Attaining the Millennium Development Goals in India: How Likely & What Will It Take?

Millennium Development Goals (MDGs)

As you all know, the MDGs are a set of numerical and time-bound targets to measure achievements in human and social development.

Five MDGs analyzed in this Report

Child and infant mortality reduction Reduction in child malnutrition

Universal primary enrollment

Elimination of gender disparity in school

enrollment Reduction of hunger-poverty (calorie deficiency)

Limitations of much of the MDG discussion so far

Analysis has been at a highly aggregate level

typically the level of the country. This is meaningless in a large and heterogeneous country like India. The likelihood of attaining the MDGs hasnt been usefully linked to the factors that influence MD indicators. This is necessary to address the question: what will it take to attain the MDGs?

MDG Attainment in the Poor States of India

The poorest states in India (e.g., Uttar Pradesh, Bihar, Rajasthan, Orissa, and Madhya Pradesh): are among the most populous in the country, and have among the worst MD indicators.
Owing to more rapid population growth, these states will account for an even larger share of Indias population in 2015. Therefore, Indias attainment of MDGs will largely depend on the performance of these states.

Tremendous spatial variation in levels of & changes in MD indicators

There are very large inter-state and intra-state variations in all MD indicators in India. For instance, the IMR for the country is 66 infant deaths per 1,000 live births. But it varies from a figure of 11 in Kerala to 90 in Orissa.
Intra-state variations in infant mortality and in primary school enrollment rates are even greater, as seen in the following map.

Infant Mortality Rate, 1997-99

IMR (Regions)
per 100 liv e births

100 to 130 (3) 90 to 100 (10) 80 to 90 (6) 70 to 80 (15) 60 to 70 (9) 50 to 60 (8) 20 to 50 (5) 0 to 20 (2) missing (21)

Net primary enrollment rates also vary a great deal across regions

And there is a great deal intrastate variation in IMR decline as well, with some regions showing

 as in changes in net primary enrollments.

Geographic Concentration of MD indicators

The wide disparity in MD indicators results in the geographical distribution of these indicators being heavily concentrated. This indicates the need for targeting MDGrelated interventions to poorly-performing states, districts, and perhaps even villages (if these could be identified).

Case of infant mortality

Four states

Uttar Pradesh Madhya Pradesh Bihar Rajasthan Account for more than 50% of infant mortality in India Four more states account for another 21%, or a cumulative 72%

Contribution of the 21 larger states to national infant deaths, 2000

100 90
Cumulative contribution (%)

83 76 67 57 43

89

93

96

97

80 70 60 50 40 30 20 10 0
Uttar Pradesh

Cumulative share in total number of infant deaths nationally Share in total number of infant deaths nationally

25 9 9 8

6
Andhra Pradesh

5
Maharashtra

5
Orissa

5
West Bengal

4
Gujarat

4
Karnataka

3
Tamil Nadu

3
Assam

3
Jharkhand

2
Chhatisgarh

2
Haryana

2
Punjab

1
Jammu & Kashmir

0
Delhi

0
Uttaranchal

0
Himachal Pradesh

0
Kerala

Bihar

Madhya Pradesh

Rajasthan

51%

21%

 Infant

deaths are even more concentrated at the district and the village levels.

Only one-fifth of the districts and villages in the country account for one-half of all infant deaths
Cumulative distribution of infant deaths in India across districts and villages, 1994-98
100 90

Cumulative % of national infant deaths

80 70 60 Villages 50 40 30 20 10 0 0 10 20 30 40 50 60 70 80 90 100 Cumulative % of districts or villages (ranked by infant deaths) Districts

 and more than half of all underweight children are found in only a quarter of all villages and districts in the country.
Cumulative distribution of all underweight 0-35 month old children in India across villages and districts, 1998-99
100

Cumulative % of all underweight children in the country

90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 80 90 100 Cumulative % of villages or districts (ranked by number of underweight children)

