Map of Gaya
4.10 District Map of Gopalganj
4.11 District Map of Jamui
4.12 District Map of Jehanabad
4.13 District Map of Kaimur (Bhabua)
4.14 District Map of Katihar
4.15 District Map of Khagaria
4.16 District Map of Kishanganj
4.17 District Map of Lakhisarai
4.18 District Map of Madhepura
4.19 District Map of Madhubani
4.20 District Map of Munger
4.21 District Map of Muzaffarpur
4.22 District Map of Nalanda
4.23 District Map of Nawada
4.24 District Map of Paschim Champaran
4.25 District Map of Patna
4.26 District Map of Purba Champaran
4.27 District Map of Purnia
4.28 District Map of Rohtas
4.29 District Map of Saharsa
4.30 District Map of Samastipur
4.31 District Map of Saran
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4.32 District Map of Sheikhpura
4.33 District Map of Sheohar
4.34 District Map of Sitamarhi
4.35 District Map of Siwan
4.36 District Map of Supaul
4.37 District Map of Vaishali
4.38 Bihar decadal growth of population,1991-2001
4.39 Bihar, density of population, 2001
4.40 Bihar, sex ratio, 2001
4.41 Bihar, child sex ration, 2001
4.42 Bihar, female literacy rate, 2001
4.43 Bihar, girls marrying below age of 18 years
4.44 Bihar, birth order 3+
4.45 Bihar, ANC
4.46 Bihar, institutional delivery
4.46 Bihar, immunization figures
4.48 Bihar, CPR prevalence
4.49 Bihar, socio-demographic development index, 2007
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Glossary
AIDS
ANC
ANM
ARI
ASDR
ASFR
ASHA
AWW
BCC
BMI
BoD
BPL
BSACS
BSS
CBO
CBHA
CBR
CDR
CES
CGHS
CHC
CHW
CNA
CPR
CSR
CVD
DALYs
DLHS
DNP
Acquired Immuno Deficiency Syndrome
Ante Natal Care
Auxiliary Nurse Midwife
Acute Respiratory Infection
Age Specific Death Rate
Age-Specific Fertility Rate
Accredited Social Health Activist
Anganwadi Worker
Behaviour Change Communication
Body Mass Index
Burden of Disease
Below Poverty Line
Bihar State AIDS Control Society
Behaviour Sentinel Surveys
Community Based Organization
Central Bureau of Health Information
Crude Birth Rate
Crude Death Rate
Coverage Evaluation Report
Central Government Health Services
Community Health Centre
Community Health Worker
Community Needs Assessment
Contraceptive Prevalence Rate
Child Sex Ratio
Cardio Vascular Disease
Disability Adjusted Life Years
District Level Household Survey
District Nutrition Profile
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DOTS
DPT
DRHS
EIP
EMCP
EMoC
ESIS
FRU
FSW
GBoD
GDI
GFR
GRR
HBNC
HDI
HIV
HMIS
ICDS
ICMR
ICPD
IEC
IFA
IMNCI
IMR
IUD
JE
LBW
LHV
MDG
MDT
MIS
MLA
MMR
MoHFW
MTP
NACO
xvi
Directly Observed Treatment, Short-course
Diptheria Pertusis Tetanus
District Rapid Household Survey
Expanded Immunization Programme
Enhanced Malaria Control Project
Emergency Obstetric Care
Employment State Insurance Scheme
First Referral Unit
Female Sex Worker
Global Burden of Disease
Gender Disparity Index
Gross Fertility Rate
Gross Reproduction Rate
Home Based Neo-natal Care
Human Development Index
Human Immuno-deficiency Virus
Health Management Information System
Integrated Child Development Scheme
Indian Council of Medical Research
International Conference on Population and Development
Information Education Communication
Iron and Folic Acid
Integrated Management of Nutrition and Childhood Illnesses
Infant Mortality Rate
Intra-uterine Device
Japanese Encephalitis
Low Birth Weight
Lady Health Visitor
Millennium Development Goals
Multi Drug Treatment
Management Information System
Member of Legislative Assembly
Maternal Mortality Ratio
Ministry of Health and Family Welfare
Medical Termination of Pregnancy
National AIDS Control Organization
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NAMP
NCAER
NCC
NCD
NHP
NFHS
NGO
NLEP
NPP
NRHM
NSSO
NSV
NTP
NYK
OPV
PCPNDT Act
PFI
PHC
PPP
PRI
QoC
RCH
RMP
RNTCP
RTI
SDI
SRS
STD
STI
TB
TBA
TFR
TT
UIP
UNFPA
UNICEF
WHO
National Anti-Malaria Programme
National Council of Applied Economic Research
National Cadet Corps
Non-Communicable Diseases
National Health Policy
National Family Health Survey
Non Government Organization
National Leprosy Eradication Programme
National Population Policy
National Rural Health Mission
National Sample Survey Organization
No Scalpel Vasectomy
National TB Programme
Nehru Yuva Kendra
Oral Polio Vaccine
Pre-Conception and Pre-Natal Diagnostic Techniques Act
Population Foundation of India
Primary Health Centre
Public–Private Partnership
Panchayati Raj Institution
Quality of Care
Reproductive and Child Health
Rural Medical Practitioner
Revised National TB Control Programme
Reproductive Tract Infection
Social Development Index
Sample Registration System
Sexually Transmitted Disease
Sexually Transmitted Infection
Tuberculosis
Trained Birth Attendant
Total Fertility Rate
Tetanus Toxoid
Universal Immunization Programme
United Nations Population Fund
United Nations Children’s Fund
World Health Organization
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Map 1.1 : Position of Bihar in India, 2001
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1
Introduction
The health status of its population reflects the socio-economic development of a state. Health
status is shaped by a variety of factors — level of income and standard of living, housing,
sanitation, water supply, education, employment, health consciousness and personal hygiene, and
the coverage, availability, accessibility, acceptability and affordability of health services. The
poor health status of states is a product of inadequate nutrition, lack of protected water supply,
and overcrowded and insanitary housing conditions. These conditions are conducive to deficiency
diseases, airborne diseases, faecally related and waterborne diseases, which dominate the
morbidity and mortality pattern in less developed regions.
The relationship between health and poverty or health and development is complex and
multifaceted. Poverty in its various dimensions could be a manifestation as well as a determinant
of an individual’s health. In its most basic form — as a state of food deprivation and nutritional
inadequacy — poverty has a direct bearing on the morbidity and longevity of people. The other
aspects of deprivation, such as lack of access to critical amenities including safe water, sanitation,
non-polluting domestic fuels, connectivity of life support services and, most importantly, to
education and general awareness, contribute to reinforcing ill health and morbidity, even leading
to higher mortality levels. High child mortality levels on account of supervening infections,
particularly diarrhoea and respiratory infections, are fairly widespread among people deprived
of these basic amenities of life. These commonly seen childhood infections often exacerbate
malnourishment. Undernourishment in children in turn reinforces the consequences of such
infections.
By any index to measure socio-economic development the state of Bihar lags far below the
national average and remains well behind other states. Some of these parameters of backwardness
are per hectare productivity in agriculture, industrial output, dependence of people on the
secondary and tertiary economic sectors, employment scenario, per capita income, and efforts
in social modernization.
The root cause of poor health status in the state of Bihar is poverty (both income and human
poverty) and social deprivation, low literacy (especially female literacy) and structural
inequalities in terms of class, caste and sex. The state has the lowest per capita net domestic
product among all the Indian states. As much as 32.5% of the population of the state lives below
the poverty line (as per the 61st Round NSSO survey 2004-05), which is the second-highest rate
after Orissa (39.9%). The state also has the lowest literacy rate of 47.0% and also the lowest
female literacy rate of 33.1% among Indian states and Union territories, as revealed by the 2001
census. It also has the lowest ratio of girls in schools.
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The poor socio-economic status of the state of Bihar is in ironic contrast to its illustrious
history. In ancient times it was the Magadh kingdom. Patliputra (modern Patna) was home to
great monarchs like Chandragupta Maurya and Ashoka, who ruled over the Indian subcontinent.
The word Bihar derives from Viharas, the Sanskrit word for Buddhist monasteries. The region
gave birth to great religious leaders such as Lord Buddha, Lord Mahavira and Guru Govind Singh.
It was witness to the Satyagraha movement of Mahatma Gandhi in Champaran. The state gave the
nation its first President Dr Rajendra Prasad and national leaders such as Jayaprakash Narayan.
The modern state of Bihar, which came into existence in 1956, is located between 21°58′ to
27°31′ N latitude and 83°19′ to 88°17′ E longitude. It is bounded by Nepal on the north, West
Bengal on the east, Uttar Pradesh in the west and Jharkhand on the south. The state has two
distinct physiographic regions, viz. Sub-Himalayan area (North Bihar plains) and Gangetic plains
(South Bihar plains), marked by the river Ganges which flows from west to east to join the Bay of
Bengal. In November 2000 the state of Jharkhand was carved out of the state of Bihar by transfer
of 13 districts to the new state. The remaining 29 districts have been reorganized into 38 districts.
Table 1.1 presents details of the reorganization of districts.
Table 1.1. Reorganization of Districts in Bihar
Original District
New Districts after Reorganization
Bhojpur
Buxar
Gaya
Jehanabad
Jehanabad
Arwal
Munger
Lakhisarai, Sheikpura, Khagaria
Purnia
Araria, Kishanganj
Rohtas
Kaimur (Bhabua)
Saharsa
Supaul, Madhepura
Sitamarhi
Sheohar
12,407,132 are rural and 1,336,998 are urban.
Administratively, Bihar
now has 9 divisions, 101
subdivisions and 533
community development
blocks. There are 130 towns,
including 125 statutory
towns and 5 census towns,
and 45,098 villages, out of
which 39,015 are inhabited.
There are 9032 gram
panchayats, 7 municipal
corporations, 42 munici-
palities, 3 nagar panchayats,
and 853 police stations.
The households number
13,744,130, of which
Bihar has a land area of 94,163 sq km, which is 2.86% of the land area of India (3,287,240 sq
km). The state’s rural land area is 92,358.40 sq km (98.08%) and urban land area is 1804.60 sq km
(1.92%). Total irrigated land is 4807,000 hectares (1999-2000). The Ganges and its tributaries are
the major source of water for the state. Other major rivers include Gandak, Ghagra, Kosi and
Baghmati. The agricultural economy of the state is characterized predominantly by cash crops
such as cotton, hemp, jute, oilseeds and tobacco. Maize, potato, rice and wheat are the other crops.
Litchis, mangoes, bananas and jackfruit are the main fruits.
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Bihar at a Glance
Area (sq kms)
Revenue Divisions
Districts
Sub-Divisions
Community Development Blocks
Towns
Villages
Inhabited Villages
Gram Panchayats
Municipal Corporations
Municipalities
Nagar Panchayats
Police Stations
Population Total (2001)
Males
Females
Rural (percent)
Urban (percent)
Scheduled Castes (percent)
Scheduled Tribes (percent)
Decadal Growth Rate (percent) 1991-2001
Annual Exponential Growth Rate 1991-2001 (percent)
Density of Population (per sq km), 2001
Overall Sex-Ratio, 2001
Sex-Ratio (0-6 years), 2001
Total Literacy (percent)
Female Literacy
Total Work Participation Rate
Female Work Participation RatePeople living below Poverty Line (percent)
Per Capita Income (in Rupees)
Human Development Index (HDI)Value
Human Development Index (HDI)Rank
Social Development Index (SDI) Urban Value
Social Development Index (SDI) Urban Rank
Social Development Index (SDI) Rural Value
Social Development Index (SDI) Rural Rank
Gender Disparity Index (GDI)Value
Gender Disparity Index (GDI)Rank
Infant Mortality Rate (IMR), SRS-2005
Crude Birth Rate (CBR), SRS-2005
Crude Death Rate (CDR), SRS-2005
Total Fertility Rate (TFR), NFHS-III
Life Expectancy at Birth, 2000
Maternal Mortality Ratio, SRS 2001- 2003
Community Health Centres (CHCs)
Primary Health Centres (PHCs)
Sub Centres
4
State of Health in Bihar
94,163
9
38
101
533
130
45,098
39,015
9032
7
42
73
853
82,998,509
43,243,795
39,754,714
89.5
10.5
15.7
0.9
28.6
2.5
881
919
942
47.0
33.6
33.7
18.832.5
6719
0.27
15
27.10
19
16.13
20
0.47
32
61
30.4
8.1
4
60.8
371
70
1641
8858
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2
Demographic and
Socio-economic Scenario
According to the 2001 census, the population of the state of Bihar is 82,998,509 persons, consisting
of 43,243,795 males and 39,754,714 females. The state accounts for 8.07% of the country’s population
(1,028,737,436). Currently (2007), India’s population is estimated at 112 crore while that of Bihar is
estimated at 9.2 crore. The population of the state is predominantly rural, with 89.5% of the population
(74,316,709 persons) residing in rural areas. According to the 2001 census, 273,836 persons were
living in institutional households, against 170,412 persons in 1991. Further, 42,298 persons were
houseless in the 2001 census, against 35,355 houseless persons in the 1991 census.
In 1991, with a population of 64,530,554, the state ranked fifth in the country in terms of
population. In the 2001 census it ranked third, after Uttar Pradesh and Maharashtra. The state
along with Uttar Pradesh, Maharashtra, West Bengal, Andhra Pradesh, Tamil Nadu, Madhya
Pradesh, Rajasthan and Karnataka constitutes almost 50% of the population of India. Table 2.1 and
Figures 2.1 and 2.2 present details.
Table 2.1. Population Growth in Bihar Compared to that of India, Census,1901–2001
Year
Bihar
India
Population Proportion of
Bihar in India
Population
Decadal
growth rate
Population
Decadal
growth rate
1901
1911
1921
1931
1941
1951
1961
1971
1981
1991
2001
27,311,865
28,314,281
28,126,675
31,347,108
35,170,840
38,782,271
46,447,457
56,353,369
69,914,734
86,374,465
82,998,509
—
1.52
–0.97
9.74
12.22
10.58
19.79
20.91
24.16
23.38
28.62
238,396,327
252,093,390
251,321,213
278,977,238
318,660,580
361,088,090
436,234,771
548,159,652
683,329,097
846,421,039
1,028,737,436
—
5.75
–0.31
11
14.22
13.31
21.64
24.8
24.66
23.86
21.54
11.46
11.23
11.19
11.24
11.04
10.74
10.65
10.28
10.23
10.20
8.07
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Figure 2.1. Absolute increase in the population of Figure 2.2. Decadal growth rate of Bihar
Bihar, Census 1901–2001
compared with that of India, Census 1901-2001
Decadal Growth
During the decade 1991–2001, Bihar was the only state where the growth rate increased from
23.38 to 28.62, which is higher than the national average of 21.54 whereas all other states had a
drop in decadal growth rate. Annual average exponential growth rate, which was 2.10 during
1981–91, has also increased to 2.50 during 1991–2001.
Population Density
The state has a population density of 881 persons per sq km as compared to 325 persons per sq
km at the national level. In 1991 the corresponding figures were 685 and 267. Carving out of the
state of Jharkhand has increased the population density of the state, bringing its rank in the country
in this respect to the 7th place in 2001 from the 8th rank in 1991 and comes only after Delhi,
Chandigarh, Pondicherry, Lakshadweep, Daman and Diu and West Bengal. The density of the
population of the state is 4811 in urban areas as compared to 805 of rural areas. Table 2.2 and
Figure 2.3 present details.
Table 2.2. Population Density (per sq km) in
Bihar Compared with that of India, 1951–2001
Year
Bihar
India
Figure 2.3. Population density, Bihar and India,
Census 1951–2001
1951
223
117
1961
267
142
1971
324
177
1981
402
216
1991
685
267
2001
881
325
Note: Figures for Bihar till 2001 include the present Jharkhand
state.
Source: Census of India 2001, Registrar General of India, New
Delhi.
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Sex Ratio
The sex ratio, i.e. number of females per thousand males in the state was favourable to females
till 1961 except in 1931, when it declined to 995. After 1961 the sex ratio in the state has been
unfavourable to females. The sex ratio of the state since 1901 had always remained higher than
that for the country as a whole till the 1981 census. However, the sex ratio of 907 of Bihar in 1991
was much below the sex ratio of 927 at the national level. There has, however, been some
improvement in the 2001 census in this regard where the sex ratio of Bihar is 919 as compared to
933 at the national level for India. There has been a 12 point increase in sex ratio for the state. The
state ranked 22nd in 2001 as compared to 25th rank in 1991 (see Table 2.3).
Table 2.3. Change in Sex Ratio in Bihar and India, Census 1901–2001
Year
1901
India
972
Variance
Bihar
1061
Variance
1911
964
–8
1051
–10
1921
955
–9
1020
–31
1931
950
–5
995
–25
1941
945
–5
1002
+7
1951
946
+1
1000
–2
1961
941
–5
1005
+5
1971
930
–11
957
–48
1981
934
+4
948
–9
1991
927
–7
907
–41
2001
933
+6
919
+12
The child sex ratio (CSR) for Bihar is 942 as compared to 927 for India in 2001. The
corresponding figures in 1991 were 953 and 945. The state ranks 20th in CSR in 2001 as compared
to 21st rank in 1991 (see Table 2.4 and Figures 2.4 and 2.5). The percentage of women who desire
the next child to be a son in Bihar is 55.5% (India 38.1%); the percentage of husbands who desire
the next child to be a son is also high at 45.2% (India 35.6%).
Table 2.4. Change in Child Sex Ratio in Bihar and India, 1951–2001
Year
1971
1981
1991
2001
Bihar
964
962
964
981
Variance
–12
–2
–24
+17
India
945
927
953
942
Variance
–17
–18
–28
–11
Source: Census of India 2001, Registrar General of India, New Delhi.
Figure 2.4. Child sex ratio in Bihar, 1991
Figure 2.5. Child sex ratio in Bihar, 2001
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Age Distribution
The high fertility in the decades 1961–2001 is reflected in a young age structure for the country,
with about 54% of the population being below the age of 24 years (Census 2001). Of this 35% are
in the age group 10–14 years and 19% in the age group 15–24 years. In Bihar as well, the age
pyramid reflects the growing base of youth population in the state. The population of the state is
very young, with 42.0% below the age of 15 (see Table 2.5 and Figure 2.6). As per World Youth,
2006 Data Sheet, produced by the Population Research Bureau, there are about 33.1 crore young
people (10 to 24 years) in India, representing a little less than one-third of the population.
Table 2.5. Age-wise Population Distribution (%) in Bihar, Census 2001
Age Group
Total
Male
Female
Rural
0-4
13.3
10.5
10.3
13.6
5-9
15.4
11.8
11.8
15.7
10-14
13.3
10.9
10.2
13.3
15-19
8.7
9.8
10.5
8.4
20-24
7.6
8.9
9.6
7.5
25-29
7.1
8.6
10.2
7.1
30-34
6.7
7.3
7.2
6.7
35-39
6.1
7.2
6.3
6.1
40-44
5.0
5.1
4.6
5.0
45-49
4.2
4.7
4.1
4.1
50-54
3.3
3.1
2.7
3.2
55-59
2.5
2.9
3.9
2.5
60-64
2.5
3.2
3.4
2.6
65-69
1.6
2.4
2.1
1.6
70-74
1.2
2.0
1.5
1.3
75-79
0.5
1.3
1.1
0.5
80+
0.9
0.4
0.4
0.9
Urban
10.6
13.2
13.6
10.7
8.8
7.5
6.8
6.5
5.4
4.6
3.3
2.5
2.3
1.6
1.1
0.5
0.9
Source: Census of India 2001, Registrar General of India, New Delhi.
Figure 2.6a. Age pyramid, Bihar, 2001
Figure 2.6b. Age pyramid, India, 2001
The term ‘youth’ encompasses a diverse set of young people — urban, schoolgoing, rural
youth, married adolescents and out-of-school youth. In addition, one has to consider youth from
marginalized sections of society who have faced historical discrimination. The United Nations
Population Fund (UNFPA) defines adolescence as 10–19 years, with 10–14 years being early
adolescence and 15–19 years as late adolescence. The National Youth Policy of India (2003)
recognizes people in the age group of 13 to 35 years as youth.
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Population Projection
The Registrar General of India’s population projection in 2006 suggests that the population of
Bihar would swell to approximately 113 crore, with a growth rate of 0.8 and TFR of 2 by the year
2026. The proportion of female population also shows an increase of 8%, with female population
between 15–49 years being approximately 55%, whereas the proportion of 0–14 years would
decline to 24.9%. It is estimated that population above 60 years of age would double from 6.3% in
2006 to 11% in 2026, marking a gradual ageing of the population (see Figure 2.7). Table 2.6
presents the quinquennial projected population characteristics of the state until 2026.
Figure 2.7. Projected population composition in Bihar by age groups, RGI, 2006
Table 2.6. Projected Population Characteristics of Bihar, 2006–2026
Indicator
Population (’000)
Sex Ratio
Population Density (per sq km)
Population Growth Rate
Population by Broad Age
Groups (’000)
Proportion (%)
Median Age (years)
Dependency Ratio
Total (Young and old)
Total
Male
Female
18 years and
above
0–14
15–59
60+
0–14
15–59
15–49 (female)
60+
Young (0–14)
Old (60+)
2006
90752
47165
43586
924
964
1.5
49447
3461
50151
5740
38.4
55.3
49.0
6.3
20.14
695
114
810
2011
97720
50640
47080
930
1038
1.2
57499
33191
57536
6993
34.0
58.9
51.9
7.2
22.11
577
122
698
2016
103908
53676
50231
936
1103
1.0
65984
30944
64438
8525
29.8
62.0
54.4
8.2
24.22
480
132
613
Source: Population Projection, 2001–2026, Registrar General of India, New Delhi 2006.
2021
109431
56341
53091
942
1162
0.8
73538
2026
113947
58409
55437
949
1209
79591
29816
69250
10365
27.2
63.3
54.7
9.5
26.58
431
150
580
28347
73007
12493
24.9
64.1
54.9
11.0
29.05
388
171
559
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Religious Composition
The population of Hindus in Bihar is about 83% (6,90,76,919), compared to 17% of Muslims
(1,37,22,048). The rest comprise Christians (53,137), Sikhs (20,780), Buddhists (18,818), Jains
(16,085), those who did not state religion (37,817), and others (52,905).
The recently published Sachar Committee Report (2007) has drawn attention to the unequal
opportunities for the Muslim population, who are systematically disadvantaged because they are
discriminated against in public institutions such as in education and in health services. They are
more likely to be poor and more likely to be denied access to income, assets and services.
Scheduled Castes and Scheduled Tribes
The Scheduled Caste population of Bihar was 15.7% in 2001, as compared to 16.2% for India.
The corresponding figures for 1991 were 15.5% and 16.5%. The Scheduled Tribe population was
0.9% in 2001, as compared to 8.2% for India in 2001 and 8.1% in 1991 (see Table 2.7 and Figure
2.8). The state ranked 16th in the Scheduled Caste population and 27th in the Scheduled Tribe
population in 2001.
Table 2.7. Scheduled Caste and Scheduled Tribe Population of Bihar Census, 2001
Total Population
Rural
Urban
Total
Male Female
Total
Male Female
Total
Male Female
Scheduled Castes
13048608 6784676 6263932 12178555 6321221 5857334 870053 463455 406598
(15.7%)
(52%)
(48%) (16.4%) (51.9%) (48.1%) (10.0%) (53.3%) (46.7%)
Scheduled Tribes
758351
(0.9%)
393114
(51.8%)
365237
(48.2%)
717702 371009
(1.0%) (51.7%)
346693
(48.3%)
40649 22105 18544
(0.5%) (54.4%) (45.6%)
Figure 2.8. Scheduled Caste and Scheduled
Following are the notified Scheduled Castes
Tribe population of Bihar, Census, 2001 (%) and Scheduled Tribes in Bihar.
Scheduled Castes: Bantar, Bauri, Bhangi,
Bhogta, Bhuiya, Bhumji, Chamar, Mochi, Chaupal,
Dabgar, Dasadh, Dhangad, Dharhi, Dhobi, Dom,
Ghasi, Halalkhor, Hari, Kanjar, Kurariar, Lalbegi,
Mehtar, Musahar, Nat, Pan, Pasi, Rajwar, Sawasi,
Turi.
Scheduled Tribes: Assure, Baiga, Banjara,
Bathudi, Bedia, Bhumij, Binjhia, Birhor, Birjia,
Chero, Chik Baraik, Gond, Gorait, Ho, Karmali,
Kharia, Kharwar, Khond, Kisan, Kora, Korwa,
Lohara, Mahli, Mal Paharia, Munda, Oraon, Pahariya, Santal, Sauria Paharia, Savar.
It needs to be noted that some of the population groups now belong to the state of Jharkhand.
10
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Development and Social Exclusion
The greatest challenge that Bihar faces today is development. This relates to income, poverty,
undernourishment, illiteracy and social exclusion based on caste and gender. Under the prevalence
of such backward societal conditions and inequalities in Bihar between people in urban and rural,
between rich and poor, between the educated and the illiterate and between those who posses
some form of entitlements and those who do not, development has to be viewed not just in terms
of economic prosperity but in terms of human, social and gender development.
Human Development Index (HDI) is a composite index representing three dimensions of human
development, namely, economic, health and education. The indicators are life expectancy, literacy
rate and adjusted income. The combined HDI of Bihar is 0.367 as compared to 0.472 for India.
The state ranks 15th in HDI. Table 2.8 and Figure 2.9 show HDI among marginalized groups in
Bihar and India. The HDI among marginalized groups is a cause for concern as they are lagging
behind on all fronts of development. Table 2.9 shows SDI by residence.
Table 2.8. HDI According to Social Groups for Figure 2.9. HDI according to social groups for
Bihar and India, 2006 HDRC/UNDP India 2007
Bihar and India, 2006
Bihar India
All social groups
0.279 0.366
Scheduled Castes
0.195 0.303
Scheduled Tribes
0.201 0.270
Other Castes
0.301` 0.393
Source: Human Poverty and Socially Disadvantaged Groups in
India Delhi, HDRC/UNDP India 2007.
Improvement in economic parameters such as gross domestic product (GDP), per capita income,
etc. has been impressive in India but improvement in social indicators such as literacy, nutritional
status of women and children, infant mortality rate, unemployment rate and incidence of poverty
has been far from satisfactory. This is mainly due to the inadequacy of social infrastructure and
lack of access to basic amenities, especially for the socially and economically marginalized sections
of society.
Table 2.9. Social Development Index According to Residence for Bihar, 1991 and 2001
1991
Urban
Rural
Value
Rank
Value
Rank
22.45
20
16.03
20
2001
Urban
Value
Rank
27.10
19
Rural
Value
16.13
Rank
20
Source: Social Development Index, Council for Social Development, New Delhi, 2006.
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In 2006 the Council for Social Development brought out a report on India’s Social Development.
Social Development Index is a composite index of six major dimensions of social development,
namely demographic parameters, health situation, educational attainments, availability of basic
amenities, incidence of unemployment and poverty and extent of social deprivation as of 1991 and
2001.
Gender Disparity Index (GDI) is estimated as proportion of female attainments to that of
males for a common set of variables (National Human Development Report, March 2001). The
variables used to capture economic attainments are worker population ratio, which is different
from the variable used to capture economic attainment in the HDI. GDI value is 0.469 for Bihar,
the lowest in the country, the all-India figure being 0.676. Figure 2.10 presents the development
indicators for the state in terms of HDI, SDI and GDI.
Figure 2.10. Development Indicators, Bihar,
2001
Social exclusion describes a process by which
certain groups are systematically disadvantaged
because they are discriminated against on the basis
of their ethnicity, race, religion, sexual orientation,
caste, descent, gender, age, disability, HIV status,
migrant status or where they live. Mainly women
and marginalized groups who are discriminated
against often end up excluded from society,
economy and political participation.
Literacy
The number of literates in Bihar in 2001 was 3,16,75,607. Literate males outnumber females
2 to 1 (see Table 2.10 and Figure 2.11). Bihar ranks lowest in literacy rate in the country, with
literacy rate of 47.0% as compared to 64.8% for India (2001 census). The corresponding figures
for 1991 were 37.5% and 52.2%.
Table 2.10. Literacy Rate in Bihar,
1951–2001
Year
Total
Male
Female
1951
13.49
22.68
4.22
1961
21.95
35.85
8.11
1971
23.17
35.86
9.86
1981
32.32
47.11
16.61
1991
37.49
51.37
21.99
2001
47.0
60.32
33.57
Source: Census of India, Registrar General of India,
New Delhi.
Figure 2.11. Literacy rate in Bihar, Census 1951–2001
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Male literacy in India during the 2001 census was 75.3% and female literacy was 53.7%. The
corresponding figures for Bihar were 60.3% and 33.6%. According to the Census of 2001, literacy
rate among the Scheduled Castes was 28.5% and among the Scheduled Tribes, 28.2%. Literacy
rates of these segments of population in the 1991 census were 18.4% and 18.95 respectively at the
state level. Table 2.11 provides details. Figure 2.12 illustrates the scenario graphically.
Table 2.11. Literacy Rates for Scheduled Castes and Scheduled Tribes, Bihar, Census 2001
Overall
Scheduled Caste
Scheduled Tribe
Total
Total
Rural
Urban
Total
Male
Rural
Urban
Female
Total Rural
31109577 25876919 5232658 20644376 17513010 3131366 10465201 8363909
(47.0%) (43.9%) (71.9%) (59.7%) (57.1%) (79.9%) (33.1%) (29.6%)
2880895 2536205 344690 2128948 1900047
169895 147420 22475 125048 111086
228901
13962
751947 636158
44847 36334
Urban
2101292
(62.6%)
115789
8513
Figure 2.12. Literacy rates for Scheduled Castes and
Scheduled Tribes, Bihar, Census 2001
According to the NSSO 55th round, the net
primary enrolment for Bihar in 1999-2000
was 52 compared to 77 for India. Women’s
enrolment (34%) is considerably lower than
that of men, with an enrolment gap of 14%.
Bihar is the only state where primary
enrolment has fallen between 1993-94 and
1999-2000 by 2%.
Occupational Status
Work Participation. According to the 2001 census, work participation rate in Bihar was 33.7%
as compared to 30.6% in 1991. The corresponding all-India figures were 39.1% and 37.5%. The
state has improved its rank in work participation to 30th place in 2001 as compared to 33rd place
in 1991.
Male work participation rate during the 2001 census for total population, Scheduled Castes
and Scheduled Tribes were 47.4%, 49.2% and 52.9%, respectively; in the 1991 census the
corresponding figures were 47.6%, 50.4% and 53.6%. Thus, work participation rate declined in
2001 in all the male categories of population. During 2001 special efforts were made to cover
female contribution in the economy in paid as well as unpaid work in family farm, collection of
tendu leaves, bidi rolling, rearing of goats/sheep, rice dehusking, etc. Special training modules
and wider publicity were undertaken to capture female work participation, especially in those
areas where it showed inordinately low rates in the 1991 census. As a result, work participation
rate among females increased appreciably from 11.8% in 1991 to 18.8% in 2001. Among the
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Scheduled Castes female work participation rate increased from 23.3% in the 1991 census to
29.5% in 2001. Similarly, among the Scheduled Tribes the percentage of female workers rose
from 31% to 36.9%.
Main Workers. During 2001 the percentage of main workers to total workers in respect of
total population, Scheduled Castes and Scheduled Tribes has been recorded as 75.3%, 71% and
68.7%, respectively. The corresponding figures for the 1991 census were 95.2%, 95.4% and 92.8%,
respectively. One reason for this decline is attributed to the fact that during the 2001 census
special emphasis was placed on netting of marginal workers, leading to major gains in the category
marginal workers and consequent decline in the proportion of main workers across the country.
In main work participation the state was ranked 8th in 1991 and 23rd in 2001.
Marginal Workers. According to the 2001 census, the percentage of marginal workers to total
workers was 24.7% against 4.8% recorded in 1991. Further, 29% among the Scheduled Castes and
31.45% among the Scheduled Tribe workers were marginal workers in 2001. The corresponding
figures in the 1991 census were 4.6% and 7.2%, respectively. In marginal workers the state ranked
27th in 1991 and 12th in 2001. In view of the high incidence of leasing-in of land among the small
and marginalized farmers and social groups, tenurial arrangements do have a significant impact
on the livelihood of the poor. Efforts to provide legal protection to tenants (1963) through tenancy
and land reforms have not met with much success, with the result that majority of tenancy contracts
continue to exploit the poor.
Cultivators. The proportion of cultivators to total workers in Bihar decreased from 41.1% in
1991 to 32.2% in 2001. The proportion of cultivators among Scheduled Castes was 8.7% while
that of Scheduled Tribes was 23.9%. This is a decline from 12.1% and 31.2% respectively in these
categories in the 1991 census.
The proportion of agricultural labour to total workers increased from 43.7% in 1991 to 48.0%
in 2001. Bihar has the highest number of agricultural labour in India, with more than 75% of
overall workers being either cultivators or agricultural labour. Further, 75.4% among the Scheduled
Caste workers and 60.9% among the Scheduled Tribe workers are engaged in agricultural labour,
a slight decline from the corresponding figures of 79.2% and 61.0% in 1991. Total number of
household industry workers in Bihar was 1.5% in 1991 and 3.9% in 2001.
Land Ownership. As much as 75% of the rural poor in the state are landless or near landless.
Land reforms have led to the acquisition of only 1.5% of cultivable land for distribution as compared
to the requirement of 20% for redistribution.
Crop Yield. The state average agriculture yield is almost half of that of the potential yield in
comparison to the yield at all-India levels. The gap is particularly large in the case of rice and
maize; wheat yield shows a much lower gap (see Table 2.12). Currently, horticulture crops account
for less than 5% of cropped area and show strong promise for growth in several districts. Litchi
cultivation is one such success story.
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Table 2.12. Crop Yield and Yield Gap in Bihar (kg per hectare)
Potential Yield
Average Yield
Gap
All-India yield
Rice
3026
1218
1818
1994
Maize
4056
1844
2212
1810
Wheat
3052
1816
1236
2703
Sugarcane
62780
48856
13924
70578
Litchi
1850
1000
850
–
Source: Export Potential of Indian Agriculture 2000, New Delhi.
Livestock ownership. A majority of rural households own some livestock. The poor and socially
disadvantaged household tends to own low quality livestock (goats rather than cows and buffaloes).
The total value of livestock per household among the richest is almost six times that of the poor.
Employment. According to the Director General of Employment and Training, Ministry of
Labour and Employment, Government of India, total employment in the organized sector in Bihar
for the quarter ending 31 March 2002 was 1613.0 (in thousand), with 1360.10 in the public sector
and 252.90 in the private sector. For the quarter ending 31 March 2003 total employment was
634.9, with 590.5 in the public sector and 44.4 in the private sector.
