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Gender Hierarchies and Inequalities: Taking Stock of Women's Sexual and Reproductive Health

Following the United Nations conferences on women in Cairo and Beijing, which established the importance of gender as a critical dimension of reproductive and women's health, India initiated several changes in its family welfare programmes in a phased manner. However, despite these changes, the sexual and reproductive health of women continues to be an area of concern. This paper examines the socio-cultural determinants to women's health in Rajasthan in the light of the National Family Health Survey-3 data as well as the current policies and programmes affecting women's health. It asserts that in the present context, women's bodies, health and sexuality are being grossly neglected and abused in Rajasthan and there is a dire need for reform in the state's attitude towards women's health needs.

SPECIAL ARTICLEdecember 6, 2008 EPW Economic & Political Weekly54Gender Hierarchies and Inequalities: Taking Stock of Women’s Sexual and Reproductive HealthKanchan Mathur This paper draws substantially on one chapter of the report “Situation of Women and Children in Rajasthan: A Report” prepared by Rajagopal S, Mathur K and Varsha Kalla at the Institute of Development Studies, Jaipur.I wish to acknowledge the critical comments and inputs provided by Abhijit Das, Centre for Health and Social Justice, New Delhi and Narendra Gupta, Prayas, Chittorgarh on an earlier draft of this paper. I would also like to thank Maithreyi Krishnaraj for her suggestions and support.Kanchan Mathur ( is with the Institute of Development Studies, Jaipur.Following the United Nations conferences on women in Cairo and Beijing, which established the importance of gender as a critical dimension of reproductive and women’s health, India initiated several changes in its family welfare programmes in a phased manner. However, despite these changes, the sexual and reproductive health of women continues to be an area of concern. This paper examines the socio-cultural determinants to women’s health in Rajasthan in the light of the National Family Health Survey-3 data as well as the current policies and programmes affecting women’s health. It asserts that in the present context, women’s bodies, health and sexuality are being grossly neglected and abused in Rajasthan and there is a dire need for reform in the state’s attitude towards women’s health needs.The concern for women’s health in India has grown over the past three decades more so since the United Nations Cairo conference (1994). The Programme of Action, adopted by 179 governments at Cairo, marked a new understanding among world bodies that population and development are inextricably linked, and that women’s empowerment is the key to both. For the first time, the reproductive and sexual health and rights of women became a central element in an inter-national agreement on population and development. Also the reproductive health and human rights of women got linked to the global struggle to reduce poverty and achieve sustainable de-velopment. Subsequently, the Beijing conference (1995) estab-lished the importance of gender as a critical dimension of repro-ductive and women’s health. India being a signatorytoboth conferences initiated changes in its own approach to the family welfare programme in a phased manner by adopting a target freeapproach in April 1996 – the Reproductive and Child Health Programme (October 1997) and the National Population Policy (March 2000). Against this backdrop, this paper examines the socio-cultural determinants to women’s health status in Rajasthan in the light of the current policies and programmes affecting women’s health. It argues that despite increased awareness, women’s health continues to be grossly neglected as evidenced both in indicators revealed by the National Family Health Survey-3 (NFHS-3) data as well as in the outcomes of family health pro-grammes. The paper throws light on some emerging challenges and argues for a paradigm shift in the state accountability towards women’s health. 1 Rajasthan: Socio-cultural DeterminantsThe considerable and largely preventable burden of poor reproduc-tive health falls most heavily on the poorest women and their families, who can least afford its consequences. The ability to make free and informed choices in reproductive life, including those involving child-bearing, underpins self-determination in all other areas of women’s lives. Because these issues affect women so profoundly, reproductive health cannot be separated from the wider goal of gender equality (UNFPA 2005).Many interrelated factors impinge upon and shape the health and nutritional status of women and girls in Rajasthan with gender inequalities cutting across different strata of society.An analysis of the women’s health status usingthegender relations frame-work reveals that in Rajasthan, men’s control over women’s bodies and lives, their labour, sexuality, reproductive capacity and life choices operates through taken-for-granted asymmetries about
