Reducing Child Mortality in India

The initiative

In 1997, the Government of India launched the RCH programme, an initiative to reduce infant, child and maternal mortality rates. In 2000, the country signed the Millennium Declaration adopted at the UN General Assembly - which has as its fourth goal for 2015 that of reducing child mortality and as its fifth goal improving maternal health.[4]

In addition, the Indian government has adopted ambitious targets related to children that are in line with - and at times more ambitious than - the Millennium Development Goals (MDGs) through "five-year plans". These centrally sponsored schemes have increased public resources to key sectors, which included the RCH Programme II and the National Health Mission (NHM). The NHM comes under the Ministry of Health and Family Welfare (MoHFW).

The NHM implemented several initiatives to bring down the mortality rate of children across the country, including the following:

• "Emphasis on facility-based newborn care at different levels to reduce child mortality: setting up of facilities for care of sick newborns such as Special Newborn Care Units...
• "Capacity-building of healthcare providers [with training] being conducted under the NHM to train doctors, nurses and ANMs [auxiliary nurse midwives] for early diagnosis and case management of common ailments of children and care of the mother during pregnancy and delivery...
• "Management of malnutrition: Nutritional Rehabilitation Centres (NRCs) have been established for the management of severe acute malnutrition
• "Appropriate Infant and Young Child Feeding practices are being promoted in [convergence with the Ministry of Women and Child Development...
• "Universal Immunisation Programme (UIP): vaccination protects children against many life-threatening diseases such as Tuberculosis, Diphtheria, Pertussis [whooping cough], Polio, Tetanus, Hepatitis B and Measles."[5]

The challenge

In 1990, over 2.3 million infants died in India before reaching one year of age, the largest total of any country in the world. The country's infant mortality rate (IMR) in the same year was 88.3 per 1,000 live births and 125.8 for children under five years of age. The IMR in that year was under 10 for countries such as Singapore (6.2) and the United States (9.4).[1]

The main challenge was in reducing neonatal deaths, that is, infant deaths that occur within the first 28 days of life. The scale of undernutrition in expectant mothers and children posed a critical development challenge for India.[2] A 2014 UNICEF report noted the importance of the neonatal period of life. "A massive 45% of under-five deaths occur in the neonatal period - the first 28 days of life. Prematurity, pneumonia, complications during labour and delivery, diarrhoea, sepsis and malaria are leading causes of death for children under five years old. Nearly half of all under-five deaths are associated with undernutrition."[3]

The public impact

The programmes launched by the Indian government managed to achieve progress in reducing the country's child, infant and neonatal mortality, but fell short of the MDGs' targets:

• Child mortality rates have decreased to less than half of their 1990 levels. Under-fives deaths dropped from 12.7 million per year in 1990 to 5.9 million in 2015 - the first year the figure went below the six million mark.[6]
• A 2012 UNICEF report concluded that there had been a consistent decline in the IMR and Under-Five Mortality Rate (U5MR) in India. However, based on projections, at the existing rate of decline India was unlikely to meet the targets for the U5MR established by the MDGs for 2015.
• Six states in India were likely to achieve the IMR and U5 MR target of MDG-4: Tamil Nadu and Kerala in the South, Maharashtra in the West, West Bengal in the East, and Punjab and Himachal Pradesh in the North.
• By 2012, there was a small or nonexistent decline in the early neonatal mortality rate (ENMR), which was relatively static at around 30/1000 live births. The ENMR is an indicator of the quality of perinatal care.
• For the past decade, the IMR decline in urban areas was much less pronounced than in rural areas, narrowing the gap between the rural and urban parts of the country.[7]

Stakeholder engagement

There is evidence of collaboration between several parties in the creation of the programmes to reduce child mortality. In September 2006, the governments of India and Norway launched the Norway India Partnership Initiative (NIPI), to support the existing National Rural Health Mission. “NIPI is run by a partnership between the focus states, the government, UNICEF, the World Health Organization and UNOPS [the United Nations Office for Project Services]. The focus states are the key stakeholders in the partnership and NIPI works as a catalyst to help them innovate and find new ways of delivering health services.”[8] The key states are those Indian states in which the IMR is most severe.