The NSSO data show that wage employment in agricultural labour accounted for nearly 40%
of the rural work force of Bihar in 1999-2000 as compared to 42% in 1993-94. Agricultural
labour and cultivation together accounted for around 80% of occupations in 1999-2000. Thus,
there is very limited occupational opportunity outside the sector. The poor are far more likely to
be agricultural wage workers or casual non-farm labourers, rather than cultivators or employed
in a regular non-farm job. Over time, agricultural labour among the poorest has declined while
casual non-farm labour and self-employed non-farm occupations have increased. Such a shift does
not necessarily mean an improvement in occupational status. Casual non-farm labour is a last
resort that households choose. It is the lowest paid, and is usually unstable. In urban areas, more
than 40% of household heads were self-employed and 30% had regular employment in 1999-
2000. Underemployment in rural Bihar is very high, leading to outmigration to other states.
Poverty
The State Specific Poverty Line for rural Bihar in 2004-05 was Rs 354.36 per capita per month;
its urban equivalent was Rs 435.00 per capita per month, compared to all-India figures of
Rs 356.30 and Rs 538.60, respectively. As per the latest NSSO 61st round based on Maximum
Retail Price (MRP) consumption, 32.5% of the population in Bihar was below the poverty line in
2004-05 as compared to 21.87% of the population for India. The only state worse than Bihar in
this respect is Orissa, with a 39.9% figure. People living below the poverty line in rural Bihar
comprise 32.9% of the population as compared to 21.8% for rural India; the corresponding figures
for urban areas are 28.9% and 21.7%, respectively. Per capita income in Bihar in 2005 was Rs
6719. Bihar has the lowest per capita Net State Domestic Product (Rs 5772) among the states.
The head count indices declined in Bihar by 6.9 percentage points between 1993-94 and 1999-
2000. The decline was 7.5 percentage points for rural Bihar, which again points to the continuing
rural–urban gap. While the reduction in the head count levels was similar to the national average
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of 6.5 percentage points, both rural head count at 41% and urban head count at 24.7% were
significantly higher than the national average (26.3% for rural and 21% for urban; see Table 2.13).
Table 2.13. Poverty Indices (% Change) for Bihar and India, 1993-94 to 1999-2000
Headcount Index
Poverty Gap Index
Urban
Rural
Overall
Urban
Rural
Overall
Bihar
–7.5
–15.4
–15.0
–10.7
–20.6
–20.8
India
–32.6
–20.3
–22.3
–37.8
–25.7
–27.4
Source: India Development Report, 2004-05.
The status of women in Bihar is low in terms of income and poverty. Not surprisingly, the
state is also far below the national average on key health indicators (see Table 2.14). For most
dimensions of human development, the performance of the state during the 1990s fell well short
of what is needed to achieve the Millennium Development Goals by 2015 (see Table 2.15).
Table 2.14. Selected Socio-economic Indicators of Bihar
India
Bihar
Socio-economic
Indicator
Health Indicator
Per capita income (Rs) 2005
Persons Below Poverty Line
% (NSSO, 2004-05)
Female Literacy Rate (%)
% of Girls in School
(11-14 Yrs), NFHS-2 (1998-99)
Human Development Index (HDI)
Human Poverty Index (HPI)
TFR NFHS-3 (2005-06)
CPR
IMR
Safe Delivery (%)
Anaemic Children 6–35
months NFHS-3 (2005-06) (%)
Children Fully Immunized (%)
Maternal Mortality Rate
12,416 6719
21.8
32.5
53.7
33.1
67.0
53.0
57
47
39
52
2.9
4.3
56.3
34.1
58
61
47.6
29.5
79.2
87.6
20.18 32.8
301
371
Ranking among
16 Major States
16
Ranking Status
Lowest
2nd lowest
15
16
Lowest
Lowest
16
16
Lowest
16
Lowest
15
2nd lowest
15
2nd lowest
11
6th highest
14
3rd lowest
14
3rd lowest
16
Lowest
12
5th highest
16
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Table 2.15. Selected Millennium Development Goals Indicators for Bihar
MDG
Eradicate extreme
poverty and hunger
Poverty head count (%)
Poverty gap
Prevalence of child malnutrition/underweight
children below 5 years (%)
Achieve universal
primary education
Net primary enrolment ratio (%)
Promote gender equality Literacy gap
Reduce child mortality Infant mortality rate (per 1000 live births)
Child mortality rate (per 1000 live births)
Immunization (measles) (% children below 12 months
of age)
Improve maternal health Maternal mortality ratio (per 1 lakh live births)
Delivery by skilled birth attendant (%)
Combat HIV/AIDS,
malaria and other
diseases
Incidence of tuberculosis (per 1 lakh)
Contraceptive prevalence rate (%)
Access to safe drinking Access to improved water sources (%)
water and sanitation
Access to improved sanitation (%)
Bihar 1993 Bihar 1999
45.9
39.0
0.10
0.08
62.6
54.4
54
52
0.44
89.2
127.5
0.56*
72.9
105.1
10.7
11.0
451
19
23.4
595
989
23.1
24.5
63
75.4
16.5
16.8
* Literacy gap figures for 2001 census.
Source: Bihar: Towards a Development Strategy, A World Bank Report, 2007.
India 1999
28.6
–
47.0
77
0.71
67.6
94.9
42.0
408
42.3
544
48.2
77.9
36.0
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3
Status of Health
I. Fertility
Before the Sample Registration System (SRS) was introduced in India by the Registrar General
of India in the late 1960s, information on fertility levels and trends consisted mainly of indirect
estimates prepared by various demographers using age and sex distribution from census data.
Prior to the 1970s the only other source for such estimates was the National Sample Survey,
which also was inadequate to provide dependable estimates on birth and fertility rates. This is a
problem common to data sources on population trends. Diverse sources such as censuses, the SRS
system, National Family Health Surveys, and Reproductive and Child Health Surveys are not
always in agreement and it requires caution in interpreting demographic trends in India. Whenever
new data emerge, updating the trend often requires reconsideration of the estimates from the past.
Making sense out of multiple and sometimes contradictory indicators available from diverse
sources shows up not only the vulnerability of data sources but of various forms of errors and
biases.
The SRS has been providing data for estimating fertility measures, and is considered to be the
most accurate and reliable. The fertility indicators used for analysis here are Crude Birth Rate
(CBR), General Fertility Rate (GFR), Age Specific Fertility Rate (ASFR), Gross Reproduction
Rate (GRR), and Total Fertility Rate (TFR).
Crude Birth Rate (CBR)
CBR is defined as the number of live births per 1000 population in a given year. CBR at all-
India level declined from 33.9 in 1981 to 29.5 in 1991, a decline of about 10%. CBR for Bihar
declined from 39.1 in 1981 to 30.7 in 1991, a decline of about 21%. The decline during 1991–2005
has been about 19% for India, from 29.4 to 23.8, but negligible for Bihar, at 0.97% from 30.7 to
30.4. CBR continues to be higher in rural areas (31.2) than in urban areas (23.8) in 2005. Table 3.1
and Figures 3.1 and 3.2 present details. The decline in CBR is partly attributable to increase in
women’s age at marriage and first pregnancy over the period.
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Table 3.1. CBR for Bihar and India Compared, SRS 1981–2005
Year
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Total
39.1
37.3
37.2
39.9
37.8
36.5
36.6
37.3
34.3
32.9
30.7
32.3
32.0
32.5
32.1
32.1
31.7
31.1
31.5
31.9
31.2
30.9
30.7
30.2
30.4
Bihar
Rural
39.7
37.8
37.7
40.6
38.5
37.2
37.3
38.1
35.1
33.8
31.3
33.1
33.0
33.5
33.1
33.1
32.7
32.1
32.4
32.8
32.3
31.8
31.6
31.0
31.2
Urban
33.9
32.5
32.1
33.6
31.1
29.8
30.1
30.4
27.6
24.6
25.5
25.0
25.4
24.3
23.8
23.6
23.6
23.1
25.2
25.6
23.4
23.5
23.4
23.1
23.8
Total
33.9
33.8
33.7
33.9
32.9
32.6
32.2
31.5
30.6
30.2
29.5
29.2
28.7
28.7
28.3
27.5
27.2
26.5
26.0
25.8
25.4
25.0
24.8
24.1
23.8
India
Rural
35.6
35.3
35.3
35.3
34.3
34.2
33.7
33.1
32.2
31.7
30.9
30.9
30.4
30.5
30.0
29.3
28.9
28.0
27.5
27.6
27.1
26.6
26.4
25.9
25.6
Urban
27.0
27.6
28.3
29.4
28.1
27.1
27.4
26.3
25.2
24.7
24.3
23.1
23.7
23.1
22.7
21.6
21.5
21.1
20.8
20.7
20.3
20.0
19.8
19.0
19.1
Figure 3.1. CBR for Bihar and India,
SRS 1981–2005
Figure 3.2. CBR for Bihar, Rural and Urban
SRS 1981-2005
20
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General Fertility Rate (GFR)
GFR, defined as the number of live births per thousand women in the reproductive age group
(15–49) in a given year, is a more refined measure than CBR because it specifically relates to the
reproductive age. GFR for all-India is 95.8, 70.9 in urban areas and 106.2 in rural areas. The
corresponding figure for Bihar, 139.6, is the highest among the states. GFR for rural areas is again
the highest among states at 144.6, and 101.0 in urban areas. Tables 3.2 and 3.3 and Figures 3.3 and
3.4 present details. GFR is high in northern India (Rajasthan, Haryana, Uttar Pradesh and Madhya
Pradesh), while southern India (Kerala, Tamil Nadu, Karnataka, Maharashtra and Andhra Pradesh)
exhibits values below the national average. This regional difference is attributed to the knowledge
of fertility.
Table 3.2. GFR, Bihar and India, SRS 1981–2005
Year
Bihar
India
1981 1986 1991 1996 1997 1998 1999 2000
174.5 167.8 136.5 147.1 137.0 134.9 137.2 138.9
140.9 136.5 119.2 112.5 109.9 106.5 103.2 102.8
2001 2002 2003 2004
132.2 130.4 126.4 142.4
99.5 97.1 95.3 98.6
2005
139.6
95.8
Figure 3.3. GFR, for Bihar and India,
SRS 1996-2005
Figure 3.4. GFR, Bihar and India by residence, SRS
2005
Age Specific Fertility Rate (ASFR)
ASFR is fertility rates calculated for specific age groups to see the differences in fertility
behaviour at different ages or for comparison over time. It is seen from Table 3.4 and Figure 3.5
that fertility peaks in the age group 20–24. In India fertility declines after the age of 30; in Bihar
the decline occurs after 35. Table 3.5 compares data for ASFR for Bihar and India over the last 25
years. Figure 3.6 compares ASFR for rural and urban Bihar for 2005. The National Family Health
Survey (NFHS) III has also estimated ASFR, which is low for all ages in urban areas of Bihar than
rural areas. The ASFR for Bihar also peaks in the age group 20–24 (0.274) and gradually declines
after the age 30–34 (0.106).
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Table 3.4. ASFR Bihar and India, SRS 2005
Age Group
Bihar
Total
Rural
Urban
15–19
56.4
59.0
38.2
20–24
274.5
280.5
225.4
25–29
225.1
229.4
187.4
30–34
165.5
171.9
112.6
35–39
71.2
74.9
43.5
40–44
51.0
54.3
28.3
45–49
18.0
19.2
9.4
Total
45.9
223.4
160.4
87.6
30.0
16.7
6.2
India
Rural
52.4
246.2
171.2
99.1
41.4
21.5
8.1
Urban
28.4
170.0
134.6
60.0
20.1
5.9
2.1
Figure 3.5. ASFR, Bihar and India, SRS 2005 Figure 3.6. ASFR for rural and urban Bihar for SRS
2005
Table 3.5. ASFR for Bihar and India, 1981–2005
Age Group
1981
1986
1991
1996
Bihar India Bihar India Bihar India Bihar India
15–19
114.0 90.4 113.0 91.1 78.5 76.1 52.0 55.3
20–24
275.5 246.9 264.8 252.8 2308.0 234 229.9 229.1
25–29
277.4 232.1 249.7 216.4 203.9 191.3 253.2 188.1
30–34
214.0 167.7 184.0 139.2 165.1 117 171.6 112.4
35–39
145.0 102.5 127.0 78.6 116.1 66.8 113.0 56.6
40–44
73.1
44 64.3 37.9 59.9 30.6 53.7 28.3
45–49
33.2 19.6 34.9 14.9 26.5 12.1 18.3 10.2
Source: Sample Registration System, Registrar General of India, New Delhi.
2001
Bihar India
53.5 48.9
244.6 215.9
233.3 177.3
180.9 98.5
104.3 49.9
54.6 21.2
15.3
7.3
2005 (current)
Bihar India
56.4 45.9
274.5 223.4
225.1 160.4
165.5 87.6
71.2 35.0
51.0 16.7
18.0 6.2
Gross Reproduction Rate (GRR)
GRR measures the average number of female children a woman is expected to give birth to
during her entire reproductive span conforming to ASFR for a given year if there is no mortality.
22
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The estimated value for GRR in India in 2005 is 1.4 compared to 2.1 in Bihar, which is the highest
among the states. Table 3.6 compares GRR data for Bihar and India for 1971–2005. Figure 3.7
illustrates the trend. Table 3.7 and Figure 3.8 provide the break-up by residence for 2005.
Table 3.6. GRR, Bihar and India, 1971–2005
Year
1971 1976 1981 1986 1991 1996
Bihar
n.a. n.a. 2.7 2.5 2.1 2.1
India
2.5 2.3 2.2 2.0 1.7 1.6
Source: Sample Registration System, Registrar General of India, New Delhi.
2000 2002
2.1 2.0
1.5 1.4
2003
1.9
1.4
2004
2.0
1.4
2005
2.1
1.4
Fig. 3.7. GRR for Bihar and India, SRS 1981– Figure 3.8. CBR for Bihar, Rural and Urban, SRS
2005
1981–2005
Total Fertility Rate (TFR)
TFR indicates the average number of children expected to be born to a woman during her
entire reproductive span, assuming that ASFR continues to be the same and there is no mortality.
Table 3.8 compares TFR data for Bihar and India for 1981–2005. TFR for Bihar at 4.3 in 2005 is
the highest among the states. Data from NFHS (Table 3.9) reflect that there is a clear trend of
decline in TFR for India whereas for Bihar TFR declined to 3.7 in NFHS-2 and again increased to
4 in NFHS-3. Figure 3.9 illustrates the data of Table 3.9 graphically.
TFR is influenced by the social importance attached to marriage, active discrimination against
women, and low economic value ascribed to women in a patriarchal society. This is further
compounded by regional diversity of economy and social development and gender biases in kinship
structure. Women in the South, and to some extent in the East, are better off and have greater
autonomy. The Hindi-speaking core region (including Bihar) is characterized by high fertility
due to a patriarchal value system, pronounced economic underdevelopment, and exclusion of
women in education and development. Sex ratio, child mortality, and female work force have the
most significant effect on fertility. This overlaps with other structural factors such as links between
economics, culture, education, and female child survival. The link between high fertility and high
female mortality in Bihar is statistically significant.
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Table 3.8. TFR for Bihar and India, SRS 1981–2005
Year
Bihar
Total
Rural
Urban
1981
5.7
5.8
4.8
1982
5.6
5.7
4.7
1983
5.5
5.6
4.5
1984
5.9
6.0
4.9
1985
5.4
5.6
4.4
1986
5.2
5.3
4.2
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
5.3
5.4
4.2
5.4
5.5
4.3
5.1
5.2
3.9
4.8
4.9
3.4
4.4
4.5
3.5
4.6
4.8
3.4
4.6
4.7
3.7
4.6
4.8
3.5
4.5
4.7
3.3
4.5
4.6
3.2
4.4
4.5
3.1
4.3
4.5
3.1
4.5
4.7
3.4
4.4
4.7
3.4
4.4
4.6
3.1
4.3
4.5
3.1
4.2
4.4
3.1
4.3
4.4
3.2
4.3
4.4
3.2
Total
4.5
4.5
4.5
4.5
4.3
4.2
4.1
4.0
3.9
3.8
3.6
3.6
3.5
3.5
3.5
3.4
3.3
3.2
3.2
3.2
3.1
3.0
3
2.9
2.9
India
Rural
4.8
4.9
4.9
4.8
4.6
4.5
4.4
4.3
4.2
4.1
3.9
3.9
3.8
3.8
3.9
3.7
3.6
3.5
3.5
3.5
3.4
3.3
3.2
3.3
3.2
Urban
3.3
3.4
3.4
3.5
3.3
3.1
3.2
3.1
2.8
2.8
2.7
2.6
2.8
2.7
2.6
2.4
2.4
2.4
2.3
2.3
2.3
2.2
2.2
2.1
2.1
Table 3.9. TFR Bihar and India as per NFHS
Data
Bihar
India
NFHS-1 (1992-93)
4
3.39
NFHS-2 (1998-99)
3.74
2.85
NFHS-3 (2005-06)
4
2.68
Figure 3.9. TFR for Bihar and India as per
NFHS data
24
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II. Mortality
Life Expectancy
Life expectancy is the number of years a person would live, calculated on the basis of current
death rates at any given point of time. It gives the survival rate rather than the health status of the
Table 3.10. Life Expectancy Figures for Bihar and India, 1990 and 2000
India, mid-1990
Bihar, mid-1990
India, mid-2000
Bihar, mid-2000
Total
58.7
57.5
62.5
60.8
Total
Male Female
58.6
59.0
58.4
56.4
61.6
63.3
61.4
59.5
Total
57.4
56.9
61.2
59.9
Rural
Male
57.2
57.9
60.3
60.9
Female
57.4
55.6
61.8
58.8
Total
64.1
64.8
67.9
66.8
Urban
Male
62.8
64.0
66.3
66.1
Female
65.5
66.1
69.2
67.5
Source: F. Ram, Chander Shekhar and S K Mohanty, Human Development: Strengthening District Level Vital Statistics in India, IIPS,
2005
Figure 3.10. Life expectancy in Bihar and India,
2000, by gender and residence
population. It is seen from Table 3.10, which
presents life expectancy figures for Bihar and
India for 1990 and 2000, that as of mid-2000
life expectancy at birth for Bihar is 60.8 as
compared to 62.5 for India. The state also
shows a trend of shorter life span for women
(59.5 years) than men (61.4 years), which is
against the national trend of higher life
expectancy for women. Figure 3.10
illustrates the data of Table 3.10 in terms of
gender and residence for 2000.
Source : Table 3.10
Crude Death Rate (CDR)
CDR is defined as the number of deaths per 1000 population in a given year. CDR at all-India
level declined from 12.5 in 1981 to 9.8 in 1991, a fall of about 1.2%. CDR for Bihar declined from
13.9 in 1981 to 9.8 in 1991, a fall of about 1.4%. For India during 1991–2005 the decline has been
about 0.7%, from 9.8 to 7.6; for Bihar the decline has been negligible, from 9.8 to 8.1. Table 3.11
compares data for India and Bihar over the period 1981–2005. Figure 3.11 illustrates the trend
graphically. Figure 3.12 presents the trend for Bihar in terms of residence. It is seen from Figure
3.11 that the declining trend in CDR has been fairly steady, with a disturbance in 1992 and thereafter
for about six years, and again a minor spurt in 2004. The declining trend in CDR has been attributed
to better health infrastructure, control of communicable diseases, access to modern system of
medicine, improved basic infrastructure such as safe drinking water and development activities
in Bihar. The challenge to still reduce CDR is going to be control of mortality due to non-
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communicable diseases such as cancer, diabetes and other degenerative disorders, along with the
emerging new diseases and re-emergence of old diseases.
Table 3.11. CDR for Bihar and India Compared, SRS 1981–2005
Year
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Total
13.9
14.1
13.0
14.5
15.0
13.8
13.1
12.6
12.1
10.6
9.8
10.9
10.9
10.4
10.5
10.2
10.0
9.4
8.9
8.8
8.2
7.9
7.9
8.1
8.1
Bihar
Rural
14.7
14.8
13.5
15.1
15.6
14.4
13.6
13.0
2.5
1.0
10.2
11.4
11.4
10.8
10.9
10.6
10.4
9.7
9.2
9.1
8.5
8.2
8.1
8.3
8.3
Urban
8.0
7.2
7.4
9.7
9.0
8.8
8.0
8.1
7.9
6.2
6.2
6.9
5.0
7.5
6.9
6.9
6.8
6.5
7.1
7.1
6.3
6.1
6.0
5.7
6.6
Total
12.5
11.9
11.9
12.6
11.8
11.1
10.9
11.0
10.3
9.7
9.8
10.1
9.3
9.3
9.0
9.0
8.9
9.0
8.7
8.5
8.4
8.1
8.0
7.5
7.6
India
Rural
13.7
13.1
13.1
13.8
13.0
12.2
12.0
12.0
11.1
10.5
10.6
10.9
10.6
10.1
9.8
9.7
9.6
9.7
9.4
9.3
9.1
8.7
8.7
8.2
8.1
Urban
7.8
7.4
7.9
8.6
7.8
7.6
7.4
7.7
7.2
6.8
7.1
7.0
5.8
6.7
6.6
6.5
6.5
6.6
6.3
6.3
6.3
6.1
6.0
5.8
6.0
Figure 3.11. CDR for Bihar and India, SRS
1981–2005
Figure 3.12. CDR for Bihar, SRS 1981–2005, by
residence
26
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Age Specific Death Rate (ASDR)
Age Specific Death Rate or Age Specific Mortality Rate (ASMR) is calculated for specific age
groups in order to compare mortality at different ages or at the same age over time. Because
mortality varies by sex and race, ASDR is often given separately for males and females and by
residence. CDR is only a rough estimate of mortality; ASDR provides a better and clearer
understanding of mortality statistics. Table 3.12 provides data for ASDR for Bihar and India by
residence for 2005. Figure 3.13 (a) and (b) illustrates these data graphically. Table 3.13 presents
data by broad age groups for 2005. Figure 3.14 illustrates the data graphically.
Table 3.12. ASDR for Bihar and India by Residence, SRS 2005
Age Group
Below 1
1–4
0–4
5–9
10–14
15–19
20–24
25–29
30–34
35–39
40–44
45–49
50–54
55–59
60–64
65–69
70–74
75–79
80–84
85+
Total
67.2
7.5
20.1
2.5
1.2
2.0
2.1
2.3
2.1
3.3
3.7
5.8
9.7
13.6
24.9
32.2
58.6
57.5
116.4
153.0
Bihar
Rural
69.4
7.5
20.6
2.6
1.3
2.0
2.1
2.2
2.1
3.4
3.6
5.8
10.1
13.7
24.1
33.2
60.0
68.9
115.5
152.7
Urban
45.8
7.0
15.3
1.6
0.8
1.9
2.4
3.0
2.0
2.4
4.2
5.4
5.9
12.3
31.5
22.7
45.9
56.6
124.3
156.3
Total
63.9
4.9
17.3
1.6
1.1
1.7
2.0
2.2
2.5
3.2
4.0
6.0
8.4
13.3
21.2
32.6
52.8
74.0
106.7
169.3
India
Rural
70.7
5.7
19.5
1.8
1.3
1.9
2.2
2.5
2.7
3.4
4.3
6.4
8.6
14.0
22.0
33.4
54.0
72.8
106.4
166.7
Urban
41.4
2.4
10.3
0.9
0.7
1.3
1.6
1.7
2.0
2.8
3.5
5.3
7.8
11.7
19.0
30.3
49.2
77.2
107.8
176.9
Figure 3.13a. ASDR for Bihar and India, SRS
2005
Figure 3.13b. ASDR for Bihar, SRS 2005, by
residence
State of Health in Bihar
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Table 3.13. Distribution of Deaths by Broad
Age Groups, Bihar and India, SRS 2005
Age Group
Bihar
India
<1
22.9
18.5
1–4
9.5
5.4
0–4
32.5
23.8
5–14
6.8
4.1
15–59
24.7
29.3
60+
36.0
42.8
Figure 3.14. Distribution of deaths by
broad age groups, Bihar and India,
SRS 2005
Child Mortality
It is seen from Table 3.13 and Figure 3.14 that the record of the state in child mortality lags far
below the national record, with 22.9% infant deaths (0–1 year) against the all-India figure of
18.5% and a figure of 9.5% for toddler deaths (1–4 years) against the all-India figure of 5.4%.
Table 3.14 and Figure 3.15 present figures for child mortality for Bihar and India for the decade
1995–2005. Table 3.15 and Figure 3.16 (a) and (b) present the trend in <5 year mortality by
residence for the country as a whole and for Bihar. An important facet noted from the data is that
mortality in this age bracket rose in Bihar in 2005 while the national trend has been of consistent
decline. Major causes of child mortality are pneumonia, diarrhoea, measles and malnutrition.
Table 3.14. Child Mortality Rate, Bihar and India, SRS 1995–2005
Year
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Total
28.3
27.9
25.9
22.9
20.6
19.2
19.4
17.2
17.4
17
20
Bihar
Rural
28.9
28.4
27.0
23.5
21.2
19.7
19.8
17.5
17.9
17
21
Urban
21.2
21.8
15.1
16.0
15.4
14.8
15.6
13.5
13.0
12
15
Total
24.2
23.9
23.1
22.5
20.4
19.5
19.3
17.8
17.4
17
17
India
Rural
26.5
26.2
25.6
21.0
22.9
21.7
21.5
19.7
19.2
19
19
Urban
15.0
14.2
13.1
12.8
11.7
11.5
11.2
10.3
10.2
10
10
Figure 3.15. Child mortality rate in Bihar and India, SRS 1995–2005
28
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Table 3.15. Proportion of <5 Mortality to Total Deaths, Bihar and India, SRS 1995–2005
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
% <5 mortality to total <5 deaths rates
deaths by residence
by gender
T
R U TM
F
23.8 26.1 15.6 17.3 16.4 18.2
32.5 33.0 26.7 20.1 19.1 21.1
24.4 26.5 16.5 17.0 16.6 17.5
29.4 29.7 25.0 16.8 15.8 17.9
23.9 25.9 15.5 17.4 16.4 18.5
31.1 31.7 24.7 17.4 16.8 18.1
24.9 26.9 15.9 17.8 17 18.6
31.2 31.7 26 17.2 15.4 19.1
26.5 28.7 16.9 19.3 18.3 20.5
34.4 34.9 29.5 19.4 17.7 21.3
26.8 28.9 17.8 19.5 18.6 20.6
31.5 32.2 25.1 19.2 18.4 20.1
27.7 29.7 18.7 20.4 19.8 21.1
32.7 33.4 26.3 20.6 18.9 22.5
28.8 30.6 18.4 22.5 21 24.1
32.8 33.2 27.7 22.9 21.2 24.8
n.a. n.a. n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a. n.a. n.a.
30.3 32.1 21.3 23.9 22.2 25.6
34.7 34.9 32.1 27.9 25 31.1
31.3 33.1 22.5 24.2 23.2 25.3
35.2 35.4 32 28.3 26 30.8
< 5 death rates by residence
Rural
Urban
TM
F
TM
F
19.5 18.6 20.2 10.3 9.5 11.1
20.6 19.7 21.5 15.3 13.7 17.1
19.1 18.7 19.6 10.1 9.8 10.5
17.3 16.2 18.4 12.0 11.3 12.7
19.2 18.3 20.2 10.2 8.8 11.8
17.9 17.1 18.8 13 14.3 11.5
19.7 18.8 20.7 10.3 10.3 10.2
17.5 15.6 19.7 13.5 14.1 12.9
21.5 20.3 22.8 11.2 10.6 11.8
19.8 18.1 21.7 15.6 14.5 16.9
21.7 20.6 23 11.5 11.3 11.7
19.7 19.2 20.2 14.8 11.2 18.9
22.9 21.9 23.9 11.7 12.2 11.2
21.2 19.5 23.1 15.4 13.8 17.2
24.8 23.2 26.6 12.8 12 13.6
23.5 21.5 25.8 16 17.9 13.7
n.a. n.a. n.a. n.a. n.a. n.a.
n.a. n.a. n.a. n.a. n.a. n.a.
26.2 24.3 28.3 14.2 13.8 14.8
28.4 25.7 31.5 21.8 17.9 26.4
26.5 25.2 27.8 15 14.8 15.2
28.9 26.6 31.5 21.1 19.2 23.2
Note : Data not available for 1997
Figure 3.16. Child mortality rate for Bihar, SRS 1995–2005, by residence
State of Health in Bihar
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Infant Deaths
The state also has a high rate of infant deaths to total deaths. It is a mater of particular concern
that over the past ten years (1995–2005) the proportion of infant deaths have risen, against the
trend of decline at the national level. Within the state, the rate of infant deaths has been declining
in urban areas, and the rural areas solely account for this trend of increase (see Table 3.16 and
Figure 3.17).
Table 3.16. Infant Deaths as Percentage of Total Deaths in Bihar and India, SRS 1995–2005
Year
Bihar
India
Total
Rural
Urban
Total
Rural
Urban
1995
22.3
22.5
19.4
23.2
24.6
16.6
1996
22.4
22.7
18.6
21.9
23.3
15.2
1997
n.a.
n.a.
n.a.
n.a.
n.a.
n.a.
1998
22.2
22.5
18.3
21.0
22.4
14.3
1999
22.1
22.4
19.6
20.7
22.0
14.5
2000
22.3
22.7
19.1
20.5
22.0
14.3
2001
23.4
23.8
19.4
20.0
21.4
13.6
2002
23.6
24.1
19.3
19.6
21.2
13.0
2003
23.5
23.9
18.9
18.7
20.1
12.7
2004
23.0
23.4
18.7
18.7
20.2
13.1
2005
22.9
23.5
17.1
18.5
20.1
12.6
Figure 3.17. Infant deaths as percentage of total deaths by residence, SRS Bihar 1995–2005
30
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Infant Mortality Rate (IMR)
IMR, considered to be one of the most sensitive indicators of health and development, is
defined as number of infant (under age one) deaths per thousand live births in a given year. Table
3.17 presents data for IMR for Bihar and India for 1981–2005. Figure 3.18 illustrates the trend for
the state by residence. It is seen from Table 3.17 that IMR declined dramatically in the decade of
1981–91 by 49 percentage points, from 118 in 1981 to 69 in 1991. The decline in the decade of
1991–2001 has, however, been only 7 percentage points, from 69 to 62. In the period 2001–05 the
figure fluctuated between 60 and 61.
Table 3.17. Infant Mortality Rate for Bihar and India by Residence, SRS 1981–2005
Year
Bihar
India
Total
Rural
Urban
Total
Rural
1981
118
124
60
110
119
1982
112
116
60
105
114
1983
99
102
65
105
114
1984
95
97
79
104
113
1985
106
109
62
97
107
1986
101
104
68
96
105
1987
101
104
72
95
104
1988
97
99
70
94
102
1989
91
93
63
91
98
1990
75
77
46
80
86
1991
69
71
46
80
87
1992
73
74
49
79
85
1993
70
73
41
74
82
1994
67
68
61
74
80
1995
73
74
57
74
80
1996
71
73
54
72
77
1997
71
73
53
71
77
1998
67
68
51
72
77
1999
63
64
55
70
75
2000
62
63
53
68
74
2001
62
63
52
66
72
2002
61
62
50
63
69
2003
60
62
49
60
66
2004
61
63
47
58
64
2005
61
62
47
58
64
Urban
62
65
66
66
59
62
61
62
58
50
53
53
45
52
48
46
45
45
44
44
42
40
38
40
40
State of Health in Bihar
31
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Figure 3.18. Infant mortality rate by residence, Bihar SRS 1981–2005
Disaggregated data by sex for IMR are available only for the decade 1995–2005 (see Table
3.18). It is seen from the table that IMR has declined in Bihar over the past ten years, more sharply
in urban (17 points) than rural areas (10 points). Female IMR is higher in all categories, i.e. in
total population, in urban area and rural area. Over the past ten years the gap in IMR between
Table 3.18. Infant Mortality Rates by Sex, Bihar and India, SRS 1995–2005
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
India
Bihar
Total
Rural
Urban
T
M
FT
M
F
T
M
F
58
56 61 64
62 66
40
37
43
61
60 62 62
61 63
47
45
50
58
58 58 64
64 63
40
39
40
61
60 63 63
61 65
47
44
50
60
57 64 66
63 69
38
33
34
60
59 62 62
59 65
49
59
37
63
62 65 69
67 72
40
40
39
61
56 66 62
57 67
50
47
53
66
64 68 72
70 74
42
41
44
62
57 68 63
57 69
52
49
56
68
67 69 74
72 76
44
45
42
62
62 61 63
64 61
53
42
64
70
70 71 75
75 75
44
47
40
63
63 62 64
64 63
55
53
58
72
70 73 77
76 79
45
42
49
67
67 66 68
68 69
51
65
37
71
70 72 77
76 79
45
46
44
71
72 71 73
73 73
53
61
45
72
71 73 77
76 79
46
48
44
71
68 75 73
70 76
54
50
59
74
73 76 80
78 82
48
49
47
73
75 71 74
76 72
57
60
54
32
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rural females and urban females has increased. Table 3.19 presents data for average percentage
change in the average of infant mortality between 1983–85 and 1993–95 and between 1993–95
and 2003–05.
Table 3.19. Percentage Change in IMR, Bihar and India, SRS
Period
Bihar
Total
Rural
Urban
1993–95 to 2003–05
–18.4
–18.0
–21.3
1983–85 to 1993–95
–20.2
–20.1
–11.2
Total
–20.7
–16.2
India
Rural
–19.8
–15.4
Urban
–18.6
–14.7
Neo-natal Mortality
To have an idea about the various components/elements which make up infant mortality, it is
considered in terms of neo-natal mortality (up to 28 days) and post-neo-natal mortality (from 29
days through 11 months). Neo-natal mortality rate is further considered in terms of early neo-
natal mortality rate (number of infant deaths of less than 7 days) and late neo-natal mortality rate
(number of infant deaths of 7 days to less than 29 days). Peri-natal mortality rate is defined as the
number of stillbirths, together with infant deaths of less than 7 days per 1000 live births and
stillbirths in a given year. Peri-natal mortality is a sensitive indicator of standards of healthcare
prior to and during pregnancy and childbirth as well as the effectiveness of social support to the
vulnerable segments of population. Stillbirth rate is estimated as the ratio of the number of stillbirths
per 1000 live births and stillbirths in a given year.
The main cause of infant deaths has been premature/low birth weight, acute respiratory tract
infection and diarrhoea. A majority of infant deaths are preventable by simple interventions provided
through the healthcare delivery system. The desired impact has not been felt since the health of a
child is dependent on the level of nutrition, infection load in the community, and economic and
environmental factors.
Disaggregated data collection for infant mortality commenced from 1997, including data for
neo-natal mortality (early and late), post-neo-natal mortality, and peri-natal mortality. Table
3.20 presents disaggregated data for neo-natal mortality and peri-natal mortality for the state and
for India for 1995–2005. The lower figures presented for the state as compared to the all-India
figures for neo-natal mortality rate, neo-natal deaths to total infant deaths, early neo-natal mortality
rate, early neo-natal deaths to total infant deaths, peri-natal mortality rate, and estimated stillbirth
rate may be on account of underreporting in the state. The death rate of children below the age of
five years by residence at the national level is estimated at 17.3 whereas the estimate for the state
is 20.1. Post-natal mortality has declined more than peri-natal and neo-natal mortality because
programme interventions have focused on immunization and the management of diarrhoea and
acute respiratory infection, interventions that address the major post-neo-natal causes of death.
Peri-natal mortality rate has shown only a marginal decline during the last decade. Identified risk
factors that have direct impact on peri-natal deaths, as validated by ICMR, are the age of the
mother, birth interval less than 24 months, previous stillbirth/pre-term birth, untrained birth
attendants, low birth weight, and illiteracy. Figure 3.19 illustrates the trend of neo-natal mortality
rate for the state by residence for the decade 1995–2005. Figure 3.20 presents the trend in the
share of neo-natal deaths to infant deaths.