SPECIAL ARTICLEEconomic & Political Weekly EPW december 6, 200855what is possible for, and available to, men and women. Power in this analysis inheres in the social relations which enable men to mobilise a greater range of resources, symbols and meanings, authority and recognition, objects and services – in a greater range of institutional domains: political, economic and familial (Kabeer 1994: 66). Hence, institutionalised power relations influence women’s access to and control over resources including nutritional inputs and healthcare services. Women continue to be seen primarily in the reproductive roles – i e, as homemakers and childbearers, with their identities and status being closely linked to their ability to bear sons. Further-more, gender can be seen as a significant indicator of inequality and disadvantage in relation to healthcare, which may cut across poverty indicators. It follows, therefore, that gender should be a major consideration in measuring equity in healthcare. However, as Standing argues, To the extent that gender interacts with other inequalities deriving from age, class, ethnicity, etc, it is important to contextualise its sig-nificance. The skewed allocation of resources and power within the household is a critical factor responsible for women’s disadvantageous position within healthcare system (Standing 1977: 2). Age, marital status, religion, class, caste, education, exposure to mass media, and work participation are closely associated with women’s health-seeking behaviour in the state. Also while women from the most marginalised groups, i e, lower caste/class, may enjoy greater mobility and freedom of movement outside the home, their access to healthcare services may be poor. On the other hand, women from upper castes/classes may not enjoy mobility, but may have better access to healthcare services since they have greater affluence.Gender differentials in health-seeking behaviour point to the fact that women’s health is not a priority within the household. Women’s socialisation into a mindset of self-denial and the family’s clear prioritisation to the needs of its male members do not allow early action on women’s illness. It is not surprising that women in Rajasthan suffer from health problems, which are rooted in their experiences as women, many of which are largely neglected in the official interventions, as they require much more than clinical solutions. The fact that a young girl becomes a part ofthe health system mostly as a pregnant woman is an evidence of the traditional attitude towards women, i e, women are use-ful only in their reproductive capacity and only in relation to men as wives and mothers (NFHS-1).Denial of adequate food to girls, partly due to non-availability and partly due to gender discrimination, results in the lower nutritional status of women. The height for age data shows that girls are more malnourished than boys indicating the influence of this inequality (Bhargava et al 2005). Recent official reports show that the incidence of malnutrition in Rajasthan is high despite great improvements in food production and distribution (GoR 2008).NFHS-3 indicates that about 53.1% of women in childbearing age (15-49 years) and 79.6% of the children in the age group of 6-35 months had anaemia,largelyduetounder-nourishment. There is also a rise in the percentage ofanaemic women recorded inNFHS-2, i e, 51.4% to 61.2% as per the NFHS-3 data. A benchmark survey conducted in the selected blocks of Barmer, Jaisalmer, Sawai Madhopur and Karauli indicates that 90% of women and children were found to be anaemic (IIHMR 2000). Other than the direct ill health caused, malnutrition, andespecially anaemia in adolescent girls shape the nutritional status of women during pregnancy and lactation and contribute to mortality and morbidity in infants and children. The low value accorded to women and girls and restriction on mobility often results in poor access to healthcare services and lack of informa-tion on reproductive health issues. Early marriage and early pregnancy further deplete women’s/girls’ inadequate reserves. According to 2001 Census data, Rajasthan recorded the lowest average age at marriage for girls among all states. There has been an improvement in the age at marriagefrom 1999 (NFHS-2) according to which 68.3% of girls weremarried before the legal age of 18 years. However, the NFHS-3 records that 57.1% of women surveyed in the age group of 20-24 years were found to have been married before the age of 18 years. The percentage is higher in rural areas at 65.7%. The aver-age age of marriage among some communities, particularly the Meos, is even lower between 11 and 14 years. A recent study has found 50% of the girls in the surveyed villages are married by the age of 14 years (Mathur et al 2007). Early marriage results in early childbearing and motherhood. As recorded by the NFHS-3 data16%ofthe women in the state in the age group of 15-19 years werealready mothers or pregnant. The median age at first birth for women aged 25-49 years was reportedtobe19.6%. The prevalence of child malnutrition in the state increased from 42% in 1993 to 51% in 1999. NFHS-3 records that 44% of children under the age of three are underweight, 34% are stunted and 20% are wasted. Though there has been a slight improve-ment in the percentage of stunted and underweight children from NFHS-2 toNFHS-3, the sharp rise in the percentage of wasted children which was 12 according to NFHS-2 and has risen to 20% as per NFHS-3 is alarming. A recent study found the proportion of “wasted”1 children in the age group 0-5 years was7-8%andanoverwhelming majority of children (80%) to be chronically energy deficient according to their body mass index (BMI)2intheage group 