Child mortality: will India achieve the 2015 target?BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1502 (Published 06 March 2013) Cite this as: BMJ 2013;346:f1502
- Soumyadeep Bhaumik, medical doctor, independent researcher, and freelance writer, Kolkata, India
India is increasingly seen as an emerging global power, making rapid strides in economic terms. But despite these positive changes, every minute in India three children under 5 years old die.1 Half of all children are malnourished,2 and 70% are anaemic.1 And more than 67 000 women die each year from puerperal causes.3
The big question is whether India will achieve the fourth millennium development goal (MDG) of reducing the child mortality rate by two thirds from that in 1990—that is, to 39 per 1000 live births—by 2015. If India fails it will rank among the least developed nations, confirming suspicions that economic progress is not trickling down to all sections of Indian society.
What do the numbers say?
The United Nations estimates the under 5 mortality rate (U5MR) in 2011 at 61 per 1000 live births, with an average annual reduction of 3.0% (range 3.4% to 2.3%) between 1990 and 2011.4 Almost 30% of global deaths among under 5 year olds are in India, more than in any other country.
“Of course India will have more deaths with its large population; however, the situation is rather bad, and with most of the determinants of child mortality still unaddressed, we cannot hope to improve. Almost all data on the nutrition status of the young child suggest no significant improvement in the past decade,” Yogesh Jain, a public health physician working for Jan Swasthya Sahyog, a people’s health support group at Bilaspur, Chhattisgarh, told the BMJ. Between 2006 and 2010, 43% of under 5s were classed as moderately to severely underweight; 20% had wasting; and 48% had stunting.5
An analysis by Unicef released in 2012 (based on three rounds of the National Family Health Survey, conducted in 1992-3, 1998-9, and 2005-6) suggests that India will be able to lower its U5MR only to 52 deaths per 1000 live births by 2015.6
However, Ghulam Nabi Azad, union minister of health and family welfare, in a statement in the Rajya Sabha on 24 April 2012, said, “Between 2008 and 2010, under 5 mortality rate has declined by 5 [percentage] points each year. At this pace of decline, the under 5 mortality in 2015 is expected to be 34, which is lower than the goal under the MDGs.”7
The government reiterated this in February 2013 at a summit on child survival at Mahabalipuram, Tamil Nadu. Anuradha Gupta, additional secretary and mission director of the National Rural Health Mission, said, “During 2005-10, India’s decline in under 5 mortality rate has accelerated to an average of 7.5% each year. Even though the average under 5 child mortality rate has always been lower in urban areas, the rate of decline in rural areas has been much faster. The rural-urban gap in child mortality has narrowed, reflecting improved equity in healthcare.”8
Denial or optimism?
India gave a commitment to lead the war against child mortality and morbidity at this summit, which was organised by the union ministry in partnership with Unicef and USAID and was a follow-up to a global summit on child survival held in Washington, DC, in June 2012.
Ariel Pablos-Méndez, assistant administrator at the global health bureau at USAID, who was speaking from the summit in February, told the BMJ, “Though earlier studies have shown that it will be difficult for India to achieve the MDG, in the past few years the efforts of the Indian government have led to improvements, and there are nearly three years left. So it is not an impossible target. The ministry of health has committed to accelerate efforts, and more than 20 health secretaries are attending the summit.”
Raman Kumar, president of the Academy of Family Physicians of India, appreciates the government’s intentions but added, “Our health system is not evolved enough to address such a mammoth challenge. We need to keep up: innovating, developing, and strengthening the processes.”
Jain explained, “In rural Bilaspur, where I work, the infant mortality rates have gone up by one and a half times in the past year. All elected governments are given to a measure of denial and exuberant optimism to ensure they get the votes needed to get back to power. I would say that it is highly unlikely that we can achieve these targets.