State of Health in Bihar
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Table 3.20. Disaggregated Neo-natal Mortality and Peri-natal Mortality Rates, Bihar and
India, SRS 1995–2005
2005 India
Bihar
2004 India
Bihar
2003 India
Bihar
2002 India
Bihar
2001 India
Bihar
2000 India
Bihar
1999 India
Bihar
1998 India
Bihar
1996 India
Bihar
1994 India
Bihar
Neo-natal
mortality
% share of
neo-natal deaths
to infant deaths
Early neo-natal
mortality
% share early
neo-natal deaths
to infant deaths
by residence
T RU T RU T RU T RU
37 41 23 62.9 63.7 58.2 28 31 16 47.6 49.0 39.6
32 34 18 53.1 54.2 37.5 28 29 13 45.7 46.9 27.8
37 41 24 64.1 64.9 59.7 26 29 14 44.0 45.3 36.5
33 34 20 53.8 54.6 42.6 23 23 13 36.7 37.3 27.9
37 41 22 61.3 61.9 57.1 25 28 12 40.9 42.2 31.4
34 34 25 55.5 55.8 51.6 20 20 18 32.4 32.1 36.9
40 44 24 62.4 62.8 60.0 27 29 16 42 42.1 41.3
37 38 32 61.1 61.0 63.3 25 26 14 41.3 42.4 27.3
40 44 25 61.1 61.4 58.8 27 30 17 41.2 41.4 39.8
39 39 37 63.2 62.7 69.8 27 26 30 43 41.9 57.3
44 49 27 65.5 65.8 63.0 32 35 19 47.4 47.8 44.7
42 44 29 68.3 69.6 54.6 31 32 20 51.1 51.1 38.3
45 49 28 65.1 65.4 63.1 34 37 22 48.9 48.9 49.4
41 43 29 65.7 66.9 52.8 31 32 25 49.9 50.3 45.5
45 49 27 63 63.3 60.1 34 37 22 47.4 47.4 48.1
44 45 29 65.8 66.4 57.1 33 34 23 49.6 49.9 44.2
47 50 28 64.6 65.0 62.0 35 37 23 48.6 48.3 50.5
45 47 30 63.5 64.0 55.0 33 34 24 46.8 46.9 44.1
4 8 5 2 2 9 64.9 65.5 60.6 n.a. n.a. n.a. n.a. n.a. n.a.
4 4 4 5 3 4 60.8 60.8 60.1 n.a. n.a. n.a. n.a. n.a. n.a.
Peri-natal
mortality rate
by residence
T RU
37 40 24
30 31 14
35 39 23
24 25 14
33 36 20
22 22 22
35 38 23
29 31 16
36 39 25
30 29 32
40 44 26
34 35 22
44 47 30
35 36 28
42 45 29
37 38 24
44 46 32
39 39 36
45 48 31
39 39 37
Stillbirth rate
by residence
T RU
998
221
10 10 8
111
998
335
997
452
9 10 8
332
897
332
10 11 8
443
998
442
999
6 5 13
999
7 6 14
Note: Data not available for 1997.
Figure 3.19. Neo-natal mortality rate by
residence, Bihar, SRS 1995–2005
Figure 3.20. Share of neo-natal deaths to infant
deaths by residence, Bihar, SRS 1995–2005
34
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A leading cause of neo-natal mortality is low birth weight (LBW). About 80% of neo-natal deaths
occur in LBW infants, which may be directly/indirectly attributed to maternal origin (mostly due
to maternal malnutrition and lack of antenatal care of expectant mothers). Reduction in the
occurrence of LBW babies and improvement in mean birth weight may be a key to improve neo-
natal and infant survival in the state.
Maternal Mortality Ratio (MMR)
MMR, a sensitive indicator of Figure 3.21. Causes of maternal death, Bihar, SRS 2003-04
overall
socio-economic
development, social status of
women, and adequacy or
inadequacy of healthcare system,
is defined as the annual number of
maternal deaths per 1,00,000 live
births. Maternal death is defined
as the death of a woman while
pregnant or within 42 days of
termination of pregnancy,
irrespective of the duration and
site of the pregnancy, from any
cause related to or aggravated by Source: Sample Registration System, Registrar General of India, New Delhi.
the pregnancy or its management
but not from any accidental or incidental causes. Maternal mortality rate (annual number of maternal
deaths per 1,00,000 women of reproductive age) is another measure, which reflects both the risk
of deaths among pregnant or recently pregnant women and the proportion of all women who
become pregnant in a given year. MMR can be reduced either by making childbearing safer and/
or by reducing the number of unwanted pregnancies. Figure 3.21 illustrates the main causes of
maternal deaths in Bihar in 2003-04. MMR is a sensitive indicator of the status of women. Maternal
mortality implies death of women in the prime period of their lives and has a major impact on
their families.
Maternal deaths are now rare in developed countries but unfortunately remain common events
in developing countries. NFHS-1 (1992-93) was the first to provide a national estimate of 424
maternal deaths per 1,00,000 live births for the two-year period preceding the survey (IIPS, 1995).
Although it surveyed nearly 90,000 households, the survey could not produce regional or state
estimates because the sample was too small. Even at the national level, the sample inadequacies of
the NFHS came into sharp focus when NFHS-2 (1998-99) produced a maternal mortality estimate
of 540, but failed to confirm statistically the possible rise in the level of maternal mortality (IIPS
and ORC Macro 2000).
According to the latest MMR figures published in Maternal Mortality in India 1997–2003:
Trends, Causes and Risk Factors, Sample Registration System by the Registrar General of India
(2007), MMR for Bihar for the period 2001–03 was 371 as compared to 301 for India. The state
has the fifth-highest maternal mortality in the country, with a woman dying of childbirth and
pregnancy-related complications every 12 hours. Maternal mortality should also be viewed as the
tip of the iceberg of maternal morbidity. Table 3.21 and Figure 3.22 present the various estimates
State of Health in Bihar
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for MMR for Bihar and India. Though the estimates vary with different methodology used this
does not change the stark fact that MMR in India is still very high. Even going by the most
conservative estimate of 400 maternal deaths per one lakh live births means that more than one
lakh women die every year in India due to causes related to pregnancy and childbirth. This translates
into 300 Indian women dying every day during childbirth or because of pregnancy-related causes,
roughly equivalent to one death every five minutes.
Table 3.21. Status of Maternal Mortality Ratio in Bihar and India, RGI 2007
MMR- Unicef SRS SRS
FOGSI 1995 1997 1998
1992–94
NFHS-1 NFHS-2
1992-93 1998-99
Bihar 572
n.a. 451 452 n.a.
n.a.
India 1668
453
408 407 424
540
Note: Figures for Bihar include those for Jharkhand.
Figure 3.22. Various estimates of MMR for Bihar
Mari
Bhatt
1982–86
879
580
Mari
Bhatt
1998-99
1997-1998 1999–2001 2001–2003
Retrospec- SRS
Special
tive MMR Prospective Survey of
Surveys Household Deaths
Reports using RHIME
612
531
400
371
479
398
327
301
About two-thirds of maternal deaths occur in the states of Bihar, Jharkhand, Orissa, Madhya
Pradesh, Chhattisgarh, Rajasthan, Uttar Pradesh, Uttaranchal combined (the Empowered Action
Group or EAG states) and in Assam. The lifetime risk of a woman dying of or in childbirth is 1.8
per cent in these states. The pregnancy pattern in Bihar with too early, too many and too close
together enhances the risk of maternal mortality and complications. There has been substantial
decline in MMR during 1997–2003, by 16 points per year. Maternal deaths can be reduced if all
unwanted pregnancies are prevented, if childbearing is confined to the age group of 20–39, if third
and higher order of births are reduced, if age of marriage and first child is delayed and a minimum
period of three years between births can be ensured.
While fertility impacts strongly on mortality rates, infant and child mortality is also a major
determinant of fertility rates. Poor households facing a high rate of infant and child mortality tend
to have a large number of children. High fertility rates and childbearing patterns also have a
bearing on age structure and high youth dependency ratio. High fertility rates also have a direct
bearing on human capital formation, with low investment by parents on each child’s education
and health. Thus, high fertility has several adverse consequences for economic and social
development.
36
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Projections for Mortality and Fertility Indicators
In the document on population projections by the Registrar General of India, 2006, projections
for mortality and fertility indicators were made. Table 3.22 provides projections for the next 25
years for the key mortality and fertility indicators for Bihar. The projections show that by 2025,
CBR will reduce to 17.4, CDR to 6.7, and under-five mortality to 54.6. The state will reach
replacement level fertility of 2.0 in 2025. Life expectancy for males will be 70.6 and for females
will be higher at 71.4.
Table 3.22. Projected Mortality and Fertility Characteristics of Bihar, 2006–2025
Indicator
2006–10
2011–15
2016–20
2021–25
Crude birth rate
24.2
21.6
19.7
17.4
Crude death rate
6.7
6.6
6.6
6.7
Infant mortality rate
50.0
44.5
40.6
37.1
Under-5 mortality rate
73.5
65.4
59.7
54.6
Total fertility rate
3.3
2.7
2.3
2.0
Life expectancy of males
67.1
68.6
89.6
70.6
Life expectancy of females
66.7
68.7
70.2
71.4
Source: RGI, 2006. Population Projection for India and States 2001 to 2026, Report of the Technical Group on Population Projection
constituted by the National Commission on Population 2006.
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III. Morbidity
The distribution of the Burden of Diseases (BoD) between communicable and non-
communicable diseases highlights failure to control communicable diseases. Communicable
diseases account for 50.3% of the disease burden and constitute a major cause of premature death
in India, killing over 2.5 million children below the age of five and an equal number of young
adults every year. The proportion of total deaths on account of communicable diseases, maternal
and peri-natal conditions and nutritional deficiencies continues to be unacceptably high at 42%.
Mortality figures fail to reveal morbidity status or disease profile of the people, which remains
high due to communicable diseases. Communicable diseases such as kala-azar, malaria, tuberculosis,
Japanese encephalitis and leprosy continue to be the major public health problems of the state.
Communicable Diseases
Kala-azar
The sand fly that transmits kala-azar (medical term Visceral leishmaniasis) multiplies in the
cow dung villagers use to plaster their houses or as cow dung cakes for fuel. The flies survive on
the sap in banana and bamboo groves and decomposed cow dung heaps. They make their home in
the straw thatches of houses. The disease is characterized by fever, weight loss, swelling of the
spleen and liver, and leads to cardiovascular complications resulting in death. The disease occurs
in 62 countries, primarily in the developing world. Around 90% of cases around the world are
found in India, Bangladesh, Nepal, Sudan and north-east Brazil.
Kala-azar has been occurring in India for more than a century and a half in various forms. As
a collateral benefit of malaria eradication programme, Kala-zar prevalence was almost zero in
1965. Currently Bihar accounts for more than 76.3% of kala-azar cases and 90.3% of deaths in the
country. In the 1977 epidemic of kala-azar about one lakh people died. The epidemic recurred in
1992 due to lack of surveillance and harvested a death toll of almost 2,50,000. The control measures
put in place then were subsequently slackened from 1994 because DDT spray and surveillance
were discontinued. In 2000 the numbers were low but started rising from 2003. Table 3.23 presents
the figures for occurrence of kala-azar both in Bihar and India since 2001. It is a matter of concern
that the incidence of the disease has increased in 2005 and further in 2006. According to the
Annual Report of the Ministry of Health and Family Welfare, Government of India, 32 districts
Table 3.23. Kala-azar Occurrence in Bihar and India, 2001–06
Year
(1)
2001
2002
2003
2004
2005
2006 (P) Up to
September
Bihar (2)
10327
9684
13960
17324
21797
Cases
All India (3)
12239
12140
18214
24340
31217
col. (2) as % of
col. (3)(4)
84.38
79.77
76.64
71.18
69.82
Bihar (5)
204
160
187
107
124
23001
30160
76.26
169
Source: Annual Report 2006-07, Ministry of Health and Family Welfare, Government of India.
Deaths
All India
(6)
213
168
210
156
157
col. (5) as %
of col. (6)(7)
95.77
95.24
89.05
68.59
78.98
187
90.31
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of Bihar are kala-azar endemic. The district of Muzaffarpur has the highest number of cases,
followed by Vaishali, Saharsa, Samastipur, Purnia and East Champaran. In early 2007 the state
government set up a task force on kala-azar to suggest measures to eradicate the disease by 2010.
The task force believes that continuous spraying of insecticides for at least five years in a phased
manner and supervised administration of Amphotericin B could eliminate the disease. Experts
say that poor living standards and unhygienic conditions make members of the Mushahar
community in Bihar an easy prey to the disease.
Malaria
Malaria used to be the leading vector-borne disease of the country as well as Bihar at the time
of independence. Initial efforts at malaria reduction brought down the caseload from an estimated
75 million to a record 1,00,000 cases in the 1960s. But subsequently, due to various financial,
technical and logistical constraints the momentum was slackened. This led to resurgence of malaria
in 1976, taking the caseload to 6.4 million. A modified plan of action helped reduce malaria cases
by 1984. Efforts towards a further reduction were not successful due to vector and parasite resistance
to conventional insecticides and drugs, respectively, in some high endemic areas, as well as
continuing financial and management constraints. Malaria resurfaced in 1994, which also included
increase in cases of Plasmodium falciparum malaria, the most dangerous strain of malaria, between
1995 and 1999. Some of the high endemic states are Madhya Pradesh, Chhattisgarh, Orissa,
Rajasthan, Bihar and Andhra Pradesh. The national programme focuses on reduction of the reservoir
of infection in humans by early detection and prompt radical treatment, reduction in vector
population through vector control measures, anti-larval measures and enhancement of community-
based action. This strategy is being implemented across the country along with the Enhanced
Malaria Control Project (EMCP), which focuses on the high endemic districts in the high focus
states. The malaria control programme today is known as National Vector Borne Disease Control
Programme, which includes malaria, dengue, filarial, Japanese encephalitis and kala-azar. Table
3.24 presents the figures for the incidence of malaria in Bihar and India. Some of the high prevalence
districts of malaria in the state are Gaya, Aurangabad, Rohtas, Munger and Jamui. A major concern
is the resurgence of malaria in the flood-prone districts of the state every year.
Table 3.24. Malaria and Pf Cases in Bihar and India, 2001–06
Year
Malaria
Bihar
All India col. (2) as % of Bihar
col. (3)
(1)
(2)
(3)
(4)
(5)
2001
4108
2085484
0.2
1027
2002
3683
1841229
0.2
1705
2003
2652
1869403
0.14
1080
2004
1872
1915363
0.10
333
2005
2733
1817093
0.15
427
2006 (P) Up to
September
948
727952
0.13
182
Source: Annual Report 2006-07, Ministry of Health and Family Welfare, Government of India.
Pf
All India col. (5) as %
of col. (6)
(6)
(7)
1005236
0.12
897446
0.19
857101
0.13
890152
0.04
805699
0.05
329686
0.05
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Tuberculosis (TB)
The Indian Council of Medical Research (ICMR) nation-wide survey of TB, conducted during
1955–59, covered 40% of the population and indicated an active prevalence level of 1.5%. These
estimates continue to be used. The National TB Programme (NTP) was launched in 1962 and an
impressive infrastructure of district TB centres, TB clinics, hospitals and beds was established. In
spite of the huge amounts spent on NTP, the outcome is unsatisfactory due to poor diagnosis,
inappropriate regimens and lack of patient evaluations or follow-up. The WHO extended technical
support to pilot test the DOTS strategy. Based on these reviews and the results of controlled pilot
projects, the Revised National TB Control Programme (RNTCP) was formulated with the DOTS
strategy as its cornerstone. The DOTS strategy is based on five principles: case detection, ensuring
adequate drug supply, administration of short course chemotherapy under direct supervision,
systemic monitoring and accountability for every patient diagnosed, and political will. The DOTS
strategy is implemented along with RNTCP across the country. Some of the challenges to be
overcome by the TB programme are weak coverage, weak involvement of civil society, weak
health system, unsupervised private practitioners following their own line of treatment, and the
threat of a dual disease burden of HIV/AIDS and TB as opportunistic infection with a potential to
increase the number of cases substantially. Table 3.25 presents data for Bihar and India for 2005.
It is seen from the table that the coverage of the RNTCP programme is very low in the state, 43%
as compared to the country as a whole (93%). Such low coverage has implications for the number
of patients registered for treatment and early diagnosis. The number of New Sputum Positive
cases for TB in Bihar for all four quarters in 2006 is 40.
Table 3.25. TB Incidence, Prevalence and Treatment Rates in Bihar and India, 2005
Population
Covered by
RNTCP
Patients
Registered
for
Treatment
Smear
Positive
Patients
Diagnosed
New smear Annual new
Positive Smear Positive
Patients Case Detection
Registered Rate
New Sputum
Positive Cases
out of new
pulmonary cases (%)
Bihar
395 (43%)
7809
3705
2386
25 (34%)
40
India
10302 (93%) 346264 209961
138718 55
74
Source: State Health Society, Bihar, 2005.
TB has re-emerged as a major public health problem in India and often as an associated illness
of HIV/AIDS. In India it continues to be a serious health threat even in the absence of HIV/AIDS
due to poverty, high illiteracy and poor sanitation. For the first time, TB prevalence has been
reported in NFHS-3. Bihar ranks third in TB prevalence in the country (735 per 1,00,000 persons)
after Arunachal Pradesh (9096) and Manipur (804). In Bihar 96.1% of men have heard about TB,
of which 58.5% have misconceptions about its transmission. The disease still carries a high level
of stigma in the state, with 17.2% of those surveyed still wanting the fact of a family member’s TB
kept secret from neighbours.
Japanese Encephalitis
This vector-borne disease is prevalent in about 65 districts in ten endemic states; the annual
caseload is about 2500 cases and 500 deaths, mostly of children below the age of five. Nearly 90%
of cases are reported from Andhra Pradesh, Uttar Pradesh, Karnataka and West Bengal. But this
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disease has spread to non-traditional areas as well such as in Kerala. Control strategies continue to
focus on early diagnosis, case management, vector control (two rounds of residual insecticidal
spraying), fogging by Malathion insecticide, and segregation of pigs and promotion of personal
prophylaxis. While high costs limit the use of vaccination, no curative drugs exist. Table 3.26
presents data for the incidence of the disease in Bihar and India for the period 2001–05. It is seen
from the table that the state had a low concentration of Japanese encephalitis cases till 2003
excepting for the year 2001. However, the number of cases rose from 85 in 2004 and reached a
high of 195 in 2005. The country as a whole also experienced more number of Japanese encephalitis
cases in 2005. The number of deaths were the highest 64 in 2005 in Bihar.
Table 3.26. Japanese Encephalitis Cases in Bihar and India, 2001–05
Year
Cases
Deaths
Bihar
All India col. (2) as % of Bihar All India col. (5) as %
col. (3)
of col. (6)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
2001
48
2061
2.3
11
479
2.3
2002
8
1765
0.4
1
466
0.2
2003
6
2568
0.2
2
707
0.3
2004
85
1714
4.9
28
367
7.6
2005
192
6727
1.3
64
1682
3.8
2006 (P) Up to
September
21
2069
1.0
3
444
0.6
Source: Annual Report 2006-07, Ministry of Health and Family Welfare, Government of India.
Leprosy
Leprosy is caused by Mycobacterium leprae, which morphologically resembles Mycobacterium
tuberculosis. The reservoirs of leprosy are infectious leprosy patient(s) who are not taking Multi
Drug Therapy (MDT) and are in prolonged contact with healthy persons. About 95% of people in
the community are immune to the disease. Only less than 20% of leprosy patients are of infectious
type and with MDT they become non-infectious rapidly. MDT is a combination of the drugs
Rifampicin, Clofazimine and Dapsone. Even a single dose of MDT kills 99.9% leprosy bacilli
under laboratory conditions. There is no threat of disease transmission if the patient is taking
treatment at home. It takes only six months to one year of complete treatment with MDT to cure
paucibacillary and multibacillary type of patients, respectively. Leprosy bacilli have very weak
potential of causing the disease and they multiply very slowly as compared to most other bacteria.
Under the National Leprosy Eradication Programme (NLEP), domiciliary treatment is advised.
Leprosy deformity is not associated with infectivity of the disease. Patients seen with mutilated
limbs are old burnt-out cases with no active disease and thus do not transmit disease.
Leprosy is endemic mainly in the states of Bihar, Jharkhand, Chhattisgarh, Uttar Pradesh,
West Bengal, Orissa and Madhya Pradesh. Of the total 2.66 lakh recorded leprosy cases as on 31
March 2004, 75% cases have been contributed by seven states: Orissa (5%), Chhattisgarh (5%),
Jharkhand (4%), Uttar Pradesh (23%), Bihar (17%), Maharashtra (11%), West Bengal (10%). Before
the introduction of MDT in the early 1980s India recorded a prevalence of 57.6 leprosy cases per
10,000 population in 1981.
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Bihar is a high prevalence state and ranks seventh-highest in India after Chhattisgarh,
Chandigarh, Jharkhand, Orissa and Uttar Pradesh. Number of females detected with leprosy are
15,909, which is 39.38% of patients. The number of child patients are 7430, which is 18.39% of
patients. This is for 2004-05. Bihar has not yet achieved the level of leprosy eradication. The state
had 15.5% of the leprosy cases in the country as of 2006 (see Table 3.27).
Table 3.27. Leprosy Cases and Prevalence in Bihar, 2006
Bihar
India
Estimated
Population,
March 2005
91482682
1109670816
New Cases
Detected
40395
260063
Cases
Discharged as
Cured
68214
376934
Cases on
Record under
Treatment
16532
148910
Prevalence
Rate (per
10,000 population)
1.81
1.34
Source: Annual Report 2006-07, Ministry of Health and Family Welfare, Government of India.
Four nation-wide Modified Leprosy Elimination Campaigns (MLECs) with intensified
community IEC (information, education, communication) have been conducted as special efforts
towards early detection of leprosy cases and their prompt MDT. The Fifth MLEC was conducted
in eight high-priority states during 2003-04. The hard-to-reach areas in rural/tribal/hilly terrain
as well as urban slums are given special priority for continued surveillance and prompt MDT to
leprosy patients. MDT is now available free-of-cost on all working days at all Sub Centres, Primary
Health Centres, government dispensaries and hospitals across the country.
Lymphatic Filariasis
Filariaris declined in the late 1980s in India, but increased from 1989 to 2000. The National
Filaria Control Programme provides assistance to all eighteen endemic states, the most endemic
being Andhra Pradesh, Orissa, Uttar Pradesh, West Bengal, Tamil Nadu, Kerala and Bihar. The
estimated population exposed to the risk of filariais and microfilaria carriers and filaria cases
during 2004-05 is given in Table 3.28.
Table 3.28. Estimated population exposed to risk of filariais and microfilaria carriers and filaria
cases, 2004-05
Bihar
India
Population at Risk
Total
2004 2005
72.00 72.00
472.69 472.69
Rural
2004
2005
62.80 62.80
347.81 347.81
Microfilaria
Carriers
Urban
2004 2005 2004 2005
9.20 9.20 0.49 0.64
124.88 124.88 0.66 0.32
Diseased
Person
2004
3.20
1.17
2005
2.72
1.13
Source: Annual Report 2006-07, Ministry of Health and Family Welfare, Government of India.
HIV/AIDS
HIV/AIDS is a major health problem in India. Currently about 5.2 million people are living
with the virus. This is a medical and social problem. Information on or awareness of HIV/AIDS is
available only for NFHS-2 and 3. These show that the level of awareness of AIDS has increased
among men and women, but NFHS-3 shows that the level of awareness of AIDS among women is
extremely low, a pattern seen in the RCH II data as well. Data are not available for RCH I.
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The RCH II awareness data for RTI (reproductive tract infection) and STI (sexually transmitted
infection) throw light on interesting findings. Significantly more number of women in Bihar are
aware of RTI and STI than in India. But the percentage of women seeking treatment is very low as
compared to men (see Table 3.29). RTI/STI management and treatment remains one of the most
neglected areas in maternal health. Keeping in mind the increasing vulnerability of married women
to HIV/AIDS, there is need to bring in more women to treatment and counselling centres for
reduced gynaecological problems and better maternal health.
Table 3.29. Knowledge of HIV/AIDS among Ever Married Adults (15–49 years) Bihar and
India (%)
Women who have heard of AIDS
Men who have heard of AIDS
Women who know that consistent condom use can reduce the
chances of getting HIV/AIDS
Men who know that consistent condom use can reduce the chances of
getting HIV/AIDS
NFHS-3
Bihar
35.2
70.0
22.4
India
57.0
80.0
34.7
NFHS-2
Bihar
10.5
n.a.
n.a.
India
40.3
n.a.
n.a.
RCH IIDLHS
2002–04
Bihar India
28.8 53.6
62.1 75.8
58.4 68.1 n.a. n.a.
Part of the vulnerability of the state lies in a population where illiteracy is still widespread
despite improving educational levels. The state is also a major crossroads for commercial traffic,
which is one way HIV is known to spread. Bihar is India’s most rural state with 89% of its population
living in rural areas, so that reaching people with essential HIV information is especially difficult.
A low level of HIV prevalence presents both an opportunity and a danger. The opportunity to
arrest its spread is here today. The danger is that its quiet nature will expand its devastation
tomorrow. While HIV prevalence is low at present, the state is considered highly vulnerable by
the National AIDS Control Organization (NACO). Table 3.30 presents the prevalence of HIV
infection in Bihar and India in 2003–06 as per the STD and ANC sentinel surveillance sites.
Figure 3.23 illustrates the data graphically for Bihar. As per NFHS-3 Bihar has HIV prevalence of
0.13%, with the rate among women being 0.09% and for men being 0.18%.
Table 3.30. Prevalence of HIV Infection in Bihar
and India, 2003–06 (%)
Year
Bihar
India
STD
ANC
STD
ANC
2003 0.40
0.00
5.7
0.9
2004 1.20
0.00
5.6
0.9
2005 0.43
0.38
5.6
0.9
2006 1.05
0.36
n.a.
n.a.
Source: HIV/AIDS Chart book, Population Foundation of India,
2007.
Figure 3.23. HIV/AIDS prevalence in Bihar,
PFI-PRB 2003–06 (%)
Statewide, the percentage of positive cases rose from 0.67 in 2005 to 0.76 in 2006. This is a
danger sign. In 2006 BSACS greatly increased the number of sentinel sites to widen the scope of
HIV surveillance. Data are also available for 2005 and 2006 of HIV prevalence among female sex
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workers (FSW) and men having sex with men (MSM). The prevalence rate among FSW was 2.24
in 2005 and 1.68 in 2006. Similarly, the prevalence rate among MSM was 0.40 in 2005 and 0.30
in 2006. The reduction is attributed to increase in sentinel sites.
The presence of a sexually transmitted disease (STD) increases the risk of HIV. As a result,
knowledge of STD and the link between them and HIV is clearly essential. Knowledge of the
existence of STD in Bihar is the lowest in India at only 18% and only 11% among women. Only
15% were aware of STD and of the fact that such diseases increase the likelihood of contracting
HIV.
Coverage data for HIV testing as per NFHS-3 show that in Bihar the coverage rate in the age
group 15-49 is 88.2% among women and 87.9% among men.
Non-communicable Diseases
Health transition, whereby non-communicable diseases (NCDs) become the dominant
contributor to Burden of Diseases (BoDs), is principally due to a combination of demographic and
lifestyle changes resulting from socio-economic development. Demographic transition is
characterized by changes in population age structure with a decline in fertility and an ageing
population. As more individuals survive to middle age, the years of exposure to the risk factors of
chronic disease increase. Simultaneously, urbanization, industrialization and globalization are
often accompanied by undesirable lifestyle alterations: changing diet, decreased physical activity
and augmentation of psychosocial stress. India contributes substantially to the global burden of
NCDs. The 1998 Global Burden of Diseases (GBoDs) study estimates that injuries, other than
self-inflicted, contribute to 4.3% of deaths in India. They account for significant morbidity,
disability and economic loss. NCD epidemics are emerging or accelerating in most developing
countries and cardiovascular diseases (CVD), cancers, diabetes, neuro-psychiatric ailments and
other chronic diseases are becoming major contributors to the BoD. The existing health system
will need to be reoriented to deliver the expanded mandate of primary and secondary healthcare
involving the prevention, surveillance and management of chronic diseases.
Diabetes has a high prevalence in urban and migrant population. As the quality of dietary
habits and physical activity decreases and obesity increases, diabetes becomes a greater contributor
to NCD. As per NFHS-3 the number of women aged 15–49 per 1,00,000 who reported as diabetic
in Bihar were 1024 as compared to 881 in India. In Bihar 940 men suffer from diabetes as compared
to 1051 for India. This rate of diabetes among women in Bihar is on the higher side since it is
above 1000.
Disorders of mental health merit special attention because of the large burden of disability
(DALY loss) resulting from them, even though they are not major contributors to mortality. The
prevalence of major mental illness in the country has been estimated to be 1–2 per thousand,
while minor mental illness occurs in 5–10% of the population, as per various estimates.
It may appear that the problem of our ageing population is not yet relevant except for a few
states in the South. However, given the fact that fertility decline is taking place in large segments
of the country, it will not be long before this issue becomes important.
National Survey of Blindness 2001-02 (visual acuity) reveals that less than 6/60 vision in
Bihar is 0.78% as compared to 0.56% for India.
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Injury prevention and management has been limited to the provision of emergency care that
functions with limited access and coverage. Currently, no structured programme is available.
There is need to develop an inter-sectoral-based programme addressing increasing injuries in the
growing context of urbanization and infrastructure development. The state needs to keep in view
the increasing dense urban habitat and develop better city management.
Tobacco use is associated with a wide range of diseases, including several types of cancers of
the heart and lungs. It also poses great health risks such as infertility, pregnancy complications,
premature births, low birth weight babies, stillbirths and infant deaths for those women who use
tobacco. Addiction to tobacco and other type of substances is high in Bihar. Chewing tobacco is an
area of concern in the state along with alcoholism and substance abuse such as drugs, heroin,
cocaine and marijuana, khaini, zarda and gutka. Consumption is particularly higher among the
rural poor, the youth rather than the urban population. Therefore tobacco-related NCD could be
higher in future in Bihar. About 30% of cancers are caused by tobacco use. These can be prevented
with health, education and avoiding tobacco in all forms. The 50th round of NSSO and NFHS-2
reported use of tobacco by all household members in Bihar. According to NFHS-3 in Bihar 66.6%
of men and 8.0% of women use tobacco in any form. Men who smoke cigarettes and bidis constitute
29.0% of the tobacco using population in the state, the corresponding figure for women being
4.9%. Alcohol use among men in the state stands at 34.9% and 9.0% among women.
It is seen from NFHS-3 data that Bihar has a high number of people, particularly women
suffering from asthma, 1696 per 100,000, which corresponds to the all-India figure. For men the
corresponding figures are 981 (Bihar) and 1627 (India).
Goitre or other thyroid disorders in Bihar have been moderate. As per NFHS-3, 853 women
per 1,00,000 persons suffer from goitre or other thyroid disorders in Bihar as compared to 273 for
men. In India the figures are slightly higher, with 949 for women and 383 for men.
The Burden of Disease also includes the entire spectrum of cardiovascular diseases, which
includes stroke and rheumatic heart disease. These and other types of cancers such as of the breast,
cervix, oral cavity and gastrointestinal tract are rapidly advancing. While the precise dimensions
of the diseases are not clear, it needs to be kept in mind that these are emerging problems of the
future, more so among women.
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IV. Nutrition
Malnutrition continues to be a predominant problem of the state and its manifestation and
consequences are diverse and alarming. The level of malnourishment is quite high. Of all segments
of the population children and women appear to be more at risk than are others. Malnutrition is
seen to be a major contributing factor in over 50% of child mortality; states with high mortality
are also generally those with high levels of malnutrition. Nutritional deficiencies have been observed
to affect physical and mental development of children adversely, impairing health and productivity
of work. Tables 3.31 and 3.32 present data for the levels of malnourishment in the under-3 and
under-5 category, respectively, in Bihar and India. Figures 3.24a and 3.24b illustrate the data
from Table 3.32. Figure 3.25 presents the level of malnutrition in the state in 1998. Table 3.33 and
Figure 3.26 present the distribution of severely undernourished children (1–5 years) in India in
1998. The India Nutritional Profile Study (1998) found the maximum number of severely
malnourished children (1–6 years) were from Bihar (26%), followed by Tripura (19%) and Rajasthan
(10%). Nutritional status of children (5–12 years) severely malnourished was the highest in
Bihar (21.7%), followed by Dadra, Nagar Haveli and Daman and Diu (13.7%) and Rajasthan
(11.5%).
Table 3.31. Nutritional Status of Children under 3 Years in Bihar and India as per NFHS-2 (%)
Weight for Age
Height for Age
Weight for height
Below –3SD Below –2SD Below –3SD Below –2SD Below –3SD Below –2SD
Bihar
25.5
54.4
33.6
53.7
5.5
21.0
India
18.0
47.0
23.0
45.5
2.8
15.5
Source: India Nutrition Profile (1998), Food and Nutrition Board, Department of Women and Child Development, Ministry of Human
Resource Development, p. 18.
Figure 3.24a. Nutrition levels in boys in rural
Bihar, India Nutrition Profile 1998
Figure 3.24b. Nutrition levels in girls in rural
Bihar, India Nutrition Profile 1998
Table 3.32. Distribution of Nutritional Status of Children (1–5 years) According to Weight for Age,
in Percentage (Gomez Classification), 1998, as per NFHS-2
Area
Boys
Girls
Total
Normal Mild Moderate Severe Normal Mild Moderate Severe Normal Mild Moderate Severe
Total
16.3 27.1 29.4
27.2 19.3
25.3 30.4
25.0 17.7
26.2 29.9
26.2
Rural
15.8 26.6 29.7
27.8 18.5
25.7 30.5
25.3 17.1
26.2 30.1
26.6
Urban 18.5 29.3 27.9
24.3 23.3
23.3 29.6
23.9 20.7
26.5 28.7
24.1
Source: India Nutrition Profile (1998), Food and Nutrition Board, Department of Women and Child Development, Ministry of
Human Resource Development, p. 18.
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Table 3.33. Distribution of Severely Undernourished Children (1–5 years) in States/UTs (in %),
Gomez Classification (District Nutritional Profile Study), 1998
Prevalence (%) States
<=5
Haryana, Himachal Pradesh, Punjab, Chandigarh, Sikkim, Assam, Manipur, Meghalaya,
Mizoram, Nagalanad, Goa
6–10
Rajasthan, Delhi, Arunachal Pradesh, Tripura, Dadar and Nagar Haveli, Daman and Diu,
Sikkim
>10
Bihar (26%)
Source: India Nutrition Profile (1998), Food and Nutrition Board, Department of Women and Child Development, Ministry of
Human Resource Development, p. 18.
Figure 3.25. Severe under-nutrition levels in boys
and girls in Bihar, 1998
Figure 3.26. Severe under-nutrition levels
in children 1–5 years in India, 1998
Source: India Nutrition Profile (1998), Food and Nutrition Board, Source: Table 3.33.
Department of Women and Child Development, Ministry of Human
Resource Development.