11-17 years in Banswara and 18-19% in Tonkdistricts (Bhargava et al 2005).Gender relations at the household level determine women’s access to healthcare services at the community level. A maternal death, for instance, is the outcome of a chain of events and dis-advantages that a woman experiences throughout her life span. Lack of appropriate care during childhood, pregnancy and child-birth and post-delivery, seems to result in most of the maternal deaths. A significant proportion of these deaths also reflect women’s/girls’ reproductive burden exacerbated by the burden of both domestic and paid work and their concurrent poor nutrition (NPC 2005; Gupta and Khanna 2005). Poor access and availability of quality obstetric care, inadequate health facilities for institu-tional deliveries and lack of skills among healthcare providers, in essential and emergency obstetric care are the key systemic factorsthat influence health-seeking behaviour (NPC 2005).Child-bearing at an early age is also a major factor influencing maternal mortality ratio (MMR). Abortion, haemorrhage, anaemia of pregnancy,malpositioning of the child (fetal malpresentation),
Jharkhand Bihar AP UP

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SPECIAL ARTICLEdecember 6, 2008 EPW Economic & Political Weekly58complementary food is delayed for a majority of children. Accord-ing toNFHS-3 only 38.7% children in the age group six to nine months consume solid or semi-solid food and breast milk. Malnourishment reduces the resistance of babies to disease and infections, which, in turn, further drains the body of nutri-ents. In cases of extreme poverty and malnutrition, infection and disease result in high rates of mortality (Nayyar 1991). An adequate nutrition is thus critical for child health and survival, as well as for overcoming the potential vicious cycle of poverty and under-nutrition (GoI 2002).Early marriage and the risk of maternal mortality in teenage pregnancy are almost 10 times more. With early and closely timed pregnancies before their bodies are sufficiently mature, adolescent mothers give birth to premature and to low birth weight babies. The health of mother and child is severely endan-gered and often permanently damaged. If a mother is under 18, her baby’s chances of dying in the first year of life is 60% greater than that of a baby born to a mother older than 19 years. Even if the child survives, he or she is more likely to suffer from low birth weight, under-nutrition and late physical and cognitive develop-ment (UNICEF 2007). Thus, leading to repeated/intergenerational cycles of ill health. 3 PoliciesandProgrammesAt the policy level, the state healthcare services have been modelled on the lines of the national health policy guidelines. Various schemes and programmes have been implemented to address basic healthcare of mothers and children and associated programmes of safe water, sanitation and supplementary nutrition (GoR 2004). However, despite intensified efforts at maternal health and family planning, healthcare becomes increasingly inaccessible and health of women remains poor.The state women’s policy was launched on 8 March 2000. One of the key objectives of this policy is a focus on adopting a lifecycle and holistic approach to address the health and nutrition needs of women. It explicitly highlights propagating gender sensitivity in all government departments at all levels and to create a con-genial and enabling environment to make political leaders, policymakers and media gender-sensitive (GoR 2002;GoI2006b). However, more than eight years down the line the policy has not been implemented.The state does not have a health policy but a population policy. The population policy of Rajasthanwas released in January 2000. It underlines action through the following strategies: ensuring marriage at the legally permissible age, encouraging responsible parenthood, ensuring prenatal and postnatal effective services, safe delivery services, child health and adoption of effective methods for couple protection and ensuring male participation. However, the population policy is incongruous with the commit-ments made at the International Conference on Population and Development (ICPD) since it is demographically driven and ignores both women’s empowerment and an approach to repro-ductivehealthcare. The policy takes the stand that in order to achieve certain demographic goals and population stabilisation, measures such as incentives and disincentives, i e, making the two-child norm a precondition for elected representatives, linkinghealthinsurance benefits to sterilisation and even pro-posing denial of food rations and free education to the third child would be necessary. Following the population policy the Rajiv Gandhi Population Missionwasset up on 5 July 2001. The population mission aimed at tackling problems through a “mission approach”, within a time bound frame. Some of the stated objective of the mission are: to bring down birth rate from 31.1 per thousand to 18.4 by 2016, to reduce death rate from 8.4 per thousand to 7.0 by 2016, to bring down infant mortality rate from 83 per thousand live births, to 56.8 by 2016. Controlling fertility, improving children’s and women’s health, tackling different aspects of high fertility and low levels of health such as child marriage, teenage pregnancy; lowspacing between births; strong son-preference; lack of male participation and low level of