Districts Villages

Out-of-school children are even more concentrated. Nearly three-quarters of all out-of-school children in the country are found in a mere 20% of villages (and 50% of districts).
Cumulative distribution of all out-of-school 6-11 year olds in India across villages and districts, 1999-2000
100

Cumulative % of all out-of-school 6-11 year olds in the country

90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 80 90 100 Cumulative % of villages or districts (ranked by number of out-of-school 6-11 year olds) Districts Villages

Identification of villages with poor MD indicators

Unfortunately, currently-available data cannot allow identification of specific villages that account for most of the infant deaths, underweight children, or out-of-school children in the country, because most sample surveys are not large or representative enough at the village level. But new, emerging methodologies are available to do this.

Most Deprived Regions in India

But we can identify the most-deprived regions in the country. There are two regions in the country that are the most deprived in terms of all the 5 MDG indicators we have analyzed (Southwestern M.P. and Southern Rajasthan). There are another 6 regions that are most deprived in terms of 4 of the 5 indicators we have analyzed.

MDG attainment

Clearly, attaining the MDGs will require action in the poorest states, districts and villages.
How can it be done? What will it take?

Estimation of household, behavioral models of MD indicators

Using household survey data from various sources, we have attempted to quantify the factors associated with the reduction of infant mortality, child malnutrition, schooling enrollment, gender disparity, and hunger-poverty.
These models are used to project changes in MD indicators in the poor states by 2015 under certain intervention scenarios.

We have considered:
General

Interventions

Economic growth Expanded adult male and female schooling Increased access to water & sanitation Improved electricity coverage Increased access to pucca roads

Sectoral Interventions

Increased government spending on health and family welfare, nutrition, and elementary education Various sector-specific interventions, such as More professionally-assisted deliveries Antenatal care coverage and tetanus toxoid immunization for pregnant women Increased number of primary schools per child aged 6-11 Reduction in the pupil-teacher ratio Greater irrigation coverage Increased foodgrain production per capita.

Results of the Simulations

Large improvements in all the MD indicators are possible with concerted action in many areas.
Both general and sector-specific interventions will be important in attaining the MDGs.

Infant mortality could decline by 50% if the poor states were to be brought up to the level of the non-poor states
Projected decline in the infant mortality rate in the poor states by 2015 under different intervention scenarios (Base IMR=76 in 2000)
Sanitation coverage Electricity coverage Regular electricity coverage Adult female schooling Government expenditure per capita on health and family welfare Pucca road coverage Tetanus toxoid immunization coverage Antenatal care coverage
73 74 71 68 65 67 65 64 62 71 67

Intervention

75 75

74

55

51 46

45

43 39

35 National average Average of the non-poor states Poor states are brought up to the:

Any single intervention wont go very far in attaining the MDGs.

What is needed is a package of interventions.

The child underweight rate could decline by 40% if the poor states were to be brought up to the level of the non-poor states
Projected decline in the in the child underweight rate in the poor states by 2015 under different intervention scenarios (Base rate=51 in 2000)
Sanitation coverage Electricity coverage Regular electricity coverage Adult female schooling Improved living standards (consumption expenditure per capita) Government expenditure on nutrition programs per child aged 0-6 years Pucca road coverage Medical attention at birth
49 48 49 47 44 43 43 48

Intervention

50 50 45 40 35 30 25

50

47 43 40

34 31 30

National average

Average of the non-poor states Poor states are brought up to the:

The net primary enrollment rate in the poor states could increase from 50% to 69% if the poor states were to be brought up to the level of the non-poor states
Projected increase in the net primary attendance rate for 6-11 year olds in the poor states by 2015 under different intervention scenarios (Base rate=50% in 2000)
Adult male schooling Adult female schooling Improved living standards (consumption expenditure per capita) Government expenditure on elementary education per child 6-15 years Crime against women and girls Pucca road coverage Electricity coverage Number of primary schools per 1,000 children aged 6-11 Pupil teacher ratio in primary schools
68 64 63 64 64 69 69