The nutritional status of children is strongly related to maternal nutritional status, which
reflects in infant birth weight. Malnutrition generally sets in during the first two years of life. The
most vulnerable age group has been identified as six months to two years, the ‘period of perpetual
hunger’ when the infants are dependent on another person for feeding. The Independent Commission
of Health in India 1998, states that every infection is a potentially fatal illness and the risk of death
is doubled for the mildly undernourished children, tripled for the moderately undernourished
children and maybe as many as eight times for severely undernourished children. NFHS-3 data
indicate that only 4% of children under 3 years are exclusively breast-fed in Bihar as compared to
55% in India. Exclusive breast-feeding of infants less than five months old is also very low in
Bihar (27.9%) as compared to India (60%, see Table 3.34). Table 3.35 presents data for breast-
feeding and colostrum feeding practices in Bihar and India for 2005. Table 3.36 presents data on
the nutritional status of children and married adults in Bihar compared to India. It may be noted
that most of the nutrition-related data are not comparable for NFHS-1. Figures 3.27 and 3.28
illustrate the data graphically. It is seen from the table that the nutritional status of children in
Bihar continues to be the worst in India. The proportion of children who are stunted decreased
steadily with age from NFHS-2 (54.9%) to NFHS-3 (42.3%), whereas the proportion of under-
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weight and wasted children increased (from 19.9%, NFHS-2 to 27.7%, NFHS-3) up to the age of
12–23 months and then declined significantly at age 24–35 months over the five years between
the two surveys. Girls and boys are equally undernourished but girls are slightly more likely than
boys to be underweight and stunted, whereas boys are slightly more likely to be wasted.
Undernourishment generally increases with birth order. Young children in families with four or
more children are nutritionally the most disadvantaged. It is a matter of concern that the overall
level of malnutrition has increased among children in Bihar from NFHS-2 to NFHS-3.
Table 3.34. Child Feeding Practices in Bihar and India, NFHS data (%)
Child Feeding Practices
NFHS-3
(2005-06)
NFHS-2
(1998-99)
Bihar India
Bihar India
Children under 3 years breast-fed within one hour
of birth
4.0
50.0
5.4
16.0
Children age 0–5 months exclusively breast-fed
27.9
60.0
n.a.
n.a.
Children below 6–9 months receiving solid or
semi-solid food and breast milk
57.3
77.6
n.a.
n.a.
NFHS-1
(1992-93)
Bihar
India
n.a.
9.5
n.a.
n.a.
n.a.
n.a.
Table 3.35. Breast-feeding and Colostrum Feeding Practices in Bihar and India, 2005 (%)
Bihar
India
Breast feeding < 2 hours
17.4
40.9
Breast feeding between 2–24 hours
41.8
27.8
Exclusive breast feeding
25.9
39.3
New-born given colostrum
61.5
75.1
Source: Annual Report 2006-2007, Ministry of Health and Family Welfare, Government of India, New Delhi.
Table 3.36. Nutritional Status of Children and Married Adults in Bihar (%)
NFHS-3
Bihar India
Nutritional
Status of
children
under 3 years
Stunted i.e. height/age – too short for age
Wasted i.e. weight for height – too thin for
height
Underweight i.e. weight for age – too thin
for age
42.3 38.4
27.7 19.1
58.4 45.9
Nutritional Women whose Body Mass Index is below
43.0 33.0
Status of Ever normal
Married Adults Men whose Body Mass Index is below normal 28.7 28.1
(age 15–49) Women who are overweight or obese
5.3 14.8
Men who are overweight or obese
8.5 12.1
Anaemia
Children age 6–35 months who are anaemic 87.6 79.2
Ever married women age 15–49 who are
anaemic
68.3 56.2
Pregnant women age 15–49 who are anaemic 60.2 57.9
Ever married men age 15–49 who are anaemic 32.4 24.3
NFHS-2
Bihar India
54.9 45.5
19.9 15.5
NFHS-1
Bihar India
n.a. n.a.
n.a. n.a.
54.3 47.0 21.8 51.5
39.1 36.2 n.a. n.a.
n.a. n.a. n.a. n.a.
3.9 10.6 n.a. n.a.
n.a. n.a. n.a. n.a.
81.1 74.2 n.a. n.a.
60.4 51.8 n.a. n.a.
46.4 49.7 n.a. n.a.
n.a. n.a. n.a. n.a.
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Figure 3.27. Nutritional status of children in
Bihar under 3 years, NFHS-3 and NFHS-2
Figure 3.28. Nutritional status of married adults
in Bihar, NFHS-3 and NFHS-2
Weight for height ratio is used to calculate several indicators of women’s nutritional status.
An adult’s height is an outcome of several factors, including nutrition during childhood and
adolescence. A woman’s height can be used to identify women at risk of having a difficult delivery,
since small stature is often related to small pelvic size. The risk of having a baby with low birth
weight is also higher for mothers who are short. Short stature is particularly strongly related to
poverty.
Body mass index (BMI) is defined as the weight in kilograms for height in square metres
(kg/m2). It is an index that can be used to assess both thinness and obesity. BMI for women in
Bihar who are below normal is 43%, which indicates high levels of nutritional deficiency. Women
from households with low standard of living are more than two times likely to have a low BMI
than women from households with a high standard of living.
Anaemia is characterized by a low level Figure 3.29. Anaemia prevalence in Bihar, NFHS-3
of haemoglobin in the blood. Anaemia and NFHS-2
usually resolves from a nutritional
deficiency of iron, folic acid, vitamin B12
and some other micro nutrients. This type
of anaemia is commonly referred to as iron
deficiency anaemia. Iron deficiency is the
most widespread form of malnutrition in
India and is estimated at 50% (Sheshadri
1998). Anaemia has a detrimental effect on
the health of women and children and may
become an underlying cause of maternal
mortality and peri-natal mortality and
results in increased risk of premature
delivery and low birth weight babies. In Bihar anaemia level is 68.3% among women in NFHS-3
as compared to 60.4% in NFHS-2. Anaemia is relatively high for illiterate women and women
belonging to religions other than Hindu or Muslim, Scheduled Tribe women and self-employed
women. Pregnant women are more likely to have moderate to severe anaemia than non-pregnant
women. Figure 3.29 presents data for anaemia prevalence in Bihar.
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Iodine deficiency. Approximately two-
thirds of the population of Bihar is prone to
iodine deficiency. Only 37.7% of the population
uses fortified iodized salt as compared to 56.8%
in India. A significant one-fourth of the
population in the state use non-iodized salt.
This increases the danger of higher incidence
of goitre. Table 3.37 and Figure 3.30 (a) and
(b) present details.
Table 3.37. Households Reporting Use of Salt
Types in Bihar and India, 2005 (%)
Bihar
India
Iodized (> 15 ppm)
37.7
56.8
Iodized (1–15 ppm)
37.6
26.2
Not iodized
24.7
17.0
Source: Coverage Evaluation Report 2005, Government of India.
Figure 3.30. Use of iodized and non-iodized salt in (a) Bihar, (b) India, Coverage evaluation
Report 2005
To sum up, among adults the level of undernourishment is especially high among women,
with less BMI and significantly high percentage of married women and pregnant women are
anaemic. Another cause for concern is the increased level of anaemia among children, married
women and pregnant women between NFHS-2 and NFHS-3, which raises issues related to the
effectiveness and access to nutritional services and schemes for children and pregnant women.
Special attention needs to be given to younger married women and younger women who are
pregnant, many of whom are in their adolescent years and are often left out of healthcare services.
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V. Reproductive and Child Health
Until 1994 thinking and policy orientation on population issues focused on the control of
numbers and limiting the level of population. ICPD (Cairo 1994) brought about a paradigm shift
in this thinking. Now there is recognition of the need for comprehensive reproductive health (RH)
and reproductive rights. This new agenda is a holistic agenda which addresses reproductive health
through a lifecycle approach. Reproductive health has been defined as:
State of complete physical, mental and social well-being and not merely the absence of disease or infirmity,
in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore
implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce
and the freedom to decide if, when and how often to do so. Implicit in this condition are the rights of men and
women to be informed and to have access to safe, effective, affordable and acceptable methods of family
planning of their choice, as well as other methods for the regulation of fertility which are not against the law, and
the rights of access to appropriate healthcare services that will enable women to go safely through pregnancy and
childbirth and provide couples the best chance of having a healthy infant.
In the context of India child mortality and infant mortality being critical, the reproductive
health concept was broadened into Reproductive and Child Health (RCH) and the RCH programme
was launched in 1997, which included child health as a component. Now the components of RCH
programme include fertility regulation, safe motherhood, child health and child survival, and
RTI/STI interventions, including HIV/AIDS. In the following paragraphs on the status of RCH in
Bihar key data have been used from large-scale surveys such as the NFHS, District Rapid Household
Survey (DRHS), and District Level Household Survey (DLHS) under the RCH programme.
Marriage and Fertility
TFR for Bihar at 4.0 as per NFHS-3 is
higher than that of India (2.7) and also higher
than 3.7 of NFHS-2. High TFR is associated
with high percentage of women marrying
before the age of 18 years (60.3% in Bihar).
Almost one-fourth (25.0%) of married
women in the age group of 15–19 years were
pregnant at the time of the survey. Median
age at first birth was 18.7 years. It is seen
from Table 3.38, presenting marriage and
fertility rates for Bihar and India, that a high
percentage of women cohabit before 18 years
of age. Figure 3.31 illustrates the data
graphically.
Figure 3.31. Women married by age 18, NFHS
Bihar (%)
Source: Table 3.38.
As per NFHS-3, the proportion of women aged 20–24 married by the age of 18 in rural Bihar
(65.2%) is almost twice that of urban Bihar (37.3%). Percentage women marrying below the age
of 18 has a positive correlation with education. Higher percentage of women with no education
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Table 3.38. Marriage and Fertility Rates for Bihar and India
Marriage and Fertility
Women age 20–24 married by age 18 (%)
Men age 25–29 married by age 21 (%)
Total fertility rate
Women age 15–19 who were already mothers or
pregnant at the time of the survey (%)
Median age at first birth for women age 25–49
Birth order 3+
Married women with 2 living children wanting
no more children (%)
Married women with 2 living children wanting
two sons (%)
Married women with 2 living children wanting
one son, one daughter (%)
Married women with 2 living children wanting
two daughters (%)
NFHS-3
(2005-06)
Bihar India
60.3
44.5
43.3 29.3
4.0
2.68
25.0 16.0
18.7
19.8
n.a.
n.a.
60.2 83.2
77.4 89.9
67.5 88.1
20.0 62.1
NFHS-2
(1998-99)
Bihar India
71.9 50.0
n.a.
n.a.
3.71
2.85
n.a.
n.a.
18.9 19.3
54.6
45.2
41.8
72.4
58.8
82.7
43.7
76.4
10.8
47.0
NFHS-1
(1992-93)
Bihar
India
n.a.
52.4
n.a.
n.a.
n.a.
3.99
n.a.
n.a.
n.a.
19.4
56.4
48.6
n.a.
59.7
n.a.
71.5
n.a.
66.0
n.a.
36.9
(76.8%) were married below the age of 18 as compared to only 19.3% women who have completed
10 years of education. This implies that education is an important determinant in improving the
age at marriage.
NFHS-1 and 2 data show that across religion there is a differential in age at marriage. Higher
percentages of Muslim girls marry below the age of 18 than Christian girls. The age of marriage
also shows significant increase with standard of living. More number of girls from poor families
with low standard of living marry early than girls from families with higher standard of living.
The age at which a woman starts childbearing is an important determinant of reproductive
health. The median age at first birth for women aged 25–49 has decreased from 18.9 in NFHS-2 to
18.7 in NFHS-3 (see Figure 3.32). The urban–rural divide in Bihar is by a year for women aged
25–49. The trend with women with no education is as low as 18.3% to 21.3% for those who have
completed 10 years and above of education.
The distribution of birth by birth order is yet another way to view fertility. It is seen from
Figure 3.33, which presents data for birth order 3 and above, that birth order 3+ has decreased in
Figure 3.32. Age at first birth for women, Bihar Figure 3.33. Birth order 3 and above, Bihar and
and India, NFHS data
India, NFHS data
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the state across the various survey periods, NFHS-1 (56.4%) to NFHS-2 (54.6%) and from RCH I
(45.8%) to RCH II (42.0%). This is in keeping with the all-India trend. The proportion of births of
order 3+ is relatively large for births to illiterate women, Muslim women and Scheduled Caste
and Scheduled Tribe women, and women with a low standard of living. There is also a positive
association between fertility and work status.
The desire for additional children in rural Bihar is very high, especially for two children and
in favour of sons. The birth interval is shorter if the previous child was a girl than if it was a boy.
The interval is 29 months for Bihar as compared to 31 months for India. The primary reason for
this desire is high mortality and morbidity in infants, especially neonates. The significantly higher
levels of fertility and childbearing have implications for access to and quality of family planning
programmes and services.
Marriage of girls at young age in India leads to teenage pregnancy and motherhood. Young
women who become pregnant experience a number of health, social, economic and emotional
problems. In addition to their relatively high level of pregnancy, complications because of
psychological immaturity and inexperience associated with child care practices also influence
maternal and infant health. As per NFHS-3 25% women in the age group 15–19 in Bihar have
begun childbearing as compared to 16.0% in India. The proportion who have begun childbearing
is more than twice as high in rural areas (19%) than in urban areas (9%). Early start to childbearing
reduces educational and employment opportunities of women and is associated with high levels
of fertility.
As per family welfare statistics 2006, unwanted pregnancies in India are extremely high due
to high unmet need of contraception. The number of MTPs (medical termination of pregnancy)
for 2004-05 was 29,669 in Bihar. Of these, 80.1% were conducted during the first 12 weeks of
pregnancy (India 86.9%) and 19.9% during 12–20 weeks of pregnancy (India 13.2%). In terms of
age group 19.3% of MTPs were for the age group 15–19 (India 4%), 31.7% for age 20–24 (India
28.6%), and 27.1% for age 25–29 (India 35.6%).
Family Planning
Family planning services have improved in Bihar across the three NFHS surveys (see Table
3.39) but continue to be lower than for India as a whole. There is overwhelming focus on female
sterilization as a family planning method in comparison to male sterilization and other temporary
methods. This is consistent with the all-India trend. Although resort to spacing methods has
improved over the NFHS survey years, the level of condom use is very low (2.3% in NFHS-3)
with use of pills and IUDs being even lower (1.3% and 0.6%, respectively). The trend remains the
same for RCH also (see Figure 3.34).
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Table 3.39. Current Use of Family Planning Methods, Bihar and India, NFHS data (%)
Current Use
NFHS-3
(2005-06)
NFHS-2
(1998-99)
NFHS-1
(1992-93)
RCH-2
RCH-1
Bihar India Bihar India Bihar India Bihar India Bihar India
Any method
34.1 56.3 23.5 48.2 23.1 40.7 31.0 53.0 24.8 48.6
Any modern method
28.8 48.5 21.6 42.8 n.a. 36.5 27.3 45.7 23.3 42.4
Total sterilization
24.4 38.3 19.5 36.0 18.6 30.8 22.3 35.2 21.2
35
Female sterilization
23.8 37.3 18.5 34.1 n.a. 27.4 21.9 34.3 20.5 33.5
Male sterilization
0.6
1.0
1.0
1.9 n.a.
3.5
0.4
0.9
0.7
1.5
Total spacing methods
4.2
10.2
2.0
6.8 2.9
5.5
8.4
17.6
3.6 13.6
IUD
0.6
1.8
0.6
1.6 n.a.
1.9
0.8
1.9
0.5
1.9
Pill
1.3
3.1
0.8
2.1 n.a.
1.2
1.9
3.5
1.1
2.4
Condom
2.3
5.3
0.6
3.1 n.a.
2.4
2.0
4.8
0.6
3.1
Figure 3.34. Spacing methods of contraception, Bihar and India, NFHS and RCH data
Figure 3.35 presents contraceptive prevalence rate for Bihar and India. Current use of
contraceptive method is considerably high in urban areas in the state (50.6%) than in rural (31.4%).
This is true for each specific modern or traditional method. Current use of contraceptive method
is much lower among illiterate women (29%) than women who have completed ten years and
above of education. The differences by education are also on account of the predominance of
sterilization in the method mix and the fact that more educated women tend to be younger women
who may not yet have reached their desired level of fertility. The use of spacing methods generally
rises with education. The use of traditional methods also rises with education. Contraceptive
prevalence is the lowest among Muslims and approximately three times higher among Hindus
and Christians. Contraceptive prevalence is also highest among women who do not belong to the
marginalized communities.
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Figure 3.35. Contraception prevalence rate, NFHS and RCH Bihar and India
The low use of contraceptive methods in Bihar is contradictory to the 100% awareness levels
among women and 99.4% among men of contraceptive use in Bihar (NFHS-3). Awareness of
limiting methods among women is 99.9% for female sterilization and 92.3% for male sterilization;
the corresponding figures for awareness among men are 98.0% and 95.8%, respectively. For both
men and women awareness of spacing methods is very low for pills (95.7% for women and 86.5%
for men), IUDs (79.15% and 48.2%), male condom (81.9% and 91.3%) and emergency contraception
(4.7% and 19.8%).
In recent years the focus of the family planning programme has been on women and especially
female sterilization. Male sterilization in Bihar is less than 1% (0.6% in NFHS-3 and 0.4% in
RCH II) as compared to total sterilization (24.4% for NFHS-3 and 22.3% for RCH II; see Figure
3.36). Little attention has been paid to men, their role, needs, responsibilities, and involvement.
Although men constitute half of the reproductive equation, the stereotype that most men do not
care about family planning persists and family planning has been considered as women’s business.
Figure 3.36. Limiting methods of contraception, NFHS and RCH Bihar and India
State of Health in Bihar
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Female sterilization constitutes approximately four-fifths of all modern methods, with male
sterilization accounting for the least. 31.2% of urban females are sterilized as compared to 22.6%
in rural Bihar. A similar pattern is seen where illiterate women constitute 21.3% of female
sterilization as compared to 29.0% of education class ten and above.
Unmet Need
The low levels of use of family planning methods are reflected in the high unmet need for
family planning services in the state. Total unmet need for family planning is very high in the
state (23.1%) as compared to 13.2% for India in NFHS-3, though unmet need has marginally
reduced from 25.7% in NFHS-2 to 23.1% in NFHS-3. The demand for spacing and limiting has
also decreased across the three NFHS surveys and RCH surveys (see Table 3.40 and Figure 3.37).
This could be on account of increased access to family planning surveys in the state. Total wanted
fertility rate in Bihar as per NFHS-3 is 2.4 as compared to 1.9 for India. This is almost half the
TFR of Bihar, which is 4.0.
Table 3.40. Unmet Need for Family Planning, Bihar and India NFHS data (%)
Unmet need
NFHS-3
(2005-06)
NFHS-2
(1998-99)
NFHS-1
(1992-93)
RCH-2
Bihar India Bihar India Bihar India Bihar India
Total
23.1 13.2 25.7 15.8 25.1 19.5 36.7 21.1
For spacing
10.7
6.3 13.1
8.3 NA 11.0 14.9
8.5
For limiting
12.4
6.8 12.5
7.5 NA
8.5 21.8 12.7
RCH-1
Bihar
42.0
18.3
23.7
India
25.3
10.7
14.6
Figure 3.37. Unmet need of contraception, Bihar and India (NFHS and RCH data)
Achievements in Family Planning
TFR in India has shown a consistent decline since independence but the states of Bihar, Uttar
Pradesh, Rajasthan and Madhya Pradesh, which account for over half of the country’s population,
continue to have high fertility. NFHS-2 indicates that the number of unwanted births account for
one-fourth of TFR. If there could be intervention in regard to these unwanted births TFR would
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fall to 3 for Bihar. This would also promote maternal and child survival. The achievements of the
state in promoting various methods of family planning services over the past five years are presented
in Table 3.41 and Figure 3.38.
Table 3.41. Achievements of the State of Bihar in Family Planning, 2000-01 to 2005-06
Sterilizations
IUD Condom Users
Oral Pill Users Other Methods
2000-01
130550
110949
36570
58997
95567
2001-02
152219
145310
63065
84105
147170
2002-03
111924
158896
63043
67938
130981
2003-04
120899
126882
37329
51051
88380
2004-05
88126
108168
241638
456853
698491
2005-06
96341
99847
61965
49818
Source: Family Welfare Statistics in India, 2006, Ministry of Health and Family Welfare, Government of India.
111783
Figure 3.38. Achievement in family planning, Bihar, 2006
Source: Table 3.41.
Table 3.42 presents data for selected family planning methods in Bihar for 2001-02 to 2004-
05. It is seen from the table that the number of tubectomy operations completely overshadow the
number of vasectomy operations. Women in the age group of 25–29 years are among the maximum
acceptors of the method (41.6%). The high level of acceptance of methods in which the
responsibility devolves entirely on women reflects the fact that the entire focus of the family
planning and RH programme in the state places the responsibility of fertility reduction on women,
particularly in their early reproductive age. The state has a long way to go towards building
awareness and promoting other methods of family planning, such as Non-Scalpel Vasectomy
NSV and other spacing methods. Table 3.43 and Figure 3.39 present data on effective CPR methods
in the state.
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Table 3.42. Selected Family Planning Methods, Bihar, 2001–05
Total Vascetomy acceptors
Acceptors of tubectomy 25–29years (%)
Acceptors of tubectomy 30–34 years (%)
Acceptors of IUD 25–29 years (%)
Acceptors of IUD 30–35 years (%)
MTP cases up to 12 weeks (%)
2001-02
482
41.6
32.3
53
41.2
n.a.
2002-03
599
n.a.
n.a.
0
0
62.7
2003-04
n.a.
30.7
20.5
30.5
40.5
82
Source: Family Welfare Statistics in India, 2006, Ministry of Health and Family Welfare, Government of India.
2004-05
n.a.
n.a.
n.a.
n.a.
n.a.
80.1
Table 3.43. Effective CPR due to All Methods, Bihar, 2001 to 2005
Year
2001
2002
2003 2004
2005
Bihar
17.4
17.3
17.3
15.2
16.6
Source: Family Welfare Statistics in India, 2006, Ministry of Health and Family Welfare,
Government of India.
Infertility
In the last forty years India’s growing concern with population stabilization has unfortunately
overlooked some other closely related problems of human reproduction, which can in their own
way seriously compromise the quality of life. Infertility has found no place in either our family
welfare programme or in the reproductive and child health package.
Maternal Health
Table 3.44 reflects the poor status of maternal health determinants in Bihar across the three
NFHS surveys. The following indicators may be noted from the data available.
Table 3.44. Status of Maternal Health Determinants in Bihar (%)
Maternity care (for births
in the last three years)
Any ANC
NFHS-3
(2005-06)
Bihar India
n.a.
n.a.
NFHS-2
(1998-99)
Bihar India
36.3 65.4
NFHS-1
(1992-93)
Bihar India
36.8 62.3
Mothers who has at least
16.9
3 ANC visits for their last birth
50.7 15.9
44.2 n.a.
43.9
Mothers who consumed IFA
9.7 22.3 n.a.
n.a. n.a.
n.a.
for 90 days or more when they
were pregnant with their last
child
Birth assisted by doctor/nurse/ 30.9
LHV/ANM/other health
personnel Institutional births
22.0
48.3 24.8
40.7 14.8
42.4 n.a.
33.6 n.a.
32.0
26.1
Safe delivery
n.a.
n.a. 23.3 42.3 18.9 34.2
Mothers who received
15.3 36.4 n.a.
n.a. n.a.
n.a.
post-natal care from
doctor/nurse/LHV/ANM/
other health personnel within
2 days of delivery for their
last birth
RCH-II
Bihar
37.9
19.6
India
73.4
50.0
8.1 20.4
8.5
7.1
23.0 40.5
29.5 47.6
RCH-I
Bihar
29.7
17.1
India
65.3
44.2
16.9 48.7
2.6
8.0
14.9 34.0
19.0 40.2
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• There has been a marginal increase in percentage of women with 3 ANCs for first birth in the
state across the three surveys.
• Only 16.9% of women had 3 ANC visits for first birth (India 50.7%) in NFHS-3.
• Only 9.7% of women consumed IFA tablets in the state (India to 22.3%) in NFHS-3.
• Only 30.9% of births were assisted by skilled personnel (including doctor) in the state (India
to 48.3%) in NFHS-3.
• The level of institutional delivery is low in the state at 22% (India to 40.7%) in NFHS-3.
• There is significantly low level of post-natal care in the state (15.3%) as compared to the
country as a whole (36.4%) in NFHS-3.
To reduce the level of maternal deaths, attention is required on three major components,
namely, ensuring services through the pregnancy period including emergency obstetric care,
ensuring safe delivery through skilled assistance, and proper post-natal care. One indicator of
good maternal health is to ensure reduced emergency risks in pregnancy and delivery. Completion
of full ANC ensures that the woman is provided with adequate amount of iron and folic acid
tablets and is regularly checked by skilled health personnel for the duration of her pregnancy. The
state has the lowest levels of full ANC, i.e. 5.4%, in RCH-II, which implies that most women lack
access to regular institutional healthcare during the course of pregnancy. Coupled with very high
levels of home delivery, this is a matter of concern. As per RCH-II data, 76.8% of deliveries in the
state are conducted at home, primarily by TBA. This falls far short of the NRHM goal of ensuring
that every pregnant woman delivers in an institution. The high levels of home delivery reflect the
lack of functional first contact care, poor status of referral units, and poor levels of social mobilization
and awareness generation by community health workers.
Figure 3.40 presents ANC figures for the state and the country as a whole. One cause for the
low ANC rate in Bihar is that most of the women concerned, about two-thirds, did not consider
having a check-up necessary or customary. The remaining one-third reported financial cost as the
main reason. Very few cited lack of knowledge as the main reason. A small significant number
cited as reason that their families did not approve of such check-ups. This suggests the need for
dissemination of information. Lowering the cost and making the service more accessible would
also improve ANC in the state.
Figure 3.40. Any ANC, Bihar and India, NFHS and RCH data
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Table 3.45 presents disaggregated data for ANC for both Bihar and India, 2005. It may be
noted from the data that ANC coverage in the state in rural areas is only half that of the urban. A
similar low level of coverage is seen for SC/ST. Only 33.6% women received IFA tablets but only
2.1% consumed the tablets. This indicates the low health-seeking behaviour of rural Bihar and
low levels of awareness. A dismal 2.1% rural women received full ANC, which correlates with
the high unmet need in the state. Overall, the state lags far behind in the national average in
coverage of services: awareness level of ANC services among mothers (Bihar 65.8%, India 73.5%),
one or more TT (Bihar 42.4%, India 62.9%), and IFA tablets (Bihar 17.7%, India 33.9%).
Table 3.45. Ante-natal Care, Bihar and India, 2005
ANC
TT
90+ IFA
tablets
Full ANC
One or more
Three or more
First check-up
within 12 weeks
Received one or
more TT
Received
Consumed
3 or more check-ups
+ one or more TT
+ received 90+ IFA
tablets
3 or more check-ups
+ one or more TT
+ consumed 90+
IFA tablets
Rural
33.3
11.6
62.9
78.1
33.6
2.1
2.1
0.7
Bihar
Urban Total
67.3
36.8
41.7
14.8
75.4
65.2
92.4
79.6
24.2
5.7
11.8
3.2
18.5
3.8
9.5
1.6
Source: Coverage Evaluation Report 2005, Government of India.
SC/ST
n.a.
7.8
n.a.
74.5
4.8
2.9
2.0
Rural
66.7
36.7
58.5
86.5
30.1
15.0
17.9
2.0
9.6
India
Urban
89.4
66.8
67.0
Total
75.0
47.2
62.0
93.5
89.2
40.7
33.9
22.5
19.1
34.8
23.6
SC/ST
n.a.
43.0
n.a.
87.1
31.3
17.8
20.5
24.6
14.4
13.0
Table 3.46 presents data for healthcare received in child delivery. It is seen from the table that
considerable work needs to be done in the state to increase the proportion of institutional deliveries
and post-natal care for the rural and SC/ST segments of the population.
Table 3.46. Healthcare Received in Child Delivery
Institutional delivery
Home Delivery
Skilled delivery
TBA
Rural
16.0
5.6
81.6
Bihar
Urban Total
59.2
20.4
17.4
6.4
79.1
81.5
Received PNC
6.4
24.2
8.3
Source: Coverage Evaluation Report 2005, Government of India.
SC/ST
10.6
3.2
n.a.
5.1
Rural
39.7
9.8
61.3
33.7
India
Urban
78.5
21.0
59.9
Total
53.3
11.9
61.3
64.5
44.2
SC/ST
43.8
10.1
n.a.
39.0
Other Female Morbidity
The leading causes of female morbidity in rural areas not linked to pregnancy are non-specific
fever, acidity, serious communicable diseases such as TB and malaria, respiratory infections, eye/
ear problems, diarrhoeal diseases, weakness, dizziness, breathing problems and anaemia. Urban
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women face, in addition, high blood pressure, heart ailments, and paralysis. Health problems such
as lack of nutrition, anaemia among married and pregnant women, RTI/STI and HIV/AIDS
prevalence have been discussed earlier. Women also face various gynaecological morbidities
such as menstrual problems, excessive discharge, vaginitis, cervical erosion, and pelvic
inflammatory diseases.
Women’s Empowerment
It is important to note that women’s health-seeking behaviour and the determinants of their
access to timely and quality healthcare are linked to their socio-cultural status such as status in
society, role, function and behaviour within households, etc.
It is being increasingly recognized that women’s health issues go much beyond maternal
morbidity and mortality to include nutrition, child bearing, contraception, abortion, reproductive
health, RTI, STI, HIV/AIDS and communicable diseases. As elsewhere, in Bihar also women are
affected by many of the same health conditions as men, but experience it differently. This is
because of multiple factors such as women’s low decision-making power, low mobility, experience
of violence, women’s low social status, etc.
NFHS-3 shows that in Bihar 84% of currently married women reported that they jointly make
decisions related to her earnings, whereas only 63.7% women take joint decisions regarding how
their husband’s earnings are used. In comparison, only 73.4% of men responded that they and their
wives jointly take a decision about her earnings. This lack of space for decision making in economic
affairs of the household puts the woman at a disadvantage both in her house and in society despite
her status of being employed. A little over 50% of the women in the state said that they take
decisions alone or jointly with their husband regarding household purchases, household needs,
own healthcare and visits to family and relatives. Only 32.2% of women take decisions regarding
all four aspects. Only 41.6% of men responded that their wives should have joint decision making
power.
Women’s autonomy in the state has a long way to go, as reflected from the figures related to
their access to money and cash. NFHS-3 reveals that most women in Bihar have access to cash,
with 58.6% of women having money that they can decide how to use. However, only 8.2% of
women have a bank account or a savings account which they can operate themselves, thereby
limiting their access to the cash. Most women in the state (73%) are not aware of micro-credit
programmes and only 1% of women have taken a loan from a micro-credit programme. Only
25.2% of women in the state have mobility since most of the decisions regarding women stepping
out of the house are taken by the men.
As regards attitude towards wife beating and violence NFHS-3 shows that 56.9% women age
15–49 in the state agree that husbands beating wives is justified. A similar percentage of men
(57.4%) believe the same. In comparison, 67.6% of women feel that it is all right for the wife to
refuse sexual intercourse with the husband if she knows that he has a sexually transmitted disease,
knows that he has sex with other women or if she is tired and not in the mood. Only 6.1% of men
agree that women have a right to refuse sex for these reasons and 28.4% of men approve of the
husband reprimanding the wife for refusing to have sex, with 15.1% of the men approving of use
of force to have sex with their wives. Such attitude approving of force is the highest in the state.
NFHS-3 statistics for the various forms of domestic violence experienced by women age 15–49 in
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the state are as follows: physical violence only, 38.9% (the highest in the country); sexual violence
only, 2.9%; physical and sexual violence, 13.8%; physical or sexual violence, 55.6% (the highest
in the country); and emotional violence, 19.7%.
It should be clear from the preceding statistics that some of the social realities of women in
Bihar are their economic dependence, lack of influence in decision making, their experience of
violence and the negative attitude of men. Added to these are poverty, lack of food and inequitable
distribution of food for girls and women in the household, inadequate access to safe drinking
water and sanitation facilities, which additionally impact on women’s health.
Child Health
Immunization
The status of infant and child mortality in the state has been highlighted earlier. The present
discussion is about immunization, childhood disease treatment, knowledge of diarrhoea treatment,
and child feeding practices. The Expanded Immunization Programme (EIP), launched in the country
in 1978, followed by the Universal Immunization Programme (UIP) in 1985, sought to protect all
infants and children in the country against preventable diseases and deaths. Strengthening routine
immunization was seen as the cornerstone of the endeavour to reduce infant and child mortality.
With 158,000 deaths occurring annually, Bihar contributes about 9.9% of infant deaths in the
country. In 2001 the state contributed 2.6 million non-immunized children to the pool of susceptible
children, the second largest in India (estimate from 2001 Coverage Survey by UNICEF/WHO and
2001 census). Bihar is among the few states where the performance of Routine Immunization
Programme also continues to be significantly below the national average. The 2001-02 Coverage
Evaluation Survey indicated that full immunization coverage level among children in Bihar was
only 13%. BCG coverage level was at 39%, indicating poor access and utilization of immunization
services. Coverage levels for DPT3, OPV3, measles and vitamin A were at 21.1, 21.1, 13.8, and
11.1%, respectively. District Level Rapid Household Survey (DRHS), performed in 30 districts in
Bihar in 1998-99 and again in 2002-03, showed that full immunization rates have decreased in 11
districts. These findings indicate a strong need for focusing greater efforts on strengthening
immunization in the state.
The stagnating routine immunization coverage rates, high drop-out rates and declining trend
in some of the districts in Bihar are issues of major concern (see Table 3.47). The indirect indicator
for reach of services, i.e. BCG and the acceptance of services (DPT) shows a drop of approximately
20%. This drop needs to be addressed to improve routine immunization and subsequently child
survival.
Table 3.47. Immunization Coverage in Bihar (%)
Antigen
Fully vaccinated
BCG
DPT3
Measles
Three Doses of Polio
Drop-out: BCG, Measles
DRHS
1998-99
22.4
40.8
34.9
25.6
37.4
n.a.
NFHS-2
1998-99
11
38
24
17
41
21
CES
2001
13
39
21
14
n.a.
25
CES
2005
19.0
52.8
36.5
28.4
n.a.
n.a.
DLHS
2002–04
23
44
33
26
34.3
18
Reported
Coverage
2003-04*
n.a.
50
44
30
n.a.
20
NFHS-3
Coverage
2005-06
32.8
64.7
46.1
40.4
82.4
n.a.
Reported
Coverage
2004-05
n.a.
58
40
37
n.a.
21
Source: Data for reported coverage 2004-05 from Bihar State Demographic Cell and Bihar State Immunization Cell.
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According to NFHS-3 data, the state has achieved significant improvement in immunization
coverage. The coverage of full immunization has gone up to 32.8%, which is approximately 19.8%
more than the NFHS-1 coverage (11%). Improvement is seen for the entire range of measles,
Polio3, DPT3 and BCG. Table 3.48 presents data for immunization status by residence and among
the SC/ST segment of the population in Bihar and India for 2005.
