Suitability of HDI for Assessing Health and Nutritional Status Author(s): Grace Maria Antony, K. Visweswara Rao, N.

Balakrishna Source: Economic and Political Weekly, Vol. 36, No. 31 (Aug. 4-10, 2001), pp. 2976-2979 Published by: Economic and Political Weekly Stable URL: http://www.jstor.org/stable/4410947 Accessed: 29/06/2009 03:39
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for Assessing Health Suitability of HDI and NutritionalStatus

This paper attempts to studv the validity of the Human Development Index (HDI) which is used widely to measure health inequality and standard of living. It examines the behaviour of HDI with variations in demographic, socio-economic, health, dietary habits and nutritionalstatus and studies the correlation of these indicators with HDI.
MARIAANTONY, VISWESWARA N BALAKRISINA K GRACE RAO,

ublic health is the art of applying science in the contextof politics to reduceinequalitiesin healthwhile ensuringthe best health for the greatest number [WHO1998].Everyhuman being and hasadesire a healthier better for world. WHOreport(1998) indicatesthathealth expectancyis more importantthan life expectancy.The impact of poverty and malnutrition health has widened the on the gapbetween richandthepoor.A recent reviewby the UnitedNationsConference on Tradeand Development(2000) suggests that the global economy has been Evenamong rising inequality. experiencing Indianstates, there is inequalityin the gradesof development.In India though are and hunger malnutrition common,the extentandpattern differfromstateto state. Nutritionalstatus of the populationdeand pendsonfoodconsumption notmerely on food production availability.The and of underemployproblem unemployment, mentandpoverty severein developing are like countries India,andhas an impacton statusof the commonpeople. nutritional therewas anoverallimprovement Though in the standard living, the disparities of betweenthe rich and the poor have also increased. Healthof the populationis directly related to economic efficiency, educationalstatus,accessibilityto basic healthservices and also on politicalstaIn bility,socialandcultural development. remains poverty spiteof economicgrowth, and an appreciablenumber of people due remains undernourished to lack of Econopowerand morbidity. purchasing mistssee povertyas theprincipal causeof the largeandwidespread incidenceof undernutrition. HDI is extensivelyusedto measurethe standardof living of a country [UNDP 1998]. According to Human DevelopmentReport(1998), India'sHDI is lower 2976

than 0.5 and was classified along with less developed countries. Later Anand Sudhirand Sen (1999) suggesteda new method for calculation of the income indexandHDI andit showedthatIndia's HDI value is higher and was grouped along with the mediumdevelopedcountries [UNDP 1999]. Variationsin HDI among Indian states and their impact on health and nutrition are of interest for this study. The objectivesof this studyare:(1) To calculatethe HDIof variousIndian states; the HDI (2)Tostudy behaviourof withvariations in demographic,socio-economic, and habits nutritional dietary health, status; (3) To study the correlationsof these with HDI;and (4) To find the indicators relatedto HDI and best set of indicators of to studythe suitability the indexfor the of assessment healthandnutritional status of variousIndianstates. Human is by development defined UNDP as a processof enlarging people'schoices. The HDI is calculatedfrom the threeindices:(1) Life expectancy measurelonto attainment repto gevity, (2) Educational resentknowledge,and (3) Real GDP for the The meeting basicneeds. non-availability of data for many regions has always for causeddifficulties theevaluation the of suitabilityof this index. The details of calculationof HDI are providedbelow: Human Life Expectancy Development Index+ = Index13 (Income Index+ x(/3) Educational Attainment Index
Actual Value -

Life

Actual Value - Minimum =

Expectancy
Index

Value of 25 years MaximumValue of

85 years - Minimum

Value for 25 years IncomeIndex log Y-logYminimum (Sen's Index 19993,13)=

ogYmaximum

where Y is income. Educational Attainment Index = (2 x Adult LiteracyIndex + CombinedGross Enrolment Index)Adult literacyindex is calculatedfrom the combined adult literacy rate of the population.Combined gross enrolment indexis calculated considering comthe by bined primaryand secondaryschool enrolmentratios. Since our interestis an iatenr e comin incomesof parison India,the maximum Indianstatesareconsidered the calcufor lationof income index andHDI is calculated(method1).The incomeindexis also calculatedusing the world, maximumincome in the denominator thus HDI and valueis calculated (HDIby method2, i e, UNDP method).The agreement between thesetwo methodsis foundby calculation of the correlation coefficientand also by the and Demofinding sensitivity specificity. socio-economic, health,food and graphic, nutritional status indicators availablefor Indian states have been collected from variousreportspublishedby the government of India and other relevant Details of indicatorsused organisations. are providedin Table1. The relationships HDI with all other of healthand socio-economic, demographic, nutrition indicators are assessed with calculation the correlation of coefficients.