As part of the push for MDGs4 and 5, Ethiopia, India and the US, in collaboration with UNICEF, co-organised a meeting called "Child Survival Call to Action: Promise Renewed" in 2012. The Government of India was one of the key sponsors of the meeting, whose purpose was to discuss future iterations of the national road map and prioritise the convergence of health and childcare services under universal health coverage.[9]

There were deficiencies, however, in the efforts to engage and educate Indian citizens. A report focused on the state of Maharashtra concluded that people often lack much of the basic information and resources necessary to improve their health and reduce the incidence of disease and child mortality. “Either they do not have access to accurate information, especially in rural areas and among those who cannot read or write, or they have received mixed, inconsistent, or insufficient messages about proper health practice. In the case of diarrhoeal diseases, for example, the message of correct management simply has not reached its audience in a consistent and sufficient way.”[10]

Political commitment

The Government of India has demonstrated continuous commitment to the improvement of child mortality rates in the country. Various ministries have implemented child-centric policies and programmes to address the issues related to child health. This includes the National Policy on Children (2013); the National Policy on Early Childhood Care and Education; Integrated Child Development Services (ICDS); and other initiatives focused on child development.[11]

With the commitments to achieve the MDGs, the government increased the implementation of national flagship programmes for education, reproductive and child health, child development, child protection, child nutrition, and water and sanitation. It also adopted the principle of "Sabka Sath, Sabka Vikas" (“together with all, development for all”), and stated that the "first claim on development belongs to the poor".[12]

A commissioner from the MoHFW's Child Health Programme stated in 2014 that: “The government has accorded the highest priority to improving newborn health and it has come out with special interventions to improve newborn survival”.[13]

Clarity of objectives

The initial efforts of the government to tackle the problem were relatively broad, but they became increasingly targeted, specific and measurable over time. The first RCH programme aimed to improve participation and the quality and coverage of existing welfare services and to extend the impact of such services to disadvantaged areas - but no measurable targets were set.[14]

India's health goals for 2000 included reducing the U5MR to less than 100 per 1,000 live births; the IMR to less than 60 per 1000 live births; and the perinatal mortality rate to less than 85 per 1000 live births.[15] For the MDGs, the goal for India was to reduce the U5MR by two-thirds between 1990 and 2015. The other metrics defined by the UN to measure the progress of these targets include the IMR and the proportion of one-year-old children immunised against measles.[16]

Strength of evidence

There is no evidence of pilot projects or examples for particular policy measures implemented. However, there is evidence of a good use of data to establish the priorities for different policies targeting infant mortality. The National Family Health Survey (NFHS) is one of the main sources of indicators for children's health and trends.

Knowing that low birth weight is a key predictor of malnutrition and a determinant metric of child mortality, efforts have been made to collect representative estimates of birth weights at the national level, from institutional and community deliveries, but the findings vary greatly. "In a study of fifteen centres across India, the National Neonatology Forum found a prevalence of low birth weight of 33%, of which 32% were premature births. The 1992-93 NFHS found that small birth size — a proxy for birth weight — carries a risk of infant death 2.5-times higher than the risk for average or large birth size. Low birth weight has also been identified as a factor in the retardation of motor, adaptive, social and language development, as well as in the susceptibility of adults to diseases."[17]

The nutritional status of mothers has also been found to be important for child mortality. "Analysis of the NFHS data showed that neonatal mortality among children born to mothers with a low Body Mass Index (BMI) (<18.5) was slightly higher than those with normal BMI (18.5-24.9). Similarly, children born to obese mothers (high BMI, >18.5) showed 2.7 times higher mortality during neonatal period than those of mothers with normal BMI. This effect was much less marked beyond the neonatal period."[18]

The quality of services and sanitation is also an important factor that needed to be included in the policymaking: "IMR and U5MR are consistently lower among children living in families who accessed drinking water from a safe source as compared to those who accessed drinking water from an unsafe source. Similarly, the IMR and U5MR are consistently lower among children living in families with access to an improved toilet as compared to those who do not have such an access."[19]

Feasibility

We do not have information on the feasibility assessments of the country's health programmes. However, there is evidence of several initiatives to support child development, as well as funding for health being increased at the time the MDGs were launched.