Table 3.48. Immunization Status by Residence and among SC/ST in Bihar and India, 2005
Antigen
Bihar
India
BCG
DPT 3
OPV 3
Measles
Full Immunization
Vitamin A
Pulse Polio
Source: Coverage Evaluation Survey, 2005.
Rural
51.2
35.0
25.7
26.4
17.6
31.0
99.0
Urban
66.5
49.8
38.8
45.5
30.6
31.6
99.5
Total
52.8
36.5
27.1
28.4
19.0
31.0
99.1
SC/ST
47.0
28.0
19.9
21.3
14.2
31.9
n.a.
Rural
79.1
60.6
54.4
61.8
47.4
51.4
94.8
Urban
90.7
79.6
73.9
79.4
67.8
58.9
95.1
Total
83.4
67.3
61.3
68.1
54.5
54.0
94.0
SC/ST
83.7
65.7
57.0
66.7
52.7
56.4
n.a.
The coverage of immunization and the method of sterilization by auto disabled (AD) syringes
in Bihar is extremely low. As against 2% coverage of type of syringes for immunization and
sterilization for India, the coverage rate is only 1.7% in Bihar as per CES 2005. Although disposable
syringe coverage rate is high in the state (88.6%) there needs to be increased coverage for AD
syringes to check reuse. Currently, 50% of syringes are reused in the country. Table 3.49 presents
data for syringe use in 2005. Tables 3.50 and 3.51 present data on the achievement of the
immunization programme in the state. Figure 3.41 presents the data of Tables 3.48, 3.50 and 3.51
graphically.
Table 3.49. Coverage of Type of Syringes used for
Immunization and Method of Sterilization, Bihar and
India
Bihar
India
Total
Glass
4.6
9.9
Disposable
88.7
70.1
AD
1.7
2.0
Rural
Glass
4.8
10.4
Disposable
88.6
70.1
AD
1.9
1.5
Urban
Glass
3.6
9.2
Disposable
89.7
70.0
AD
0.7
2.8
Source: Coverage Evaluation Survey, 2005.
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Figure 3.41. Immunization coverage in Bihar: (a) progress; (b) compared with all-India level; (c)
by residence; (d) among SC/ST
Table 3.50. Child Immunization and Vitamin A Supplementation, Bihar and India (%)
NFHS-3 (2005-06) NFHS-2 (1998-99)
RCH-II
RCH-I
Bihar India
Bihar India
Bihar India
Bihar India
Children 12-13 months fully
32.8
28.4
immunized (BCG, measles,
and 3 doses each of polio/DPT
11.6 42.0
23.0
45.8
22.4 54.2
Children 12–23 months who
have received BCG
64.7
57.7
36.0
71.6
47.3
75.0
40.8 73.0
Children 12–23 months who have 82.4
55.8
received 3 doses of polio vaccine
42.2
62.8
33.2
57.2
37.4 68.0
Children 12–23 months who have 46.1
39.9
received 3 doses of DPT vaccine
24.9
55.1
33.8
58.2
34.9 6.1
Children 12–23 months who have 40.4
38.3
received measles vaccine
16.2
50.7
26.9
56.0
25.6 60.4
Children 12–35 months who
received a Vitamin A dose
in last 6 months
29.4
17.4
n.a.
n.a.
9.6
31.1
7.3
35.0
Children 12–13 months with no
immunization
49.4
19.8
48.8 18.8
Table 3.51. Achievement in Immunization (%)
Period
2000-01
2001-02
2002-03
2003-04
2004-05
2005-06
TT
DPT Polio
BCG
(III dose) (Below
1 year)
26.2 42.7 44
58.9
43.4 63.5 65.1
83.4
39.5 58.8 60
77.3
33.1 45.2 48.9
70.7
28.7 48.4 48.8
69
27.5 55.2 51.8
82.5
Source: Coverage Evaluation Survey, 2005.
Measles
(Below
1 year)
37.4
51.1
48.7
30.7
43.3
50.7
DT
TT
TT 16
10 years years
111.9 54.4
45.5
31.8 14.1
12.4
28.1 15
12.2
23
15.4
12.7
33.6 13.4
12.2
60.5 19.3
14.9
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Immunization coverage in the state is very poor, with services in poor condition. In terms of
awareness about immunization the state lags far behind all-India levels, especially among the
rural and SC/ST segments. However, it needs to be recognized that the achievements have been
under very difficult working conditions. Data for distance of the nearest place for immunization
show that 68.1% of sub-centre and urban health posts in the state are within 2 km of residence
from the nearest place for immunization (India 84.2%), which is a positive feature reflecting the
high level of commitment of staff especially at the lower level, despite major constraints. Instead
of viewing immunization as a programme which has been imposed, Bihar as a high-focus state
needs to give increased attention to the programme through decentralization in authority and
decision making. There needs to be emphasis on problem solving at district and block level. The
state needs to effectively utilize the vast number of human resources available at the community
level through other programmes such as ICDS.
Various assessments performed by several agencies over the last few years, including the UIP
review done in Bihar, have identified critical problems in the immunization system. These are
well known, and include low capacity to supervise, monitor and implement micro-plans at district
level; lack of effective vaccine distribution to immunization sites; ageing and poorly maintained
cold chain; lack of adequately trained human resources; low managerial and support capacity at
the state and district immunization units; and weak management of fund flows.
Childhood Diseases and Treatment
Acute respiratory infection (ARI) is a leading cause of childhood morbidity and mortality,
along with diarrhoea. Bihar has a prevalence of 6.8% for ARI symptoms as per NFHS-3, in
comparison to 5.8% for India. 70.2% children under five years with symptoms of ARI sought
treatment from a health facility or provider and 13.5% received antibiotics. Tables 3.52 and 3.53
present data for treatment of childhood diseases and knowledge of diarrhoea management.
Table 3.52. Treatment of Childhood Diseases (Children under 3 years) (%)
Children with diarrhoea in the last 2 weeks who
received ORS
Children with diarrhoea in the last 2 years taken
to a health facility
Children with acute respiratory infection or fever
in the last 2 weeks taken to a health facility
NFHS-3
(2005-06)
Bihar India
22.4
33.5
48.7
37.9
54.6
43.6
NFHS-2
(1998-99)
Bihar India
13.8
26.9
58.9
65.3
n.a.
n.a.
NFHS-1
(1992-93)
Bihar
India
12.7
17.8
n.a.
61.9
n.a.
n.a.
State of Health in Bihar
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Table 3.53. Knowledge of Diarrhoea Management and Treatment (%)
Women aware of diarrhoea management
Women aware of ORS
Women whose child suffered from diarrhoea
and treatment was sought
Children with diarrhoea who were treated
with ORS
Bihar
67.2
22.3
84.6
RCH-II
India
64.7
27.6
73.0
14.2
29.7
Sexually Transmitted Infections
RCH-I
Bihar
64.4
25.3
3.7
India
66.1
29.7
13.2
8.6
11.2
Sexually transmitted infections (STIs) is a co-factor for HIV transmission. Early diagnosis
and treatment of STIs is important in increasing awareness on HIV/AIDS awareness and prevention
of HIV. NFHS 3 shows that in India 11% of women and 5% of men who have ever had sex had an
STI or STI symptom. The state-level figures reflect that Bihar, Assam, Madhya Pradesh, Tripura
and Rajasthan have STI prevalence of 15% and higher. In Bihar STI prevalence among women is
2.8% and 0.4% among men.
66
State of Health in Bihar
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4
District Health Profile
and Ranking of Districts
State averages can be misleading because broad aggregates mask the disparities and variations
which exist between districts. Health needs across the districts also vary. Constraints to effective
service delivery also differ between districts, as do opportunities for overcoming these constraints.
At the national and state level there are a number of indicators available through census,
sample registration systems, NFHS and RCH survey, etc. The 73rd and 74th amendments to
the Constitution have brought about decentralized planning and programme implementation,
thereby making the district the focus. The district has now become the critical unit of planning
and programme implementation. However, the data base for district-level planning has been
inadequate and limited. Realizing the need for data at the district level, the International
Institute of Population Sciences (IIPS), Mumbai, conducted the DRHS 1998-99 and DLHS in
2002-04 as part of the RCH Programme of the Ministry of Health and Family Welfare,
Government of India.
DRHS 1998-99 for the first time provided a set of key reproductive and child health
indicators along with the Provisional Census 2001 for the district. The integration of DRHS
1998-99 and Provisional Population Results of the Census of India, 2001, provided the basis for
the first composite socio-demographic development index, which was computed by IIPS in
2002.
The India Socio-demographic Development Index, published by Population Foundation of
India, is based on similar indices used by IIPS to compare and assess the overall development
of 593 districts in India in the last five years. The computation by PFI is an integration of
DLHS 2002-04 and the Final Population results, Census of India, 2001.
The ensuing sections present
1. District Health Profile,
2. Ranking of Districts by Demographic and key RCH indicators, and
3. Composite Socio-Demographic Development Index.
State of Health in Bihar
67
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I. District Health Profile
General information
Area (sq km): 2830
Community Development Blocks: 9
ARARIA
As proportion of state’s area: 3.0%
Towns: 3
Villages: 783
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
68
State of Health in Bihar
2158606
1128105
1030503
93.9
6.1
13.6
1.4
28.5
5.4
33.9
763
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Sex Ratio (females per 1000 males)
1991
907
2001
913
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
986
2001
963
Literacy rate (7+)
Persons
35.0
Males
46.4
Females
22.4
Work participation rate
Total
39.5
Female
25.8
Household amenities
Households with kutchha houses (%)
74.6
Households with safe drinking water (%)
98.7
Households with electricity connection (%)
10.3
Vital rates
Crude Birth Rate
36.2
Total Fertility Rate
4.9
Infant Mortality Rate
71
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
50.5
Birth order 3 + (%)
56.3
Current use of any FP Method (%)
31.2
Total unmet need (%)
38.0
Pregnant women with any ANC (%)
34.2
Pregnant women with 3+ ANCs (%)
12.0
Pregnant women received IFA tablets (%)
4.8
Safe delivery (%)
20.6
Institutional delivery (%)
9.1
Children with full immunization (%)
19.6
Communicable Diseases
Kala-azar prevalence (%)
5.4
TB incidence (%)
3.2
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
91.9
Aware of HIV/ AIDS (%)
19.2
Health Infrastructure
CHCs
3
PHCs
39
Sub-Centres
200
State of Health in Bihar
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General information
Area (sq km): 3305
Community Development Blocks: 11
AURANGABAD
As proportion of state’s area: 3.5%
Towns: 5
Villages: 1828
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
70
State of Health in Bihar
2013055
1040945
972110
91.6
8.4
23.5
0.1
30.3
7.0
30.7
609
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Sex Ratio (females per 1000 males)
1991
915
2001
934
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
970
2001
943
Literacy rate (7+)
Persons
57.0
Males
71.1
Females
41.9
Work participation rate
Total
33.3
Female
20.2
Household amenities
Households with kutchha houses (%)
14.2
Households with safe drinking water (%)
83.5
Households with electricity connection (%)
7.8
Vital rates
Crude Birth Rate
32.3
Total Fertility Rate
4.3
Infant Mortality Rate
59
Key RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
45.6
Birth order 3 + (%)
53.7
Current use of any FP Method (%)
25.7
Total unmet need (%)
34.3
Pregnant women with any ANC (%)
37.8
Pregnant women with 3+ ANCs (%)
19.9
Pregnant women received IFA tablets (%)
4.3
Safe delivery (%)
28.7
Institutional delivery (%)
21.3
Children with full immunization (%)
32.6
Communicable Diseases
Kala-azar prevalence (%)
0
TB incidence (%)
2.5
HIV + prevalence among STD Clinics
0.5
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
93.0
Aware of HIV/ AIDS (%)
20.1
Health Infrastructure
CHCs
3
PHCs
69
Sub-Centres
207
State of Health in Bihar
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General information
Area (sq km): 3020.0
Community Development Blocks: 11
BANKA
As proportion of state’s area: 3.2%
Towns: 2
Villages: 1737
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
72
State of Health in Bihar
1608773
843293
765480
96.5
3.5
12.4
4.7
28.3
6.8
24.5
533
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10.1 Page 91 |
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Sex Ratio (females per 1000 males)
1991
893
2001
908
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
969
2001
965
Literacy rate (7+)
Persons
42.7
Males
55.3
Females
28.7
Work participation rate
Total
39.6
Female
28.2
Household amenities
Households with kutchha houses (%)
48.6
Households with safe drinking water (%)
49.9
Households with electricity connection (%)
4.7
Vital rates
Crude Birth Rate
33.8
Total Fertility Rate
4.8
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
56.0
Birth order 3 + (%)
54.4
Current use of any FP Method (%)
36.9
Total unmet need (%)
31.0
Pregnant women with any ANC (%)
38.5
Pregnant women with 3+ ANCs (%)
24.1
Pregnant women received IFA tablets (%)
8.5
Safe delivery (%)
36.4
Institutional delivery (%)
25.4
Children with full immunization (%)
25.6
Communicable Diseases
Kala-azar prevalence (%)
0.02
TB incidence (%)
1.1
HIV + prevalence among STD Clinics
0.7
HIV + prevalence among ANC Clinics
0.4
Women’s Health Awareness
Aware of RTI/ STI (%)
98.8
Aware of HIV/ AIDS (%)
22.7
Health Infrastructure
CHCs
3
PHCs
34
Sub-Centres
227
State of Health in Bihar
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General information
Area (sq km): 1918
Community Development Blocks: 18
BEGUSARAI
As proportion of state’s area: 2.0%
Towns: 2
Villages: 815
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
74
State of Health in Bihar
2349366
1228874
1120492
95.4
4.6
14.5
0.1
30.7
6.2
29.5
1225
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Sex Ratio (females per 1000 males)
1991
898
2001
912
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
961
2001
946
Literacy rate (7+)
Persons
48.0
Males
59.1
Females
35.6
Work participation rate
Total
31.8
Female
15.9
Household amenities
Households with kutchha houses (%)
18.7
Households with safe drinking water (%)
89.2
Households with electricity connection (%)
16.8
Vital rates
Crude Birth Rate
34.0
Total Fertility Rate
4.8
Infant Mortality Rate
62
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
50.6
Birth order 3 + (%)
52.6
Current use of any FP Method (%)
27.6
Total unmet need (%)
41.3
Pregnant women with any ANC (%)
33.5
Pregnant women with 3+ ANCs (%)
18.3
Pregnant women received IFA tablets (%)
4.8
Safe delivery (%)
28.7
Institutional delivery (%)
15.7
Children with full immunization (%)
21.4
Communicable Diseases
Kala-azar prevalence (%)
1.4
TB incidence (%)
2.3
HIV + prevalence among STD Clinics
0.5
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
92.8
Aware of HIV/ AIDS (%)
26.8
Health Infrastructure
CHCs
2
PHCs
42
Sub-Centres
288
State of Health in Bihar
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General information
Area (sq km): 2569
Community Development Blocks: 16
BHAGALPUR
As proportion of state’s area: 2.7%
Towns: 5
Villages: 1052
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
76
State of Health in Bihar
2423172
1291658
1131514
81.3
18.7
10.5
2.3
30.4
6.7
26.9
943
|
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Sex Ratio (females per 1000 males)
1991
864
2001
876
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
944
2001
966
Literacy rate (7+)
Persons
49.5
Males
59.2
Females
38.1
Work participation rate
Total
35.3
Female
21.4
Household amenities
Households with kutchha houses (%)
28.7
Households with safe drinking water (%)
69.6
Households with electricity connection (%)
19.1
Vital rates
Crude Birth Rate
31.9
Total Fertility Rate
4.5
Infant Mortality Rate
62
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
42.6
Birth order 3 + (%)
51.9
Current use of any FP Method (%)
39.6
Total unmet need (%)
33.1
Pregnant women with any ANC (%)
48.5
Pregnant women with 3+ ANCs (%)
27.9
Pregnant women received IFA tablets (%)
7.7
Safe delivery (%)
41.6
Institutional delivery (%)
29.2
Children with full immunization (%)
42.8
Communicable Diseases
Kala-azar prevalence (%)
0.7
TB incidence (%)
3.4
HIV + prevalence among STD Clinics
0.2
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
98.9
Aware of HIV/ AIDS (%)
38.1
Health Infrastructure
CHCs
2
PHCs
57
Sub-Centres
280
State of Health in Bihar
77
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General information
Area (sq. km): 2474
Community Development Blocks: 14
BHOJPUR
As proportion of state’s area: 2.6%
Towns: 6
Villages: 1129
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
78
State of Health in Bihar
2243144
1179611
1063533
86.1
13.9
15.3
0.4
30.7
7.5
25.1
907
|
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Sex Ratio (females per 1000 males)
1991
904
2001
902
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
924
2001
940
Literacy rate (7+)
Persons
59.0
Males
74.3
Females
41.8
Work participation rate
Total
29.1
Female
12.6
Household amenities
Households with kutchha houses (%)
6.6
Households with safe drinking water (%)
91.0
Households with electricity connection (%)
10.0
Vital rates
Crude Birth Rate
30.1
Total Fertility Rate
4.2
Infant Mortality Rate
54
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
55.3
Birth order 3 + (%)
54.0
Current use of any FP Method (%)
36.9
Total unmet need (%)
30.8
Pregnant women with any ANC (%)
51.3
Pregnant women with 3+ ANCs (%)
23.5
Pregnant women received IFA tablets (%)
14.5
Safe delivery (%)
49.0
Institutional delivery (%)
37.4
Children with full immunization (%)
32.3
Communicable Diseases
Kala-azar prevalence (%)
0.3
TB incidence (%)
2.1
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0.5
Women’s Health Awareness
Aware of RTI/ STI (%)
97.1
Aware of HIV/ AIDS (%)
32.3
Health Infrastructure
CHCs
2
PHCs
32
Sub-Centres
284
State of Health in Bihar
79
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General information
Area (sq km): 1624
Community Development Blocks: 11
BUXAR
As proportion of state’s area: 1.7%
Towns: 2
Villages: 882
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
80
State of Health in Bihar
1402396
738354
664042
90.8
9.2
14.1
0.6
29.8
7.6
28.9
864
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Sex Ratio (females per 1000 males)
1991
884
2001
899
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
905
2001
925
Literacy rate (7+)
Persons
56.8
Males
71.9
Females
39.9
Work participation rate
Total
29.1
Female
11.9
Household amenities
Households with kutchha houses (%)
9.0
Households with safe drinking water (%)
87.8
Households with electricity connection (%)
11.5
Vital rates
Crude Birth Rate
31.7
Total Fertility Rate
4.4
Infant Mortality Rate
76
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
59.2
Birth order 3 + (%)
55.1
Current use of any FP Method (%)
31.0
Total unmet need (%)
36.8
Pregnant women with any ANC (%)
38.2
Pregnant women with 3+ ANCs (%)
16.6
Pregnant women received IFA tablets (%)
4.6
Safe delivery (%)
40.9
Institutional delivery (%)
30.4
Children with full immunization (%)
22.0
Communicable Diseases
Kala-azar prevalence (%)
0.1
TB incidence (%)
1.4
HIV + prevalence among STD clinics
0
HIV + prevalence among ANC clinics
0.4
Women’s Health Awareness
Aware of RTI/ STI (%)
97.2
Aware of HIV/ AIDS (%)
23.0
Health Infrastructure
CHCs
0
PHCs
27
Sub-Centres
158
State of Health in Bihar
81
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General information
Area (sq km): 2279
Community Development Blocks: 18
DARBHANGA
As proportion of state’s area: 2.4%
Towns: 1
Villages: 1179
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
82
State of Health in Bihar
3295789
1722189
1573600
91.9
8.1
15.5
0.0
30.1
6.4
31.3
1446
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11.1 Page 101 |
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Sex Ratio (females per 1000 males)
1991
911
2001
914
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
954
2001
915
Literacy rate (7+)
Persons
44.3
Males
56.7
Females
30.8
Work participation rate
Total
31.2
Female
14.9
Household amenities
Households with kutchha houses (%)
31.7
Households with safe drinking water (%)
99.0
Households with electricity connection (%)
8.8
Vital rates
Crude Birth Rate
33.1
Total Fertility Rate
4.5
Infant Mortality Rate
74
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
49.8
Birth order 3 + (%)
56.5
Current use of any FP Method (%)
31.9
Total unmet need (%)
40.0
Pregnant women with any ANC (%)
33.3
Pregnant women with 3+ ANCs (%)
16.6
Pregnant women received IFA tablets (%)
6.3
Safe delivery (%)
25.5
Institutional delivery (%)
16.9
Children with full immunization (%)
22.0
Communicable Diseases
Kala-azar prevalence (%)
3.6
TB incidence (%)
5.1
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0.2
Women’s Health Awareness
Aware of RTI/ STI (%)
96.0
Aware of HIV/ AIDS (%)
38.9
Health Infrastructure
CHCs
2
PHCs
64
Sub-Centres
261
State of Health in Bihar
83
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General information
Area (sq km): 4976
Community Development Blocks: 24
GAYA
As proportion of state’s area: 5.3%
Towns: 5
Villages: 2832
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
84
State of Health in Bihar
3473428
1792163
1681265
86.3
13.7
29.6
0.1
30.7
6.7
30.3
698
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Sex Ratio (females per 1000 males)
1991
922
2001
938
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
983
2001
968
Literacy rate (7+)
Persons
50.4
Males
63.3
Females
36.7
Work participation rate
Total
36.8
Female
25.5
Household amenities
Households with kutchha houses (%)
20.6
Households with safe drinking water (%)
71.8
Households with electricity connection (%)
10.0
Vital rates
Crude Birth Rate
33.2
Total Fertility Rate
4.4
Infant Mortality Rate
48
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
54.7
Birth order 3 + (%)
50.5
Current use of any FP Method (%)
28.4
Total unmet need (%)
41.1
Pregnant women with any ANC (%)
33.0
Pregnant women with 3+ ANCs (%)
21.3
Pregnant women received IFA tablets (%)
7.6
Safe delivery (%)
37.9
Institutional delivery (%)
23.6
Children with full immunization (%)
14.4
Communicable Diseases
Kala-azar prevalence (%)
0.2
TB incidence (%)
4.6
HIV + prevalence among STD Clinics
0.4
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
90.7
Aware of HIV/ AIDS (%)
25.2
Health Infrastructure
CHCs
2
PHCs
68
Sub-Centres
439
State of Health in Bihar
85
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General information
Area (sq km): 2033
Community Development Blocks: 14
GOPALGANJ
As proportion of state’s area: 2.2%
Towns: 4
Villages: 1475
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
86
State of Health in Bihar
2152638
1075710
1076928
93.3
6.1
12.4
0.3
30.1
7.3
26.3
1059
|
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11.5 Page 105 |
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Sex Ratio (females per 1000 males)
Child Sex Ratio (0–6 years) (girls per 1000 boys)
Literacy rate (7+)
Work participation rate
Household amenities
Vital rates
RCH indicators from DLHS, 2002–04
Key RCH indicators
Communicable Diseases
Women’s Health Awareness
Health Infrastructure
1991
2001
1991
2001
Persons
Males
Females
Total
Female
Households with kutchha houses (%)
Households with safe drinking water (%)
Households with electricity connection (%)
Crude Birth Rate
Total Fertility Rate
Infant Mortality Rate
Girls marrying below 18 years (%)
Birth order 3 + (%)
Current use of any FP Method (%)
Total unmet need (%)
Pregnant women with any ANC (%)
Pregnant women with 3+ ANCs (%)
Pregnant women received IFA tablets (%)
Safe delivery (%)
Institutional delivery (%)
Children with full immunization (%)
Kala-azar prevalence (%)
TB incidence (%)
HIV + prevalence among STD Clinics
HIV + prevalence among ANC Clinics
Aware of RTI/ STI (%)
Aware of HIV/ AIDS (%)
CHCs
PHCs
Sub-Centres
968
1001
966
964
47.5
63.0
32.2
29.8
15.1
35.3
97.3
6.0
31.9
4.4
63
34.6
54.2
30.1
34.8
53.3
28.4
12.5
35.2
24.0
39.0
4.3
1.6
1.6
0
97.6
29.7
3
32
186
State of Health in Bihar
87
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11.6 Page 106 |
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General information
Area (sq km): 3098
Community Development Blocks: 10
JAMUI
As proportion of state’s area: 3.3%
Towns: 2
Villages: 1373
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
88
State of Health in Bihar
1398796
729138
669658
92.6
7.4
17.4
4.8
30.3
6.1
33.0
452
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11.7 Page 107 |
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Sex Ratio (females per 1000 males)
1991
903
2001
918
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
967
2001
963
Literacy rate (7+)
Persons
42.4
Males
57.1
Females
26.3
Work participation rate
Total
42.7
Female
34.8
Household amenities
Households with kutchha houses (%)
9.9
Households with safe drinking water (%)
38.3
Households with electricity connection (%)
7.0
Vital rates
Crude Birth Rate
32.8
Total Fertility Rate
4.5
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
64.7
Birth order 3 + (%)
49.8
Current use of any FP Method (%)
28.9
Total unmet need (%)
33.2
Pregnant women with any ANC (%)
43.7
Pregnant women with 3+ ANCs (%)
22.7
Pregnant women received IFA tablets (%)
12.0
Safe delivery (%)
27.4
Institutional delivery (%)
23.5
Children with full immunization (%)
13.1
Communicable Diseases
Kala-azar prevalence (%)
0.1
TB incidence (%)
1.1
HIV + prevalence among STD Clinics
2.0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
95.3
Aware of HIV/ AIDS (%)
20.0
Health Infrastructure
CHCs
3
PHCs
28
Sub-Centres
166
State of Health in Bihar
89
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11.8 Page 108 |
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General information
Area (sq km): 1569
Community Development Blocks: 12
JEHANABAD
As proportion of state’s area: 1.7%
Towns: 2
Villages: 928
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
90
State of Health in Bihar
1514315
784946
729369
92.6
7.4
18.9
0.1
30.1
7.4
28.9
965
|
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11.9 Page 109 |
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Sex Ratio (females per 1000 males)
1991
919
2001
929
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
967
2001
917
Literacy rate (7+)
Persons
55.3
Males
70.1
Females
39.4
Work participation rate
Total
38.4
Female
27.9
Household amenities
Households with kutchha houses (%)
17.0
Households with safe drinking water (%)
83.4
Households with electricity connection (%)
4.6
Vital rates
Crude Birth Rate
32.0
Total Fertility Rate
4.1
Infant Mortality Rate
80
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
60.4
Birth order 3 + (%)
57.9
Current use of any FP Method (%)
28.2
Total unmet need (%)
44.9
Pregnant women with any ANC (%)
33.6
Pregnant women with 3+ ANCs (%)
20.0
Pregnant women received IFA tablets (%)
6.9
Safe delivery (%)
42.6
Institutional delivery (%)
35.1
Children with full immunization (%)
16.8
Communicable Diseases
Kala-azar prevalence (%)
0
TB incidence (%)
1.2
HIV + prevalence among STD Clinics
1.2
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
93.4
Aware of HIV/ AIDS (%)
25.8
Health Infrastructure
CHCs
2
PHCs
29
Sub-Centres
81
State of Health in Bihar
91
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11.10 Page 110 |
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General information
Area (sq km): 3362
Community Development Blocks: 11
KAIMUR (BHABUA)
As proportion of state’s area: 3.6%
Towns: 1
Villages: 1398
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
92
State of Health in Bihar
1289074
677623
611451
96.8
3.2
22.2
2.8
28.5
7.4
31.1
383
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12 Pages 111-120 |
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12.1 Page 111 |
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Sex Ratio (females per 1000 males)
1991
884
2001
902
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
918
2001
940
Literacy rate (7+)
Persons
55.1
Males
69.7
Females
38.8
Work participation rate
Total
34.4
Female
20.7
Household amenities
Households with kutchha houses (%)
5.5
Households with safe drinking water (%)
75.0
Households with electricity connection (%)
11.3
Vital rates
Crude Birth Rate
34.4
Total Fertility Rate
4.8
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
48.6
Birth order 3 + (%)
54.4
Current use of any FP Method (%)
33.6
Total unmet need (%)
39.1
Pregnant women with any ANC (%)
36.1
Pregnant women with 3+ ANCs (%)
21.6
Pregnant women received IFA tablets (%)
7.4
Safe delivery (%)
28.8
Institutional delivery (%)
13.1
Children with full immunization (%)
17.5
Communicable Diseases
Kala-azar prevalence (%)
0.4
TB incidence (%)
1.5
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
90.9
Aware of HIV/ AIDS (%)
29.8
Health Infrastructure
CHCs
2
PHCs
49
Sub-Centres
107
State of Health in Bihar
93
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General information
Area (sq km): 3057
Community Development Blocks: 16
KATIHAR
As proportion of state’s area: 3.2%
Towns: 3
Villages: 1393
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
94
State of Health in Bihar
2392638
1246872
1145766
90.9
9.1
8.7
5.9
29.1
5.5
31.1
783
|
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12.3 Page 113 |
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Sex Ratio (females per 1000 males)
1991
909
2001
919
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
975
2001
966
Literacy rate (7+)
Persons
35.1
Males
45.3
Females
23.8
Work participation rate
Total
37.5
Female
23.1
Household amenities
Households with kutchha houses (%)
48.5
Households with safe drinking water (%)
96.5
Households with electricity connection (%)
7.0
Vital rates
Crude Birth Rate
38.2
Total Fertility Rate
5.3
Infant Mortality Rate
68
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
46.2
Birth order 3 + (%)
56.4
Current use of any FP Method (%)
33.6
Total unmet need (%)
39.1
Pregnant women with any ANC (%)
36.1
Pregnant women with 3+ ANCs (%)
21.6
Pregnant women received IFA tablets (%)
7.4
Safe delivery (%)
28.8
Institutional delivery (%)
13.1
Children with full immunization (%)
17.5
Communicable Diseases
Kala-azar prevalence (%)
2.1
TB incidence (%)
5.1
HIV + prevalence among STD Clinics
2.5
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
95.4
Aware of HIV/ AIDS (%)
28.9
Health Infrastructure
CHCs
3
PHCs
43
Sub-Centres
257
State of Health in Bihar
95
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12.4 Page 114 |
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General information
Area (sq km): 1486
Community Development Blocks: 7
KHAGARIA
As proportion of state’s area: 1.6%
Towns: 2
Villages: 298
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
96
State of Health in Bihar
1280354
679267
601087
94.0
6.0
14.5
0.0
29.7
6.0
29.7
862
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12.5 Page 115 |
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Sex Ratio (females per 1000 males)
1991
868
2001
885
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
943
2001
932
Literacy rate (7+)
Persons
41.3
Males
51.8
Females
29.3
Work participation rate
Total
36.5
Female
22.9
Household amenities
Households with kutchha houses (%)
34.8
Households with safe drinking water (%)
95.8
Households with electricity connection (%)
8.9
Vital rates
Crude Birth Rate
35.7
Total Fertility Rate
5.1
Infant Mortality Rate
72
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
58.2
Birth order 3 + (%)
59.4
Current use of any FP Method (%)
30.8
Total unmet need (%)
35.2
Pregnant women with any ANC (%)
23.3
Pregnant women with 3+ ANCs (%)
9.6
Pregnant women received IFA tablets (%)
3.1
Safe delivery (%)
20.2
Institutional delivery (%)
15.1
Children with full immunization (%)
21.1
Communicable Diseases
Kala-azar prevalence (%)
3.2
TB incidence (%)
0.8
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
89.9
Aware of HIV/ AIDS (%)
25.0
Health Infrastructure
CHCs
1
PHCs
24
Sub-Centres
151
State of Health in Bihar
97
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12.6 Page 116 |
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General information
Area (sq km): 1884
Community Development Blocks: 7
KISHANGANJ
As proportion of state’s area: 2.0%
Towns: 3
Villages: 815
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
98
State of Health in Bihar
1296348
669552
626796
90.0
10.0
6.6
3.6
29.5
4.9
31.7
688
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12.7 Page 117 |
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Sex Ratio (females per 1000 males)
1991
933
2001
936
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
982
2001
947
Literacy rate (7+)
Persons
31.1
Males
42.7
Females
18.6
Work participation rate
Total
32.2
Female
10.2
Household amenities
Households with kutchha houses (%)
52.2
Households with safe drinking water (%)
90.9
Households with electricity connection (%)
4.5
Vital rates
Crude Birth Rate
39.0
Total Fertility Rate
5.3
Infant Mortality Rate
81
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
42.6
Birth order 3 + (%)
65.6
Current use of any FP Method (%)
23.1
Total unmet need (%)
47.3
Pregnant women with any ANC (%)
28.3
Pregnant women with 3+ ANCs (%)
12.4
Pregnant women received IFA tablets (%)
2.8
Safe delivery (%)
20.5
Institutional delivery (%)
14.1
Children with full immunization (%)
7.9
Communicable Diseases
Kala-azar prevalence (%)
1.1
TB incidence (%)
0.9
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
84.0
Aware of HIV/ AIDS (%)
22.4
Health Infrastructure
CHCs
2
PHCs
15
Sub-Centres
136
State of Health in Bihar
99
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12.8 Page 118 |
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General information
Area (sq km): 1228
Community Development Blocks: 6
LAKHISARAI
As proportion of state’s area: 1.3%
Towns: 2
Villages: 410
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
100
State of Health in Bihar
802225
417672
384553
85.3
14.7
15.8
0.7
29.5
6.6
24.1
653
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12.9 Page 119 |
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Sex Ratio (females per 1000 males)
1991
880
2001
921
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
955
2001
951
Literacy rate (7+)
Persons
48.0
Males
60.7
Females
34.0
Work participation rate
Total
36.5
Female
23.3
Household amenities
Households with kutchha houses (%)
15.7
Households with safe drinking water (%)
57.6
Households with electricity connection (%)
