Indian women, health, and productivity

/ - @ Policy, Research, and External Atiilra WORKING PAPERS Women in Development Population and Human Resouroes Department The World Bank October 1990 WPS 442 Indian Women, Health, and Productivity Meera Chatterjee Documentation of the interaction of Indian women's poor health status and low productivity and evidence that raising the eco- nomic value of women is ultinmatelv the most effective way of improving their health. 'IJhe P'o!i Rewe.rch, ond H tem! Vra! ('onf 1 C l r c 'N I'KI'A I W-k rg v ! di o'-atc the f ndt.rp ,f , rk in. prgriss an. cr.' C rage tc ex,ha-;e if ees a ,Ir g 134ark Ite!! .. he' rs . .ere*' t! .: pi ....... 1 e 'ancrs carry the names ot the a. ;trs. .r 1P . v :.ze:r 'ieuuc.a:'.t 'ho .> ! * . ., e. a. .iFg> a1 e<'.;gi, :j .epreta'in ai - and e. ,,)ns are tke a d, 'ri h A - 1 h n .0 * ar 'tei, to tee W r,rz Han,. H.. l i d Ihre.tom tr ' \1i r dgrerm tor a , if ii mcemherc cntne.,  Policy, Research, and External Afalrs Women in Developinent WPS 442 TIhis paper -- a prodJuct of the Women in l)Dvelopment D)ivision, Population and Human Resources Department --- is part of a larger cffort in PRE to understand the linkages between improving WomenC's access to education, extension training, credit, health care and other public resources, and iincreasing women's productivity and thus family welfare. Copies are available free 1from tlle WN.orld Bank, IS 1s I1 Street NWA', Washington DC 2(433. Plcase contact Rosc Vo, room S9- 125, exctensioni 35108 (I 30 pages, with figures and tables). To overcome constraints on Indian women's prepared for marriage and motherhood. lialf ol access to healtih care reqluires social interventions all rural girls aged 15 to 19, and 44 percent of all (freeinrg women to seek health care), economic girls in this age group, are married. Providing interventions (improving the opportunity costs of more and better education and employment for their doing so). and service interventions (mak- girls and women is an important strategy for ing relevant health care services more casily an(i delaying the marriage age an(i recducing ferility idcly a ailable). and infant mortality. Over the lon terin, thc most ctlhctive meanis In the short term, the most effective means of' imipro,. %n '.i' etn's healilh and reducing o0 improving wonmen's healtih iS to incrIcase thc ic nility levls are tiose that IA ill raise the jumber acrnd improve the traiining and deploy - perceived economic ValIC of womcn. mnit o Ivillage-based lhcalth care workers (mnainli womncn) and their ahilitN to deliver Anion the othellr issues discussed in this healah care scr, ics to women in iheir homcs. ni ajor repon- are thel flOl1o\ in'' On c a! to strengthcn the lunction andi local \W'omf en C IC I to Ceat than mie, .o llle lisnnt ions of th ese wollmcln 'nigIlt be to orga- Iiin its their ph\ sii.d dcvelopnent. reproduIcn' e niiic thcir serviceis and trainiing around a sinmle suLccsS, aId l'i'o tiU \l itV. Ihe c\ .c of malnutri- mnajorhecalth intervention: distributing ironl- tionl produMes lv%' hirth %%ci'eht anld io ina1n1 t folatc tablets to control aneimiia. w\hich affects mtl< mate.mall su I'al -.. hlich cnxou ra"as niiore than 60 perrcent ofInian women A ne. nAneia mnoth,er roundll of hrieh fiertility and attendant increases womcn's susccptibility to illncss. stress on the ' omen ani d oni socict s rcsources. conm p1lications in prcnane . nlaaternlal dc aItht, and SUF i` ,,11, gencrallv'. 'I'thus it lo,A ers lithi rroduc:- I iorts to improve \Aotnen's participation in ti,, itv. tlie alior for:e stho h1(i hb Ii ikeid 1to eorts to provide suLppI ort lfacilities lor clil(d care arid Improving hlialth, nlutrition, and famili,, miaten!at l and child lhiealt,1 planning scrvices -all thrce toetlher-- "ill minpro',c tite balance btucctin tihe cncrgies 'I'the citical target _roup for f'erti lit\ planninig womenri expend in pr(xiuction anld reprodiluction is rural adolcscnt girls. "110o muILIst bIe givCen anid thiir rewards. educationml and \ ocational pporlunitics and 1K' P'RE W,k .` I' v'.'r S'ric, kil"W111'r Lir the F.!:r1Iq ,'1 AI tk IMrx.T r 'I\ -TI Il'l HJ1tn. P 11i\'. RC"OX01. Air, F \1,irTIJ Gi ;s(S";;>\ >I, t> thel Icr.c II t IIt '1:e! li"" ! ou,rt qwk.>'\, \c.n it preIeTlilthtll', ;Irt I.sI thdTIr 11'!v *> ~~~~~~~:. .'T; '''''.I"" .;x1s1- A'~ .. 0711, il: '7) ' II'; 'I;5'r Bi' t<i9-; djN'iifl ..Ink )d; i'T.^ ) .(II l Lh C P! i'R I )>'i l!!l Atlh'l ( .r C  TABLE OF CONTENTS Page Executive Summary . . . . . . . . . . . . . . . . . . . . . . i I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . I Part A. Women's Health Status II. Female and Maie Mortality . . . . . . . . . . . . . . . . . . 2 A. Overview . . . . . . . . . . . . . . . . . . . . . . . . 2 B. Mortality Levels and Trends . . . . . . . . . . . . . . . 3 - Sex Ratio and Mortality . . . . . . . . . . . . . . . 3 - Regional Variations . . . . . . . . . . . . . . . . . 5 - Declining Mortality Trends . . . . . . . . . . . . . . 6 - Life Expectancy . . . . . . . . . . . . . . . . . . . 6 - Mat..nal Mort&aity . . . . . . . . . . . . . . . . . . 7 C. Socio-Economic Determinants of Mortality . . . . . . . . 8 III. Morbidity and Malnutrition . . . . . . . . . . . . . . . . . 11 A. Introduction . . . . . . . . . . . . . . . . . . . . . . 11 B. Causes of Death . . . . . . . . . . . . . . . . . . . . . 