INDIA BRIEFING: AUGUST The state of child mortality in India. Progress on meeting Millennium Development Goal 4 to reduce child mortality

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1 INDIA BRIEFING: AUGUST 2010 The state of child mortality in India Progress on meeting Millennium Development Goal 4 to reduce child mortality While there is much to celebrate and admire in India s rising prosperity, and in its growing cultural and political influence, the country s level of child mortality remains high. Nearly 9 million children die each year before their fifth birthday. Of these, a staggering 1.83 million are Indian. Half of these deaths occur within a month of the child being born (the neonatal period). These levels of child deaths persist despite twenty years of relatively high economic growth in India, and with India now as a significant force in the global economy (set to become the world s third largest economy by 2020). In the year 2000, world leaders committed themselves to eight Millennium Development Goals, including MDG 4 which calls for a two-thirds reduction in under-five mortality between 1990 and While India has made some progress, with the under-five mortality rate falling from 116 per thousand live births in 1990 to 69 per thousand live births in 2008, this progress is inadequate when compared to the overall target to be met. The aggregate figures mask gross inequalities between states and between different social, cultural, economic and gender groups within them. There is now general agreement among programme and policy makers about the actions needed to rapidly reduce child mortality. At the end of September this year, world leaders meet in New York at the United Nations Millennium Development Goal Review Summit to assess progress against the goals. On the table for discussion will be a proposed Global Strategy for maternal and child health, put forward by the UN Secretary General. As the country with the highest number of child deaths anywhere in the world, there remains a particular obligation on the part of India to demonstrate leadership on this issue. This means implementing the right kind of policies to expand coverage of proven interventions like skilled personnel available to support mothers during child birth, early postnatal care, preventive and curative treatment for pneumonia, diarrhoea and malaria; support for nutrition, including exclusive breastfeeding, complementary feeding, conditional cash transfers and wider social protection programmes. These interventions will need to be delivered through more effective systems, so that the poorest and most marginalised families can also get the healthcare, nutrition security and other services they need. For this change to be sustainable, it will also need to be complemented by a concerted drive to tackle discrimination and to strengthen the rights and social status of the poor, especially lower caste groups, and girls and women. With the necessary leadership and the right policies, MDG 4 can be achieved in India. 1 P a g e

2 What has India committed to? India was a signatory to the original Millennium Declaration and has reaffirmed its support for the Millennium Development Goals, including MDG 4. Despite progress against the target, on the current trajectory, India will fall short of achieving it. The current annual percentage of reduction of Under 5 mortality is 2.25%, whereas the required annual percentage of reduction to reach the MDG goal in this regard during the remaining seven years has to be 6.28%. India is also a signatory to a series of international human rights agreements and treaties that are highly relevant to child survival. Clear commitments to safeguard the lives of newborn babies and young children are contained in the UN Convention on the Rights of the Child (UNCRC), the International Covenant on Civil and Political Rights, and the International Covenant on Economic, Social and Cultural Rights. For example, Article 6 of the UNCRC refers to children s inherent right to life, survival and development, while Article 24 calls on governments to take appropriate measures to diminish infant and child mortality and to ensure the provision of necessary medical assistance and healthcare to all children. India s own constitution also sets out comparable commitments. But India s political leaders are falling short on fulfilling their commitments to India s children. Where are India s children dying? Of the 26 million children born in India in a year, nearly 2 million still die before their fifth birthday and half within a month of being born. But these aggregate figures conceal huge inequities in mortality rates across the country, within states and between them, as well as between children in urban and rural areas, from upper caste and lower caste families and from tribal and non tribal communities. The latest figures suggest that the under-five mortality rate in Kerala is 14 deaths per thousand live births. This contrasts with a rate of 92 per thousand in Madhya Pradesh, 91 per thousand in Uttar Pradesh and 89 per thousand in Orissa. These inequalities are also marked in respect of newborn mortality rates. While the rate for Kerala is 7 per thousand, the comparable figures for Madhya Pradesh, Uttar Pradesh and Orissa are 48, 45 and Mortality rates vary considerably in relation to maternal education, wealth, religion, caste and tribe. The table below sets out these disparities in detail. 1 NFHS3, data 2 P a g e

3 Early Childhood Mortality Rates by Socio-Economic Background, India, NFHS-3 2 Background Characteristics Neo-natal Mortality Rate Infant Mortality Rate Under-five Mortality Rate Education of Mother No education < 5 years complete years complete years complete years complete or more years complete Wealth Index Quintiles Lowest Second Middle Fourth Highest Religion Hindu Muslim Christian Sikh Buddhist Caste/Tribe Scheduled caste Scheduled tribe Other backward class Other All Source: IIPS and Macro International, Note: The rates are per thousand births and refer to five years preceding the NFHS-3 survey, that is, to P a g e