12.9
Vital rates
Crude Birth Rate
33.8
Total Fertility Rate
4.7
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
57.4
Birth order 3 + (%)
50.0
Current use of any FP Method (%)
32.6
Total unmet need (%)
31.6
Pregnant women with any ANC (%)
40.4
Pregnant women with 3+ ANCs (%)
21.9
Pregnant women received IFA tablets (%)
13.4
Safe delivery (%)
30.9
Institutional delivery (%)
25.4
Children with full immunization (%)
23.2
Communicable Diseases
Kala-azar prevalence (%)
0.2
TB incidence (%)
0.3
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
1.0
Women’s Health Awareness
Aware of RTI/ STI (%)
96.7
Aware of HIV/ AIDS (%)
24.3
Health Infrastructure
CHCs
1
PHCs
17
Sub-Centres
102
State of Health in Bihar
101
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General information
Area (sq km): 1788
Community Development Blocks: 13
MADHEPURA
As proportion of state’s area: 1.9%
Towns: 2
Villages: 450
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
102
State of Health in Bihar
1526646
797180
729466
95.5
4.5
17.1
0.6
28.3
5.7
29.6
854
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|
13.1 Page 121 |
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Sex Ratio (females per 1000 males)
1991
885
2001
915
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
942
2001
927
Literacy rate (7+)
Persons
36.1
Males
48.8
Females
22.1
Work participation rate
Total
44.8
Female
37.3
Household amenities
Households with kutchha houses (%)
72.1
Households with safe drinking water (%)
96.6
Households with electricity connection (%)
3.8
Vital rates
Crude Birth Rate
36.7
Total Fertility Rate
4.8
Infant Mortality Rate
67
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
54.3
Birth order 3 + (%)
50.4
Current use of any FP Method (%)
31.5
Total unmet need (%)
37.9
Pregnant women with any ANC (%)
27.5
Pregnant women with 3+ ANCs (%)
11.7
Pregnant women received IFA tablets (%)
8.9
Safe delivery (%)
21.7
Institutional delivery (%)
11.8
Children with full immunization (%)
21.7
Communicable Diseases
Kala-azar prevalence (%)
3.5
TB incidence (%)
1.8
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0.5
Women’s Health Awareness
Aware of RTI/ STI (%)
89.2
Aware of HIV/ AIDS (%)
17.3
Health Infrastructure
CHCs
1
PHCs
30
Sub-Centres
115
State of Health in Bihar
103
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General information
Area (sq km): 3501
Community Development Blocks: 21
MADHUBANI
As proportion of state’s area: 3.7%
Towns: 4
Villages: 1150
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
104
State of Health in Bihar
3575281
1840997
1734284
96.5
3.5
13.5
0.0
28.6
6.6
26.2
1021
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13.3 Page 123 |
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Sex Ratio (females per 1000 males)
1991
932
2001
942
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
953
2001
939
Literacy rate (7+)
Persons
42.0
Males
56.8
Females
26.2
Work participation rate
Total
34.3
Female
20.1
Household amenities
Households with kutchha houses (%)
61.6
Households with safe drinking water (%)
98.1
Households with electricity connection (%)
5.1
Vital rates
Crude Birth Rate
33.3
Total Fertility Rate
4.3
Infant Mortality Rate
86
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
60.8
Birth order 3 + (%)
54.7
Current use of any FP Method (%)
30.4
Total unmet need (%)
31.8
Pregnant women with any ANC (%)
36.0
Pregnant women with 3+ ANCs (%)
15.5
Pregnant women received IFA tablets (%)
5.6
Safe delivery (%)
15.4
Institutional delivery (%)
7.7
Children with full immunization (%)
15.5
Communicable Diseases
Kala-azar prevalence (%)
1.7
TB incidence (%)
3.7
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
71.0
Aware of HIV/ AIDS (%)
26.2
Health Infrastructure
CHCs
2
PHCs
95
Sub-Centres
430
State of Health in Bihar
105
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13.4 Page 124 |
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General information
Area (sq km): 1419
Community Development Blocks: 1.5
MUNGER
As proportion of state’s area: 1.5%
Towns: 1.5
Villages: 633
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
106
State of Health in Bihar
1137797
607730
530067
72.1
27.9
13.3
1.6
31.2
6.8
20.6
802
|
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13.5 Page 125 |
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Sex Ratio (females per 1000 males)
1991
856
2001
872
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
934
2001
914
Literacy rate (7+)
Persons
59.5
Males
69.9
Females
47.4
Work participation rate
Total
29.1
Female
13.4
Household amenities
Households with kutchha houses (%)
23.5
Households with safe drinking water (%)
51.0
Households with electricity connection (%)
23.7
Vital rates
Crude Birth Rate
29.0
Total Fertility Rate
4.0
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
48.3
Birth order 3 + (%)
50.7
Current use of any FP Method (%)
38.6
Total unmet need (%)
35.4
Pregnant women with any ANC (%)
48.1
Pregnant women with 3+ ANCs (%)
22.5
Pregnant women received IFA tablets (%)
5.5
Safe delivery (%)
47.3
Institutional delivery (%)
38.8
Children with full immunization (%)
26.4
Communicable Diseases
Kala-azar prevalence (%)
0
TB incidence (%)
2.0
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
96.7
Aware of HIV/ AIDS (%)
36.8
Health Infrastructure
CHCs
1
PHCs
19
Sub-Centres
123
State of Health in Bihar
107
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13.6 Page 126 |
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General information
Area (sq km): 3172
Community Development Blocks: 16
MUZAFFARPUR
As proportion of state’s area: 3.4%
Towns: 3
Villages: 1824
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
108
State of Health in Bihar
3746714
1951466
1795248
90.7
9.3
15.9
0.1
29.5
7.0
26.8
1181
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13.7 Page 127 |
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Sex Ratio (females per 1000 males)
1991
904
2001
920
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
943
2001
928
Literacy rate (7+)
Persons
48.0
Males
59.1
Females
35.8
Work participation rate
Total
30.4
Female
12.7
Household amenities
Households with kutchha houses (%)
42.9
Households with safe drinking water (%)
93.1
Households with electricity connection (%)
12.5
Vital rates
Crude Birth Rate
32.7
Total Fertility Rate
4.6
Infant Mortality Rate
64
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
44.5
Birth order 3 + (%)
51.9
Current use of any FP Method (%)
32.5
Total unmet need (%)
37.8
Pregnant women with any ANC (%)
40.4
Pregnant women with 3+ ANCs (%)
20.8
Pregnant women received IFA tablets (%)
7.8
Safe delivery (%)
31.0
Institutional delivery (%)
19.4
Children with full immunization (%)
35.9
Communicable Diseases
Kala-azar prevalence (%)
12.4
TB incidence (%)
8.4
HIV + prevalence among STD Clinics
0.4
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
66.6
Aware of HIV/ AIDS (%)
38.4
Health Infrastructure
CHCs
1
PHCs
61
Sub-Centres
473
State of Health in Bihar
109
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General information
Area (sq km): 2355
Community Development Blocks: 20
NALANDA
As proportion of state’s area: 2.5%
Towns: 5
Villages: 1140
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
110
State of Health in Bihar
2370528
1238599
1131929
85.1
14.9
20.0
0.0
30.0
7.1
18.7
1007
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13.9 Page 129 |
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Sex Ratio (females per 1000 males)
1991
898
2001
914
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
962
2001
942
Literacy rate (7+)
Persons
53.2
Males
66.4
Females
38.6
Work participation rate
Total
38.1
Female
27.0
Household amenities
Households with kutchha houses (%)
12.9
Households with safe drinking water (%)
63.3
Households with electricity connection (%)
10.4
Vital rates
Crude Birth Rate
31.2
Total Fertility Rate
4.2
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
59.6
Birth order 3 + (%)
59.1
Current use of any FP Method (%)
26.4
Total unmet need (%)
37.9
Pregnant women with any ANC (%)
33.2
Pregnant women with 3+ ANCs (%)
15.0
Pregnant women received IFA tablets (%)
5.5
Safe delivery (%)
38.0
Institutional delivery (%)
30.8
Children with full immunization (%)
21.8
Communicable Diseases
Kala-azar prevalence (%)
0.1
TB incidence (%)
4.6
HIV + prevalence among STD Clinics
1.3
HIV + prevalence among ANC Clinics
0.2
Women’s Health Awareness
Aware of RTI/ STI (%)
96.8
Aware of HIV/ AIDS (%)
27.0
Health Infrastructure
CHCs
3
PHCs
48
Sub-Centres
302
State of Health in Bihar
111
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General information
Area (sq km): 2494
Community Development Blocks: 14
NAWADA
As proportion of state’s area: 2.6%
Towns: 3
Villages: 1051
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
112
State of Health in Bihar
1809696
929960
879736
92.3
7.7
24.1
0.1
30.4
6.8
33.1
726
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14.1 Page 131 |
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Sex Ratio (females per 1000 males)
1991
936
2001
946
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
974
2001
978
Literacy rate (7+)
Persons
46.8
Males
60.6
Females
32.2
Work participation rate
Total
37.3
Female
25.8
Household amenities
Households with kutchha houses (%)
13.6
Households with safe drinking water (%)
74.0
Households with electricity connection (%)
6.7
Vital rates
Crude Birth Rate
33.3
Total Fertility Rate
4.3
Infant Mortality Rate
48
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
58.6
Birth order 3 + (%)
55.1
Current use of any FP Method (%)
28.8
Total unmet need (%)
45.9
Pregnant women with any ANC (%)
35.1
Pregnant women with 3+ ANCs (%)
15.4
Pregnant women received IFA tablets (%)
5.8
Safe delivery (%)
34.1
Institutional delivery (%)
26.1
Children with full immunization (%)
25.4
Communicable Diseases
Kala-azar prevalence (%)
0
TB incidence (%)
1.7
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0.2
Women’s Health Awareness
Aware of RTI/ STI (%)
90.9
Aware of HIV/ AIDS (%)
27.3
Health Infrastructure
CHCs
2
PHCs
37
Sub-Centres
129
State of Health in Bihar
113
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PASCHIM CHAMPARAN
General information
Area (sq km): 5228
Community Development Blocks: 18
As proportion of state’s area: 5.6%
Towns: 5
Villages: 1484
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
114
State of Health in Bihar
3043466
1600839
1442627
89.8
10.2
14.3
1.5
28.1
6.1
30.4
582
|
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14.3 Page 133 |
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Sex Ratio (females per 1000 males)
1991
877
2001
901
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
963
2001
953
Literacy rate (7+)
Persons
38.9
Males
51.1
Females
25.2
Work participation rate
Total
37.9
Female
23.6
Household amenities
Households with kutchha houses (%)
52.3
Households with safe drinking water (%)
96.8
Households with electricity connection (%)
6.2
Vital rates
Crude Birth Rate
35.7
Total Fertility Rate
5.0
Infant Mortality Rate
73
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
63.9
Birth order 3 + (%)
57.0
Current use of any FP Method (%)
24.6
Total unmet need (%)
37.2
Pregnant women with any ANC (%)
35.1
Pregnant women with 3+ ANCs (%)
17.5
Pregnant women received IFA tablets (%)
4.5
Safe delivery (%)
37.1
Institutional delivery (%)
28.6
Children with full immunization (%)
7.6
Communicable Diseases
Kala-azar prevalence (%)
1.9
TB incidence (%)
5.2
HIV + prevalence among STD Clinics
1.2
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
51.6
Aware of HIV/ AIDS (%)
7.7
Health Infrastructure
CHCs
2
PHCs
41
Sub-Centres
389
State of Health in Bihar
115
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General information
Area (sq km): 3202
Community Development Blocks: 24
PATNA
As proportion of state’s area: 3.4%
Towns: 12
Villages: 1565
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
116
State of Health in Bihar
4718592
2519942
2198650
58.4
41.6
15.5
0.2
31.7
6.7
30.4
1474
|
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14.5 Page 135 |
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Sex Ratio (females per 1000 males)
1991
867
2001
873
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
937
2001
923
Literacy rate (7+)
Persons
62.9
Males
73.3
Females
50.8
Work participation rate
Total
30.2
Female
13.3
Household amenities
Households with kutchha houses (%)
9.4
Households with safe drinking water (%)
77.5
Households with electricity connection (%)
42.8
Vital rates
Crude Birth Rate
28.4
Total Fertility Rate
3.9
Infant Mortality Rate
52
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
44.7
Birth order 3 + (%)
48.1
Current use of any FP Method (%)
36.8
Total unmet need (%)
34.0
Pregnant women with any ANC (%)
52.4
Pregnant women with 3+ ANCs (%)
31.0
Pregnant women received IFA tablets (%)
15.4
Safe delivery (%)
49.2
Institutional delivery (%)
45.3
Children with full immunization (%)
39.9
Communicable Diseases
Kala-azar prevalence (%)
1.4
TB incidence (%)
8.5
HIV + prevalence among STD Clinics
3.2
HIV + prevalence among ANC Clinics
0.7
Women’s Health Awareness
Aware of RTI/ STI (%)
96.0
Aware of HIV/ AIDS (%)
47.5
Health Infrastructure
CHCs
4
PHCs
86
Sub-Centres
418
State of Health in Bihar
117
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General information
Area (sq km): 3968
Community Development Blocks: 27
PURBA CHAMPARAN
As proportion of state’s area: 4.2
Towns: 7
Villages: 2835
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
118
State of Health in Bihar
3939773
2077047
1862726
93.6
6.4
13.0
0.1
28.4
6.2
29.5
993
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14.7 Page 137 |
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Sex Ratio (females per 1000 males)
1991
883
2001
897
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
944
2001
937
Literacy rate (7+)
Persons
37.5
Males
49.3
Females
24.3
Work participation rate
Total
32.7
Female
14.7
Household amenities
Households with kutchha houses (%)
45.0
Households with safe drinking water (%)
93.0
Households with electricity connection (%)
6.3
Vital rates
Crude Birth Rate
34.8
Total Fertility Rate
4.9
Infant Mortality Rate
81
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
59.0
Birth order 3 + (%)
54.9
Current use of any FP Method (%)
27.8
Total unmet need (%)
38.4
Pregnant women with any ANC (%)
42.6
Pregnant women with 3+ ANCs (%)
23.5
Pregnant women received IFA tablets (%)
11.0
Safe delivery (%)
27.2
Institutional delivery (%)
18.6
Children with full immunization (%)
14.6
Communicable Diseases
Kala-azar prevalence (%)
6.0
TB incidence (%)
3.2
HIV + prevalence among STD Clinics
1.6
HIV + prevalence among ANC Clinics
0.5
Women’s Health Awareness
Aware of RTI/ STI (%)
80.5
Aware of HIV/ AIDS (%)
26.0
Health Infrastructure
CHCs
3
PHCs
66
Sub-Centres
315
State of Health in Bihar
119
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General information
Area (sq km): 3229
Community Development Blocks: 14
PURNIA
As proportion of state’s area: 3.4%
Towns: 3
Villages: 1197
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
120
State of Health in Bihar
2543942
1328417
1215525
91.3
8.7
12.3
4.4
28.8
5.4
35.4
788
|
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14.9 Page 139 |
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Sex Ratio (females per 1000 males)
1991
903
2001
915
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
965
2001
967
Literacy rate (7+)
Persons
35.1
Males
45.6
Females
23.4
Work participation rate
Total
37.8
Female
23.3
Household amenities
Households with kutchha houses (%)
72.6
Households with safe drinking water (%)
98.2
Households with electricity connection (%)
7.1
Vital rates
Crude Birth Rate
37.6
Total Fertility Rate
5.0
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
42.2
Birth order 3 + (%)
59.6
Current use of any FP Method (%)
30.0
Total unmet need (%)
31.2
Pregnant women with any ANC (%)
26.3
Pregnant women with 3+ ANCs (%)
12.5
Pregnant women received IFA tablets (%)
3.1
Safe delivery (%)
19.0
Institutional delivery (%)
13.0
Children with full immunization (%)
28.5
Communicable Diseases
Kala-azar prevalence (%)
6.0
TB incidence (%)
3.4
HIV + prevalence among STD Clinics
0.4
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
96.5
Aware of HIV/ AIDS (%)
27.1
Health Infrastructure
CHCs
2
PHCs
45
Sub-Centres
278
State of Health in Bihar
121
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General information
Area (sq km): 3851
Community Development Blocks: 18
ROHTAS
As proportion of state’s area: 4.1%
Towns: 5
Villages: 1855
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
122
State of Health in Bihar
2450748
1283485
1167263
86.7
13.3
18.1
1.0
30.0
6.9
27.8
636
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15 Pages 141-150 |
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|
|
15.1 Page 141 |
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Sex Ratio (females per 1000 males)
1991
894
2001
909
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
965
2001
951
Literacy rate (7+)
Persons
61.3
Males
75.3
Females
45.7
Work participation rate
Total
30.4
Female
13.5
Household amenities
Households with kutchha houses (%)
2.4
Households with safe drinking water (%)
92.6
Households with electricity connection (%)
16.5
Vital rates
Crude Birth Rate
32.1
Total Fertility Rate
4.5
Infant Mortality Rate
41
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
46.8
Birth order 3 + (%)
46.5
Current use of any FP Method (%)
35.0
Total unmet need (%)
30.5
Pregnant women with any ANC (%)
52.4
Pregnant women with 3+ ANCs (%)
25.8
Pregnant women received IFA tablets (%)
8.7
Safe delivery (%)
50.5
Institutional delivery (%)
39.7
Children with full immunization (%)
24.6
Communicable Diseases
Kala-azar prevalence (%)
1.3
TB incidence (%)
2.6
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0.5
Women’s Health Awareness
Aware of RTI/ STI (%)
86.6
Aware of HIV/ AIDS (%)
30.7
Health Infrastructure
CHCs
1
PHCs
30
Sub-Centres
186
State of Health in Bihar
123
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General information
Area (sq km): 1702
Community Development Blocks: 10
SAHARSA
As proportion of state’s area: 1.8
Towns: 1
Villages: 504
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
124
State of Health in Bihar
1508182
789432
718750
91.7
8.3
16.1
0.3
29.4
5.8
33.2
886
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15.3 Page 143 |
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Sex Ratio (females per 1000 males)
1991
884
2001
910
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
920
2001
912
Literacy rate (7+)
Persons
39.1
Males
51.7
Females
25.3
Work participation rate
Total
39.1
Female
28.4
Household amenities
Households with kutchha houses (%)
57.5
Households with safe drinking water (%)
96.5
Households with electricity connection (%)
6.9
Vital rates
Crude Birth Rate
35.5
Total Fertility Rate
4.6
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
47.9
Birth order 3 + (%)
62.6
Current use of any FP Method (%)
37.7
Total unmet need (%)
34.1
Pregnant women with any ANC (%)
28.9
Pregnant women with 3+ ANCs (%)
14.7
Pregnant women received IFA tablets (%)
3.5
Safe delivery (%)
21.5
Institutional delivery (%)
16.4
Children with full immunization (%)
22.9
Communicable Diseases
Kala-azar prevalence (%)
8.2
TB incidence (%)
2.6
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
1.1
Women’s Health Awareness
Aware of RTI/ STI (%)
99.5
Aware of HIV/ AIDS (%)
30.1
Health Infrastructure
CHCs
0
PHCs
40
Sub-Centres
152
State of Health in Bihar
125
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General information
Area (sq km): 2904
Community Development Blocks: 20
SAMASTIPUR
As proportion of state’s area: 3.1%
Towns: 4
Villages: 1230
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
126
State of Health in Bihar
3394793
1760692
1634101
96.4
3.9
18.5
0.1
29.5
6.7
24.9
1169
|
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15.5 Page 145 |
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Sex Ratio (females per 1000 males)
1991
926
2001
928
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
942
2001
938
Literacy rate (7+)
Persons
45.1
Males
57.6
Females
31.7
Work participation rate
Total
31.6
Female
15.1
Household amenities
Households with kutchha houses (%)
25.7
Households with safe drinking water (%)
86.7
Households with electricity connection (%)
7.4
Vital rates
Crude Birth Rate
34.8
Total Fertility Rate
4.9
Infant Mortality Rate
78
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
67.7
Birth order 3 + (%)
58.6
Current use of any FP Method (%)
22.7
Total unmet need (%)
42.6
Pregnant women with any ANC (%)
23.4
Pregnant women with 3+ ANCs (%)
8.8
Pregnant women received IFA tablets (%)
8.5
Safe delivery (%)
19.1
Institutional delivery (%)
11.1
Children with full immunization (%)
16.0
Communicable Diseases
Kala-azar prevalence (%)
6.7
TB incidence (%)
4.2
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0.7
Women’s Health Awareness
Aware of RTI/ STI (%)
87.0
Aware of HIV/ AIDS (%)
17.8
Health Infrastructure
CHCs
1
PHCs
73
Sub-Centres
354
State of Health in Bihar
127
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General information
Area (sq km): 2641
Community Development Blocks: 20
SARAN
As proportion of state’s area: 2.8%
Towns: 5
Villages: 1708
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
128
State of Health in Bihar
3248701
1652661
1596040
90.8
9.2
12.0
0.2
30.2
8.0
26.3
1230
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15.7 Page 147 |
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Sex Ratio (females per 1000 males)
1991
963
2001
966
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
960
2001
949
Literacy rate (7+)
Persons
81.8
Males
67.3
Females
35.8
Work participation rate
Total
26.5
Female
10.4
Household amenities
Households with kutchha houses (%)
12.6
Households with safe drinking water (%)
86.9
Households with electricity connection (%)
7.1
Vital rates
Crude Birth Rate
32.6
Total Fertility Rate
4.7
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
28.9
Birth order 3 + (%)
58.6
Current use of any FP Method (%)
30.5
Total unmet need (%)
36.6
Pregnant women with any ANC (%)
32.7
Pregnant women with 3+ ANCs (%)
18.2
Pregnant women received IFA tablets (%)
10.0
Safe delivery (%)
22.3
Institutional delivery (%)
15.9
Children with full immunization (%)
35.3
Communicable Diseases
Kala-azar prevalence (%)
4.9
TB incidence (%)
2.7
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
95.8
Aware of HIV/ AIDS (%)
35.1
Health Infrastructure
CHCs
3
PHCs
60
Sub-Centres
413
State of Health in Bihar
129
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General information
Area (sq. km): 689
Community Development Blocks: 6
SHEIKHPURA
As proportion of state’s area: 0.7%
Towns: 2
Villages: 315
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
130
State of Health in Bihar
525502
273992
251510
84.5
15.5
19.7
0.0
29.9
6.7
25.0
793
|
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15.9 Page 149 |
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Sex Ratio (females per 1000 males)
1991
896
2001
918
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
965
2001
955
Literacy rate (7+)
Persons
48.6
Males
61.9
Females
33.9
Work participation rate
Total
37.0
Female
25.0
Household amenities
Households with kutchha houses (%)
11.5
Households with safe drinking water (%)
55.4
Households with electricity connection (%)
10.1
Vital rates
Crude Birth Rate
34.3
Total Fertility Rate
4.7
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
85.0
Birth order 3 + (%)
56.7
Current use of any FP Method (%)
23.9
Total unmet need (%)
43.1
Pregnant women with any ANC (%)
37.0
Pregnant women with 3+ ANCs (%)
23.0
Pregnant women received IFA tablets (%)
5.7
Safe delivery (%)
44.9
Institutional delivery (%)
23.1
Children with full immunization (%)
18.5
Communicable Diseases
Kala-azar prevalence (%)
0
TB incidence (%)
0.4
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
62.7
Aware of HIV/ AIDS (%)
26.2
Health Infrastructure
CHCs
1
PHCs
21
Sub-Centres
74
State of Health in Bihar
131
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General information
Area (sq km): 443
Community Development Blocks: 5
SHEOHAR
As proportion of state’s area: 0.5%
Towns: 1
Villages: 213
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
132
State of Health in Bihar
515961
273680
242281
95.9
4.1
14.4
0.0
28.2
6.9
36.6
1165
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16.1 Page 151 |
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Sex Ratio (females per 1000 males)
1991
876
2001
885
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
946
2001
916
Literacy rate (7+)
Persons
35.3
Males
45.3
Females
23.9
Work participation rate
Total
31.2
Female
9.8
Household amenities
Households with kutchha houses (%)
60.9
Households with safe drinking water (%)
98.1
Households with electricity connection (%)
3.1
Vital rates
Crude Birth Rate
35.8
Total Fertility Rate
5.1
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
59.2
Birth order 3 + (%)
58.4
Current use of any FP Method (%)
19.7
Total unmet need (%)
45.8
Pregnant women with any ANC (%)
23.7
Pregnant women with 3+ ANCs (%)
10.3
Pregnant women received IFA tablets (%)
5.5
Safe delivery (%)
16.1
Institutional delivery (%)
8.4
Children with full immunization (%)
18.3
Communicable Diseases
Kala-azar prevalence (%)
0
TB incidence (%)
0.4
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
97.5
Aware of HIV/ AIDS (%)
21.5
Health Infrastructure
CHCs
1
PHCs
10
Sub-Centres
34
State of Health in Bihar
133
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General information
Area (sq km): 2200
Community Development Blocks: 17
SITAMARHI
As proportion of state’s area: 2.3%
Towns: 5
Villages: 945
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
134
State of Health in Bihar
2682720
1417611
1265109
94.3
5.7
11.8
0.1
28.4
6.5
33.2
1219
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Sex Ratio (females per 1000 males)
1991
884
2001
892
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
921
2001
924
Literacy rate (7+)
Persons
38.5
Males
49.4
Females
26.1
Work participation rate
Total
31.9
Female
11.2
Household amenities
Households with kutchha houses (%)
34.1
Households with safe drinking water (%)
98.0
Households with electricity connection (%)
5.4
Vital rates
Crude Birth Rate
36.3
Total Fertility Rate
5.1
Infant Mortality Rate
42
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
56.0
Birth order 3 + (%)
59.1
Current use of any FP Method (%)
27.9
Total unmet need (%)
38.3
Pregnant women with any ANC (%)
27.9
Pregnant women with 3+ ANCs (%)
13.6
Pregnant women received IFA tablets (%)
6.5
Safe delivery (%)
16.1
Institutional delivery (%)
11.6
Children with full immunization (%)
25.5
Communicable Diseases
Kala-azar prevalence (%)
3.5
TB incidence (%)
3.2
HIV + prevalence among STD Clinics
2.0
HIV + prevalence among ANC Clinics
0.5
Women’s Health Awareness
Aware of RTI/ STI (%)
95.2
Aware of HIV/ AIDS (%)
21.4
Health Infrastructure
CHCs
1
PHCs
51
Sub-Centres
213
State of Health in Bihar
135
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General information
Area (sq km): 2219
Community Development Blocks: 19
SIWAN
As proportion of state’s area: 2.4%
Towns: 3
Villages: 1545
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq. km)
136
State of Health in Bihar
2714349
1336283
1378066
94.5
5.5
11.4
0.5
30.6
8.0
25.0
1223
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Sex Ratio (females per 1000 males)
Child Sex Ratio (0–6 years) (girls per 1000 boys)
Literacy rate (7+)
Work participation rate
Household amenities
Vital rates
RCH indicators from DLHS, 2002–04
Key RCH indicators
Communicable Diseases
Women’s Health Awareness
Health Infrastructure
1991
2001
1991
2001
Persons
Males
Females
Total
Female
Households with kutchha houses (%)
Households with safe drinking water (%)
Households with electricity connection (%)
Crude Birth Rate
Total Fertility Rate
Infant Mortality Rate
Girls marrying below 18 years (%)
Birth order 3 + (%)
Current use of any FP Method (%)
Total unmet need (%)
Pregnant women with any ANC (%)
Pregnant women with 3+ ANCs (%)
Pregnant women received IFA tablets (%)
Safe delivery (%)
Institutional delivery (%)
Children with full immunization (%)
Kala-azar prevalence (%)
TB incidence (%)
HIV + prevalence among STD Clinics
HIV + prevalence among ANC Clinics
Aware of RTI/ STI (%)
Aware of HIV/ AIDS (%)
CHCs
PHCs
Sub-Centres
1017
1031
963
934
51.6
67.3
36.9
26.9
12.8
16.3
96.4
5.2
32.9
4.6
41
39.5
54.0
23.7
45.7
43.3
22.9
6.8
33.6
24.1
38.9
3.4
1.7
4.7
0
82.3
27.2
2
49
370
State of Health in Bihar
137
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General information
Area (sq km): 2410
Community Development Blocks: 11
SUPAUL
As proportion of state’s area: 2.6%
Towns: 3
Villages: 591
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
138
State of Health in Bihar
1732578
902207
830371
94.9
5.1
14.8
0.3
28.5
5.8
29.0
719
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16.7 Page 157 |
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Sex Ratio (females per 1000 males)
1991
904
2001
920
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
941
2001
925
Literacy rate (7+)
Persons
37.3
Males
52.4
Females
20.8
Work participation rate
Total
42.0
Female
33.0
Household amenities
Households with kutchha houses (%)
78.3
Households with safe drinking water (%)
97.4
Households with electricity connection (%)
4.7
Vital rates
Crude Birth Rate
36.2
Total Fertility Rate
4.7
Infant Mortality Rate
NA
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
61.1
Birth order 3 + (%)
51.6
Current use of any FP Method (%)
36.4
Total unmet need (%)
25.0
Pregnant women with any ANC (%)
24.9
Pregnant women with 3+ ANCs (%)
9.7
Pregnant women received IFA tablets (%)
3.3
Safe delivery (%)
27.8
Institutional delivery (%)
12.5
Children with full immunization (%)
15.7
Communicable Diseases
Kala-azar prevalence (%)
2.3
TB incidence (%)
1.1
HIV + prevalence among STD Clinics
0.4
HIV + prevalence among ANC Clinics
0
Women’s Health Awareness
Aware of RTI/ STI (%)
85.4
Aware of HIV/ AIDS (%)
15.4
Health Infrastructure
CHCs
1
PHCs
37
Sub-Centres
178
State of Health in Bihar
139
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General information
Area (sq km): 2036
Community Development Blocks: 16
VAISHALI
As proportion of state’s area: 2.2%
Towns: 3
Villages: 1889
Demographic particulars (Census, 2001)
Population
Persons
Males
Females
Rural (%)
Urban (%)
Scheduled Castes (%)
Scheduled Tribes (%)
Young people (10–24 years) (%)
Elderly population (60+ years) (%)
Decadal growth rate, 1991–2001 (%)
Population density (per sq km)
140
State of Health in Bihar
2718421
1415603
1302818
93.1
6.9
20.7
0.1
29.6
7.3
26.7
1335
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16.9 Page 159 |
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Sex Ratio (females per 1000 males)
1991
921
2001
920
Child Sex Ratio (0–6 years) (girls per 1000 boys)
1991
946
2001
937
Literacy rate (7+)
Persons
50.5
Males
63.2
Females
36.6
Work participation rate
Total
28.8
Female
10.9
Household amenities
Households with kutchha houses (%)
26.8
Households with safe drinking water (%)
77.7
Households with electricity connection (%)
9.0
Vital rates
Crude Birth Rate
31.9
Total Fertility Rate
4.6
Infant Mortality Rate
61
RCH indicators from DLHS, 2002–04
Key RCH indicators
Girls marrying below 18 years (%)
61.6
Birth order 3 + (%)
50.0
Current use of any FP Method (%)
33.0
Total unmet need (%)
37.0
Pregnant women with any ANC (%)
46.4
Pregnant women with 3+ ANCs (%)
25.3
Pregnant women received IFA tablets (%)
6.7
Safe delivery (%)
37.8
Institutional delivery (%)
23.1
Children with full immunization (%)
26.1
Communicable Diseases
Kala-azar prevalence (%)
11.4
TB incidence (%)
4.3
HIV + prevalence among STD Clinics
0
HIV + prevalence among ANC Clinics
0.5
Women’s Health Awareness
Aware of RTI/ STI (%)
93.4
Aware of HIV/ AIDS (%)
31.8
Health Infrastructure
CHCs
2
PHCs
47
Sub-Centres
336
State of Health in Bihar
141
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Table. 4.1. District-wise Key RCH Indicators, Bihar, RCH-2 (DLHS: 2002–04)
District
Sex
ratio
Population
Density
% Decadal
Growth
rate
Female
Literacy
Girls
% of
CPR % of
Marrying Births of
women
below
Order 3
with any
18 (%)
and above
ANC
% of
Safe
Delivery
Araria
913 763
33.9
22.4
50.5
56.3
31.2 34.2
20.6
Arwal
60.4
57.9
28.2 33.6
42.6
Aurangabad
934 609
30.7
41.9
45.6
53.7
25.7 37.8
28.7
Banka
908 533
24.5
28.7
56.0
54.4
36.9 38.5
36.4
Begusarai
912 1225
29.5
35.6
50.6
52.6
27.6 33.5
28.7
Bhagalpur
876 943
26.9
38.1
42.6
51.9
39.6 48.5
41.6
Bhojpur
902 907
25.1
41.8
55.3
54.0
36.9 31.3
49.0
Buxar
899 864
28.9
39.9
59.2
55.1
31.0 38.2
40.9
Champaran East
897 993
29.5
24.3
59.0
54.9
27.8 42.6
27.2
Champaran West 901 582
30.4
25.2
63.9
57.0
24.6 35.1
37.1
Darbhanga
914 1446
31.3
30.8
49.8
56.5
31.9 33.3
25.5
Gaya
938 698
30.3
36.7
54.7
50.5
28.4 33.0
37.9
Gopalganj
1001 1059
26.3
32.2
34.6
54.2
30.1 53.3
35.2
Jamui
918 452
33.0
26.3
64.7
49.8
28.9 43.7
27.4
Jehanabad
929 965
28.9
39.4
60.4
55.9
28.2 33.6
42.6
Kaimur
902 383
31.1
38.8
48.6
54.5
29.2 40.1
44.1
Katihar
Khagaria
919 783
885 862
31.1
23.8
46.2
56.4
33.6 36.1
28.8
29.7
29.3
58.2
59.4
30.8 23.3
20.2
Kishanganj
936 688
31.7
18.6
42.6
65.6
23.1 28.3
20.5
Lakhisarai
Madhepura
921 653
915 854
24.1
34.0
57.4
50.0
32.6 40.4
30.9
29.6
22.1
54.3
50.4
31.5 27.5
21.7
Madhubani
Munger
942 1021
3.5
26.2
60.8
54.7
30.4 36.0
15.4
872 802
20.6
47.4
48.3
50.7
38.6 48.1
47.3
Muzaffarpur
920 1181
26.8
35.8
44.5
51.9
32.5 40.4
31.0
Nalanda
Nawada
914 1007
18.7
38.6
59.6
59.1
26.4 33.2
38.0
946 726
33.1
32.2
58.1
55.1
28.8 35.1
34.1
Patna
Purnia
873 1474
30.4
50.8
44.7
48.1
36.8 52.4
49.2
915 788
35.4
23.4
42.2
59.6
30.0 26.3
19.0
Rohtas
Saharsa
909 636
910 886
27.8
45.7
46.8
46.5
35.0 52.4
50.5
33.2
25.3
47.9
62.6
37.7 28.9
21.5
Samatipur
928 1169
24.9
31.7
67.7
58.6
22.7 23.4
19.1
Saran
Sheikhpura
966 1230
26.3
35.8
28.9
58.6
30.5 32.7
22.3
918 763
25.0
33.9
85.0
56.7
23.9 37.0
44.9
Sheohar
Sitamarhi
885 1165
36.6
23.9
59.2
58.4
19.7 23.7
16.1
892 1219
33.2
26.1
56.0
59.1
27.9 27.9
16.1
Siwan
Supaul
Vaishali
1031 1223
25.0
36.9
39.5
54.0
23.7 43.3
33.6
920 719
29.