11 C. Morbidity . . . . . . . . . . . . . . . . . . . ... . . . 13 D. Nutritional Status . . . . . . . . . . . . . . . . . . . 14 E. Dietary Intake . . . . . . . . . . . . . . . . . . . . . 18 F. Micro-Nutrient Deficiencies . . . . . . . . . . . . . . . 20 C. Female Nutrition and Low Birth Weight . . . . . . . . . . 21 IV. Women's Work and Health . . . . . . . . . . . . . . . . . . . 23 A. Introduction . . . . . . . . . . . . . . . . . . . . . . 23 R Ntilritional Energy for Work . . . . . . . . . . . . . . . 23 C. Effects of Health on Work . . . . . . . . . . . . . . . . 24 D. Occupational Health Problems . . . . . . . . . . . . . 26 - Maternity Benefits . . . . . . . . . . . . . . . . . . 29 E. Women's Work and Household Nutrition . . . . . . . . . . 30 F. Women's Decision-Making Role . . . . . . . . . . . . . . 32 C. Women's Time Allocation to Productive/Domestic Work . . . 33 H. Other Benefits to Health of Women's Work . . . . . . . . 37 V. Marriage and Fertility . . . . . . . . . . . . . . . . . . 38 A. Mean Age at Marriage . . . . . . . . . . . . . . . . . . 38 B. Fertility Rates . . . . . . . . . . . . . . . . . . . . . 40 C. Mortality-Fertility Relationships . . . . . . . . . . . . 43 D. Social and Economic Phenomena Linking Nutrition, Health and Fertility . . . . . . . . . . . . . . . . . . . . . . 46 - Economic Utility of Children . . . . . . . . . . . . . 47 - Women's Seclusion: The Inside-Outside Dichotomy . . 47  Part B. Women's Access to Health Care VI. Women's Use of Health Services . . . . . . . . . . . . . . . 49 A. Introduction . . . . . . . . . . . . . . . . . . . . . 49 B. Differential Treatment ................ . 50 C. Mother's Access to Child Health Care . . . . . . . . . . 52 D. Female Education: An Important Determinant of Health . . 53 E. Girls' Schooling vs. Work . . . . . . . . . . . . . . . . 56 F. Family Planning Practice ..... . . . . .. . . . . . 58 VII. Health Services for 'Women . . . . . . . . . . . . . . . . . . 59 A. Available Health Services . . . . . . . . . . . . . . . . 59 B. Impediments to Women's Access to Health Care. . . . . . . 60 - Critical Practical Problems . . . . . . . . . . . . . . 60 - Key Conceptual Inadequacies . . . . . . . . . . . . . . 61 Part C. Points of Intervention VIII. Points of Intervention ............ . 64 A. Introduction .......... ... ... ... .. . 64 B. Areas for Action ........ ... .. ... .. .. . 64 C. Specific Health Sector Interventions Recommended . . . . . 65 Textual Appendices . . . . . . . . . . . i . . . . . . . . . 68 A. Improvements in the Sex Ratio and Mortality Declines . . . 68 B. Further Details of the Relationship between Female Economic Value and Survival . . . . . . . . . . . . . . . 72 C. Regional Variations in Male:Female Differences in Dietary Intake . . . . . . . . . . . . . . . . . . . . . . . . . . 75 D. Infant Mortality and Mothers' Use of Health Services . . . 77 E. Female Literacy and Some Comparisons with Male Literacy . 80 F. Work Participation Among Children and Young Adults . . . . 82 Statistical Appendices . . . . . . . . . . . . . . . . . . . 84 Figures 1. Relationships Between Women's Productivity, Women's Health and Family Health . . . . . . . . . . . . 1 2. Female Male Ratio in India, by Region . . . . . . . . . 5 3. Female/Male Distribution of Children in Income Groups by Grade of Malnutrition . . . . . . . . . . . . . . . . 15 4. Female/Male Proportion of Children in Age Groups by Grade of Malnutrition .16 5. Female/Male Proportion of Children (0-5 Years) by Grade of Malnutrition . . . . . . . . . . . . . . . . 16 6. Age Specific Fertility Rates (15-19 Year Olds) Urban and Rural, by States and Regions . . . . . . . . . 41 7. Determinants for Use of Health Services . . . . . . . . . 50 8. Female/Male Mortality Ratios, Patterns, by Age Group. . . 69  lables 1. Estimated Age-Specific Death Rate by Sex, All India, 1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 2. Ratios of Age-Specific Death Rates, All India, 1984 . . . 86 3. Estimated Age-and-Sex-Specific Survival Rates, All India, 1981-85 . . . . . . . . . . . . . . . . . . . . . . . . . 87 4. Life Expectancy at Different Ages for Females and Males, 1981 (in years). . . . . . . . . . . . . . . . . . . . . 88 5. Morbidity Pattern of Children in Rural Tamil Nadu . . . . 88 6. Distribution of Male and Female Infants Among Different Grades of Malnutrition. . . . . . . . . . . . . . . . . . 89 7. Distribution of Male and Female Children under 5 in Different Grades of Malnutrition . . . . . . . . . . . . 89 8. Distribution of Male and Female Children in Different Grades of Malnutrition by Income Class . . . . . . . . . 90 9. Foods Received by Male and Female Children of Different Ages in Rural Tamil Nadu . . . . . . . . . . . . . . . . 90 10. Proportions of Households and Individuals in Different States with inadequate Calorie Intakes, 1982 . . . . . . 91 11. Percent Prevalence of Anemia in Different Parts of India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 12. Age at Marriage of Females and Males in Different States, Rural and Urban Areas, 1981 . . . . . . . . . . . . . . . 92 13. Percent of Married Females in Different Age Groups . . . 92 14. Selected Nuptiality Indicators, India and Major states, 1981 . . . . . . . . . . . . . . . . . . . . . . . . . . 