logYminimum

Minimum Value
Index =

Maximum ValueMinimumValue

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Based on the correlation and regression states/unionterritoriesusing regression some difficulties in explaining the real some of the missing values methods.Non-availability some of the standardof living and HDI. However of procedures, of indicators stateswereextrapolated. indicatorsat same time periods caused maximumeffort is made to collect the for HDI was calculatedfor 22 Indianstates/ union territories...One way analysis of Table 1: Details of Indicators Studied variance (ANOVA)was utilisedto comIndicatorsUtilised parethe differencesin variousindicators Sets of Indicators by the grades of HDI (HDI<0.65 and Demographic Lifeexpectancy in years at birth and 5 th year formale and female; HDI>=0.65). Totalfertility rate, crude birthrate, crude death rate, maternal rate for infantmortality for mortality (MMR) 1,000 livebirths; Discriminant rate(lMR) function analysishasbeen male and female; utilised tracing bestsetof indicators for the rate Mortality of 1- 5 years oldchildren(maleand female), population associated with the variationsin HDI. growthrate(percent). Discriminant functionanalysis is useful Socio-economic GDP (Gross Domestic Product), Percentage of people underpovertyline, for situations,where we want to build a Maleand female literacy(per cent), model based on linear combinationsof Femaleandmalegross schoolenrolment and ratio(primary secondary), the predictorvariablesthat provide the Governmentexpenditureon education(percent) Prevalenceof contraceptiveuse(per cent), bestdiscrimination between the groups. Health of Availability sanitation( per cent), Thisprocedure whichwas simultaneously Healthservices and safe drinkingwater(percent), developedby well known statisticians Prevalenceof severely and moderatelyunder-weight children less of R A FisherandP C Mahalanobis also can than fouryears. Cereals, pulses, roots and tubers,spices, sugar, meat and flesh give the numberof cases correctlyand Food intake(perconsumpand foods, fruits,milk milk products,green leafyvegetables and other The set tion unit/day in grams) incorrectly assignedto thegroups. vegetables. of variablesto be of use was found by: Nutrients intake Totalfat, totalcalories, total protein. (a) Testingthe significanceof the differ- (perconsumptionunit/day) enlcesbetween the mean values of the variables for considered groups.Those of Table 2: Human Development Index(HDI) of Indian States the variables showing significance of States /UnionTerritories HDI Rank differencesare taken for use in the disMethod Method2** Method2** Method1' criminant function.(b) Best set of vari0.603 0.461 14 16 ablesthataredifferent betweengroupscan AndhraPradesh Assam 0.546 0.461 17 17 bearrived bythisprocedure at [Visweswara Bihar 0.415 0.371 22 22 Rao 1996]. The variablesprovidingsig- Gujarat 0.695 0.527 8 10 nificantutility were tested using an ap- Haryana 0.695 0.511 9 12 0.628 0.491 12 13 'F' test which is also knownas Karnataka propriate Kerala 0.756 0.635 5 1 varianceratiotest. Pradesh 0.501 0.410 19 19 Madhya The formulafor F is Orissa 0.499 0.416 20 18 0.764 0.557 4 6 Punjab (nl n2) D2 (N-P-1) 0.505 0.407 18 20 Rajasthan (nl+n2) (N-2) P TamilNadu 0.704 0.556 7 7 nl, n2 are numberof samples in each UttarPradesh 0.474 0.398 21 21 0.657 0.535 11 8 of West Bengal group,N = nl+n2 andP is the number 0.839 0.611 1 3 takenintoconsideration. is the Goa variables D Mizoram 0.750 0.611 6 2 distancebetweenthe samplemeansmea- Arunachal Pradesh 0.623 0.467 13 15 0.819 suredin units of standard deviationand Delhi 0.586 4 2 0.662 0.534 10 9 is known Mahalanobis as distance. 'F' HimachalPradesh The Maharashtra 0.781 0.580 3 5 ratiois used for finding the significance Meghalaya 0.585 0.471 15 14 level of D2. The proportion cases that Tripura of 0.582 0.525 16 11 ** 0.640?0.119 0.506?0.076 *"' arecorrectlyclassifiedormisclassifiedas India highandlow HDI andhencethe percent- Notes: * HDI The income index is calculatedusing the maximumincome for Indianstates. * The income index is calculatedusing the maximum income forcountries(UNDPmethod). age of misclassificationis also foundout ** Mean?SD. dicriminant function analysis. using SPSS software package (version 10.0) Table 3: Human Development Index (HDI) by Regions of India has been made use of for the statistical States/UnionTerritories HDI(Mean? SD) Regions of India analysis. The basic data needed for the calcu- South AndhraPradesh, Karnataka, TamilNadu,Kerala 0.673?0.070 a lation of HDI was available for only North Delhi,Haryana,HimachalPradesh, Punjab,Rajasthan 0.689?0.120a 0.488?0.019 bc MadhyaPradesh, UttarPradesh 16 states.Since some of the information Central East 0.524?0.123 C Bihar,Orissa, West Bengal was notavailable a few states,the life West for Maharashtra 0.772?0.072 a Goa,Gujarat, at and Arunachal expectancy birth maternal mortality North-east Pradesh,Assam, 0.617?0.079 ac ratehavebeenestimated theircorrelaMeghalaya, Mizoram,Tripura by tionwithinfant rate Hence Note: Variations superscriptsindicatesignificanceof differencebetween regions (P<0.05). mortality (IMR). in HDI has been calculatedfor all the 22 'F'ratio withlog transformation(df)=3.880(5,16). 0.05). (P< Economicand PoliticalWeekly August 4, 2001