20.8
61.1
51.6
36.4 24.9
27.8
920 1335
26.7
36.6
61.6
50.0
33.0 46.4
37.8
% of
Children
with
Complete
Immunization
19.6
16.8
32.6
25.6
21.4
42.8
32.3
22.0
14.6
7.6
22.0
14.4
39.0
13.1
16.8
12.5
17.5
21.1
7.9
23.2
21.7
15.5
26.4
35.9
21.8
25.4
39.9
28.5
24.6
22.9
16.0
35.3
18.5
18.3
25.5
38.9
52.8
26.1
142
State of Health in Bihar
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II. Ranking of District
State of Health in Bihar
143
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Table 4.2. Ranking of Districts According to Decadal Population Growth Rate (%)
Rank in 2001
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Sheohar
Purnia
Araria
Sitamarhi
Saharsa
Nawada
Jamui
Kishanganj
Darbhanga
Kaimur (Bhabua)
Katihar
Aurangabad
Pashchim Champaran
Patna
Gaya
Khagaria
Madhepura
Purba Champaran
Begusarai
Supaul
Buxar
Jehanabad
Rohtas
Bhagalpur
Muzaffarpur
Vaishali
Gopalganj
Saran
Madhubani
Bhojpur
Sheikhpura
Siwan
Samastipur
Banka
Lakhisarai
Munger
Nalanda
Bihar
1991–2001
36.61
35.40
33.94
33.22
33.18
33.10
33.03
31.73
31.26
31.10
31.08
30.72
30.42
30.41
30.34
29.69
29.63
29.47
29.46
29.02
28.94
28.89
27.82
26.87
26.84
26.67
26.31
26.26
26.24
25.12
25.04
25.03
24.95
24.47
24.11
20.58
18.75
31.14
1981–1991
23.77
23.76
26.69
23.77
24.40
23.70
20.15
22.20
25.04
22.58
27.77
24.49
18.30
19.84
23.92
28.44
22.16
25.46
24.61
24.40
19.64
19.43
22.58
22.17
25.30
29.08
25.12
23.44
21.76
19.64
20.15
22.04
28.35
22.17
20.15
20.15
21.73
23.54
Rank in 1991
15
17
5
16
12
18
29
22
9
20
4
11
37
33
14
2
25
6
10
13
34
36
21
23
7
1
8
19
27
35
30
26
3
24
31
32
28
Note:
According to the 2001 census, the growth rate of population during 1991–2001 for the state was 31.14% as
compared to 23.54% for 1981–1991. Among the districts, Sheohar (36.61) has the highest decadal growth
rate, followed by Purnia (35.40) and Araria (33.94). Nalanda (18.75) has the lowest decadal growth rate,
followed by Munger (20.58) and Lakhisarai (24.11).
144
State of Health in Bihar
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State of Health in Bihar
145
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Table 4.3. Ranking of Districts According to Density of Population (per sq km)
Rank in 2001
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Kaimur (Bhabua)
Jamui
Banka
Pashchim Champaran
Aurangabad
Rohtas
Lakhisarai
Kishanganj
Gaya
Supaul
Nawada
Sheikhpura
Araria
Katihar
Purnia
Munger
Madhepura
Khagaria
Buxar
Saharsa
Bhojpur
Bhagalpur
Jehanabad
Purba Champaran
Nalanda
Madhubani
Gopalganj
Sheohar
Samastipur
Muzaffarpur
Sitamarhi
Siwan
Begusarai
Saran
Vaishali
Darbhanga
Patna
Bihar
Census 2001
383
452
533
582
609
636
653
688
698
719
726
763
763
783
788
802
854
862
864
886
907
943
965
993
1007
1021
1059
1165
1169
1181
1219
1223
1225
1230
1335
1446
1474
665
Census 1991
402
476
573
446
466
402
476
522
536
602
545
476
569
597
582
476
659
664
703
602
703
573
749
767
844
809
838
905
936
931
905
978
946
974
1054
1102
1130
497
Rank in 1991
1
7
14
3
4
2
6
9
10
17
11
5
12
16
15
8
19
20
22
18
21
13
23
24
27
25
26
28
31
30
29
34
32
33
35
36
37
Note: According to the 2001 census, Bihar has a high density of population, with 665 persons per sq km, as compared
to 497 during the 1991 census. Among the districts, Kaimur (Bhabua) has the lowest density of population (383),
followed by Jamui (452) and Banka (533). Patna (1474) has the highest density of population, followed by
Darbhanga (1446) and Vaishali (1335).
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Table 4.4. Ranking of Districts According to Sex Ratio
Rank in 2001
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Siwan
Gopalganj
Saran
Nawada
Madhubani
Gaya
Kishanganj
Aurangabad
Jehanabad
Samastipur
Lakhisarai
Muzaffarpur
Supaul
Vaishali
Katihar
Jamui
Sheikhpura
Madhepura
Purnia
Darbhanga
Nalanda
Araria
Begusarai
Saharsa
Rohtas
Banka
Bhojpur
Kaimur (Bhabua)
Pashchim Champaran
Buxar
Purba Champaran
Sitamarhi
Khagaria
Sheohar
Bhagalpur
Patna
Munger
Bihar
Census 2001
1031
1001
966
946
942
938
936
934
929
928
921
920
920
920
919
918
918
915
915
914
914
913
912
910
909
908
902
902
901
899
897
892
885
885
876
873
872
919
Census 1991
1017
968
963
936
932
922
933
915
919
926
882
904
895
921
909
882
882
885
903
911
898
907
898
895
891
876
896
891
877
896
883
882
868
882
876
867
882
911
Rank in 1991
1
2
3
4
6
8
5
11
10
7
28
15
21
9
13
27
29
25
16
12
18
14
17
22
24
34
20
23
33
19
26
32
36
31
35
37
30
Note:
According to the 2001 census Bihar has shown a decline in sex ratio, with 942 girls per 1000 boys as compared
to 953 the previous decade. The district with the highest sex ratio is Nawada (987), followed by Gaya (968)
and Purnia (967). The district with the lowest sex ratio is Munger (872), followed by Patna (873) and
Bhagalpur (872).
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Table 4.5. Ranking of Districts According to Child Sex Ratio
Rank in 2001
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Nawada
Gaya
Purnia
Bhagalpur
Katihar
Banka
Gopalganj
Araria
Jamui
Sheikhpura
Pashchim Champaran
Lakhisarai
Rohtas
Saran
Kishanganj
Begusarai
Aurangabad
Nalanda
Bhojpur
Kaimur (Bhabua)
Madhubani
Samastipur
Sitamarhi
Purba Champaran
Vaishali
Siwan
Khagaria
Muzaffarpur
Madhepura
Buxar
Supaul
Patna
Jehanabad
Sheohar
Darbhanga
Munger
Saharsa
Bihar
Census 2001
978
968
967
966
966
965
964
963
963
955
953
951
951
949
947
946
943
942
940
940
939
938
938
937
937
934
932
928
927
925
925
923
917
916
915
914
912
942
Census 1991 Rank in 1991
974
5
983
2
965
11
944
24
975
4
969
7
966
10
986
1
967
8
964
13
963
14
956
19
965
12
960
18
982
3
961
17
970
6
962
16
924
33
918
36
953
21
942
28
921
34
944
25
946
22
963
15
943
26
943
27
942
29
905
37
941
30
937
31
967
9
946
23
954
20
934
32
920
35
953
Note:
According to the 2001 census Bihar has shown a decline in child sex ratio, with 942 girls per 1000 boys, as
compared to 953 the previous decade. The district with the highest child sex ratio is Nawada (987), followed
by Gaya (968) and Purnia (967). The district with the most unfavourable child sex ratio is Saharsa (912),
followed by Munger (914) and Darbhanga (915).
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Table 4.6. Ranking of Districts According to Female Literacy
Rank in 2001
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Patna
Munger
Rohtas
Aurangabad
Bhojpur
Buxar
Jehanabad
Kaimur (Bhabua)
Nalanda
Bhagalpur
Siwan
Gaya
Vaishali
Saran
Muzaffarpur
Begusarai
Lakhisarai
Sheikhpura
Darbhanga
Nawada
Gopalganj
Samastipur
Khagaria
Banka
Jamui
Madhubani
Sitamarhi
Saharsa
Pashchim Champaran
Purba Champaran
Sheohar
Katihar
Purnia
Araria
Madhepura
Supaul
Kishanganj
Bihar
Census 2001
50.8
47.4
45.7
41.9
41.8
39.9
39.4
38.8
38.6
38.1
36.9
36.7
36.6
35.8
35.8
35.6
34.0
33.9
33.6
32.2
32.2
31.7
29.3
28.7
26.3
26.2
26.1
25.3
25.2
24.3
23.9
23.8
23.4
22.4
22.1
20.8
18.6
39.4
Census 1991
60.8
42.8
51.4
51.8
47.8
47.8
49.2
51.4
50.4
38.5
40.3
42.1
45.2
42.7
37
40.3
42.8
42.8
36.2
41.3
33.3
37.7
33.6
38.5
42.8
31.6
28.7
25.7
27.5
27.2
28.7
27.3
27.2
23.1
25.8
25.7
17.4
39.9
Rank in 1991
1
13
4
2
8
7
6
3
5
20
17
15
9
14
22
18
10
11
23
16
25
21
24
19
12
26
28
35
29
31
27
30
32
36
33
34
37
Note: According to the 2001 census female literacy in the state was 39.4 as compared to 39.9 in the 1991 census.
The district with the highest female literacy was Patna (50.8), followed by Munger (47.4) and Rohtas (45.7).
The districts with low female literacy were Kishanganj (18.6), Supaul (20.8) and Madhepura (22.1).
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Table 4.7. Ranking of Districts According to Girls Marrying Below the
Age of 18 Years (%)
Rank in
2002–04
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Saran
Gopalganj
Siwan
Purnia
Bhagalpur
Kishanganj
Muzaffarpur
Patna
Aurangabad
Katihar
Rohtas
Saharsa
Munger
Kaimur (Bhabua)
Darbhanga
Araria
Begusarai
Madhepura
Gaya
Bhojpur
Banka
Sitamarhi
Lakhisarai
Khagaria
Nawada
Purba Champaran
Sheohar
Buxar
Nalanda
Jehanabad
Madhubani
Supaul
Vaishali
Pashchim Champaran
Jamui
Samastipur
Sheikhpura
Bihar
DLHS
2002–04
28.9
34.6
39.5
42.2
42.6
42.6
44.5
44.7
45.6
46.2
46.8
47.9
48.3
48.6
49.8
50.5
50.6
54.3
54.7
55.3
56.0
56.0
57.4
58.2
58.6
59.0
59.2
59.2
59.6
60.4
60.8
61.1
61.6
63.9
64.7
67.7
85.0
51.5
DRHS
1998-99
51.3
58.4
43.6
48.6
58.8
48.2
53.4
40.8
63.5
47.5
69.6
56.5
60.6
69.6
51.3
51.2
58.6
66.4
62.0
56.7
58.8
64.7
60.6
63.9
72.9
63.0
64.7
65.4
59.2
54.5
64.1
56.5
63.4
79.4
60.6
64.1
60.6
58.2
Rank in
1998-99
8
14
2
5
17
4
9
1
26
3
35
11
21
34
7
6
15
33
23
13
16
31
20
27
36
24
30
32
18
10
28
12
25
37
19
29
22
Note: According to RCH-DLHS 2002–04, girls married below the age of 18 years in Bihar is 51.5%. The district of
Sheikhpura (85.0) has the highest percentage followed by Samastipur (67.7) and Jamui (64.7). At the lower
end of the scale are Saran (28.9), Gopalganj (34.6), and Siwan (39.5).
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Table 4.8. Ranking of Districts According to Birth Order 3 and Above (%)
Rank in
2002–04
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Rohtas
Patna
Jamui
Vaishali
Lakhisarai
Madhepura
Gaya
Munger
Supaul
Muzaffarpur
Bhagalpur
Begusarai
Aurangabad
Siwan
Bhojpur
Gopalganj
Banka
Kaimur (Bhabua)
Madhubani
Purba Champaran
Buxar
Nawada
Araria
Katihar
Darbhanga
Sheikhpura
Pashchim Champaran
Jehanabad
Sheohar
Saran
Samastipur
Sitamarhi
Nalanda
Khagaria
Purnia
Saharsa
Kishanganj
Bihar
DLHS
2002–04
46.5
48.1
49.8
50.0
50.0
50.4
50.5
50.7
51.6
51.9
51.9
52.6
53.7
54.0
54.0
54.2
54.4
54.5
54.7
54.9
55.1
55.1
56.3
56.4
56.5
56.7
57.0
57.9
58.4
58.6
58.6
59.1
59.1
59.4
59.6
62.6
65.6
54.4
DRHS
1998-99
58.7
60.3
59.6
53.3
59.6
57.0
55.9
59.6
53.3
59.7
53.7
56.7
57.0
57.7
55.6
56.6
53.7
58.7
56.2
56.9
61.2
56.5
58.1
62.5
59.8
59.6
52.8
53.6
56.9
59.4
58.7
56.9
53.8
58.4
58.1
53.3
64.8
56.7
Rank in
1998-99
25
34
28
4
29
19
10
30
3
32
7
14
18
20
9
13
6
24
11
15
35
12
21
36
33
31
1
5
16
27
26
17
8
23
22
2
37
Note: According to RCH-DLHS 2002–04, the birth order 3 and above for Bihar is 54.4. The district of Kishanganj
(65.6) has the highest percentage followed by Saharsa (62.6) and Purnia (59.6). At the lower end of the scale
are Rohtas (46.5), Patna (48.1) and Jamui (49.8).
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Table 4.9. Ranking of Districts According to Any Antenatal Care (%)
Rank in
2002–04
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Gopalganj
Rohtas
Patna
Bhojpur
Bhagalpur
Munger
Vaishali
Jamui
Siwan
Purba Champaran
Lakhisarai
Muzaffarpur
Kaimur (Bhabua)
Banka
Buxar
Aurangabad
Sheikhpura
Katihar
Madhubani
Nawada
Pashchim Champaran
Araria
Jehanabad
Begusarai
Darbhanga
Nalanda
Gaya
Saran
Saharsa
Kishanganj
Sitamarhi
Madhepura
Purnia
Supaul
Sheohar
Samastipur
Khagaria
Bihar
DLHS
2002–04
53.3
52.4
52.4
51.3
48.5
48.1
46.4
43.7
43.3
42.6
40.4
40.4
40.1
38.5
38.2
37.8
37.0
36.1
36.0
35.1
35.1
34.2
33.6
33.5
33.3
33.2
33.0
32.7
28.9
28.3
27.9
27.5
26.3
24.9
23.7
23.4
23.3
37.9
DRHS
1998-99
33.9
33.5
22.8
38.7
32.0
29.7
26.8
29.7
32.4
27.0
29.7
21.7
33.5
32.0
27.4
22.3
29.7
19.8
15.9
28.6
37.8
23.0
19.9
36.2
26.7
41.5
20.7
31.7
17.9
17.8
16.5
19.9
22.2
17.9
16.5
13.1
24.4
29.6
Rank in
1998-99
5
7
23
2
10
14
19
12
8
18
13
26
6
9
17
24
15
30
36
16
3
22
28
4
20
1
27
11
31
33
35
29
25
32
34
37
21
Note:
According to RCH-DLHS 2002–04, the percentage of women who received any antenatal care (ANC) is 37.9
for the state of Bihar, an increase from 29.6 in RCH-DRHS 1998-99. Leading in this respect were the districts
of Gopalganj (53.3), Rohtas (52.4) and Patna (52.4). At the lower end of the scale were Khagaria (23.3),
Samastipur (23.4) and Sheohar (23.7).
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Table 4.10. Ranking of Districts According to Institutional Delivery (%)
Rank in
2002–04
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Patna
Rohtas
Munger
Bhojpur
Jehanabad
Kaimur (Bhabua)
Nalanda
Buxar
Bhagalpur
Pashchim Champaran
Nawada
Lakhisarai
Banka
Siwan
Gopalganj
Gaya
Jamui
Sheikhpura
Vaishali
Aurangabad
Muzaffarpur
Purba Champaran
Darbhanga
Saharsa
Saran
Begusarai
Khagaria
Kishanganj
Katihar
Purnia
Supaul
Madhepura
Sitamarhi
Samastipur
Araria
Sheohar
Madhubani
Bihar
DLHS
2002–04
45.3
39.7
38.8
37.4
35.1
33.6
30.8
30.4
29.2
28.6
26.1
25.4
25.4
24.1
24.0
23.6
23.5
23.1
23.1
21.3
19.4
18.6
16.9
16.4
15.9
15.7
15.1
14.1
13.1
13.0
12.5
11.8
11.6
11.1
9.1
8.4
7.7
23.0
DRHS
1998-99
12.4
21.1
17.9
31.9
26.0
21.1
23.2
28.3
14.1
43.7
17.8
17.9
14.1
14.4
17.0
12.1
17.9
17.9
13.9
18.8
10.6
9.6
12.0
9.4
14.8
15.7
10.4
6.7
6.1
5.3
9.4
9.0
8.2
6.6
6.8
8.2
7.4
14.9
Rank in
1998-99
21
7
11
2
4
6
5
3
19
1
13
10
18
17
14
22
9
12
20
8
24
26
23
27
16
15
25
34
36
37
28
29
31
35
33
30
32
Note: According to RCH-DLHS 2002–04, 23% of women in Bihar had institutional delivery as compared to 14.9%
in RCH-DRHS 1998-99. Leading in this respect are the districts of Patna (45.3), Rohtas (39.7) and Munger
(38.8). At the lower end of the scale are Madhubani (7.7), Sheohar (8.4) and Araria (9.1).
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Table 4.11. Ranking of Districts According to Full Immunization (%)
Rank in
2002–04
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Bhagalpur
Patna
Gopalganj
Siwan
Muzaffarpur
Saran
Aurangabad
Bhojpur
Purnia
Munger
Vaishali
Banka
Sitamarhi
Nawada
Rohtas
Lakhisarai
Saharsa
Darbhanga
Buxar
Nalanda
Madhepura
Begusarai
Khagaria
Araria
Sheikhpura
Sheohar
Katihar
Jehanabad
Samastipur
Supaul
Madhubani
Purba Champaran
Gaya
Jamui
Kaimur (Bhabua)
Kishanganj
Pashchim Champaran
Bihar
DLHS
2002–04
42.8
39.9
39.0
38.9
35.9
35.3
32.6
32.3
28.5
26.4
26.1
25.6
25.5
25.4
24.6
23.2
22.9
22.0
22.0
21.8
21.7
21.4
21.1
19.6
18.5
18.3
17.5
16.8
16.0
15.7
15.5
14.6
14.4
13.1
12.5
7.9
7.6
23.0
DRHS
1998-99
25.2
14.2
21.2
30.8
30.1
20.9
18.3
12.0
17.3
11.0
22
25.2
18.6
28.7
8.4
11.0
20.1
21.8
24.1
13.2
15.8
16.4
26.3
20.4
11.0
18.6
25.7
27.1
19.6
20.1
17.9
15.4
24.3
11
8.4
11.4
36.8
22.4
Rank in
1998-99
9
28
14
2
3
15
22
30
24
34
12
8
21
4
37
33
17
13
11
29
26
25
6
16
35
20
7
5
19
18
23
27
10
32
36
31
1
Note:
According to RCH-DLHS 2002–04, 23% of children in the age group of 12–35 months in Bihar received full
immunization as compared to 22.4% in RCH-DRHS 1998-99. Leading in this respect were the districts of
Bhagalpur (42.8), Patna (39.9) and Gopalganj (39.0). At the lower end of the scale were Pashchim Champaran
(7.6), Kishanganj (7.9) and Kaimur (12.5).
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State of Health in Bihar
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Table 4.12. Ranking of Districts According to Contraceptive Prevalence Rate (%)
Rank in
2002–04
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
District
Bhagalpur
Munger
Saharsa
Bhojpur
Banka
Patna
Supaul
Rohtas
Katihar
Vaishali
Lakhisarai
Muzaffarpur
Darbhanga
Madhepura
Araria
Buxar
Khagaria
Saran
Madhubani
Gopalganj
Purnia
Kaimur (Bhabua)
Jamui
Nawada
Gaya
Jehanabad
Sitamarhi
Purba Champaran
Begusarai
Nalanda
Aurangabad
Pashchim Champaran
Sheikhpura
Siwan
Kishanganj
Samastipur
Sheohar
Bihar
DLHS
2002–04
39.6
38.6
37.7
36.9
36.9
36.8
36.4
35.0
33.6
33.0
32.6
32.5
31.9
31.5
31.2
31.0
30.8
30.5
30.4
30.1
30.0
29.2
28.9
28.8
28.4
28.2
27.9
27.8
27.6
26.4
25.7
24.6
23.9
23.7
23.1
22.7
19.7
31.0
DRHS
1998-99
24.7
21.9
27.7
22.9
24.7
20.8
27.7
20.0
17.2
23.1
21.9
24.7
25.2
24.4
26.5
19.4
26.8
17.5
21.8
14.5
22.6
20.0
21.9
19.7
21.0
20.6
16.6
19.3
21.9
23.9
21.1
35.3
21.9
20.4
15.5
22.0
16.6
23.3
Rank in
1998-99
8
19
2
13
7
24
3
28
33
12
18
9
6
10
5
30
4
32
21
37
14
27
17
29
23
25
35
31
16
11
22
1
20
26
36
15
34
Note:
According to RCH-DLHS 2002–2004, the percentage of women currently using any family planning methods
is 31.0 as compared to 23.3 in RCH-DRHS 1998-99. Leading in this respect are the districts of Bhagalpur
(39.6), Munger (38.6) and Saharsa (37.7). At the lower end of the scale are Sheohar (19.7), Samastipur (22.7)
and Kishanganj (23.1).
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III. Composite Socio-Demographic Development Index
Table 4.13. Ranking of Districts According to Socio-Demographic Development
Indicators
District
Birth
Order
3+
Full Full
ANC Immu-
nization
Safe
Delivery
Girls
Marrying
under
18 Years
of Age
Child Female
Sex Literacy
Ratio
GDI Population
Proportion
Sheohar
25.52
Kishanganj
15.10
Samastipur
25.23
Khagaria
24.12
Pashchim
Champaran
27.51
Sitamarhi
24.52
Purba Champaran 30.63
Madhubani
30.90
Supaul
35.32
Saharsa
19.49
Sheikhpura
27.92
Araria
28.57
Madhepura
37.02
Darbhanga
28.30
Purnia
23.83
Jamui
37.99
Kaimur (Bhabua) 31.16
Jehanabad
26.19
Begusarai
33.87
Katihar
28.34
Nalanda
24.46
Buxar
30.31
Lakhisarai
37.68
Nawada
30.22
Banka
31.34
Vaishali
37.68
Gaya
36.94
Aurangabad
32.27
Muzaffarpur
34.93
Saran
25.23
Siwan
31.87
Bhojpur
31.81
Munger
36.68
Gopalganj
31.63
Rohtas
42.62
Bhagalpur
34.89
Patna
40.39
3.41 18.40
1.17 7.97
4.26 16.09
2.13 21.22
0.75
3.52
9.13
3.52
2.34
2.02
4.26
2.24
6.55
3.73
3.09
8.36
2.24
4.16
2.66
3.84
1.92
2.34
9.52
2.98
6.84
5.25
5.01
1.49
5.65
7.00
4.58
6.15
1.92
7.06
5.33
6.41
13.61
7.63
25.65
14.73
15.64
15.82
23.06
18.64
19.71
21.89
22.18
28.74
13.15
12.55
16.93
21.50
17.59
21.95
22.12
23.35
25.60
25.80
26.25
14.46
32.86
36.16
35.54
39.21
32.56
26.58
39.24
24.81
43.06
40.14
7.82
12.63
11.12
12.32
30.85
7.81
20.01
7.02
20.63
13.78
39.45
12.78
13.94
18.10
10.97
20.26
38.56
36.96
21.66
21.71
31.84
35.05
24.03
27.62
30.15
31.65
31.82
21.67
24.19
14.58
27.02
43.95
42.13
28.79
45.61
35.83
44.22
30.42
49.88
20.34
31.60
55.76
67.29
63.94
61.71
6.80
0.07
16.85
13.86
24.81
34.10
30.65
28.54
28.14
43.72
0.00
40.62
36.14
41.43
50.43
23.95
42.90
28.96
40.47
45.68
29.97
30.36
32.53
31.11
34.17
27.58
35.63
46.37
47.70
66.06
53.53
34.96
43.20
59.31
44.92
49.90
47.49
69.52
58.74
63.57
64.31
59.11
54.28
70.26
73.23
59.85
55.39
74.72
73.23
74.35
56.13
66.91
64.68
65.43
59.11
68.77
78.81
73.98
63.57
75.09
65.80
60.22
68.03
62.45
64.68
55.02
73.61
68.77
74.35
58.36
8.56
9.72
7.32
9.87
2.87
8.61
19.74
4.88
4.54
15.70
6.23
9.96
6.72
26.76
21.96
26.06
25.75
27.42
19.80
17.49
12.99
23.17
23.28
30.02
22.17
25.75
23.56
29.89
37.11
17.49
34.93
25.17
41.52
52.90
62.05
60.61
52.83
55.76
54.19
54.98
63.11
59.22
57.43
58.78
57.98
58.26
58.02
58.25
58.87
58.95
60.80
57.67
55.97
67.38
55.43
59.28
63.83
56.94
59.21
62.41
61.65
59.14
67.38
79.17
55.84
50.55
73.75
57.25
51.24
50.60
18.74
8.11
16.60
11.10
14.22
17.95
14.50
20.92
14.91
16.16
16.99
9.76
11.94
22.35
12.17
24.60
9.80
26.75
19.76
16.72
23.48
27.11
15.54
23.91
20.41
23.08
24.39
24.31
24.34
23.48
21.30
30.58
35.86
21.99
24.56
26.44
40.73
RCH
Index
17.12
17.98
16.30
20.26
SDI
Index
Socio-
Demo-
graphic
Develop-
ment
Index
Rank
2007
Rank
2002
Change
in
Rank
33.55
23.06
4 16
–12
34.38
24.54
7
2
5
39.50
25.58 10 22
–12
34.88
26.11 11 37
–26
19.09
37.01
26.26 13
4
9
20.40
35.15
26.30 14
6
8
21.96
35.09
27.21 15 10
5
19.21
39.55
27.35 16 13
3
23.16
34.03
27.51 17 14
3
23.37
34.12
27.67 18 25
–7
18.73
41.44
27.81 21 33
–12
22.43
36.46
28.04 22 28
–6
24.41
33.65
28.10 24
3
21
24.20
37.86
29.66 34 30
4
24.37
37.84
29.76 35 34
1
21.95
41.66
29.84 36 29
7
25.94
37.46
30.55 44 32
12
23.38
42.61
31.07 51 72
–21
24.43
41.58
31.29 53 56
–3
25.09
40.86
31.40 55 27
28
22.53
45.51
31.72 59 77
–18
25.10
42.27
31.96 63 46
17
26.56
40.85
32.28 67 35
32
24.23
46.01
32.94 71 45
26
27.59
41.08
32.99 72 44
28
26.86
42.26
33.02 73 52
21
25.2
46.29
33.64 83 50
33
26.48
45.44
34.07 85 48
37
30.13
41.47
34.67 93 67
26
29.70
46.16
36.28 119 62
57
29.69
46.62
36.46 123 69
54
31.12
45.25
36.77 126 109
17
31.64
44.63
36.83 129 66
63
32.56
46.71
38.22 148 40
108
33.06
46.38
38.39 150 53
97
35.08
44.30
38.76 156 97
59
37.17
47.80
41.42 193 228
–35
Note:
Table 4.13 sums up the findings of the India Socio-Demographic Development Index, published by Population Foundation of India, New Delhi in 2007 and The Ranking
of Districts in India for Area-specific Planning and Programme Interventions, published by the International Institute of Population Sciences (IIPS), Mumbai, 2002. These
two publications attempted to compute composite indices based on ten key variables/indicators (using six indicators of DLHS and DRHS under the RCH programme and
four indicators of the Census of India, 2001, respectively. These computations identified districts as ‘vulnerable’, i.e. socially and demographically weak/backward. The
variables/indicators were chosen to reflect overall socio-demographic development. It may be noted that in both documents all districts of Bihar figure as vulnerable/socio-
demographically backward. Districts such as Sheohar, Kishanganj, Samastipur, Khagaria, West Champaran, Sitamarhi, Purba Champaran, Madhubani, etc. are perpetually
at the bottom.
State of Health in Bihar
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Note:
Map 4.12. Bihar, socio-demographic development index, 2007
It is seen from Table 4.13 and Map 4.12 that all districts in Bihar have a composite index of ‘value’ less than 50,
identifying them as ‘vulnerable’, i.e. socially and demographically backward/weak. The message is clear that
all districts of Bihar need focused attention.
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5
Health Service Delivery
The establishment of health service delivery through this approach started as early as 1952 on
the basis of the recommendations of the Bhore Committee Report 1946 with the setting up of a
three-tier delivery system. The healthcare delivery system comprises the primary health centre
(PHC), community health centre (CHC) and sub-centre (SC). Primary health care or first contact
care is provided at the PHC, the secondary care at the CHC and tertiary care at medical colleges
and district hospitals. The sub-centre is the most peripheral health institution catering for the
health care needs of the rural population. It is also the most peripheral contact point between the
primary health care system and the community. It is manned by one male multipurpose worker
(MPW/M) and one female multipurpose worker (MPW/F) or ANM. A PHC on the other hand is
the first contact point between the village community and the medical officer. A PHC is expected
to have a medical officer (MO) and 14 para-medical and other staff. It acts as a referral unit for
five to six sub-centres. Activities of the PHC involve curative, preventive and promotive services.
CHCs are basically referral centres for PHCs approximately in the ratio of 1:4. The staff strength
of a CHC includes 4 medical specialists, i.e. surgeon, physician, gynaecologist and paediatrician,
supported by 21 para-medical and other staff.
Table 5.1 provides details of population coverage by the three-tier healthcare system. Figure
5.1 presents the administrative structure of the health delivery system in the state. At the district
level the Civil Surgeon is the chief health and medical officer. At the block level the block medical
officer (BMO) heads the health administration. Table 5.2 presents details.
State of Health in Bihar
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Table 5.1. Health Care Infrastructure in Bihar, March 2006.
Particulars
Community Health Centres (CHCs) (No.)
Primary Health Centres (PHCs) (No.)
Sub Centres (No.)
CHCs
Average Rural Population Served by a CHC
Average Rural Area (sq km) Covered by a CHC
Average Radial Distance (km) Covered by a CHC
Average Number of Villages Covered by a CHC
PHCs per CHC (No.)
PHCs
Average Rural Population served by a PHC
Average Rural Area (sq km) Covered by a PHC
Average Radial Distance (km) covered by a PHC
Average Number of Villages covered by a PHC
Sub Centres per PHC (No.)
Sub Centres
Average Rural Population Served by a Sub Centre
Average Rural Area (sq km) Covered by a Sub Centre
Average Radial Distance (km) covered by a Sub Centre
Average Number of Villages covered by a Sub Centre
FRUs
At PHC
At CHC
At Sub District Level
At District Level
Source: Bulletin on Rural Health Statistics in India, 2006, Special Revised Edition
Table 5.2. Availability of Health Personnel in Bihar, March 2006
Required
In Position
Sub Centres
14959
8858
PHC
2489
1641
CHC
622
70
Source: Bulletin on Rural Health Statistics in India, 2006, Special Revised Edition
Bihar
70
1641
8858
1061667
1319.41
18.96
644
23
45287
56.28
4.23
27
5
8390
10.43
1.82
5
94
21
21
27
25
Shortfall
6101
848
552
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Fig. 5.1. Organogram of Health and Family Welfare Department, Government of Bihar
As per the Bulletin on Rural Health Statistics (MoHFW, 2006), of the 8858 sub-centres 72%
have ANM quarters but only 105 have ANMs living in the quarters; 29% are without regular
supply of water and 37% are without all-weather motorable road. Of the 1641 PHCs only 13% are
equipped with labour room, 3% with operation theatre, 48% with 4–6 beds, and only 14% with
24-hour delivery facility. In terms of communication facility only 11% are equipped with telephone
and 1% with computers. In terms of basic amenities 33% of PHCs are without electricity supply,
42% are without regular water supply, and 18% are without all-weather motorable road.
Urban health infrastructure under Family Welfare Programme shows that there are 28 district-
level post-partum centres, 34 sub-district-level post-partum centres, no urban health posts, and
26 urban family welfare centres.
In terms of personnel, 56% of the PHCs have only one doctor, 19% have two doctors, 8% have
three doctors, 9% have four doctors; only 5% have a lady doctor. Many sub-centres are without
ANM and most of them are without any male health worker. Tables 5.3, 5.4 and 5.5 present data
about the shortfall of health personnel in the state as on March 2006. Table 5.6 presents data on
staff position at PHCs and sub-centres. It is seen from the data presented that while the healthcare
delivery system in the state has expanded significantly over the last 15 years, most people still do
not get the benefits of the existing health services. Services are often not accessible either
geographically or financially. Among additional reasons for people not accessing these services
are that they do not believe in the relevance of these facilities or are put off by the service providers’
unhelpful interface with them. A study conducted by NCAER in 1995-96, NSSO 52nd round, also
showed that spending on public sector health services in Bihar was predominantly in favour of
wealthier or richer groups (see Figure 5.2).
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Table 5.3. Shortfall in Health Personnel in Bihar, March 2006
Personnel
MHW/ANM Female at CHC
MHW/ANM female at PHC
Health worker male at Sub Centre
Health worker female/LHV at PHC
Health worker male/LHV at PHC
Required
8858
10499
8858
1641
1641
Sanctioned
8858
10499
2135
850
649
In Position
7672
8904
1035
491
323
Source: Bulletin on Rural Health Statistics in India, 2006, Special Revised Edition
Vacant
1186
1595
1100
359
326
Shortfall
1186
1595
7823
1150
1318
Table 5.4. Shortfall of Specialists and Techinicians in Health Facilities in Bihar, March 2006
Required Sanctioned In Position Vacant Shortfall
Doctors at PHCs
Surgeons at CHCs
Gyne Obs
Physicians
Paediatricians
Total Specialists
Radiographers at CHCs
Pharmacists at CHCs
Lab technicians at PHCs and CHCs
Nurse, Midwife at PHCs and CHCs
1641
70
70
70
70
280
70
1711
1711
2131
2078
70
70
70
70
280
89
989
82
1482
1606
472
35
28
42
42
19
51
51
29
41
41
12
58
58
88
192
192
15
74
55
291
698
1420
16
66
1695
1163
320
968
Source: Bulletin on Rural Health Statistics in India, 2006, Special Revised Edition
Table 5.5.
Centre
Health
Staff
Position
at
PHCs
and
Sub
Fig. 5.2.2 : Concentration Curve of
Spending on Curative Health Care
Public
PHCs
Number
With 4 and more doctors
With 3 doctors
With 2 doctors
With 1 doctors
With no doctors
With lady doctor
Without pharmacists
Without lab technicians
Sub Centre
Without HW (F)/ANM
Without HW (M)
Without both
141
137
317
925
121
74
686
810
854
3564
854
Source: Bulletin on Rural Health Statistics in India, 2006, Special
Revised Edition.
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The state also had the lowest levels of public Fig. 5.3.3 : Visit to health facility for health
sector health services provided among the major or family planning services : Rural
states, and the most inequitable distribution of its
public services. The people of Bihar mostly depend
on the private sector for their curative care. The
1995-96 NSSO survey also points out that the public
sector provided only a fraction of outpatient care
(8% overall), with the wealthier/richer quintiles
consuming higher rates of services in both public
and private sectors. The study also found that
outpatient services are largely provided by rural
medical practitioners (RMPs). RCH II data also
disclose that only 8.6% of the population visit government health facility whereas 90.3% visit
private healthcare facilities. But the Government has done little to regulate the private sector to
ensure that it provides safe, effective and accountable health services. Figures 5.3, 5.4 and 5.5
provide data about people’s preponderant preference for private health facilities.
Fig. 5.4. Visit to health facilities-public vs.
private rural area
Fig. 5.5. Change in utilization of health facility
NFHS-II vs. follow-up
An increasing number of households are not using government facilities, as reflected in the
rise in percentage of households not using government facilities, from 89% in NFHS-2 to 93.3%
in NFHS-3. This is the highest in the country. The reasons cited are: lack of access to a facility
(44.9%), facility timing not convenient (8.4%), health personnel often absent (21.4%), and waiting
time too long (14.2%). But the majority of households (83.7%) in the state do not use government
health facilities due to poor quality of care. Coupled with health personnel often not available,
these figures are the highest in India. Only 19.2% of the women had any contact with a health
worker. Among those who had access to a health worker, a very high percentage (98.2%) said that
he/she talked appropriately with them and 96.2% said that he/she made sure that the client
understood the information given. It is thus seen that wherever present, community health workers
have better client provider relationship and provide adequate information. However, access to a
government health facility and regular visits by health worker are extremely poor in the state.