There have been several programmes implemented in India support the comprehensive development of children and improve child conditions in the country: "Various Ministries under the Government of India are implementing child-centric policies and programmes which are vigorously attending to the issues related to child health. This includes the National Policy on Children (2013); National Policy on Early Childhood Care and Education; ICDS; and other initiatives focusing on holistic child development."[20]

On the other hand, there has been no significant change in health expenditure on children by the government. "Between 2001-02 and 2004-05, it ranged from 0.28% to 0.31% of the total expenditure of the government, and between 2.06% and 2.5 % of gross domestic product (GDP), according to a joint study by UNICEF and [the] Centre for Budget and Government Accountability, a thinktank based in New Delhi. In 2005-06, the allocation for child development was increased to 0.56% of the total expenditure (4.17% of GDP).  The increase was due to the focus on meeting the challenges of the... MDGs."[21]

Management

The MoHFW is in charge of several complementary programmes to support the challenge of child mortality, yet several sources have identified constraints on management's capacity, especially in remote areas. The central government is leading the various programmes to tackle this challenge, including initiatives for environmental development and improving sanitation, education and health. Most of these activities fall under the MoHFW and the Ministry of Women and Child Development, along with various committees. The MoHFW's functions have evolved based on the goals defined in various five-year plans. From the sixth plan onwards, health policies have focused more on improving health infrastructure in rural areas.[22]

The Financial Management Group, which reports to the NHM's Finance Division, is responsible for the planning, budgeting, accounting, financial reporting, internal controls including internal audit, external audit, procurement, disbursement of funds and monitoring, with the goal of managing the resources and achieving the objectives of the programme.[23]

In an interview in 2014, Dr Mickey Chopra, global head of UNICEF's health programmes, explained how disparities in management across the country was one of the main administrative challenges. "The problem [in India] has been that the capacity of public health management and operational management to implement at the sub-national level has been a bottleneck. The capacity for advocacy in these big countries is quite uneven. In some places we have strong advocacy as we have strong civil society, as in Kerala and Tamil Nadu. Whereas in other states the management is weak and technical skills are inadequate. These two factors can increase inequity. So the potential benefits of having a decentralised system are not always realised."[24]

Measurement

There is a good health statistics survey that has historically measured indicators for childhood mortality, and it is used across the country to measure levels and trends - for the neonatal and post neonatal mortality rates, the IMR, the child mortality rate, and the U5MR.[25]

The NFHS has become an important source of reliable information on demography, health and nutrition for India, including the tracking of early childhood mortality rates around the country. It consists of interviews all around the country conducted by the MoHFW in partnership with the International Institute for Population Sciences in Mumbai. The first survey (NFHS-1) was carried out in 1992-93, the second (NFHS-2) in 1998-99, and the third (NFHS-3) in 2005-06.[26]

The Indian Sample Registration System (SRS) is another source of infant mortality data, whose annual estimates are consistent with the NFHS. The SRS was started in a few states in 1965 and extended to all states in 1970, tracking births through continuous enumeration and biannual surveys. It publishes IMRs and child deaths annually, but omits child mortality rates. Its registration and survey results are matched and verified in the field to minimise duplication and omission. However, it has still shown some inaccuracies: a 1980 survey into omissions found that death rates were underestimated by about 3% nationally; by 1985, this had improved to only 2.5%.[27]

Alignment

There has been solid commitment and support from external organisations towards the local initiative both for privately funded programmes and for providing support to local activities through capacity-building, etc. On the other hand, the coordination of such initiatives at the local level has not been wholly successful.

Merck Sharp & Dohme (MSD) for Mothers - an initiative tackling female mortality from complications in pregnancy and childbirth - launched a global initiative to help reduce maternal mortality in India in 2013. It partnered with three NGOs in efforts to improve the quality of healthcare that pregnant women in India receive through the private sector.[28]

Similarly, Save the Children helped draft the India New-born Action Plan, which aims to reduce the annual IMR to a single-digit figure by 2030. Save the Children is working with the MoHFW to support the global Every Newborn Action Plan, and has actively participated in the development of newborn healthcare policies.[29]

The UN also provides support to India to help it accomplish the agreed development goals, through local capacity development initiatives to address implementation challenges. "UNDP works directly with more than 15 central ministries and several states, strengthening the capacity of elected representatives and government officials at state, district and local levels and strategic government development programmes and schemes which are geared towards achievement of MDGs and national development goals."[30]

On the other hand, Save the Children has reported that the efforts channelled through the country's several programmes have not been as successful as they would have been had they been coordinated more effectively. “The Indian government runs a number of important programmes that address the key issues identified in this brief, for example the RCH programme, the UIP [and] the ICDS programme... While these have brought benefits, they need better coordination and implementation at the federal, state and local level, and the services provided locally needs to be of better quality.”[31]

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