93 15 Mean Age at Marriage of Females by Education Level, Rural and Urban, 1981 . . . . . . . . . . . . . . . . . 94 16. Age-Specific Martial Fertility Rates, India, 1978 . . . . 94 17. Cumulative Percent Fertility, India, Rural & Urban, 1978. . . . . . . . . . . . . . . . . . . . . . . . . 95 18. Age-Specific Martial Fertility Rates by Age at Marriage, India, 1978 . . . . . . . . . . . . . . . . . . . . . . . 95 19. Percent Distribution of Live Births by Order of Birth and Age at Marriage, 1978 . . . . . . . . . . . . . . . 96 20. Age-Specific Fertility and Martial Fertilitv Rates by Educational Level of the Women, India, 1978 . . . . . . . 97 21. Percent Distribution of Live Births by Order of Birth and by Le,el of Education, 1978 . . . . . . . . . . . . . 98 22. Birth Rates of Different Occupational Groups . . . . . . 99 23. Distribution of Deaths during Pregnancy and Childbirth by Specific Causes and Age Groups . . . . . . . . . . . .100 24. Infant Mortality Rates by Mother's Age at Marriage . . . 101 25. Infant Mortality Rate by Mother's Education . . . . . . 101 26 Sex Ratio of Children Lorn and Surviving by Age of Mother, 1981 . . . . . . . . . . . . . . . . . . . . . . 101 27. Decades Required to Achieve a Literacy Rate of 85X in the Total Population or lOOX among 5-14 Year-olds for Major States Change -.n Literacy Rates between 1971 and 1981 for Major States . . . . . . . . . . . . . . . . . 102 28. Literacy Rates among Scheduled Castes and Tribes by Sex and Rural-Urban Residence (1981) . . . . . . . . . . 103 29. Agewise Distribution of Child Attending School: 1981 . . 103  30. Workforce Participation Rates for Children not Attending School by Age, 1981 . . . . . . . . . . . . . . . . . . 104 31. Working Status of Children Aged 5-14 Years (1971 and 1981) . . . . . . . . . . . . . . . . . . . . 105 32. Work Participation RateF for Main Workers by Age and Sex 1971, 1981 . . . . . . . . . . . . . . . . . . . . . 106 33. Distribution of Male and Female Workers in the 5-14 Year Age Group among Nine Occupational Categories, 1981 (Percent of Total) . . . . . . . . . . . . . . . . 107 34. Average Population Covered by Key Health Personnel Facilities in Different States, 1987 . . . . . . . . . . 108 ARpendix Tables 1. Sex Ratios, by States and Union Territories, 1981 . . . 109 2 Ratio of Female to Male Age-Specific Death Rates, '981 . l10 3. Distribution of Deaths by Cause and Age-Sex Groups, All-India, 1986 . . . . . . . . . . . . . . . . . . . 111 Appendix Table 3, contd . . . . . . . . . . . . . . . . 112 4. Distribution of Male and Female Children (1-5 years) by Grade of Malnutrit2or. in Selected States, 1980 . . . 113 5. Intake of Calories in r .fferent Demographic Groups in Selected States . . . . . . . . . . . . . . . . . 114 6. Mean Nutrient Intakes of Women in Different Age Groups in Selected States as Percent of Recommended Amounts 115 7. Age Specific Fertility Rates among 15-19 Years-olds in the Major States, Rural and Urban Populations, 1984 116 8. Selected Indicators of Fertility by Socio-Economic Levels, India, 1978 . . . . . . . . . . . . . . . . . . 117 Appendix Table 8, contd . . . . . . . . . . . . . . . 118 9. Ranking of Major States by Various Fertility/Socio- Economic Indicators . . . . . . . . . . . . . . . . . . 119 9a: Mortality Indices . . . . . . . . . . . . . . 119 9b: Fertility Indices . . . . . . . . . . . . . . 119 9c: Socio-Economic Indices . . . . . . . . . . . . 120 9d: Health Service Indices . . . . . . . . . . . . 120 10. Female Literacy Rates and Selected Associated Variables for Different States and India, 1981 .. 121 Bibliography. . . . . . . . . . . . . . . . . 122  Executive Summary A V'wo-Way telationshiD i. That the health st. us of women affects their productivity, and thereby their roles in society and development, is almost too obvious a statement to require explanation. The nature and extent of this relationship are important to establish, however, particularly in the context of poverty, where women's wor'- is essential for family survival or for improved "quality of life." This pape: seeks, therefore, to document Indian women's health status; it hopes to enhance understanding of the set of constraints on women's productivity that are related to ill health. ii. It may be equally obvious that productivity affects health. But the effects of work, income, or socioeconomic status on women's health or of women's productive work on family health have not been previously assessed. The second aim of this paper is, therefore, to collate and analyze available information on the health effects of Indian women's work, so that efforts to enhance women's productivity can be adequately informed of their potential impact on health. This two-way relationship is complex and complicated by a host of intervening factors such as women's education, marriage, an' fertility. Some attempts are made to bring these to bear on the analysis of health and productivity. Women's Health Status iii. The review of women's health status establishes that females are worse off than males in terms of mortality up to the age of 35 years, after wbich they have lower mortality rates. This pattern is inversely related to women's social and economic value. The cultural preference for sons, and consequent bias against daughters, and the "triple burden" placed on young women - - reproduction, domestic