WHO states that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”(Health and Well-Being, n.d.). Health is a “critically significant constituent of human capabilities” which means equality in availability of healthcare is crucial for social justice since it is an essential enabling component for a person to flourish as a prosper human being. Thus, inequalities in health services and care are a prime concern which is a barrier for developing nation(Banerjee & Roy Chowdhury, 2020). In terms of improving equality, eliminating poverty, and promoting social capital, maternal health is critical for every nation’s development(REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRAMME, n.d.). In recent years, there has been a lot more emphasis on children's challenges and improve their health and wellbeing. Children are gaining significant attention as they are sensitive to disease and require special care, and also for what they will be in future in building a sound human capital, families, fuelling the workforce, and assuring the viability of democracy and help in the development of the country(Council (US) & Medicine (US), 2004). The millennium development goal endorsed in UN summit of 2000 for the year 2015 the goal 4 and 5 focused on to reduce child mortality and improve maternal health(Affairs, 2016). The MDG saw significant progress in health targets for improving the quality of care for the maternal and child health with a 44 percent decrease in maternal mortality rate, of which approximately 22 percent of them are living in South Asian countries(Akseer et al., 2017). Thereafter the sustainable development goal 2030 agenda was adopted in 2015 whose goal 3 clearly focus on ensuring healthy lives for all and promote well- being for all ages. The goal of WHO is to reduce the global maternity mortality ratio to less than 70 per 100000 live births by 2030(Affairs, 2019)... After independence the first national health policy came into effect in 1983 which focused on preventive, primitives and rehabilitative aspects of health also a progressive, time-bound programme for establishing a well-distributed network of complete primary healthcare, connected with extension and health education program, and planned in the context of the reality on the ground that individuals can solve basic health problems on their own(Nhp_1983.Pdf, n.d.). In 2002 the second health policy was launched with aim of improving the Indian public’s health to an acceptable level by improving infrastructure in existing institutions and the public health system can be decentralised for better outcome(National Health Policy 2002 (India), n.d.). The context has changed in the since the last health policy of India came 14 years before, and the primary aim of the National Health Policy, 2017, is directed to advise, clearly articulate, solidify, and prioritising the authority role in building health sector infrastructure in every direction like investment, medical management, disease prevention and promotion through cross-sectoral activities, access to technologies, human resource development, and encouraging medical diversity. Improve health status by unified policy action across all sectors, and expand preventative, promotive, curative, palliative, and rehabilitative services provided by the public health sector with a focus on quality and regaining trust in public health services(National_health_policy_2017.Pdf, n.d.).WHO stated universal health coverage as “that all individuals and communities receive the health services they need without suffering financial hardship also includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course”. One of the goals that countries around the world established when they adopted the SDGs in 2015 was to achieve universal health coverage. It also supports the WHO’s purpose of the right to the best possible health, Health for All, and the Sustainable Development Goals. By 2030, nearly 18 million additional health workers will be required to satisfy the SDGs' and UHC objectives' health workforce requirements. Low income and lower-middle income countries have the major supply and demand gaps of the health employees. By 2030, the increased demand for health personnel is expected to contribute an estimated 40 million jobs to the world economy(Universal Health Coverage (UHC), n.d.). During 1990 and 2019, the new born death rate was remarkably low, falling from 37 deaths per 1000 live birth to 18 deaths per 1000 live births, while the worldwide maternal mortality rate declined by around 38% during 2000 and 2017. Nearly every day, over 810 maternal individuals die, many of which are preventable and treatable. Every day 6,700 children under 1 month age die due to lack of proper antenatal and prenatal care(UN-IGME-Child-Mortality-Report-2020.Pdf.Pdf, n.d.). During year 2019, around 2.4 million infants have died globally, with approximately 1.9 million of births were stillborn. UHC definition in India is “ ensuring equitable access to cheap, accountable, appropriate health services of assured quality (motivational, preventative, curative, and rehabilitative) for all Indian residents living in any area of the country, regardless of income level, social status, gender, caste, or religion, as well as public health services addressing the health determinants available to individuals, with the government working as sponsor and facilitator but also not only provider of health services”(Universal Health Coverage | National Health Portal Of India, n.d.).
Advancing toward the Millennium Development Goals (MDGs) and then the Sustainable Development Goals (SDGs) to improving reproductive maternity, new-born, and child health (RMNCH) has gained recognition on the world level(Kothavale & Meher, 2021). Measuring coverage of reproductive, maternal, new-born, and child health (RMNCH) services is required to monitor achievement of the Sustainable Development Goals (SDGs), which succeeded the Millennium Development Goals (MDGs). The accomplishment of universal coverage of health interventions is the major focus of these goals. Universal health coverage (UHC) implies equality in health services as well as an increase in the total coverage of RMNCH interventions, and it is claimed that coverage measurements play a pivotal role in identifying policy approaches directed at accomplishing universal coverage and the SDGs(Https://Doi.Org/10.1371/Journal. Pone.0258244, n.d.).