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information about variousindicatorsfor similartime periods.

is notdifferent betweenthe two gradesof female literacy. The development in HDI (Table4). Maharashtra betterdue to the industrial is Tamil Nadu, Maharashtra and disparities development. "Interregional interstate in in HDIareseen due to variations social andWestBengalregistered Results birth declining The of development. development Kerala anddeathrates.In West Bengalandother HDI of Indianstates is calculatedand is better to thehighest of maleand less developedstates,however,birthand due rate the credibility this index in explaining of Table 4: Mean?SD Values of the Indicators In Indian States by Grades of HDI the real statusof standard living, lonof Grades of HDI 'F' Ratio gevity and knowledge,health and nutri- Indicators <0.65 >0.65 tionalstatusof the communityhas been studied. The results are presented in Lifeexpectancyat birth Male 57.95?2.24 63.83*3.02 19.53** Tables2 to 6. Female 58.38?3.40 15.1' 65.96?4.35 HDIis calculated usingthemaximum Infantmortality rate by 98.86:21.35 61.92?18.72 8.53* incomeof Indian states andalso by using Male Female 95.07?23.04 60.82?21.27 5.73* the world maximumincome of UNDP Maternal rate 5.14?1.31 3.40?1.0 8.43 mortality (per 1,000 live births 8238?2112 14104?4671 16.56** are in method provided Table2. Sinceboth GDP (Rs per capita/year) HDIsarewellcorrelated = 0.944,p<0.01) Literacyrate(percent) (r Male 65.00?9.77 80.09?8.25 15.78** 47.00?19.27 6.12* 62.55?14.38 andthe sensitivityandspecificityrespec- Female School enrolmentratio are 100 per cent and 92 per cent, (primary secondary) tively and 73.05?10.68 84.22?12.03 4.89 * one can be used in place of the other. Per cent of people below povertyline 35.99+10.22 25.25?8.66 6.24 34.14?17.71 58.09?14.88 8.462* usage (percent) Valuesof HDI are lower with UNDP in- Contraceptive Milk milkproducts and 70.90?53.12 8.77 * 158.40?97.17 come methodbecauseof the lower value Sugar (gm/day/cu) (gms/day/cu) 14.27?8.94 32.25?11.12 16.03** Totalcalories intake(kcal/day/cu) 2149? 226 2150? 147 0.00 of rupeeat the international level. HDI of Indian States The HDI is higher for Goa, Delhi, Kerala and Punjab. Goa Maharashtra, comes firstandDelhi is rankedsecond in human Bihar,Uttar Pradesh, development. and Orissa,MadhyaPradesh,Rajasthan Assamhavea low level of human development(Table2). All IndiaHDIis 0.64 with a standard deviationof 0.119. Northern andwestern regionshavehighervaluesof are HDI.Since the variations high among was regions,log transformation utilisedto theHDIvaluesandANOVAandmultiple comparison test procedure was done. TheHDIvaluesaresignificantly different between the various regions of India (p<0.05). Regions of west, north and southhavemostlyhigherHDI valuesthan the regions of central and east India (Table3). Lifeexpectancy birth, infantmortality at rate, toddler mortality rate, maternal mortalityrate and birthrate, are significantly differentbetween the states with HDI lowerthan0.65 andHDIof 0.65 and Per higher. capitaincomesandeducational are diflevels of parents alsosignificantly ferent between stateswithlowerandhigher levels of HDI. Primary school enrolment ratiois notdifferent stateswhereas between school enrolment varies. secondary of Prevalence contraceptive usage is also higherin stateswithHDIof 0.65 or above. The meanintakeof qualitative foods like milk is significantlyhigherin stateswith intake HDIof 0.65 orabove.Protein higher
Totalproteinintake(gm/day/cu) Totalfat intake(gm/day/cu) 64.9?15.1 24.67?9.30 63.7? 9.4 40.54?10.13 0.04 13.39 ** Note: Allthe F ratioswhichare markedwithstars are only significant ** *p<0.01, p<0.001. Table 5: Correlation Coefficients Indicators Birth rate Infant rate mortality Male Female Toddlermortality rate Male Female Maternal rate mortality (per 1,000 live births) Per cent of people who have access to safe drinking water children <4years Per cent of severely and moderatelyunder-weight Per cent of people underpovertyline Prevalenceof contraceptiveusage of Availability sanitationfacilities of Availability healthservices intake Sugar Totalenergy intake Totalproteinintake Totalfat intake Note: Correlation coefficientsmarkedwithstars are only significant. *p<0.05, **p<0.01. Table 6: Order and Best Set of Indicators Different between Indian States by Grades of HDI Component Orderand Best Set of Indicators Lifeexpectancy at birth(male) (1) GDP (2) Lteracyrate(male) Prevalenceof contraceptive usage Sugar intake Totalfat intake (1) GDP (2) Literacy rate(male) (3) Prevalenceof contraceptive usage Standardised D2 Coefficients 'F' Ratio PerCent Correctly Classified 15.22 16.56 23.77 13.18 13.59 13.39 81.8 95.5 77.3 81.8 81.8 of Some of the Indicators with HDI Correlation Coefficient -0.792** -0.721* -0.727** -0.877** -0.875" -0.763** 0.317* -0.561*' -0.643** 0.476* 0.531** 0.427* 0.666** -0.233 -0.027 0.570**

