India Lags in Addressing Child Mortality

Sixty-one years since Indian independence, a plethora of sops, schemes, programs, projects and a complete ministry dedicated to the child -- and yet over 2 million children did not live to see their fifth birthday in 2006, accounting for one-fifth of the world's children who died before turning five. India is home to 20 percent of the world's under-fives. What this means is that the global attainment of the health-related Millennium Development Goals (MDG) depends on New Delhi's achievements in this respect.

India has pledged itself to the health-related Millennium Development Goals (MDGs) for 2015. And child survival - reducing child mortality, also referred to as MDG 4 - poses one of the most serious challenges to these goals. It requires reducing the global rate of under-five deaths by two-thirds by 2015 from the 1990 levels. The death rate should be 30 deaths per 1,000 live births to meet the target.

While there has been a sure decline in the number of infant deaths in the Asia Pacific region, having come down to around four million in 2006 from 6.7 million in 1990, India alone, that year, accounted for half the number (2.1 million). Since 1960, the country has managed to reduce the death rate from 236 deaths per 1000 live births to 76 per 1,000 live births, and a growing economy has enabled India to reduce the under-five mortality rate by one-third. Yet despite the fact that the country is witnessing an economic boom, the growth restricted to small pockets of the country. Sixty percent of the under-five deaths occur in just five states -- telling a poignant story of the fight to survive. An Indian child's chance of celebrating the fifth birthday clearly depends on the state or community it is born into.

The urban-rural divide and several other socio-economic factors evidenced in the disparate Infant Mortality Rate (IMR) -- like the gap in the rural and urban IMR rates of 64 and 40, respectively; between boys and girls of 56 and 61, respectively; and in states ranging from 76 in central state of Madhya Pradesh to 14 in the southern and literacy high state of Kerala -- are the disparities in society reflected in the under-five deaths, and also indicate a strong link between poverty and child mortality.

The country's economy is growing at an average rate of nine percent a year, but still, two out of every five children in India are malnourished. Accompanying the economic boom is the shift to privatization of many essential services which has only widened the gap when it comes to accessibility of even very basic facilities. As the affluent demand better services, there has been a further deterioration in the availability and quality of government facilities. And since the MDGs are related to improving health, nutrition, water and sanitation, education and child protection, gender equality and women's empowerment, it is hardly surprising that the child mortality is a direct manifestation of the lack of these. More than 50 percent of this country's under-five deaths are associated with malnourishment and anemia, while another 30 per cent are caused by pneumonia. Further, an estimated nine percent of children are suffering from diarrheal diseases; in absolute numbers a figure that is even higher than that in Afghanistan.

That South Asia, as a region, spends only 1.1 percent of its Gross Domestic Product (GDP) on public health expenditure, much below the world average of 5.1 percent, also reflects trends in the region. While the Indian budget did reflect a fifteen percent increase in the health sector, it still remains at a mere one percent of the GDP.

A new study by Save the Children compares child mortality in a country to its national income per person, clearly placing India behind poorer neighbors like Bangladesh and Nepal when it comes to cutting child deaths. Of the 41 countries ranked depending on how well they are using their resources to boost child survival rates India stands at a low 16, behind both Bangladesh and Nepal, who are in the top ten.

The entrenched discrimination against the girl child, evidenced in various forms of medical and technological misuse over the years (and the insidious transformation of older practices of infanticide to what came to be commonly termed as ‘feticide' in more recent years), also finds itself reflected in many communities in discriminatory child-rearing practices. What this means is that gender inequalities in the country determine access to food and medicine. Moreover, the poor health of the pregnant mother, also a manifestation of the status of women even in the marital homes with regard to diet and access to medical or health care facilities, also directly impacts the newborn. Lack of knowledge or information on child rearing and nutrition also play a part. With one out of every three women being underweight in India, it leads to low-weight babies who are more likely to die in infancy. The largest absolute number of newborn deaths in the world occurs in South Asia and India contributes around one quarter of the global total. It is hardly surprising then that South Asia is also the only region in the world where when compared to males female life expectancy is lower. So not only is the location that determines the chances of survival for children in the country but also their gender. Being born a girl carrying higher risks as it raises the chance of premature death between the ages of one and four by about one-third. Again it is hardly surprising that the region also has a massive gender imbalance in population numbers, with around 50 million more men than women.

With maternal mortality closely linked to child mortality - since the chances of survival of a child significantly reduces if the mother has died due to childbirth related complications - it really is the health (or the ill health) of the mother that is also a crucial issue. To combat this issue the Government of India relies on its Integrated Child Development Scheme (ICDS) which has been running for over 30 years. But the MDG goals would require the government to re-evaluate its flagship program for mother and childcare, started in 1975, which provides health and nutrition education for mothers of infants and young children, along with other services, such as supplementary nutrition, basic health and antenatal care, growth monitoring and promotion, preschool non-formal education, micronutrient supplementation and immunization. The services delivered through a network of around 700,000 community (anganwadi) workers has had limited effectiveness due to a variety of factors, ranging from downright corruption and mishandling of the allocated funds, the limited skill and knowledge of anganwadi workers themselves to a lack of supervision, vacancies and flaws in program policy itself, reflected in the inadequate focus on the young children. Even today the maternal mortality remains between 300-500 deaths per 100,000 births, which means 75,000 to 150,000 women die every year in India during childbirth.

It has been interventions of local organizations, especially women's groups, working at the grassroots level within the communities that have been able to make any inroads in these orthodox structures. Working within the cultural ethos and cultural context these groups have built on the established structures within communities that extend to other areas of development, including education and credit, as well as health. And in more recent months hoping to tap into the potential of the access and community confidence these grassroots workers (like midwives) enjoy within the communities the government has adopted strategies to exploit their presence.

The UNICEF in collaboration with the center has launched a five year action plan which would use a grant of $700 million for child protection, education and nutrition and protecting children from AIDS. This 2008-2012 Country Program would jointly focus on India's infant and maternal mortality rates amongst other things. With both maternal and infant mortality so closely tied to societal practices, age-old customs and traditional roles that place less of a premium on the education and health of the girl child, the wife or the mother any effort to reverse this trend would also require a change in the status of women both in their paternal and marital homes with equal access to the most basic human needs; and where the chances of survival of the infant remain equal irrespective of the socio-economic background or geographical location of the community it is born to.