Intervention

70

65

60 54 50 50 50 54 54 54 56 56 56 51

55

51

45 National average Average of the non-poor states Poor states are brought up to the:

Trajectory of Selected MD Indicators to 2015

We

have also made some assumptions about how the various policy interventions might change over time, and traced out the path of the MD indicators to 2015.

then

Assumptions about policy interventions to 2015

Assumptions about various interventions to reduce the infant mortality rate in the poor states, 1998-99 to 2015 Intervention Starting value Assumed change per year Ending value in 2015

Population with no access to toilets (%)

Population coverage of regular electricity supply % villages having access to pucca roads Consumption expenditure per capita Adult male schooling years Adult female schooling years Government expenditure on health and family welfare per capita Government expenditure on nutrition programs (ICDS) per child 0-6 years Government expenditure on elementary education per child 6-14 years

76.5
27.7 59.5 422 4.5 2.0 95 51 955

-2% points
1% point 1% point 3% 0.25 0.3 4% 4% 4%

42.5
44.7 76.5 698 8.5 6.8 185 98 1,789

Assumptions about various interventions to reduce the infant mortality rate in the poor states, 1998-99 to 2015 Intervention Coverage of antenatal care % of pregnant women obtaining tetanus toxoid immunization % of professionally-attended deliveries Crime against women (number of female kidnappings and rapes per 100,000 population) Crime against women (number of female kidnappings and rapes per 100,000 population) Number of primary schools per 1,000 children aged 6-11 years Pupil-teacher ratio in primary schools Share of secondary education in total government expenditure on education % of area irrigated Food grain production per capita in districts Starting value 55.5 70 32.3 Assumed change per year 1% point 1% points 1.5% points Ending value in 2015 72.5 87 57.8

1.65

-0.05

0.85

1.65 5.1 91 36 29.2 186

-0.05 .2 -1 1% 1% point 2%

0.85 8.3 75 52 45.2 255

The simulations suggest that attaining the infant mortality MDG in the poor states will be challenging but not impossible with a package of interventions
Projected infant mortality rate in the poor states to 2015, under different intervention scenarios
80

(graph shows cumulative effect of each additional intervention)

80

70

70

60

60

50

Intervention
Tetanus toxoid immunization Real gov't health exp. per capita Access to sanitation Regular electricity coverage Mean schooling years of adult females Village access to pucca roads Access to antenatal care

50

40

40

30

30 MDG for poor states 20

2008 2009 2010 2011 2012 2013 2014 2015

20

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Likewise, it would be possible to reach the child malnutrition MDG in the poor states with a package of interventions
Projected % of children 0-3 who are underweight in the poor states to 2015, under different intervention scenarios (graph shows cumulative effect of each additional intervention)
55 50 45 40 35 30 25 20 55 50 45 40

Intervention Medical attention at birth Real gov't exp. on nutrition per child Access to sanitation Real income growth Regular electricity coverage Mean schooling years of adult females Village access to pucca roads
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

35 30 25

MDG for poor states

20

2009

2010

2011

2012

2013

2014

2015

 but attaining the 100% net primary enrollment goal by 2015 will be problematic in the poor states
Projected net primary enrollment rate in the poor states to 2015, under different intervention scenarios
100 95 90 85 80 75 70 65 60 55 50 45

(graph shows cumulative effect of each additional intervention)

Intervention Reduction in the primary pupil teacher ratio Increased number of primary schools per 1,000 children aged 6-11 Reduction in crime against women Real income growth Increase in the mean schooling years of adult females Increase in the mean schooling years of adult males Increased electricity access Greater gov't exp on elementary schooling per child 6-14 MDG

100 95 90 85 80 75 70 65 60 55 50 45

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Likewise, it will be very difficult for the poor states to attain the 100% primary completion goal by 2015
Projected primary completion rate (%) in the poor states to 2015, under different intervention scenarios
100 95 90 85 80 75 70 65 60 55 50 45