work, and productive labor -- result in female<' low survival in early life. Their prospects improve when they pass the reproductive stage, are established earners, and have social status as mothers-in-law. iv. The higher mortality of females in early life accounts for the skewed sex ratio characteristic of the Indian subcontinent. It is worth stressing that the large deficit of females in India, 935 females for every 1,000 males, is due primarily to the male-female differential in mortality under the age of five years. Attention to young female children is essential for a rectification of this pcpulation. imbalance. While rural-urban and regional differences in male- female mortality differentials suggest that lower socioeconomic levels are associated with lower female survival, there is evidence that at the household level females survive better in poor families. This paradox is perhaps explained by the economic value of women relative to men; this value is high in individual poor families but low in populations where female labor-force participation is restricted. v. Qualitative information on female mortality reveals only a few causes of death. Among the youngest age groups, malnutrition is a frequent direct or underlying cause. Beyond the critical survival age of 5 years, poor nutrition continues to be an associated cause, particularly in the form of anemia. Anemia affects over 60 percent of Indian women, lowering their work performance both directly and indirectly, through increased morbidity. It is also well-  ii established that anemia complicates pregnancies; the result is maternal deaths, low birth weight infants, and '.ower child survival. vi. While causes of dedtl, related to "maternity", are important in India because of the heavy reproductive burden borne by women, "maternal mortality' accounts only for 2.5 percent of all female deaths. The maternal mortality rate is 50 times that in developed countries. Yet the actual risk of an Indian woman dying from a maternity-releted cause is more than 200 times greater: she is exposed to 5 or 6 pregnancles compared with 1 or 2 among women in developed countries. And maternal mortality is only a small segment of preventable female death in India. vii. Arong other major causes of death, the most important are respiratory diseases such as tuberculosis, pneumonia, and bronchitis, fevers related to malaria, typhoid, gastroenteric, and other infectious diseases. The distribution pattern appears roughly similar for males and females of different age groups and in different areas of the country. There is evidence, however, that women are more susceptible than men to those diseases that cause death. When men and women in the same household are compared, female morbidity -- prevalence of illness -- is usually higher than that among males. One explanation for this is that female illnesses are treated less frequently and later, since women's access to health care is limited. viii. While the major morbidities are "veneral" diseases which affect both males and females, some 'female-specific' problems exist that add to the sickness 1.oad. Besides pregnancy-related conditions, gynecological infections are common among all classes of women. There are also "social" health problems such as infertility, wife-beating, or burning, which affect women's health status. A variety of occupational diseases affect women workers in agriculture or industry; they involve wojrking posture, exposure to toxins, crowded working conditions, or physical sitress. Many of these conditions -e exacerbated by -- and exa'erbate -- malnutrition, anemia, and childbearing. Women's low social status makes it difficult for them to mobilize to remove these social and occupational hazards. Legislation remains inadequate in content or reach. The low wages paid to women also perpetuate poor working conditions and ill health. Nutrition and Productivity ix. Gender is a significant determinant of nutritional levels, accounting for lower caloric intakes and consequent poorer nutritional status among females. It is in the arena of nutrition that the "backward" linkage between women's health and productivity is most clearly manifest. Girls and women In low-income groups have worse nutritional status than boys and men. Although this may appear to contradict the evidence that female-male mortality differentials are higher among the better-off, the explanation lies in the different roles that social and economic factors play in determining malnutrition and mortality. Among the poor, resources such as food are limited, and females receive a smaller share than males. But as women have a relatively high econom.'.c value, they may be maintained above the survival line. Among the better-off, the inadequate resources do not constrain female survival as much as social devaluation. Thus, females are allowed to die, but the nutritional status of survivors is more equal to that of males.  iii x. Ultimately, nutritional discrimination against females results in their failure to achieve "genetic potential" in body size. This has serious implications for work performance as well as reproductive success. Continued restriction of food -- despite high energy expenditure on work and during pregnancy and lactation -- depletes women's physical resources; premature death ensues. The cycle of malnutrition envelops the next generation through low birth weight. The lower survival of offspring, in turn, encourages high fertility among women, with its consecuent stress on the individual woman's and society's scarce resources. xi. The effect of productivity on health is also manifest through a di?