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--Jocalyn Clark (

While coverage of health care has increased considerably since the international community defined its millennium development goals to improve health around the world, health gains remain stubbornly elusive, especially in developing countries, and poor quality of care may be the reason why.

These are the conclusions of leading maternal health scholar Dr. Wendy Graham and her colleagues as they reflect on the global progress in women’s and children’s health in preparation for the global maternal health conference in Arusha, Tanzania this week that brings together 700 delegates and political leaders from around the world.

While the proportion of women and children receiving health care in the poorest countries is increasing, the authors say, improved health outcomes such as falling maternal or newborn deaths “have not matched expectations from the gains in the coverage of care.”  A recent Lancet analysis said only 13 countries in the world are expected to reach the millennium development goal (MDG) 5 to improve maternal health, and still an astonishing 300,000 women each year die trying to give birth. And while deaths among children under 5 years of age have declined in the past decade, still 7.2 million children died in 2011.

But focusing on coverage of care to redress these deplorable levels of preventable mortality is inadequate because it says only whether a person receives care, not whether that care was effective, safe, or a good experience for the patient. Quality of care involves examining these questions of effectiveness and appropriateness, and the necessary information to understanding the costs and consequences of delivering health care and improved health, but it has been a neglected area of international research and focus, and regrettably, quality of care “has not achieved the status of a political priority”, Dr Graham and colleagues say.

Last year a DFID report emphasized the importance of quality of care as a tool for achieving the MDGs. DFID estimated the economic and social costs of maternal and newborn mortality to be US$15 billion a year in lost productivity, whereas implementing quality care, including facility-based births and strengthening health systems, in 49 of the world’s poorest and aid dependent countries was said to be US$2.5 billion in 2009, rising to US$5.5 billion in 2015.

Quality of care must become the new priority in global health, Dr. Graham and colleagues say. It requires deliberate focus and investment in better data for measuring quality including adverse events, and the presence or absence of basic infrastructure such as safe water and sanitation in health clinics and hospitals. Understanding quality of care and its relationship to improved health also requires collecting information on women’s owns views about their care, which can differ markedly from how health planners and systems regard quality.

These are the personal views of Siddharth Chatterjee  and do not reflect those of his employer, the International Federation of Red Cross and Red Crescent Societies. Follow him on Twitter: @sidchat1

Since India’s independence, the mammoth task of feeding its hundreds of millions, most of whom are extremely poor, has been a major challenge to policymakers. In the coming decades, the issue of food insecurity is likely to affect almost all Indians. However, for the poorest amongst us, it could be catastrophic. India ranks 65 of 79 countries in the Global Hunger Index. This is extremely alarming.

In the past few years, uneven weather patterns combined with over exploited and depleting water resources in various parts of India have wreaked havoc on food security, particularly for small and marginal farmers, as well as the rural poor.

The recently launched Global Food Security Index (GFSI) estimates that in 2012, there are 224 million Indians, around 19 percent of the total population, who are undernourished. The same report also estimates that while the Indian government has various institutions designed to deal with the impact of inflation on food prices, it only spends 1 percent of agricultural GDP on research to build food security for the poorest. Overall, India ranked 66th on the GFSI. It is estimated that one in four of the world’s malnourished children is in India, more even than in sub-Saharan Africa.

Water insecurity, further exacerbated by climate change, is arguably the most important factor for India’s food security. India’s total water availability per capita is expected to decline to 1,240 cubic metres per person per year by 2030, perilously close to the 1,000 cubic metre benchmark set by the World Bank as ‘water scarce’.

Factors such as increasing usage, poor infrastructure, and pollution have led to a decline of water quantity and quality in India. Climate change, meanwhile, is expected to cause a two-fold impact.

One, increasing temperatures have hastened the rate of melt of the Himalayan glaciers, upon which major Indian rivers like the Ganges, Indus and Brahmaputra depend.

Second, the effect of climate change on monsoons in India will cause them to become more erratic, arriving earlier or later and lasting for shorter, more intense periods of time. India’s farming communities depend overwhelmingly on the monsoon, as their cropping patterns are built around it. The combined effect of climate change and over exploitation is violating the water cycle, degrading aquifers and  eroding ground water resources.

Over 50 percent of agricultural land in India depends entirely on groundwater. In North and Northeast India, where perennial rivers (rivers that have water year round, i.e. glacier fed rivers in India, such as the Ganges) sustain the agricultural land, have to deal with issues such as flooding caused by climate change impacts such as speedier glacier melt and erratic monsoons.

Meanwhile, farmers in states in West and South India, where rivers are seasonal, have to depend heavily on rapidly depleting groundwater resources.

The worst affected by this type of water-fuelled food insecurity are the small farmers of India. Estimates suggest that between 1995 and 2010, over 2,50,000 farmers in India, mostly from states like Andhra Pradesh and Maharashtra, killed themselves. Most of these farmers were drowning in vicious cycles of debt caused by failed monsoons and increasing droughts.

Responses to this crisis, including the National Action Plan on Climate Change, lay out various solutions and intended interventions, but most focus on the long term. To secure the future of India’s water resources vis-à-vis its agriculture in the future, it is important that certain steps be taken immediately. First and foremost, authorities will have to remove the mindset that water is an endless resource and the solution to water woes is simply a further development of India’s fast depleting groundwater.

Indeed, Dr. Mihir Shah, co-Founder, Samaj Pragati Sahayog (SPS) and member of the Planning Commission of India has stated that the ‘era of further water development may be over’ and emphasized that we have to urgently introduce more efficient water management. In this regard, promotion of irrigation efficiency will be crucial in the future.

Systems such as drip irrigation and System of Rice Intensification (SRI) to farmers across India will be essential. It will also be necessary to promote water conservation methods such as rain water harvesting, which has been successful in urban India, in villages as well.

At the same time, reducing inefficiencies and water wastage through conveyance losses will require governmental and NGO support in actions such as replacing faulty pipes and pumps.  Hence, India needs to invest on improving its water productivity, and any capacity to produce more food like rice with less water will be an important contribution to sustainable water and food security.

In short, India is facing a bleak future of becoming water scarce and painfully food insecure. How exactly are the country’s hundreds of millions, who depend entirely on agriculture for their livelihoods, as well as those that depend on agriculture for their food needs, to make ends meet?

Delaying this issue is simply not an option for India as this could lead to increased instability, poor human development and enhance inter-generational poverty. India needs to ensure food security through sustainable development and create resilience amongst the most vulnerable in the country: the poor.

(A woman carries firewood in Gujarat on Aug. 6, 2012, as others rest under a tree after they migrated because of a water shortage. Reuters photo: Ahmad Masood)

(Visit AlertNet, a service of the Thomson Reuters Foundation)

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The Direct Taxes Code (DTC) will be in focus this year. Individuals will seek more clarity on income tax slabs and the investment instruments eligible for tax exemptions. Options like tax-saving funds (ELSS) may no longer be eligible for tax breaks going ahead.

Reuters India asks its readers to don the finance minister’s cap and tell us what shape they would give to the budget.

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