female literacy are some of the challenges identified. However, with an overzealous thrust on the mission approach and an objective of bringing down the population, the Rajasthan population policy has resulted in a coercive population control programme based on incentives and disincentives. It adopts a “target approach” with service providers being penalised for not meeting targets. Newspaper reports have also highlighted the pressure on schoolteachers and other government functionaries to achieve sterilisation targets (Bose 2005). It has also come to light that some women have had to undergo tubectomy more than once but despite this they have conceived at the age of 42 to 45 years. They have had to face embarrassment within their families, especially at the hands of adolescent children. Not only this, they suffer from various sexual and reproductive health problems post-sterilisation. These women have been reporting their woes to the chief medical health officers, the ‘sarpanches’, ‘tehsildars’ as well as to the representatives of State Commission for Women (SCW) at the ‘jan sunwais’ (public hearings) conducted by the SCW. Prayas, anNGO based in Chittorgarhdistrict, conducted a survey on unsuccessful tubec-tomy cases between October and December in 2005 in three districts,ie,Banswara, Bikaner and Douse. The survey revealed that out of a total of 221 tubectomies conducted, 66 cases had been unsuccessful and 155 women complained of sexual and reproductive problems post-tubectomy operations (Rajasthan Patrika, editorial, 5 March 2005). Again in 2006-07 a total of 140 such cases were reported (Sharma 2005). Scalpel vasectomy or male sterilisation is a relatively simpler pro-cedure. However, in a patriarchal society like Rajasthan getting men to take responsibility for contraception is not an easy task. The vaginal tubectomy technique developed since 1970, whereby women can be operated in periods other than post-partum has proved disastrous. Today women have become easy targets for family planning programmeswith the bulk of sterilisations being tubal litigation operations.Table 2: Recent Trends in Male/Female Sterilisation Year Male Female Total2000-01 1,0692,65,8942,67,3902001-02 1,4102,50,6592,52,0692002-03 1,7472,84,1222,85,8692003-04 1,769 2,98,3693,00,1382004-05 8,761 3,25,2103,33,9712005-06 18,0482,99,2593,17,3072006-07 2,761 1,60,597 1,63,358Source: Annual Progress Report, Department of Health and Family Welfare, 2006-07.
SPECIAL ARTICLEEconomic & Political Weekly EPW december 6, 200859Recent figures provided by the department of health and family welfare show an enormous difference in the numbers of male vasectomies as compared to female tubectomies in the state.AsTable 2 (p 58) indicates, despite thelargeincreaseinmale vasectomies from 0.4% to 5.7% in the last sevenyears,thetotal percentage of women undergoing tubectomies has remained high at 94.3%. In Rajasthan, the “two-child” norm under the population policy has been made applicable at the panchayat level by the state government. The provision of the two-child norm was introduced in the Panchayati Raj Act by inserting a specific section and amending the act by introducing a cut-off date for implementation. For example, Section 19 (1) of the Panchayat Act of Rajasthan debars and disqualifies a person to be a member of a panchayat, if he/she has more than two living children, one of whom is born on or after 27 November 1995. The number of children producedbefore the cut-off date is immaterial and the law is not applicable to such a case. It is expected that, “…The panches and sarpanches are to set the example and maintain the norm of twochildren. Otherwise, what example can they set before the public?” (Sarkar and Ramanathan 2002: 42). However, the fieldevidence indicates that in the existing power game at the village level where caste, class and gender politics dominate, backward communities offer no role model either to the members of the highercastes or to those who are their kith and kin (Visaria et al 2006). According to recent data, the total number of elected repre-sentatives disqualified for violating the two-child norm between the years 1995 and 2000 was 145. The reported number of cases in the period 2000-05 was 598 showing an increasing trend. Thegender disaggregated data shows that out of the total 743 cases till 2005, 615 (82.77%) are males and 128 (17.23%) are females (Sharma and Narwani 2008). The imposition of a two-child norm becomes anti-women in more ways than one. As Visaria et al (2006) put it and field observations confirm, women are adversely affected because of a number of reasons. The elected husbands, in order to retain their seats, often resort to measures such as abandoning the wife, denying having fathered the child, deserting the pregnant wife, pressurising the wifetoundergo an abortion (especially, if the foetus is of a girl). If the woman is the elected representative and becomes pregnant with a male foetus, then her position is also sacrificed in favour of a son; her having to step down is of little conse-quence to the family since she would produce a male heir. In the process women’s bodies, health and sexuality are grossly neglected and abused. The central government on 23 May 2005 wrote a letter to the chief ministers of Andhra Pradesh, Maharashtra, Orissa, Rajasthan, Chhattisgarh, Haryana and Madhya Pradesh to consider with-drawing the imposition of two-child