- ct positive effect of women's wages on household nutrition. This relationship is mediated by factors such as wages, nature and seasonality of employment, women's household decisionmaking power, and the tradeoffs between women's work and child care. Efforts to increase women's labor-force participation can certainly help to improve nutritional levels among the most "vulnerable." The evidence suggests, however, that such efforts would be most effective if linked to provision of support facilities required for child care and to efforts to enhance women's access to health care. Marriage and Fertilit-y xii. Issues of marriage and fertility are closely related to Indian women's health and productivity. Education and employment affect women's marriage patterns. Their low mean age at marriage (18.3 years) is both the effect of women's low social status -- low levels of schooling and "formal" employment -- and the cause of early and prolonged child-bearing. Lack of education and of formal work deprive women of health knowledge and access to incomes that could purchase better health goods and services. Childbearing can exacerbate ill health and place a great burden on women's physical resources and the economic resources of families. xiii. A critical target group, adolescent girls, must be provided educational and vocational opportunities, and simultaneous preparation for marriage and motherhood. Almost half of all rural Indian girls in the 15-19 year age-group are married, as are 44 percent of all girls in this age-group. A delay in marriage could reduce the number of children and improve women's prospects of surviving maternal mortality, as well as contribute to the survival cf infants, and to overall well-being of their families. Female education and female employment are two strategies to bring about delayed marriage. These strategies also influence fertility and infant mortality. xiv. Early marriage and early childbearing have impact on both fertility and mortality. The risks of death are higher among young mothers and their offspring. Early motherhood results in inadequate growth, undernutrition, hypertension, and anemia. Girls who bear children before the close of the adolescent growth spurt may remain physically underdeveloped and hence at Ereater risk of obstetric complications, maternal death, and the birth of low weight infants. Low birth weight results in low infant survival. Ultimately, small mothers bear small babies who grow into small motheri -- if they survive.  iv xv. Clearly, Indian women's reproductive roles exercise a disproportionate influence on their health status and also on thteir productivity. In the presence of high levels of infection and malnutrition, childbearing is risk-laden. Frequent pregnancies leave little energy for work; they deplete body reserves drastically when work cannot be decreased. The demands of child care diminish female labor-force participation. Thus, the issues of women's health and of women's control over reproduction are intricately linked with women's social and economic status. Access to Health Care xvi. Women's access to health care is both the outcome of women's status in society and a determinant of women's health and productivity. The factors inflluencing access can be grouped into need, permission, ability, and availability. "Need" relates to female morbidity and mortality, while "permission" and "ability" refer to the social and economic boundaries of women seeking health care (i.e., demand). The "availability" of health services -- the supply -- is a fundamental constraint. Where these factors overlap, uFe of health services takes place. xvii. Data on use of health services show that despite higher morbidity, women receive less health care than males. A smaller proportion of female illnesses are treated; treatment is lower quality, received late, and more frequently ineffective. Higher proportions of patients are male. Expenditure on female health care is thus less than that for males. There is "underutilization" of facilities meant specifically for women, such as antenatal. care and delivery services. An analysis of factors influencing infant and child mortality reveals that the availability of health services and of trained birth attendants are the most significant determinants. While availability stimulates use of the services by women, female education and economic levels are important mediators in this process. In general, education and emplcyment exert effects on women's "maternal competence" through mechanisms discussed in this report. xviii. The health services available for women are described, along with "supplyside" impediments to women's access. Among these, the most important are the difficulties faced by the main "peripheral" female worker, the Auxiliary Nurse Midwife (ANM) or Multi-Purpose ' rker Female (MPWF). Problems of training, deployment, supply, and social hab'., prevent ANMs, as well as Trained Dais and Anganwadi Workers, the village based health care workers, from reaching women in their homes. Support and supervision must be improved if women's health issues are to be addressed. The most important intervention aimed directly at women's health would be a program to shore up local health-service workers. A singular intervention would be iron-folate tablet distribution to women, for anemia control. xix. In sum, attention must be paid to overcoming constraints to women's access to health care in the social arena, which restrict women from approaching health services; in the economic arena, which heighten the costs of seeking health care; and in the service arena, which restrict availability of he_alth services. Together, health, nutrition, and family-planning services will improve the balance between the energy women obtain and the ei,ergy they expend in production and reproduction.  