It is estimated that India lost 1.8 million children under five in 2008. That is more than 200 child deaths every hour, each day, or more than three deaths every minute. Out of about 25 million babies born every year in India, one million die. Most who survive do not get to grow up and develop well. About 48 per cent are stunted (sub-normal height) and 43 per cent are under-weight. Additionally, about one-third of babies are born with a low birth weight of less than 2,500 grams.
In South-East Asia, the Maldives, Sri Lanka and Thailand have reduced newborn and childhood mortality significantly. India has also demonstrated steady progress. Under-five mortality decreased from about 150 per 1,000 live births in 1990 to 74 per 1,000 live births in 2005-06. But at this rate of decline, India will not be able to achieve the Millennium Development Goal 4 (MDG) target of 50 under-five deaths per 1,000 live births by 2015. Moreover, progress has been uneven in various States in the country.
The causes of death among children are well understood in India. Newborn mortality (death within the first 28 days of life) contributes to more than half of under-five mortality. In newborns they are asphyxia (inability to breathe at the time of delivery), infections and prematurity. After 28 days of life, they are the result of acute respiratory infections (pneumonia) and diarrhoea. Undernutrition contributes to 35 per cent of deaths. In addition to these, immediate causes of childhood deaths, there are several socio-cultural factors including poverty, poor water and sanitation facilities, illiteracy (especially among women), the inferior status of women in society, and pregnancy during adolescence (that can be attributed to early marriage). Child mortality rates are also higher among rural populations when compared to their urban counterparts.
We know what needs to be done to save these precious lives. Newborn deaths can be prevented by ensuring nutrition of adolescent girls; delaying pregnancy beyond 20 years of age and ensuring a gap of three-five years between pregnancies; skilled care during pregnancy, childbirth and post-natal care; and improved newborn care practices that include early (within first hour of birth) and exclusive breastfeeding; preventing low body temperature and infections; and early detection of sickness and prompt treatment. Childhood deaths can be prevented by exclusive breastfeeding for six months and complementary feeding from six months of age with continued breastfeeding for two years; immunisation; and early treatment of pneumonia, diarrhoea and malaria. In addition, it is important for the mother and other caretakers at home to invest in appropriate child caring practices, right from birth to support early childhood development and lay a foundation to maximise human potential.
India needs to provide these life-saving interventions to most, if not all, newborn and children who need them. However, their (interventions) coverage has been quite low. For example, in 2005-06 (the National Family Health Survey – NFHS 3 report), the rate of initiation of breastfeeding within an hour of birth was only 26 per cent and exclusive breastfeeding at six months was just 46 per cent. Yet these two interventions have the potential to prevent 19 per cent of deaths. The use of oral rehydration salts in cases of diarrhoea, the most recommended treatment, was just 43 per cent and only 13 per cent cases of suspected pneumonia received antibiotics. Immunisation coverage has been relatively better, suggesting that high coverage is achievable.
The main causes of poor coverage of interventions include ineffective planning and implementation, mainly due to weaknesses in the health system. To address the systemic challenges, India launched a flagship programme, the National Rural Health Mission in 2005-06, to strengthen the health system in rural areas. Commendable initiatives have been put in place such as training about 8,00,000 village level health volunteers (Accredited Social Health Activist, or ASHA), hiring additional staff, strengthening the infrastructure of health facilities, augmenting programme management capacity at State and district levels, and enhancing community participation. However, much more needs to be done to minimise health inequities that exist among different subpopulations in the country.
Public health expenditure in India has remained at a low — about one per cent of GDP — for quite some time. This needs to be scaled up. Considering that about 70 per cent of health care is accessed from the private sector in the country, better regulation and participation of private health service providers must be ensured. Synergy between the health and nutrition sectors must be fostered through better coordination between the Ministry of Health and the Ministry of Women and Child Development, which are responsible for the ICDS (Integrated Child Development Services) programme.
To reach unreached newborns and children, there is a strong case for providing home-based newborn care as well as community-based management of non-severe pneumonia and diarrhoea in children by trained ASHAs and other community health workers. This initiative needs to be supported by provision of incentives, necessary drug supplies, close supervision and appropriate referral linkages. At the same time, the quality of health services at first-level health facilities and referral hospitals must continue to be strengthened.
Fortunately, there is renewed commitment at the global and national levels towards achievement of MDG 4. To save newborns and children, national governments, development agencies, civil society and other stakeholders must work in close collaboration.
( Dr. Poonam Khetrapal-Singh is WHO Deputy Regional Director for South-East Asia Region. )