indicators Demographic Socio-economic indicators Healthindicators Food Intake Nutrients Pooled

1.00 0.936 0.895 1.00 1.00 1.00 0.896 0.114 0.796

2.91 3.16 9.58 2.85 2.87 2.68

19.84

25.71

95.5

Note:Allthe 'F' ratiosare significant(p<0.001).

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death rates are still relatively high. The predictor variablesfor logistic regression statusof the community.But the approselection priateestimatesare not readilyavailable, factors closely associated with like stepwiseselection,forward important low dietary intake are poverty and low andbackward elimination gave simi- and a lot of expertiseis neededto collect also and maintainthe information. B3 purchasingpower" [EPW Research Foun- lar results [VisweswaraRao 1996]. The variationsin humandevelopment dation 1994]. References The poverty line defined by government between Indianstates was studied with of India is negatively correlated with utilisationof availabledata for Indiaby G M, K Visweswara Rao and N HDI(r = -0.643). Since combined adult regions.The index was higherfor states/ Antony Balakrishna (2000): 'Validity of Human territories ofGoa,Delhi,Maharashtra, Development Index', Indian Journal of literacy is utilised in the calculation of union educational index,HDI the correlation of Keralaand Punjab. The index was lower Nutrition and Diet, 37(6), January. like Uttar CentralStatisticalOrganisation(1998): Statistical female educational status and male edu- forstates Bihar, Pradesh, Madhya Abstract of India, Department of Statistics cational status is studied separately to see Pradesh,Orissa, Assam and Rajasthan. ProgrammeImplementation,Governmentof the differences. Male literacy rate has a The best indicators, which determine India, New Delhi. are higher correlation with HDI than female humandevelopment, life expectancy Departmentof Woman and Child Development, of atbirth males,percapita income,literacy Governmentof India (1998): India Nutrition literacy rate (the correlation coefficients for male and female literacy rates respec- of males andprevalence contraceptive of Profile, Ministry of Human Resource Development, New Delhi. tively are 0.811 and 0.505 with p<0.01). usage. Mortalityrate of toddlers,infants infantandmaternalmortalityrates andwomenof child-bearing werealso EPW Research Foundation (1994): 'Special Toddler, age Statistics-8 Indicators for ,Social are also well correlatedwith HDI (p<0.0 1). well correlated in thoughnotappeared the Development for India-II, Inter State This perhaps is Grades of underweight in children and best set of discriminators. Disparities, Economic and Political Weekly, variables socioof Vol XXIX(21), May 21. availability of health services are with dueto other dominating correlationcoefficients of-0.561 (p<0.0 1), economic status.Considering dietary Foundation for Research in Health Systems the (official publication)(1998): HealthMonitor, and 0.427 (p<0.05). The availability of habits,it is observedthatintakeof sugar Print Point Communications, 22, Umiya withincrease HDI. in sanitation facilities, health services and andfathasincreased Vijay Society, Satellite Road, Ahmedabadprevalence of contraceptive usage are also Milk and fruits consumption are also 380015, India. well correlated with HDI. The correlation observed different betweenstateswithlow Government of India (1999): Economic Survey 1998-99, Ministry of Finance, Economic coefficients of various indicators with HDI andhigherHDIvalues. Earlier studieson Division. are provided in Table 5. healthindex and physicalqualityof life A and C Chandrasekar (1990): The best demographic indicator of dif- for states of India showed that Kerala Indrayan, 'Statistics of an Index of Health Based on ference between states with low and high standsfirst [Indrayan and Chandrasekar FactorAnalysis:IndianExample',Statistics in HDI values is life expectancy at birth of also