Chapter I: Introduction 1.1 The relationship between woDven's health and their (physical and economic) productivity is complex and multi-dimensional. It is characterized by 'flows' in both directions and a host of intervening factors. Two simple statements summarize the major directional flows: (a) women's health affects their productivity, and (b) productivity affects women's health. In the latter case, women's own productivity, that .f their households, and even t'hat of larger units such as the local, regional or national economy may be implicated. Women's health is intricately linked with family health, and their productivity with family productivity and rel&ced characteristics (see Figure 1). Figure 1 Relationships Betweer! Women's Productivity, Women's Health and Family Health Improved lMproved Womon's C _e Family He lth Health t Incroccod Increased Inreased Outaide 'Inaide Household Accocc to* Entitlements Food Adoquate Health Care to Houlth Availability Aggregate Goods Food Supply Supply of Improved ~~~~~Increased Health / Economnic ^ _ Household 80rvicc / Statue of Income Womnen I Inercaed Incrcaod 't Gnral' Womer-Specific Employment Key: Employment/ Income/ Job/Self-Emp. Two-way Link Productivity Women Opportunitioe General - Direct Link t Means of I Specific Production, I Indlrect Link Adequate Credit, etc. Goneral Intervention Areas Women-Specific Education D_int.rwntion Areas Education & Training _________ _________A T eamning 1.2 This paper documents the nature of these relationships, using available data on Indian women which relate to a variety of health indices, and construing 'productivity' in the broadest possible way, including labor force participation, work output, income, and so on. The overall purpose is to discuss women's health within the context of the need to improve both women's productivity and welfare, Thus, women's health status, its determinants and consequences, are explored, leading ultimately to the identification of irterventions required to improve it and thereby to improve women's productivity. The suggested interventions are viewed against the Bank's past and current efforts in the health (and nutrition) sectors in India and against current overall directions in Bank programming in these sectors; they may also signal possible new initiatives for Bank assistance for the development of women and health in the country.  PART A. Women's Health Status Chapter II: Female and Male Mortality A. Ove.view 2.1. Levels of health can be measured, in the first instance, by mortality indices such as the crude death rate (CDR), the infant mortality rate (IMR) or life ex.pectation at birth (LEo). While the CDR measures mortality across a population as a whole, infant (and child) mortality rates point to premature deaths and are, thus, indicative of overall health conditions, including the availability and use of health services. The LEo sums the probability of survival across a lifetime, and age-specific death rates measure mortality risk at specific times in the life cycle. Ir. addition to actual mortality rates, or levels, at specific points in time, trends in mortality are often instructive. In order to get specifically at the issue of womuL's health status, differentials between males and females in mortality levels and trinds are most useful. Differences between regions or socio-economic groups help to identify both problem areas or groups as well as the social,'environmental determinants of mortality, izhile differeaces among age groups may point to biological causes o' death and also signal socially determiaLed periods of stress in an individual's life. 2.2 While Sections B through D discuss what is known about female mortality in India with respect to these various indices and explanatory )henomiena, the most important characteristics cf female mortality can be listed as follows: o Up to the age of 35 years, females have higher mortality rates than males; thereafter, they actua?.ly have lower mortality rates and, consequently, a longer life expectancy than males. This pattern appears to be directly related to the economic utility of women as percAved by their 'amilies. The strong cultural preference for sons (as breadwinners and old-age security for parents) and simultaneous bias against daughters (as a net economic drain on natal families because of the dowries they will take away at marriage) are reilected in lower female child survival rates. Better survival among 10-14 year old girls may be due to their higher "utility." The "key" to transition from