(graph shows cumulative effect of each additional intervention)

Intervention Reduction in the primary pupil teacher ratio Reduction in crime against women Improved road access Real income growth Increase in mean schooling years of adult females Increase in mean schooling years of adult males Greater gov't exp on elementary schooling per child 6-14 Increased electricity access MDG

100 95 90 85 80 75 70 65 60 55 50 45

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Note that increasing the net primary enrollment rate to 100% (the MD goal) is different from getting all children aged 6-11 in school.

The simulations suggest that getting all children aged 6-11 in school is attainable with the same set of interventions discussed earlier.

Projected % of children aged 6-11 attending school in the poor states to 2015, under different intervention scenarios
(graph shows cumulative effect of each additional intervention)
100 95 90 85 80 75 70 65 60 55 50
1999
100 95 90 85 80 75

Intervention Increased electricity coverage Increase in mean schooling years of adult males Increase in mean schooling years of adult females Real income growth Reduction in crime against women Reduction in the primary pupil teacher ratio Expansion of number of primary schools per child 6-11
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

70 65 60 55 50

Other MDGs

What about:
Gender disparity in schooling, and Hunger poverty?

Complete elimination of the gender disparity in primary and secondary school enrollment also appears difficult in the poor states.
Projected male-female difference (in percentage points) in school attendance rate of children aged 6-18 in the poor states to 2015, under different intervention scenarios (graph shows cumulative effect of each additional intervention)
25 25

20

20

15

15

10

Intervention Real income growth Expanded road access Increase in share of secondary educ. in total gov't exp. on educ. Increase in mean schooling years of adult females Increase in mean schooling years of adult males Reduction in crime against women Expanded electricity access
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

10

MD goal

2013

2014

2015

But elimination of hunger-poverty in the poor states is very likely with a package of interventions, especially since hungerpoverty appears to be very responsive to economic growth.
Projected incidence of hunger-poverty (calorie deficiency) (%) in the poor states to 2015, under different intervention scenarios
50

(graph shows cumulative effect of each additional intervention)

50

45

45

40

40

35 Intervention Increased access to safe water Improved road access Increase in mean schooling years of adult males Increase in mean schooling years of adult females Increased foodgrain production per capita Increased irrigation coverage Real income growth MDG Target in 2015

35

30

30

25

25

20

20

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Summing Up

Meeting the MDGs will be challenging, especially for the poor states in India. A number of interventions, including
economic growth improved infrastructure (especially water and sanitation,

electricity, and road access) expansion of female schooling, and scaling up of public spending on the social sectors

will be needed in order to attain the MDGs.

Also important will be a number of sectoral interventions, such as

improved access to antenatal care Immunization nutritional supplementation home-based neonatal services increasing the density of schools lowering the pupil-teacher ratio raising agricultural production.

Targeting interventions, public spending, and economic growth opportunities to the poor states and, within those, to the poor districts and villages will be critical.

Finally, the importance of systematically monitoring MD outcomes at disaggregated levels and evaluating the impact of public programs cannot be overemphasized. Currently, there is no system for monitoring progress toward attainment of the MDGs at the sub-national level.

In addition, most public interventions, such as the Integrated Child Development Services and the District Primary Education Program, have not been subjected to rigorous, independent evaluation. In order to choose the right set of interventions with which to attain the MDGs, it is critical to know which programs have been successful in improving MD indicators and which have not.

Caveats

Estimations and simulations subject to usual problems of measurement error, estimation bias, etc. Therefore, projections are indicative and should be used in rough-order planning.

Simulations focus on quantitative variables and not on qualitative variables, such as governance. Does not mean that governance is not important, just that it is difficult to take that into account in the simulations. The simulations assume business as usual. Any improvements in governance will result in speedier attainment of MDGs.