norm for panchayat members in their states. The then union panchayati raj minister, Mani Shankar Aiyar wrote in his letter to the respective chief ministers, “Adherence to this norm as a pre-qualification for election is inconsistent with theNPP 2000 and adversely affects women’s empowerment, young people, Dalits and weaker section without serving the expressed intent of population stabilisation”. He also wrote that given the strong son preference in the society any enforcement of the two-child norm on panchayat representatives would encourage sex selective abortion, increase discrimination against the girl child, and worsen the already declining sex ratio (SAMA 2005). This provision has been contested both within the state and outside by women activists/NGOs and also challenged in court. Some of the states including Himachal Pradesh and Madhya Pradesh have subsequently reversed the norm. However, it continues to be implemented in the state and policymakers have taken no cognisance of its impact on women’s mental and physical health. Health systems reforms in Rajasthan have been underway since 2004 under the World Bank’s Health Systems Development Project. The launch of the NationalRuralHealthMission (NRHM) in April 2006 has given further impetustoongoinginitiatives.The NRHM was launched in the state during 2005-06 to provide ef-fective healthcare services to the poor, the vulnerable and mar-ginalised sections of the society. However, one of the biggest challenges in women’s access to programmes such asNRHM in a state like Rajasthan continues to be an inadequate rural health infrastructure, particularly a shortage of trained staff. It is evident that the shortage of health centres, lack of doctors/paramedical staff and lack of privacy coupled with lack of free medicines make far fewer women approach health facilities than men. Every year, a major portion of the funds allotted to the NRHM remains unutilised in the state. Of the Rs 548 crore allotted to the state in the last financial year, only about Rs 360 crore were used (Mishra 2008). Population per doctor (in public provision) in-creased from 7,755 in 1996 to 8,933 in 2002, and population per (government-run) allopathic centre during the same period in-creased from 10,925 to 12,247. According toNSS data, a number of sanctioned posts in remote rural areas are currently lying vacant. Such decline in availability of medical personnel seems to have worsened the already skewed access to public health services (GoR 2008).The Janani Suraksha Yojana (JSY) under the NRHM has been initiated since 2005 for reducing maternal mortality and infant mortality and to increase institutional deliveries among the below poverty line (BPL) families. The institutional deliveries in govern-ment facilities have risen dramatically to 4,25,253 between April and September 2007 – a jump of 62% over the corresponding period in 2006. Almost all of this can be attributed to the mone-tary incentives offered under the JSY.3 The state government has also simplified the system of making payments under JSY. Women who deliver in the institutions are given a cheque that can be cashed the same day (GoI 2007). However, many health officials and workers have expressed concern over the future of the JSY, especially since the coverage extended to all women and children (not limited to two). While health workers admitted that institu-tional deliveries helped to reduce maternal mortality, they were also worried about the huge financial implications (ibid).Hence, despite the fact that a number of programmes related to maternal and child health are being run in the state focusing on healthcare of women, they are synonymous to child survival, safe motherhood or maternal and child health, where the main focus is always on the safer deliveries and the well-being of the
SPECIAL ARTICLEdecember 6, 2008 EPW Economic & Political Weekly60child. The Reproductive and Child Health (RCH) programme initiated in 1996-97, tried to change the picture a bit. It encouraged the male partnership in women’s health by attempting to change men’s perception and behaviour towards women. Today the RCH programme is a major component of the NRHM. The state programme implementation plan (PIP) for RCH-II has been pre-pared.Some of the proposed activities for theRCH-II programme underthe overarching umbrella of NRHM include strengthening the project management structure at state and district levels, strengthening infrastructure at various levels of health service delivery, human resource development and capacity-building, im-proving quality of care and strengthening referral system, etc (GoR 2007). However, a gradual decline in health services for women, unquestionably high maternal death rates and a lack of national and state concern for women’s reproductive health problems continues.Women’s sexual and reproductive rights including prevention, control and management of STDs and RTIs form part of the RCH programme. But the ineffective implementation of this compo-nent, biological vulnerability to these diseases, the lack of power to negotiate responsible behaviour from their sexual partners, all contribute to increasing incidence to these preventable diseases among women. Diagnoses and treatment of STDs in particular entails efficient general health services and points to the need for adopting a public health approach to reproductive healthcare andSTIs within the context of primary