high to low girl child survival appears to lie in the 5-9 ar group. After the ago of 15, women enter the period of risk -- with transfer from their natal to their marital homes and early, frequent and prolonged child-bearing, their reproductive role far over-shadowing any role they have in production. Neither in their natal nor in i:heir marital homes is women's domestic work valued in terms of its economic contribution to the household. After the age of 35, as women begin to be freed from child-rearing iesponsibilities, their labor force participation increases and their economic contributions become more "visible." o Among both males and females, 0-5 year olds have the highest mortality, and because of the large proportion of the population  3 in this age group, almost half of all deaths occur before the age of 5. As the male-female mortality differential is also high in this age p ,up, it alone accounts for the major part of the deficit of females in the country. Over the past decade, females have caught up with males in average life expectancy, but the major gains have accrued to the older (over 35 years) rather than the younger age groups. The fact that younger females are worse off than both males and older females is reason enough for a special focus on young girls in health programming. O States with the highest mortality levels have the greatest male-female differentials. O Mortality rates for males and females in all age groups are consistently higher in rural than in urban areas. O While regional and rural backwardness suggest that poorer socio-economic status is associated with lower survival of females, the relationship of female survival to socio-economic status at the household level appears to suggest that female survival chances a-e better among poor families. This paradox is perhaps explained by the economic value of women relative to men: it may be higher to individual poor families, but lower in regions where female labor force participation across socio-economic groups is low. Female survival is also mediated by pievailing social customs such as dowry payments which reflect and even worsen the low economic value of women. B. Mortality Levels and Trendz Sex Ratio and Mortalitly 2.3 India is one of the few countries in the world where males outnumber females. This fact reflects India's unusual gender differential in mortality: i.e., higher female than male mortality. The 1981 Census counted 935 females for every 1,000 males -- giving a "female-male ratio" (FMR) of 935. As in other countries, the sex ratio at birth clearly favors males (FMR - 952). In most human populations throughout the world, this biological imbalance is eliminated by the age of 1 year through the higher mortality of male infants. In contrast, in India, while the expected pattern of higher male vulnerability during the neonatal period prevails, thereafter more female infants die so that the male and female infant mortality rates are equal (104 per 1,000 live births in 1984). However, as higher female mortality continues through the early childhood years, a much higher death rate obtains among 0-4 year old females than males (43.0 and 39.5, respectively, in 1984). 2.4 Table 1 shows age-specific mortality rates (ASDRs) by sex for five-year age groups (rural, urban and total), while Table 2 gives tha female/male ratios computed from the ASDRs in Table 1 and rural/urban ratios  4 of the age-and-sex-specific mortality rates. While there is a sharp drop in mortality after the age of 5, female mortality remains between 25% and 40% higher thaii male mortality up to the age of 29 (in the "combined" group), is about 10% higher among 30-34 year olds, and finally drops belo-i male mortality after age 35. Most of the deficit of females in the country is, thus, due to the higher female mortality up to age 35. There are particularly large differentia]s in the 0-4 and 15-29 year age groups, which are not offset entirely by the higher male mortality after age 35. The aggregate mortality rate (or crude death rate, CDR) for females, at 12.8 per 1,000 population, is 3% higher than that for males (12.4 per 1,000) -- but these rates disguise marked rural-urban differentials in addition to the age differentials depicted in Table 1. 2.5 The ASDR variations and differentials described above for the country as a whole are observed in rural and urban populations separately, despite considerably higher death rates among all groups in rural areas (see Table 2). 2.6 A point emerging from these age-and-sex-specific death rates which bears emphasis is that the gender gap in survival is greatest during the first five years of life when mortality is highest -- about 20 times greater than that of any other five-year age group (Table 3). The mortality rates experienced by this age group do not occur again until after the age of 65 for males and 70 for females, and such a wide gender differential obtains again only after age 50 when male mortality exceeds that of females. 2.7 A significant feature of Indian mortality is indeed that almost half of all deaths occur by the age of five -- specifically, 48.8% of female deaths and .5.3% of male deaths in 1978. Deaths of young girls in India exceed those of young boys by almost one third of a million every year. Ever, sixth infant death is specifically due to gender discrimination. Although experience in Sri Lanka (Langford, 1984) suggests that excess female mortality in this young age group may be especially intractable, prevention of these 'arlv deaths and of female deaths among them in particular is clearly crucial for the establishment of a more equitable sex ratio. 