4 Why are India s children still dying in such large numbers? High levels of child mortality in India can be explained at three levels. 1) There are a few conditions that account for more than 90 per cent of these deaths. These are pneumonia, measles, diarrhoea, malaria and neo-natal conditions that occur during pregnancy and during or immediately after birth. The latter conditions are particularly significant when it comes to India s newborn deaths. Severe infections, asphyxia and premature births cause over 72 per cent of newborn deaths. In most cases, the conditions that are the direct cause of childhood deaths are preventable and treatable with proven interventions and services. But these interventions remain unavailable or inaccessible to many of India s poorest children. At the same time, for cultural reasons, some of India s poorest mothers and families are reluctant to use services at health facilities that do exist and may pursue traditional practices in the home or the community that are detrimental to their own health and that of their children. The survival of the newborns, for example, is critically dependent on cleanliness at the time of delivery, clean cutting of the umbilical cord, keeping the baby warm and early initiation of breastfeeding. But some traditional views can discourage these life-saving practices. Labour may be considered an unclean process, to be conducted in a dirty corner of the house, for example in a cowshed. In some cases, the delivery space is plastered with fresh cow dung to cool the room, although this increases the risks of infection. Early bathing of the baby is often practiced, which heightens the risk of hypothermia, as does leaving the newborn baby uncovered. 2) There are a set of factors that make some Indian children more prone to these medical conditions, and limit their chances of survival. These factors include: the lack of essential healthcare or the inability or unwillingness of many mothers and their children to access it; high levels of maternal and child malnutrition, poor feeding practices; lack of access to clean drinking water, safe sanitation, poor hygiene; and limited access to or use of family planning services. In India, as in other parts of the world, the costs of healthcare are often prohibitive for the poor and discourage the use of those services that do exist. The share of health, nutrition, water supply and sanitation in government expenditure stood at 5.48 percent between to But as a share of Gross Domestic Product, this was only 1.58 percent in , way short of the Government s own commitment to increase health expenditure alone to 2 to 3 per cent of GDP. Also many states with high levels of child mortality do not spend all the resources that have been allocated. Maternal and child malnutrition is significant too in explaining the continuing high rates of child mortality in India. 48 per cent of India s children under the age of five are chronically malnourished, 20 per cent are acutely malnourished and 22 per cent of India s babies are born with low birth weight. These rates of child malnutrition compare with some of the poorest countries in Africa. India s rates of child wasting, for example, are three times higher than Ethiopia. Exclusive Breast Feeding is central to child survival, strengthening the immune system and furthering healthy development. But rates of exclusive breastfeeding across India are low, and far too little is done through the health system to promote it, as well as to identify malnutrition at an early stage and then to take the necessary steps to address it. 4 P a g e

5 The deaths of Indian children are not therefore random events beyond control. To a considerable extent they are the outcome of political and policy choices taken by Indian governments, at the central, state and district levels. They are also influenced heavily by traditional cultural practices, by low levels of maternal education, and by wider economic, environmental, political and social factors that governments and civil society could help to shape or mitigate. This is the third level of explanation - the underlying or structural causes of India s child mortality. As the statistics show very clearly, it is the poorest and most marginalised Indian children who are at greatest risk of dying before their fifth birthday. Children from households in the bottom wealth quintile are three times more likely to die than those from households in the top wealth quintile. Their poverty reflects their parents lack of livelihood opportunities or assets, or their greater vulnerability to economic and environmental shocks. This lack of income and assets translates into reduced access to healthcare, inadequate nutrition, unsafe and unhygienic living conditions and limited access to education, all of which increases the risks of mortality. But inequality in India is not just about income disparities. Large parts of India suffer from deeply entrenched forms of discrimination on the grounds of gender, caste, ethnicity and religion. For example, the relative powerlessness of many women and girls prevents them from accessing services without the consent of their husbands or male relatives, and increases their chances of death. A call to action In many ways, India stands at a crossroads in respect to child mortality. Can high rates of child mortality be consigned to India s past, or will they remain an indelible stain on its future? The United Nations Millennium Development Goal Review Summit is the right moment for India s political leaders to affirm decisively that it is the former course that they want to pursue, with high level commitment and with urgency. If the MDG 4 target is to be met in India, Save the Children believes that decisive action will be needed in the following five areas: 1. Child survival must become a key metric by which India judges its success in development Rates of child mortality, especially amongst the poorest communities, are a much more telling indicator of development progress (or the lack of it) than per capita income. While India has been applauded for its high rates of economic growth over two decades, it still suffers some of the worst rates of child malnutrition in the world and accounts for more than 20 per cent of global child mortality. The Indian national and state Governments and district administrations should be encouraged to measure and report progress against newborn and child mortality and morbidity indicators (broken down by wealth quintile, caste, religion and gender), and set targets for reducing inequalities in the coverage of services and in mortality and morbidity rates. 2. Integrate and implement existing maternal and child health programmes and link them to wider development strategies The Indian government runs a number of important programmes that address the key issues identified in this brief, for example the Reproductive and Child Health Programme, 5 P a g e