The central aim of national health goal under the national rural health mission and SDGs is the improvement of the maternal and child healthcare. Indian government’s “call to action summit” which was held in February 2013 organised by the ministry of health and family welfare set in motion the reproductive, maternal, new born and adolescent healthcare strategy to trigger the main initiatives of reducing maternal deaths and child mortality. This strategy is built on the concept of continuous care and is very comprehensive in nature and design which enclose all the assessment that is to bring reproductive, maternal, child and adolescent health care all under one roof and aiming on the well thought out wheel of life approach. This strategy main aim is to increase and improve the child survival rate in India through the coverage of overall life. The characteristics of this strategy is to strengthen the health infrastructure, demand supply chain, management of health structure and building sound human resource.
To know the magnitude of the problem in the maternal and child health care that needs to be focused is important. Around 2,87,000 maternal deaths were recorded in 2010 globally and the global maternal mortality rate is 210 deaths per 100000live births. The sub-Saharan region and south Asia comprise of the 85% of the total burden of the world of maternal death in 2010. According to country level India constitutes of the 19% (that is around 56000 in absolute terms) of the total maternal deaths. In India nearly 20% of total global child death is recorded and it is the highest number of deaths of under 5-year child of 15.8 lakhs of all country and child mortality is also high 59 per 1000 births. There is a rural-urban measurable difference in under-five mortality, which levels at 28 percent; nevertheless, the good trend is that rural child death has declined faster than urban. There is also a 9-point gender disparity in the under-five category (female: 64; male: 55), highlighting the importance of addressing socioeconomic determinants of health such as the position of women and the girl child, female literacy, and women's socioeconomic empowerment.
For the planning and policy implication on the area where condition is worse it is important to know the main reason of poor maternal and child health and death in India. the reason of maternal mortality can be identified as medical, social, economic and due to poor public health system. Medical reasons might be either direct or indirect. According to SRS (2001–03), the most prevalent direct medical leading cause of maternal death are postnatal haemorrhage (37%), sepsis due to infection during pregnancy labour, and postnatal period (11%), illegal abortions (8%), hyperparathyroidism (5%), and premature labour (1%). (5 percent). These illnesses are typically preventable and treated when detected. Anaemia and malaria are the most common 'indirect causes' of maternal mortality. Children who die under age of 5 the main reason is infection which is curable. According to WHO-CHERG 2012 the reason of child death in India are (a) neonatal causes (52%), (b) pneumonia (15%), (c) toxic megacolon disease (11%), (d) measles (3%), (e) injury (4%), and (f) unspecified causes (15 percent). Premature birth (18%), that is, childbirth before 37 completed weeks of gestation, infectious diseases (16%) such as pneumonia and septicaemia, and asphyxia (10%), that is, incapacity to maintain breathing soon after birth and hereditary reasons, are the primary causes of neonatal mortality (5 percent) of which the pre mature birth is main cause of new born death. Majority of death of mother and child is due to three delays: first delay in determining to look for care second delay in getting to proper health institution and third is delay in getting treatment in the hospital. The RMNCH strategy is adopted to look inti the institutional drawbacks and improve the death caused by three delays(RMNCH + A_Strategy.Pdf, n.d.).
In 2010–11, the Annual Health Survey was conducted in the 9 high empowered and focused states (Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand) that gives a clearer image of the maternal and child healthcare status in states with a high incidence of maternal and child mortality. An examination of data from 284 districts in these nine states reveals significant inter-district difference. Like, Madhya Pradesh is a state recorded with a high under-five mortality rate, the inter-district variation ranges from 89 count between Indore (51) and Panna (140), whereas Uttar Pradesh with a 90-point variation range between Kanpur Nagar (52) and Sherawat (140)(Analysis Annual Health Survey AHS 2010-11(1).Pdf, n.d.).
There is a study that focused on inequality in coverage of maternity, neonatal, and child health (MNCH) care services across household wealth quintiles in India and its states examined Composite Coverage Index (CCI) in MNCH care using the District Level Household and Facility Survey conducted in 2007-08. At the national level, a mean overall coverage of 45 percent was calculated, ranging from 31 percent for the lowest quintile to 60 percent for the wealthiest quintile. Furthermore, the mean overall CCI showed a significant state-by-state variance among wealth quintiles. Almost half of Indian states and union territories had a 55 percent coverage rate in MNCH care services, which requires special attention(Singh et al., 2013). In Afghanistan this is the first thorough, systematic evaluation of RMNCH, nourishment and health benefits, and contextual factors of RMNCH results(Akseer et al., 2016). In Ethiopia a low-income country coverage of these intervention is less, a cross sectional study was done to analyse the continued utilisation of health care services of different wealth quartile(Tiruneh et al., 2022). The aim of this study was to use nationwide survey of Nepal Health Facility Survey (NHFS) 2015 data to evaluate the interconnected services of family planning and maternal and child health (FPMCH), which are essential elements of health institutions to provide quality maternal and neonatal care, which can be helpful in meeting the sustainable development goals (SDGs)(Health Facility Readiness to Provide Integrated Family Planning, Maternal and Child Health (FPMCH) Services in Nepal: Evidence from the Comprehensive Health Facility Survey, n.d.). The previous study has used CCI index intensively to measure the coverage of maternal and child health care.
Objective
This study aims to measure the inequality in the coverage of RMNCH strategy for different states according to place of residence. We will analyse the difference in utilisation of health care by comparing the NHFS-4 (2015-16) and NHFS-5(2019-21) data for the people residing in rural and urban area.