2.8 A significant demographic factor which is known to effect higher mortality among females in the early childhood years is birth order. A recent study in the Punjab recorded a female to male mortality ratio of 0.75 among 0-4 year olds in the case of first-born children (Das Gupta, 1987). The ratio rose dramatically to 1.23 for second children and doubled to 1.53 for fourth or later children. Even higher mortality rates were found among second-born girls if the first surviving child was already a girl. This indicates that the gender of existing siblings in a family is an important determinant of survival. These findings are especially significant in the light of the large proportion of high-order births occurring in the country. 2.9 Table 3 also lists the sex ratios pievailing in each five-year cohort, which can be taken as the summary outcome of all previous differential mortality experienced by each group. It can be seen that the sex ratio decreases continuously for the first three age groups, signifying an accumulating deficit of females up to the age of 15. It then swings upward  5 Figure 2 Female-Male Ratio in India by Region (1981) Females per 100 Males 1 1 0 - 105 100- 95 L 90, 85 i 80 I 75 70-. ..... , ...... ........ Eastert. I Southern I Centra IWeete'rq I ce' States & Regions 3o-O Cerna. of lmdl. 166i b. tween 15 and 29 years of age, anld dc,ii<'S i v,' differences carnnot be accounteld for- eitht r h: or under-enumer ration. Signif icantly, thI.'; reproductive groups. Althougth the ueswi:. in H : t.o conflict with the continued highe' moi-alla v f at this stage of the life-ccycle, it re tIt, * survival that have occurred over t imte .,imi ''r current mortal I tv ratps for the aFe - group. I -i- sex ratios are a result of the great er d i.fere-nt ril r male and female death rates in he paho Rogionnal Variatioris 2. 10 Thie sex ratio varies marrkedly atr.o.y. 'A. ., and Apperndix Table 1). At preseint, only K-ra`:m 1i. ' "' (1,()32), and onlv five other major statI-s hvet- ra- , Pradesh, Himachal Pradesh, Karnataka, C)ris an- it . . Pradesh, male out-migration helps to improv.e thf st: several major states, such as Assam, Ralasthan.i :;d'e-.d . outrumber females by almost 10%, and the s itU i: ' the Punjab, Jammu & Kashmir and Uttar Pradesh.  6 2.11 Although the 1981 Census data suggest that the historical decline in the all-India FMR (of approximately 6 females less per 1,000 males per decade) might have been arrested, the decline has continued in several states, including in the four states with the most 'favorable' sex ratios in the South. Even in Kerala, evidence of continuing decline is provided by the FMRs of the three youngest single-decade cohorts (0-9, 10-19, and 20-29 years) which are 967, 1,000 and 1,120, respectively. Out-migration of males explains part of this increase in the age-specific sex ratios -- but even if appropriate adjustments are made, the youngest group still has a lower (and 'deficient') FMR than the older cohorts. 2.12 However, some 'micro' regional and age-group improvements in the sex ratio are identified and discussed in Appendix A. These are largely the result of improvements in the socio-economic value of women in different areas and at different stages of the life-cycle. Declining Mortality Trends 2.13 In general, the evidenc, suggests that as overall mortality levels decline, male mortality begins to e.xceed that of females. For example, in Kerala, which has the lowest mortalitv rates in the country, male mortality is higher than female mortality in all age groups. Another plausible trend, however, is that when female mortality declines, overall mortality declines disproportionately more, because of a priori higher female mortality (i.e., the contribution of male mortality decline to overall mortality decline is lower.) 2.14 Trends in mortality clearly indicate that over time there has been a progressive lowering of the age at which male mortality exceeds female mortality. However, this is currently at an age (35 years) when further reductions may be slowed, because of the component of maternal mortality suffered by females between 15 and 35 years (see below). Life Expectancy 2.15 Until recently, the data unequivocally showed that women in India had a lower life expectancy than men. While overall mortality levels declined, pushing up life expectancy for both males and females, in relative terms women had fallen behind in their ability to survive. However, recent projections paint a more favorable picture for the future (see Table 4). In 1980, females were expected to live an average of 54.7 years, c'mpared with 54.1 years for males. Within these country-wide estimates are hidden slight rural-urban differentials. While in urban areas, females outlive males from birth, in rural areas, males continue to outlive females from birth, but from age 5, female life expectation exceeds that of males. 2.16 However, "life expectancy" is a somewhat misleading indicator of female health status because it is the summary effect of mortality at