“We have observed decreased food intake among people here. With food prices going up steeply over the past two years, and knowing that most people, including the farmers who own land, have to buy much food from the market, how can we expect improvement and achievement of MDGs?” World Bank data show spikes in food prices in 2010-11, which correlate with undernourishment leading to increased child mortality.9
What is wrong?
India’s abysmally high U5MR could reflect growing disparities between rich and poor. Kumar said, “In spite of talks of integration of programmes and comprehensive care, both curative care and public health remain fragmented and fractured.”
In the past decade, tertiary care has grown towards a high end, high cost model, but most of the human resource and infrastructure in public health have remained devoted to vertical programmes, such as the polio eradication. “Any intervention through the health sector can be effective only when efforts are cross sectoral and address comprehensive human needs,” added Kumar.
“In an unequal and unjust world, state services have to provide the services and also provide the benchmark for the private sector,” added Jain. At least 93% of all hospitals, 64% of all beds, and 80-85% of all doctors in India are in the private sector.10 “The development of health infrastructure and curative services should be primarily in the government services. Privatising it further, even in this new rubric of private public partnership, is likely to be counterproductive,” he said.
Vertical programmes lack a lifecycle approach and continuity of care, which a strategy launched at the child survival summit will aim to overcome. The Reproductive Maternal Newborn Child and Adolescent Health strategy will, in addition to disease prevention and mortality reduction, also focus on quality of care as well as availability, affordability, utilisation, and effectiveness.
Regional variation is also a concern, with only some states—Tamil Nadu, Kerala, Maharashtra, West Bengal, Punjab, and Himachal Pradesh—projected to achieve the targets on U5MR while the rest miss it by a long way.6
“With so much of variation among states—central Indian and Assam and a few other northeastern states, which are home to the poorer among us—achievement of MDGs will always lag. Equity concerns in public health demand that each independent unit in this nation should have achieved a target for us to say that the country has actually made it,” said Jain.
Also falls in child mortality rates might be 50% to 60% higher in rural than urban areas.11 Lack of potable water and sanitation infrastructure are big problems in rural areas, as are low maternal education levels, early marriage, and underuse of contraceptives.
Early neonatal mortality
A major problem is the near stagnation of early neonatal mortality rates (within the first 7 days of life),6 7 8 which contribute a considerable proportion of the U5MR. Key causes are birth asphyxia and prematurity. Birth asphyxia can be prevented by scaling up health infrastructure, with better hospital care and more neonatal intensive care units and midwives and so on. Prematurity is more related to social determinants, such as maternal nutrition status and education and the time between births.
“The solution to this problem lies in community based, hospital based, as well as home based interventions. Investment in building sick newborn care units and neonatal intensive care units is as essential as investment in community interventions, which affect a large population but take time to show effect. In fact, existence of facility based interventions has also led to increased confidence among community health workers,” said Gupta.
Almost everything is being tried, and lots of new schemes are being talked about or are already operating. For example, national child survival scorecards are a monitoring tool to collect and report public health data with respect to child mortality. They help provide better data to direct policy making to eliminate preventable child deaths. Similar scorecards have been tried in Africa. The Mother and Child Tracking System tries to reach and monitor all pregnant women for care during pregnancy and their child for adherence to vaccination.
Rashtriya Bal Swasthya Karyakram, a regular health screening of children in public health facilities, launched in February 2013. Aanganwadis (health workers), government hospitals, and government aided schools will screen for defects at birth, diseases, deficiencies, and development disorders and provide for free follow-up management and treatment at district and tertiary hospitals.
Infant and child mortality are the most important indicators of a nation’s public health and therefore socioeconomic development. Every child’s death is much more than a number or a target. For India to continue as a world power failure to meet the reduction in preventable child deaths is not an option.
Cite this as: BMJ 2013;346:f1502
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare that I am a country representative for the health information for all by 2015 (HIFA2015) campaign and knowledge network.
Provenance and peer review: Commissioned; not externally peer reviewed.
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