Poor health outcomes in the state justify focusing on National Population Policy (NPP 2000), the
National Health Policy (NHP 2002 and the recent National Rural Health Mission (NRHM, 2005)
efforts.
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Quality of Care
Quality of care is the degree to which health services for individuals and populations increase
the likelihood of desired health outcomes and are consistent with current professional knowledge
(Institute of Medicine, 1990). Quality of care is also defined as the way by which clients are
treated by the system, or the actual process of care giving, and by the focus on the client’s or user’s
perspective of services. Providers’ attitude towards client, client’s satisfaction and perspective,
technical appropriateness and desired health outcomes are important components of quality. Other
issues are access, training and infrastructure. The framework of quality of care as enunciated by
Judith Bruce (1990) incorporates six elements: (i) choice of methods; (ii) information given to
users; (iii) technical competence; (iv) interpersonal relations; (v) mechanisms to encourage
continuity; and (vi) appropriate constellations of services. The UNFPA definition particularly
emphasizes client’s participation in management decisions which goes beyond the concept of
client provider interactions.
Table 5.6 provides comparative data for quality of care in family planning services for Bihar
and India. It is seen from the table that there is a large gap in quality of care provided in Bihar in
this respect. Key issues in quality of care and client satisfaction and reproductive choice are
neglected, with low levels of information provided by the healthcare provider on type of
contraceptive use, inadequate counselling, and extremely low levels of community level monitoring
of maternal health, as shown in the dismal figures on home visits by ANM. Such lacunae in health
service delivery are evident across different levels of facilities and service providers in the state.
Table 5.6. Quality of Care Indicators for Bihar and India
Contraceptive Use
% informed about other methods before sterilization
% told about side-effects of sterilization
% told about side-effects of other methods
% received follow-up to sterilization
% received follow-up to other methods
% non users advised on use of contraceptive method
Maternal Care
% married women advised to have delivery by doctors/health worker
% of women visited within 2 weeks of delivery by ANM
% of women visited at least one within 6 weeks of delivery by ANM
Source: DLHS, RCH-II, IIPS, Mumbai
Bihar
20.3
18.5
16.0
7.3
2.8
4.1
10.3
1.8
2.1
India
28.9
29.3
23.3
31.2
9.1
11.7
34.2
13.0
15.6
The health service delivery system is plagued with certain inherent weaknesses, among which
those in need of priority corrective action are: effectiveness, efficiency, decentralization, and
integration.
Effectiveness. It is estimated that healthcare delivery reaches barely 10–15% of the population.
Mostly, the urban population accesses the services. The infrastructure remains poor. Outreach
care is virtually absent. Almost all district hospital services are localized and stationary, with few
personnel going out and providing ambulatory care in the villages. Referral exists more in theory
than in practice and is the weakest link in the system.
Efficiency. The underlying reason for ineffectiveness is deficient management. Earlier, policies
related to primary healthcare were adequate and appropriate while the management of the various
172
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health programmes and projects did not reflect these policies. This led to an extremely weak
system in terms of motivation, training, supervision and proper implementation of programmes.
Some key determinants of efficiency or lack of efficiency are:
• Access to care: This affects cost of services, supplies, movement of trained human resources
and frequency of supervision.
• Social cultural factors: The power of patronage, connection of class, caste, locality and poverty
dominate access to employment, promotions and transfers of individuals and to resources for
the community.
• Bureaucratic constraints: The rigid hierarchical system fits the patron-client relationship by
which access to services is often gained. Although there is little disincentive for poor
performance individual action is carefully accessed in terms of accepted norms and stepping
out is perceived as risky.
• Accountability: The government was regarded mainly as an instrument of revenue collection
and law and order. People do not expect much from public service and demands for better
performance are constrained by such social factors as mentioned above. As a result, there is no
accountability.
A major shortcoming in the managerial health process is the fact that once a policy has been
set it is translated directly into targets and numbers with little attention to planning. For example,
how these targets and numbers will be met or can be met at all, given the low number of human
resources and poor infrastructure. When it becomes obvious that the targets will not be met,
rather than being made more realistic they are made even more ambitious in order to demonstrate
political support. This leads to frustration among those responsible for implementation. They see
the planning process as irrelevant to their work or become chronically disillusioned or indifferent.
Decentralization. The effect of decentralization down to the district level has been limited.
Since budgeting remains highly centralized there is little incentive to planning and decision-
making responsibilities. Even if financial control were to be delegated, effective decentralization
would not ensue as the mechanism for district health officials to exercise such control remains
hazy. A prerequisite for making decentralized planning a reality is a sound decentralized health
management information system, as envisaged in the NRHM.
Integration. The policy of integration assumes that efficiency gains can be achieved by
combining the service activities of vertical programmes. More immediately, integration is often
perceived as a threat to long-term programme staff who may face unemployment due to their
contractual status. Although integration of services has supposedly been completed, the vertical
programmes remain largely independent in their own budgets, staff and bureaucratic imperatives.
Architectural correction and the process of integration of vertical programmes remain unresolved
under the NRHM. There is, however, the danger that the effectiveness of the established vertical
programmes might be diluted by integration and the dedicated human resource will be unprepared
to deliver the amalgamation of services expected of them. The NRHM has now accelerated the
process of integration with some success but a number of issues still remain to be resolved.
Health services in Bihar also show relatively low levels of performance. Bihar has the lowest
levels of child immunization in India and amongst the lowest levels of contraception prevalence
and safe deliveries. Delivery of services is most problematic for the poor, who need services the
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most. Bihar also had the lowest levels of public sector health services provided among the major
states, and the most inequitable distribution of its public services. The people of the state depend
mostly on the private sector for their curative care, but the Government has done little to regulate
the private sector to ensure that it provides safe, effective and accountable health services.
Hospitalization rates are also lower in Bihar than any other major state in India and are dependent
largely on the private sector. Overall the private sector provides 28% of hospitalization in the
state, with the rich 20% of the population consuming 15 times the number of public sector
hospitalization as the poorest quintile. Women from the poorest quintile have extremely low
rates of institutional deliveries, i.e. less than 5%. Women from the richest and poorest quintiles
are less likely to use the public sector if they deliver in a hospital, i.e. 28% and 49% respectively.
Health Insurance
Health insurance coverage in Bihar is far from satisfactory despite the fact that a large proportion
of the population lives below the poverty line and is illiterate. This segment of the population
lives under higher health risks. Existing insurance is largely limited to a small proportion of
people in the organized sector. Currently, the various health insurance schemes by the government
are Employment State Insurance Scheme (ESIS), Central Government Health Scheme (CGHS),
insurance through employers and medical reimbursement through employers rather than voluntary
health insurance schemes. Private providers of health insurance have only currently emerged as a
big player in the Indian health insurance market after opening of the economy. Community health
insurance scheme has been an emerging scheme introduced recently in some states. It is yet to
take off in Bihar. Currently, knowledge about such schemes is low in the state.
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6
Concerns, Challenges and
Strategies for Change
It should be evident from the discussion in the preceding chapters that the health scenario in
the state of Bihar remains dismal. To sum up, the morbidity has its roots in communicable diseases
for the whole population; malnutrition is rampant among children under 5 years of age; the female
population is at great risk from complications of pregnancy and childbirth. The state is experiencing
the classical health problems of underdevelopment and social deprivation, namely, nutritional
deficiencies and communicable diseases. The problem in the state is not necessarily and primarily
one of specific diseases calling for specific medical interventions along vertical lines, but a broad
horizontal problem of poverty, underdevelopment and social deprivation. Therefore, disease and
health in Bihar should be looked at in the context of social needs and related to health and social
inequalities.
The health scenario in the state, while presenting daunting challenges, also opens up windows
of opportunities. The overarching challenge is to improve the health and nutrition status of the
poor, especially women. Providing basic human needs and entailments — food, shelter and safe
water — is the biggest challenge. The most important recommendations for maximizing the
gains from investment in health and improving the existing health status of the people are possible
by ensuring food security, safe drinking water, housing, sanitation, and effective utilization of
health services by addressing the issues of access, quality and financing. Following are the key
strategies for the future.
Population Stabilization
A major challenge for the state is to achieve population stabilization. The country has made
tremendous strides in slowing population growth, but in states with high population, such as
Bihar, much needs to be done to address the unmet need and stabilize the population to earn
benefits from the demographic dividend. The Population Foundation of India and the Population
Reference Bureau, USA, have made projections with consistency for all the states of India. Table
6.1 reflects the comparative scenarios for Bihar and India for the next 100 years (2001–2101). It
may be noted from the projections that India’s population will reach replacement levels of TFR
2.1 in 2061 while Bihar will reach that level in 2081. This replacement level for the state will
occur when its population will be 24,57,82,000. The British parliamentarians’ report on ‘Return
of the Growth Factor: Its Impact on Millennium Development Goals’ is all the more relevant in
the context of Bihar.
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Table 6.1. Projected Population and Fertility, Bihar and India, 2001–2101
Year
Population (’000)
TFR
Bihar
India
Bihar
India
2001
82997
1028591
4.3
3.0
2011
101024
1203711
3.7
2.7
2021
122406
1380214
3.2
2.5
2031
145305
1546158
2.8
2.3
2041
168131
1695051
2.6
2.2
2051
190521
1823538
2.4
2.2
2061
211557
1930839
2.3
2.1
2071
230275
2018513
2.2
2.1
2081
245782
2087232
2.1
2.1
2091
258417
2141172
2.1
2.1
2101
267939
2181133
2.1
2.1
Historically, India’s population stabilization efforts have centred around family planning,
with focus on fertility reduction. Such narrow vertical programmes, often limited to achieving
numbers, are not the answer for India’s population stabilization.
It is well known that wherever infant mortality reduces, TFR falls. This is related to the
insecurity regarding child survival. Thus, there exists a direct relationship between infant mortality
and fertility. Reducing IMR and child mortality is, therefore, important to reduce population
growth and ultimately stabilize population. Interventions for improving child survival are well
known. These are: better education, improved access to quality health care, better nutrition, better
employment opportunities, higher earnings, safe drinking water, better sanitation, etc. Interestingly
enough, the same interventions are also required for empowering women, improving the quality
of life, and ultimately for stabilizing population.
There exists a linkage between social development indicators, health status and population
stabilization. The issue of population stabilization is not a technical issue with a technical quick-
fix solution. The answer does not lie in pushing sterilizations and chasing targets in the conventional
mode. For population stabilization it is important to improve people’s access, particularly women’s
access, to quality health care. The contraceptive mix needs to be enlarged and expanded. We are
now discovering that the obvious route to population stabilization is through social development,
through women’s empowerment, and through greater gender equality.
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Repositioning Family Planning in Primary Health Care
We need to tackle the issue of population stabilization in a holistic way. Family planning
programmes cannot be addressed in isolation. Therefore family planning has to be positioned in
the broader context of reproductive health and reproductive rights. In fact, it has to be placed and
positioned in the broader context of comprehensive primary health care (see Figure 6.1).
The most important aspect of primary health care Figure 6.1. The context of holistic
is its ‘all-inclusive equity-oriented approach’. The health care
component of equity is defined as equal access to
health care, equal utilization of health care, and equal
Positioning family
planning
care according to felt needs. Primary health care
was and still is a potentially revolutionary concept
which looks beyond the customary, conventional and
Broader
context of
reproductive
health and
rights
traditional boundaries of curative and preventive
medicine and tries to address up-front the underlying
social causes of poverty, discrimination, food
Comprehensive
primary
healthcare
security, hunger and poor health. This is, in fact, a
holistic concept and is guided by five principles,
namely, (i) equitable distribution, (ii) multi-sectoral
approach, (iii) utilization of appropriate technology,
Overall socio-
economic
development
(iv) focus on prevention, and (v) community
participation and involvement. Delivery of primary
health care requires an amalgamation of good,
preventive and promotive practices along with the assurance of high-quality curative services
that are equitably acceptable.
Population Stablization through Social Development Approach
Curbing population growth cannot be a goal in itself. It is only a means to development. If
development can help in stabilizing population, truly that is a much better and superior
solution to one where population growth is curbed in the hope that development will
automatically follow. Improvement of health and nutrition on the other hand can be an end
in itself and will lead to population stabilization. Surely, this is a better approach. This has
been accepted in principle in the National Population Policy (NPP) 2000. The policy
framework is based on the belief that people are the most valuable and precious resource of
our country and the common agenda of both population and development is the well-being
of the people. Unless the mindset of people who manage things changes, the NPP will remain
on paper and cannot be implemented in its true spirit. The paradigm shift from ‘number’ to
‘people’ has still a long way to go and it is being recognized that the shift to a reproductive
health and rights agenda has not been fully internalized. Therefore, there is a need to address
deep-rooted mindsets on critical issues relating to population and development. These issues
need to be widely disseminated in a correct perspective among various sections of society.
Given the situation in Bihar it is a matter of concern and it is becoming increasingly clear
that it can be addressed effectively only through a social development approach.
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Community Needs Assessment
For making comprehensive primary health care programmes effective the starting point should
be Community Needs Assessment (CNA). Micro-planning with CNA can help identify and address
the local problems through more acceptable strategies. This decentralized and participatory process
of health planning provides space for involvement of Panchayati Raj Institutions, increased interface
and interaction between the community and the state, addresses gender concerns, ownership and
accountability in health programme implementation. CNA should assess the health needs and
demands so that a realistic workload estimate can be made. It should distinguish community and
epidemiological priorities. At the village level the outcome of CNA should be a health improvement
plan, which ideally needs to be aggregated and included in the district action plan. CNA should
also assess the community perception of quality of care and practical indicators for quality of care
should be developed. In this exercise it is vital to install a good Health Management Information
System (HMIS) for improving the effectiveness of the programme; there will also be emphasis on
complete registration of births, marriages, pregnancies, and deaths. Against this backdrop, CNA
should be viewed as an important health sector reform initiative and not merely a reporting
system.
The need is for greater social investment, wider socio-economic development, strengthening
of public health system, and improved governance in order to achieve population stabilization.
Social investments help reach the goal of slower population growth.
Strategies for achieving population stabilization should include improving socio-economic
indicators such as addressing the needs for maternal care, child health and contraceptive services,
education of girls, ensuring a minimum age at marriage of girls, reducing infant mortality and
MMR through better health care and immunization, nutrition support to women and children.
Improvement in socio-economic indicators for population stabilization should be supported
adequately and effectively with strong political commitment, effective IEC strategy, and all-
round upgradation of health facilities.
A multi-pronged approach is required for population stabilization, such as (a) strong campaign
for delaying age at marriage after 18 years, (b) delaying age of first pregnancy, (c) ensuring
institutional delivery, and (d) meeting the unmet demand for contraception.
Delaying Age at Marriage and Spacing
Some of the key approaches in delaying age at marriage and spacing are: (i) empowering
women for increased decision making in family life, (ii) provision of health education, information,
guidance and counselling services to adolescents, (iii) ensuring greater enrolment and retention
of girls in schools, and (iv) options for vocational engagement and livelihood. Specifically for
increasing spacing in family planning there needs to be a shift in approach from sterilization to
non-sterilization spacing options, increased IUDs and NSVs, and providing comprehensive and
safe abortion care. There is need for women-centred preventive and promotive family planning
services.
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Community monitoring of health services
The NRHM Implementation Framework outlines the need for inclusion of community
monitoring or communitization of health services under NRHM. The purpose is to increase
efficiency in delivery of the entitlements under NRHM and to build people’s participation
and direct involvement in monitoring of health services. However, involvement of the
community should not be limited to monitoring. It should include community action, i.e.
planning and monitoring. It is imperative that efforts are made for building the capacity of
the community and the health service providers to jointly undertake planning and monitoring
of heath services in Bihar. This will lead to greater accountability and transparency in
programme implementation. The process includes direct involvement of self-help groups,
PRIs and CBOs. Such process will ensure that the programme addresses people’s needs and
reaches the underserved and unserved areas. The focus is on decentralized district level
planning, implementation and monitoring where CBOs are to play a proactive, effective and
meaningful role. Current pilot efforts in community monitoring being undertaken in selected
districts in nine states of the country by Population Foundation of India in collaboration with
the Ministry of Health and Family Welfare and NGOs attempt to provide lessons in good
practices in community monitoring, which can then be replicated on a large scale across the
country.
Strengthening Health Service Delivery
A second pillar in improving health care is strengthening health service delivery to be effective
and responsive. The aim should be to improve quality and increase coverage of services to reduce
infant, child and maternal mortality, establish gender-sensitive quality reproductive and maternal
health services especially among the poor and vulnerable, reduce the burden of communicable
diseases, especially kala-azar, malaria and TB. In addition, one needs to ensure effective functioning
of public primary health care system, fully utilizing existing health care centres rather than
increasing infrastructure further.
In order to achieve these, a comprehensive child health strategy needs to be developed wherein
the focus should be on reduction of infant, neo-natal mortality and child mortality through Home
Based Neo-natal Care (HBNC) and Integrated Management of New Born and Childhood Illness
(IMNCI). Secondly, there should be emphasis on complete registration of births and deaths, reduction
of malnutrition, reduction of childhood diseases with focus on acute respiratory diseases and
diarrhoea, and implementing universal immunization. A special strategy needs to be adopted to
reduce the incidence of low birth weight babies.
A gender-sensitive quality reproductive and maternal health care services also need to be
ensured. There is wide consensus on the broad determinants of quality: adequate access and
availability, and routine and reliable information on the scope of services and what is available at
which level. The latter includes the infrastructure and service environment — privacy and
confidentiality. Along with accessibility and availability of services, provision of quality care is
recognized as a priority area in RCH Programme. Good quality of care creates demand from
clients and ensures satisfied clients, who in turn return for services. Quality services are those that
are commonly accepted by clients and which meet their needs. While the client perspective focuses
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on individuals, the provider and managerial perspectives are equally important. Good quality
family welfare services and reproductive technologies that are safe and effective should be promoted.
The bottom line is that there are no shortcuts and no quick-fix formulae. The problem of quality
cannot be addressed at a micro-level of a project; rather, the entire health delivery system has to
gear itself to quality.
Quality of care
It is not enough to provide basic health services. It is equally important to ensure that quality
of care at all levels is addressed. Quality of care is a pillar of public health care which ensures
a people-oriented and client-centred approach to public health. Currently, there is little or
no focus to put into practice processes for providing quality care in the public health system.
Better quality of services ensures increased use of the public health system as providing a
higher standard of care leads to client satisfaction. Pilot attempts are being made to ensure
quality of care in reproductive health services and in other areas of NRHM. Population
Foundation of India undertook such a pilot programme in two districts (Gaya and Vaishali)
of Bihar in building capacity of the community to access better quality of care. It included
not only the aspect of building quality assurance in the system but also including community
perception of the quality of services.
The two approaches are to promote institutional deliveries and to provide good and adequate
referral support. This includes upgrading FRUs providing 24-hour emergency obstetric and basic
obstetric care and strategy for strengthening enforcement of PCPNDT Act along with monitoring
of ultrasound clinics.
The third objective is to reduce the burden of communicable diseases. The focus would be to
develop disease-specific plans with emphasis on strengthening district-level implementation. It
will also include developing an effective epidemiological information system to identify the
magnitude and distribution of communicable diseases, especially malaria and kala-azar in different
population groups, integrating all communicable disease control programmes at the primary health
care and grassroots level, adopting innovative and effective models like IMNCI and HBNC model
with community participation, and training ASHAs and retraining Dais and Skilled Birth Attendants
in a phased manner.
Strengthening Health Sector Management System
A key approach to strengthening health sector management would include capacity building
of staff and decentralized planning. This will entail district-level orientation programmes for all
health workers, including ASHA, Trained Birth Attendants and Skilled Birth Attendants,
orientation and training of PRIs (elected women representatives of the Panchayats in Bihar
constituting more than 50% of the elected representatives) so that they play an effective role,
providing necessary support systems for PRIs and ensuring devolution of financial and
administrative powers to PRIs.
Other important aspects would be to improve staff availability at the field level by human
resource planning through the formation of district cadres, short-term courses for staff, special
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initiatives for remote areas, improving the effectiveness of asset management through review of
guidelines, ensuring programme quality improvement through external reviews, client surveys,
and evidence-based policy changes. The Auxiliary Nurse Midwife (ANM) continues to be the
primary service provider. Her responsibilities include immunization, safe delivery (pre- and post-
natal check-up of pregnant women), community needs assessment, contraception motivation and
distribution, survey of eligible couples, and maintenance of CPR registers. Non-availability of
skilled medical personnel, including nurse midwives, remains the major bottleneck to universal
access to primary health care.
Intersectoral coordination has to be ensured by establishing an effective and meaningful
institutional mechanism for convergence. There needs to be increased coordination between various
departments such as health, panchayati raj, education, rural development, women and child
development, etc. Another aspect of intersectoral coordination includes intra-departmental
coordination.
Advocacy with elected representatives
The Panchayati Raj elections held recently in Bihar led to a record number of almost 60%
women elected as representatives in the panchayat system. The time has come to involve and
harness this group of elected representatives to act as the voices of the community in ensuring
better health service delivery at the village, block and district level. There is need for training
of PRIs on their role and responsibilities, activate the health subcommittees of panchayats,
and form and activate village health and sanitation committees to ensure greater grassroot
involvement and monitoring of health services.
The other important aspect is to involve the state legislators cutting across party lines and
build their perspective on health issues, especially reproductive health and rights, so that
they take greater interest in issues of the health of the people in their constituencies. The
Population Foundation of India as part of its advocacy efforts with elected representatives in
Bihar helped form the Legislative Forum on Population, Health and Development with the
participation of almost 133 MLAs of Bihar. One of the first efforts of the forum was to
undertake district-level advocacy efforts on health, beginning with Kishanganj which has the
poorest health and social development indicators. The district-level advocacy brought together
local MLAs, PRIs, health service providers, the state Health Department and people of the
district on a common platform to discuss and identify key areas for action on health. Such
initiatives need to be undertaken by donors, NGOs, institutions and the State Government
more frequently at the district level so that the district realities and the regional disparities
are addressed.
Enhancing demand and utilization of services and bringing equity and
gender into the mainstream
The low utilization of government health services in the state, especially by the poor due to
lack of access to primary health care services, leads to increasing unmet need, increased regional
disparities within the state such as between the districts of the north and the south, and increased
gender gap in access to services. A major bottleneck in access to services are the recurrent floods,
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particularly in north Bihar districts. It is the poorest people who are the most vulnerable during
floods and suffer from outbreaks of epidemics. In order to increase demand and utilization of
services the following will have to be ensured.
First would be to remove barriers to utilization of services by poor and marginalized groups.
This will need gender and equity strategy with specific focus on enhancing utilization of services,
ensuring entitlements to people with disability, and orientation of service providers and field
workers on gender equity issues in all training.
A second strategy would be to develop Behaviour Change and Communication (BCC) strategy.
Behaviour change is the key to an effective service delivery, especially in unserved and underserved
areas. In some areas this would mean raising awareness about service needs. In other words, it
also means changing health practices such as breast-feeding practices, high-risk sexual behaviour,
etc. BCC is a major component of RCH II and AIDS prevention programme. This would require
evaluation of existing information, education and communications activities on their impact on
the poor and marginalized through external agencies. There is need to use different media methods
and tools with principles of community involvement such as community radio and village wall
newspapers.
A third strategy would be to develop public-private partnership (PPP) in health service delivery.
A major part of curative health care provision in the state is by the private and corporate sector.
There is need to involve this sector in contributing to the public health goals, including the
increasingly important goal of ensuring that health care provision does not adversely impact the
poor. Quality, efficiency and accountability of private health service providers are badly wanting
in the private health sector. The process of increasing PPP would include: (i) developing a basic
minimum regulatory framework to register and accredit private health care providers,
(ii) framework to ensure that costs and quality remain within reasonable limits and the poor have
access especially in emergency situations, (iii) encouraging linkages to public health system,
especially for referral and diagnostic health services, (iv) ensuring cost and quality regulation to
supplement and not substitute existing public health care in such partnerships, (v) bringing in
private capital to contribute to health sector goals and not transfer public assets or resources to
private hands, (vi) better access for the poor to tertiary services through risk pooling mechanisms
and social insurance linkages, (vii) promoting a partnership with dedicated not-for-profit voluntary
sector in health care service provision, and (viii) acting as centres of innovation and excellence in
reaching health care to the poor. Scaling up innovative projects in the state on health, for example,
the Janani model of social franchising for reproductive child health services, the Pathfinder model
of delaying age at marriage and first pregnancy in Bihar, is also required.
Addressing the Needs of Young People
Bihar along with the rest of India has the maximum number of young people in its population.
Any programme aimed at bringing about a change in behaviour, attitude or numbers must
understand the need for addressing this demographic dividend by including and involving young
people in the process, particularly adolescents. There needs to be special focus on the married
adolescent so as to influence them and make them capable of decision making for a better family
life based on the principles of choice, dignity and rights. The issues in focus are reproductive
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NGO initiative
The key challenges mentioned in this chapter can only be achieved by a partnership between
government and non-government organizations. To supplement the efforts of the government,
the Ministry of Health and Family Welfare introduced the Mother NGO (MNGO) Scheme
under the Reproductive and Child Health Programme in the Ninth Five Year Plan. Under
this scheme, the Ministry identified and approved grants to MNGOs in allotted districts.
These MNGOs then disbursed grants to smaller NGOs called Field NGOs (FNGOs) in the
allotted areas. The basic philosophy of this scheme has been nurturing and capacity building.
The broad objectives were:
• to address the gaps in information on RCH services in the project areas;
• to build strong institutional capacity at the state, district and field level;
• advocacy and awareness generation.
In keeping with the philosophy of capacity building, NGOs of national repute were identified
as Regional Resource Centres (RRCs) to provide technical support to MNGOs. It was found
that involving the NGOs in service delivery and addressing cross-cutting issues in the RCH
service areas would be needed to make the programme more effective. PFI is the RRC for
Bihar and Chhattisgarh. PFI has been playing an important role in providing technical support
for NGO capacity enhancement, documentation of promising practices, induction and in-
service training, liaison with state governments, updating database on Reproductive and
Child Health and development of Management Information Systems (MIS) in these two states.
It is synergizing all its programmes in Bihar and Chhattisgarh with the RRC to address RCH
issues, from policy advocacy to service delivery.
health information and counselling, youth-friendly services, economic and personal development
issues, and community norms and attitudes. The common components are:
• ensuring access to reproductive health services and information;
• emphasizing youth skills development beyond traditional schooling to include life skills,
continuing education and livelihood;
• fostering change in family and community norms and attitudes to increase acceptance of
solutions that genuinely address youth reproductive health, social, and economic needs;
• developing an integrated youth policy, strategy and plan and setting up youth resource centres
at the state and district level;
• enrolling, retaining and vocationalizing formal and non-formal education as part of the strategy
to empower adolescent groups;
• forming self-help groups of adolescents for micro-finance/Prime Minister’s Rozgar Yojana.
An important aspect in focusing on young people is to improve the health and welfare of
young mothers and their children by changing traditional customs of early childbearing. In order
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to bring about a reduction in maternal and infant mortality rates and improve the survival and
general health of mothers and children, there should be delay in the first pregnancy until the
woman is 21 years of age, and space subsequent children by three to five years. Some of the target
population is adolescent girls and boys between 15 and 19 years of age, newlywed couples who
have not yet had a child, young couples with only one child, and families of young couples.
Demographically, India is one of the youngest countries in the world. Therefore investing in
young people’s education, nutrition, skill, employment and health assumes urgency and importance.
Failure to do so will have long-term repercussions on individual lives, health system, security,
demography, economy and development. The challenge is to convert young people into an asset.
The state can reap the demographic dividend as it stabilizes the population over the next fifty
years.
The consequences of this age structure are twofold. The contribution of population momentum
will be to increase the number of births. The keys to slowing population momentum are to affect
the age at marriage, delay cohabitation, or delay the age at first pregnancy. Secondly, when birth
rates begin to fall, as is happening in some states and sub-regions in India, there is low dependency
ratio where there are a large number of working adults and fewer children to care for. This is
referred to as a demographic dividend or bonus; because it is assumed that through an investment
in employability through skill training, such individuals could theoretically contribute to a country’s
economic growth and prosperity. Projections by economists indicate that in India roughly eight
million young people will look for employment each year.
Currently, in Bihar small pilot efforts are being undertaken to delay age at marriage and first
pregnancy by mobilizing youth through groups at the village level, by working with young married
couples, building awareness on issues, undertaking advocacy on youth issues at block, district and
state level, building leadership capabilities among youth in Bihar, and providing technical
assistance to the state government on policies and programmes for young people.
Advocacy on youth issues
The Government of Bihar has drafted the youth policy of Bihar. The draft policy places
emphasis on building the capacity of the young people of the state, harnessing their talent,
providing them better and suitable livelihood opportunities so that they develop as better
human beings and committed and skilled assets for the state and the country. The need is to
engage the youth directly at village, block and district levels in developing the implementation
plans based on the policy. Currently, various pilot efforts are being undertaken in the state to
address the health needs of young people. Intervention research projects on delaying age at
marriage, behaviour change communication-focused programme involving married adolescent
couples and capacity building of youth-based organizations such as Nehru Yuva Kendra
(NYK), National Cadet Corps (NCC). Population Foundation of India undertook a pilot
advocacy programme on adolescent reproductive and sexual health issues in Bihar. The
programme adopted a bottom-up approach where youth were directly involved in advocating
for themselves along with local government officials, teachers, parents, youth organizations
and elected representatives. The recommendations from this effort complemented the draft
youth policy and helped form the task group on youth issues in Bihar.
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Nutrition
Morbidity and mortality are related to high prevalence of malnutrition. The stakeholders
recognized young children, adolescents, pregnant and lactating women and elderly as the most
vulnerable. The single greatest cause of malnutrition is poverty and the single greatest remedy is
equitable development.
• The state should ensure food security to all by strengthening and universalizing the Public
Distribution System and promote employment generation schemes.
• Supplementary feeding system should reach all children through the Anganwadi and School
Mid Day Meal Programmes.
• Integrated Child Development Scheme (ICDS) should remain the key strategy. The current
ICDS Scheme should be strengthened into a comprehensive early childhood care programme
with improvements in quality and outreach.
• Reduce malnutrition and under-nutrition by 50% by 2010 and 100% in 2012.
• Every pre-school child should be assured of nutrition, pre-school education and health care
and every working mother should be assured of day care support for young children.
• Implement preventive measures against epidemics and recurrent infections such as diarrhoea,
cholera, etc. in young children through school health programme.
• Children with special needs such as the physically challenged should be provided special
nutrition with a flexible partnership approach.
• Among all these food security measures, public understanding of good dietary habits as suitable
to different cultural and economic contexts should be promoted through appropriate nutrition
and education programmes.
Addressing Emerging Health Problems
Health problems in Bihar will show a complex epidemiology in future. While we shall continue
to have problems of poverty, poor hygiene, poor nutrition, poor sanitation and poor environment,
we shall also increasingly experience the problems of development, affluence and modernization.
New diseases will come up along with the resurfacing of older diseases with newer trends and
patterns. Thus, there will be this ‘Double Burden of Disease’. Following are some of the health
problems to be tackled in the years ahead.
• malnutrition complicated by increasing chemicalization and adulteration of food;
• waterborne diseases, including diarrhoea, dysentery, gastroenteritis, typhoid, cholera, hepatitis
B and parasite infection;
• communicable diseases such as malaria, tuberculosis, leprosy, acute respiratory infection (ARI),
and preventable childhood diseases;
• non-communicable diseases, including heart disease, hypertension, diabetes and cancer;
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• problems of mental ill health;
• increased addictions and substance abuse problems;
• pollution-related diseases, including allergies, asthma and other hazards;
• problems of the physically challenged;
• health problems of the aged;
• iatrogenic diseases;
• accidents and injuries.
Issues which would further complicate the health problems are increasing environmental
pollution and deterioration of ecology, increasing challenge of providing basic environmental
sanitation, urbanization, increasing malpractice in medicine and medical care and irrational
therapeutics in medicine and medical care.
Conclusion
The slow pace of health sector reforms in Bihar poses a major challenge. Also poverty, social
justice and gender issues have not been brought centre stage in health sector reforms. Linking
health programmes to poverty alleviation is critical in the context of Bihar because the burden of
health services falls disproportionately on the poor. Poverty remains one of the main reasons for
untreated illness, thereby resulting in a sharp increase in morbidity. This burden is compounded
further in a situation of unequal gender relations on the one hand and unequal social status on the
other.
In reality, the health delivery system as it exists today is based on loosely integrated vertical
programmes of reproductive and child health, control of communicable diseases, and a stand
alone HIV/AIDS prevention/control programme. However, now that NRHM is in place, one can
take the opportunity of this programme platform. The NRHM appears to have brought back the
primacy of primary health care. It has given prominence of place to what is called
‘communitization’. In fact, it is the hallmark of NRHM. Communitization means community
ownership in terms of community-based planning, implementation, management and, of course,
monitoring.
NRHM fosters a platform for inter-sectoral coordination and collaboration. It also provides
and creates a space for decentralized planning. People say that primary health care was tried in
our country and failed. In fact, it has never been tried in its true spirit and the concept is as valid
and relevant today as it was 29 years ago.
The challenges of development in Bihar are enormous due to persistent poverty, complex
social stratification, poor infrastructure and poor governance. Corruption is endemic in all spheres
of life in the state. The development challenges must be considered in the light of India’s overall
development. The state’s performance lags seriously behind the national trends and is a significant
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contributing factor to the growing gap across states. In Bihar greater transparency and accountability
is badly needed in public affairs.
Transparency in the functioning of public health services and their accountability to
communities goes hand in hand with improving access and availability of services. Communities
need to know their right to health care, so that they make appropriate demands on health care
systems. People’s demand for services can be improved as part of the provisions of the 73rd and
74th Amendments and the Right to Information Act.
Health relates to everything that goes to constitute human lifestyle and life system. Therefore,
the concept of health and health care has to transcend the present narrow technocentric
understanding and unethical top-down prescriptive care system. Health is to be holistic and health
care is to be for health development of all and actively participatory.
Like any right, health has to be asserted rather than given or taken. Responsibility for health
policy development, management and advocacy should not be limited to health professionals. All
stakeholders and those contributing to human development and services, including the people,
should participate in the process of development. Quality of life cannot be improved without
people’s participation, involvement and initiative. Preparing the young people of the state to be
healthy and productive is crucial for utilizing the available window of opportunity. This is an
opportunity to convert 92 million people into a productive asset of society to make Bihar into a
developed state, a vibrant economy and society. It is our social responsibility to make health a
people’s agenda and take it beyond advocacy to the common concern of all in Bihar.
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.
.
POPULATION
PFI FOUNDATION
OF INDIA
B-28, Qutab Institutional Area, Tara Crescent, New Delhi 110 016
Tel. No : 42899770, Fax : 42899795
Website : www.popfound.org, E-mail : popfound@sify.com
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