healthcare. However, the state government is yet to recognise that the reproductive health needs are a subset of women’s broader health needs, and need to be approached as such. As Keysers points out, “reproductive health and justice…has to do with contraceptive services, with eradication of hunger, with education, with health, with income, with clean water, etc. All of which can be achieved only in a completely overhauled system (Keysers 1994: 6).With no mobile teams to examine women at home for malaria, tuberculosis, etc, the number of men who are diagnosed with these diseases is much higher than women. Distance of the facility coupled with the lack of transport and economic resources to go to health centres is also a major hurdle. Absenteeism, lack of privacy and lack of female medical officers in the peripheral health institutions deter women from seeking treatment, espe-cially the treatment for reproductive tract infections and STDs (GoI 2006b). Almost 5,000 doctors are presently providing services at the district hospitals, community health centres (CHCs) and public health centres (PHCs). Women comprise 24% of the doctors working at these facilities. The proportion of women doctors is lowest for the PHCs at just over 12% (GOR 2006). Frequent trans-fers of health staff also affect the quality of health services. Sub-centres lack living accommodation for the ANMs and basic facilities like electricity, drinking water, toilets, etc. Many subcentres do not have essential equipment such as infant weighing machines, examination kits, delivery kits, etc. Service delivery mechanisms in Rajasthan appear to be particu-larly weak, contributing to poor human development outcomes. A recent citizen’s survey has assessed the provision of services in the areas of drinking water, healthcare, the public distribution system (PDS), public transport, and primary education along multiple dimensions across Indian states. The survey places Rajasthan 12thamong India’s 16 major states in the delivery of healthcare services (World Bank 2006). The survey records that 41% and 27% of Rajasthan households reported that doctors and para-medics were absent compared to 30% and 17% nationally. Only 5% of Rajasthan households reported full satisfaction with behaviour of doctors and paramedics compared to 14% and 12% nationally (ibid). 4 Need for Paradigm Shift and State AccountabilityDespite some progress over the last decade in improving health status and outcomes, Rajasthan remains a state, where health indicators remain below the national average. Also, health indicators vary across social groups, genders, and regions – reflecting inequities in access to and utilisation of services (World Bank 2006). It is evident that in Rajasthan girls marry early in life, attain motherhood when still young (less than 18 years of age) and in-herit the same attitude and aspirations as their mothers. Pro-grammes related to reproductive and child health are curative, but not preventive: they deal with weak children and not the cause, namely, weak adolescent girls being pushed into early motherhood. It is important to break the intergenerational cycle of high fertility, restricted reproductive choices of mothers, son preference, early age pregnancy – factors that have led to largehousehold size and, therefore, competition for food within the household and a high proportion of children who are chroni-cally energy deficient. Poor immunisation coverage leaves mothersprone to health risks. Weak mothers give birth to weak children without adequate nutrition which increases the possi-bility of weak adolescent girls (who again get married early) be-ing pushed into intergenerational cycles of poverty and ill health. Breakingthe intergenerational cycles of ill health is a must in the Rajasthancontext.Improved immunisation services based on a strategic frame-work of strengthened community outreach should be put in place, including better linkages between theAWWs and auxiliary nurse midwives (ANMs) for increased awareness and coverage of im-munisation. Improving social mobilisation and ensuring vaccine availability at the peripheral session site would go a long way in improving routine immunisation coverage and thereby reducing infant deaths due to vaccine preventable diseases.There is a need for making available specialised services for neonatal care at the healthcare institutions. Setting up special-ised newborn care units (SNCUs) could significantly improve the survival of severely sick neonates brought to health institutions.Scaling up integrated management of neonatal and childhood illnesses (IMNCI) in the state would create a significant impact in improving the early identification and referral of childhood illnesses in the community. Effective referral linkages coupled with IMNCI would significantly reduce infant mortality rate in the state.Institutional deliveries, efficient and affordable referral link-ages and availability of 24×7 emergency obstetric care at the first referral units (FRUs) would reduce the MMR in the state. Thus,bysetting up blood storage units, strengthening the FRU

FOCUS (2006): “Abridged Report, ‘Citizens’ Initiative for the Rights of Children under Six”, Focus on Children Under Six, December,

: “

National Family Health Survey-2 (NFHS-2)

(1998-99)”, Rajasthan, International Institute

for Population Sciences, Mumbai, May.

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