6 the Universal Immunisation Programme, the Integrated Child Development Services (ICDS) programme and the more recent National Rural Health Mission and soon to be introduced National Urban Health Mission. 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. The key task is not to create yet new strategies or plans, but to implement and properly integrate many of these existing ones. This integrated approach must involve the Ministry of Health and Family Welfare, but also the Departments of Women and Child Development, Panchayati Raj, Rural Development, Education Public Health Engineering (responsible for water and sanitation) and Ministry of Housing and Urban Poverty. This integrated approach to tackling child mortality needs to feature prominently in India s 12th 5-year plan in There will also need to be a clear framework of accountability to ensure that programmes are scaled up across the country, especially in those states with the highest mortality rates (Rajasthan, Orissa, Bihar, Uttar Pradesh, Madhya Pradesh, Chhattisgarh and Jharkhand). Integrated and credible strategies for reducing child mortality need to be properly resourced. The Government of India should commit to raise federal and State funding on health from just over 1 per cent of GDP today, to 3 per cent by 2012 and 5 per cent by As importantly, there needs to be improved processes for ensuring the effective and equitable disbursal of these resources and transparency about allocation and impact. Part of this additional investment should be allocated to recruit, train, equip, monitor, supervise, incentivise and deploy more frontline health workers. Targets should be set for expanding the number of trained health workers in the poorest parts of the country, especially women frontline health workers at the community level. 3. Focus on newborns As India has made progress in reducing the deaths of slightly older children, newborn deaths have increased as a proportion of overall childhood mortality, so that they now account for 55 per cent of all Indian child deaths. Tackling newborn mortality will require interventions that enhance the health, nutrition and wellbeing of adolescents, mothers and children during and immediately after birth (the most vulnerable period for the child and the mother). Support is best provided through a continuum of care - across the lifecycle, from women of reproductive age group through birth to early childhood; and from care at home through to first referral units and other specialist health facilities. Examples include antenatal visits, skilled attendants at birth, early postnatal care in the community and facility and support for exclusive breastfeeding, and family planning services. This should be based on evidence based models, such as the home-based newborn and childcare model developed in Maharashtra by SEARCH (Society for Education, Action and Research in Community Health). 4. Prioritise equity and rights Reducing mortality rates amongst India s poorest children requires concerted action to tackle underlying causes those factors that limit the ability of poor children and their mothers to get decent healthcare, adequate nutrition, clean water and safe sanitation, and opportunities for education. In policy and programme terms it will require a comprehensive approach to break down barriers and multiple forms of discrimination and prejudice, and to ensure that children s rights and the rights of women are respected. 6 P a g e

7 Specifically, the National Rural Health Mission should have a clear focus on social inclusion of Dalits and Adivasis in terms of access to healthcare. This should also include improved training and support for community health workers, including in how to tackle sensitively but effectively some of the traditional practices around birth and early childhood care that are damaging to child health. One important way to promote rights and empowerment for marginalised groups, and to address harmful traditional practices, is by supporting those Indian civil society and community groups, as well as international agencies, that are championing these causes and working at the local level on these issues. 5. Tackle malnutrition At every level of government, India s political leaders need to enhance their action to tackle malnutrition This should involve support for initial and exclusive breastfeeding, micronutrient supplementation and fortification, child and maternity benefits, nutrition education, treatment of severe acute malnutrition, early warning systems and investments in appropriate forms of agricultural production. We would also like to see the Indian Central government and the state government and district administration setting clear targets for reducing rates of child malnutrition. This should involve the development of protocols, guidelines and implementation strategies focused on the needs of the poorest and most marginalised children with the highest levels of child malnutrition. There will also need to be enhanced training and support for community health workers to identify and treat malnutrition and to promote good infant and young child feeding practices. The Leadership Agenda for Action agreed by the Coalition for Sustainable Nutrition Security in India sets out a clear consensus on the essential interventions needed to reduce malnutrition. Conclusion India has made enormous economic strides in recent years. But millions of Indians are failing to share in this rising prosperity. After 20 years of high and sustained economic growth, nearly 2 million Indian children still die every year of conditions like pneumonia and diarrhoea, and of complications related to pregnancy and child birth. We do not need a major technological breakthrough for India to tackle this problem. Other countries, many of them poorer than India, are well on their way to doing so. And the performance of some of India s states, like Kerala and Tamil Nadu, shows what others could accomplish by pursuing similar approaches. Nor is this just a moral issue. We know from the experience of other countries and India s better performing states that improved child and maternal health and nutrition is positively correlated with inclusive and successful economic development. With the requisite political will and the right policies, India can achieve MDG4 and secure drastic cuts in child mortality. To truly shine in the global arena, India needs to act on this most important of issues with determination and urgency. For more information please contact Ben Hewitt, Project Director, Newborn and Child Survival, Save the Children India on b.hewitt@savethechildren.in Thanks to Dr Alex George, Sarit Rout, Dr Rajiv Tandon, Shireen Miller, John Butler, Ananthrapiya Subramanian, David Mepham, and Rica Garde. 7 P a g e