Health and Nutrition in K Visweswara Rao, 1990].The availableindicators show G Radhaiah and V Narayana (eds), Promales. Toddler mortality rate is also an thatKerala stands ineducational first status ceedings of the National Seminar of Indian rate important variable of difference between of females and males, low mortality Society for Medical Statistics, National low and good grades of HDI, though the of all age-groups, betternutritional status, Institute of Nutrition, Hyderabad. better health index and higher physical Ministry of Health and Family Welfare, Governimportance is lower. The socio-economic of indicators observed best for differences quality life [Indrayan Chandrasekar and ment of India (1994): Health Informationof India, CentralBureauof Health Intelligence, areincome andeducational status of males. of 1990;Government India1999;Ministry Directorate General of Health Services, and Welfare1994,1996]. Prevalence of contraceptive usage is also of Health Family Pushpa Bhavan, New Delhi. the incomeof Kerala observed to be useful for discrimination Perhaps lowpercapita (1996): Family Welfare Programme in India between the poor and good grades of HDI. slightlylowerstheHDIvaluecompared to Year Book 1995-96, Department of Family In The percentageof misclassification is only stateslikeMaharashtra. male-dominated Welfare, New Delhi. 22.7. The educational status of females countries like India, educational status NNMB (1996): Nutritional Status of Rural Population, Report of NNMB Surveys, enhancedthe differences between the poor of males has an influential role in deNational Instituteof Nutrition,IndianCouncil and good grades of HDI. This is true with ciding the expendituresof the family. of Medical Research, Hyderabad- 500 007, Kerala having high female literacy and Educatingand empoweringthe females India. better status of health [Ministry of Health will definitely improve the health and Sivakumar,A K (1996): 'UNDP's GenderRelated and Family Welfare 1994]. Intake of sugar nutritional of status thefamilyandthusthe Development Index: A Computation for Indian States', Economic and Political is more in states with higher HDI than in whole country.The calculationof HDI Weekly, Vol XXXI (14), April 6. states with low HDI. The percentage of will be betterwith inclusionof diet and Sudhir, Anand and Amartya Sen (1999): 'The status indicatorsand also by misclassification is only 18.2. The details nutritional Income Component in the HDI - Alternative are provided in Table 6. The total fat intake giving weightagefor females and males Formulations', Occasional Paper, United Nations Development Programmme,Human is also found to be different between states in the calculation life expectancy of index Development Report Office, New York. with low and high HDI. The total fat intake and educationalindex. United Nations Development Programme The dietaryintakedataof variousstates and animal fat intake are also well cor(UNDP) (1998,1999): Human Development relatedwith HDI [G M Antony et al 2000]. are basedon one-dayweighmentmethod Report, Oxford University Press, New York It Logistic regression analysis provided simi- of dietsurvey. mayhavevariations during Visweswara Rao, K (ed) (1996): Biostatistics, A Manual of Statistical Methods or Use in lar results as that of discriminant function differenttime periods.Hence the indicaHealth, Nutrition and Anthropology, in tracingthe best set of indicators torsof diet and nutrient intakehave their analysis Jaypee Brothers Medical Publishers, New different between low and high values of own limitations. is worthattempting It to Delhi. HDI. As shown in the earlier studies have detailsof morbidity and theirasso- WHO (1998): The WorldHealth Report: Life in

varioustypes of selection proceduresof

ciationstatewiseto decideuponthehealth

the 21st Century:A Visionfor All, Geneva.

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