A/HRC/14/20/Add.2 or pregnancy than in any other country in the world. In India, a maternal death occurs every five minutes. Crucially, the vast majority of these deaths are preventable. While there are about 300 maternal deaths for every 100,000 live births in India, in some of the country’s states, the situation is very much worse. In Uttar Pradesh, for example, there are over 510 — and in Rajasthan 445 — maternal deaths for every 100,000 live births. Kerala does much better, at 110. Although the rate of maternal deaths remains alarming, it is declining. But, at the present rate, neither India, nor any of its states, will reach their maternal mortality targets for 2015. 95. Why is India’s maternal mortality so much worse than the comparators? Why is progress so slow that neither India, nor any of its states, will reach their internationally agreed targets? It is tempting to answer these questions by pointing to a lack of funds. But this would be only partly right. Funding is an issue: according to the Government’s NRHM, India’s “public spending on health is amongst the lowest in the world”.56 The Government is committed to increasing this funding from 0.9 per cent of gross domestic product (GDP) to 2–3 per cent. Of course this commitment is welcome, but 2–3 per cent of GDP remains woefully little.57 Also, there is no clear path to reach anywhere near the 3 per cent target. India has a legally binding international human rights obligation to devote its maximum available resources to the health of its population. Public spending on health that continues to bracket India with “the lowest in the world” is in breach of this international legal obligation. 96. But inadequate funding does not provide a complete explanation for India’s startling maternal mortality data. A district collector told the Special Rapporteur that, due to bottlenecks in the system, in the last complete fiscal period only 55 per cent of his health budget was utilized. This is not an isolated case. While these bottlenecks must be removed as a matter of urgency, they suggest that the problem is not entirely a lack of funds. More resources without other changes — some of them identified in this report — are unlikely to help a great deal. 97. So is the problem simply one of bottlenecks that can be addressed by better maternal health policies and plans? Over the years, some of India’s maternal mortality policies have been deeply flawed and international organizations have a heavy responsibility for this. From the 1960s, for example, it was a mistake to depend so heavily on traditional birth attendants and to neglect skilled birth attendance. Between 1997 and 2004, the Reproductive Child Health I programme was a major step forward, but the health system was not robust enough to deliver the designated reforms. Today’s NRHM is a great improvement that aims “to transform the public health system into an accountable, accessible and affordable system of quality services”.58 It has weaknesses but, on the whole, NRHM is an impressive policy document. 98. So, in all these circumstances, why is it that India’s maternal mortality has not gone down more over the last two or three decades? First, there is a yawning gulf between India’s commendable maternal mortality policies and their urgent, focused, sustained, systematic and effective implementation, reinforced by robust and independent monitoring, accountability and redress. Second, the problem is aggravated by buck-passing. Under the Constitution, India’s health services are the 56 57 58 GE.10-12866 India, National Rural Health Mission, para. 2. Compare public expenditure on health as percentage of GDP: Brazil, 4.8 per cent; Cuba, 5.5 per cent; Namibia, 4.7 per cent; Chile, 2.9 per cent. Figures from United Nations Development Programme, Human Development Report 2007–2008 (New York, 2007), table 6. India, National Rural Health Mission, 2005, para. 2. 21