|Year : 2011 | Volume
| Issue : 3 | Page : 171-173
Indians can do better at improving child survival
Professor and Dean (Research), IIHMR, New Delhi, India
|Date of Web Publication||22-Oct-2011|
Professor and Dean (Research), IIHMR, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar S. Indians can do better at improving child survival. Indian J Community Med 2011;36:171-3
I chose the word 'Indians' over 'India' in the title because each one of us has a role in improving child survival in India. We should not leave it to the government alone. Government initiatives such as NRHM are laudable but will not be adequate without mobilizing other important stake holders. These stake holders include us all, from parents who want to do the best for their children to the academicians who need to take responsibility of guiding program managers, policy makers and grass root level functionaries. The government programs need to clearly identify the role of each of these stake holders with inbuilt accountabilities and help them in performing their identified role.
In India, around 1.7 million children die every year  which equals 4,730 every day and 3 every minute. Most of these deaths occur because many simple interventions which have been available for many decades have still not reached large proportion of children. Today we live in "knowledge age". We can access large amount of information through the Internet and manipulate, store, transmit and share it easily with others. There has also been tremendous improvement in the availability of modern technology to improve health care. Despite these advances there is a huge gap in converting this advantage to benefit the poor and the disadvantaged. We lag behind in achieving high coverage with inexpensive, scientifically proven and essential health interventions. There is an unacceptable inequity in health between countries, societies and population groups in both access to, and capacity to use new technologies.  For example, skilled attendance at birth is available to only 19% among the poorest quintile as compared to 89% among the richest quintile and coverage with Measles vaccine is 40% among the poorest as compared to 85% among the richest quintile.  The National Rural Health Mission launched on 12 April 2005 is a commendable effort to address many of the problems in health care delivery in rural areas through 'communitization', flexible financing, improved management through capacity building, monitoring progress against standards, and innovations in human resource management.  There has been some improvement in maternal and child mortality rates in India but the rate of decline is not enough to achieve the goals.
| The Present Situation|| |
Our country has made a good progress in reducing under-five mortality rate (U5MR) from 186 (1970) to 118 (1990), to 93 (2000) and to 66 (2009). The annual rate of reduction in U5MR which had stagnated at 2.4% during the period 1970-2000 has recently increased to 3.8% (2000-2009).  This pace is not adequate and needs to accelerate to above 6% annual rate of reduction to achieve the MDG 4 target of 38 by 2015. India is acknowledged as an economic superpower and is at the forefront of the global revolution in information technology but is way behind in passing on these advantages to the families to improve child survival. Of the 191 countries with available data, 129 are on track to meet the MDG 4 target for child survival - to reduce under-five deaths by two-thirds by 2015.  Other members growing economies popularly referred to as BRICS (Brazil, Russia, India, China and South Africa) are doing better with U5MR 21 in Brazil, 12 in Russian Federation, 19 in China and 62 in South Africa. The children in some of our neighboring countries with lesser economic growth are better off with U5MR in Srilanka at 15 and Bangladesh at 52.  Within India, there is a huge inequity in child survival between states, urban and rural areas and rich and poor. For example, a child in rural Madhya Pradesh with infant mortality rate (IMR) of 72 is seven times more likely to die before first birthday as compared to a child in urban Goa with IMR of 11. Similarly, the gender discrimination continues in India with IMR in girls being 52 compared to 49 in boys  and worsening child sex ratio which has further declined from 927 to 914 in the recent census. Government's report on MDGs  acknowledges that India is likely to fall short of U5MR target of 38 by 28 points. UNSD estimates that India will fall short by about 12 points. The states of Goa, Haryana, Jammu and Kashmir, Kerala, Sikkim and Tamil Nadu are expected to be early achievers of MDG 4 target and Delhi, Gujarat, Himachal Pradesh and Tripura are just on track. The remaining states are off track and need to redouble their efforts for India to keep its promise to its children. 
| India Can Achieve Child Survival Goals by Refocusing on Priorities|| |
There is overwhelming global evidence that we have the interventions needed to attack the problem now and prevent most child deaths in India. What is lacking is political commitment and resources.  In the last seven years, some progress has been made but a lot more still needs to be done. United Nations Children's Fund and Public Health Foundation of India have commissioned a series of systematic reviews to bridge the gap between evidence and policy for child health programs.  This is an excellent initiative. However, there is a need to focus more on how to prioritize the interventions and scale these up in a short period of time rather than revisit the efficacy of well-known interventions. The first child survival revolution in 1980s was led by James Grant, Executive Director of UNICEF using four interventions, Growth monitoring for malnutrition, Oral rehydration therapy for diarrhea, Breastfeeding for malnutrition and prevention of infections and Immunization for six vaccine preventable diseases (GOBI) strategy.  The focus on simple and a few interventions saved many lives.
There is an urgent need to focus on scale up of interventions targeting the main killers of children. The killers of under-five children in India  include neonatal conditions (55% which mainly includes, infections, preterm and asphyxia), Diarrhea(11%), Pneumonia (11%) and Measles (4%).Underweight affects about half (43%) of under five children and contributes to around one third of child deaths. The problem of underweight starts with low birth weight and is exacerbated with late initiation of breastfeeding, low prevalence of exclusive breastfeeding and inadequate complementary feeding in both quantity and quality. The problem of low birth weight (LBW) can be addressed through lifecycle approach to improve nutrition of girl child, adolescent girls and pregnant and lactating women by strengthening the nutrition and related components of existing programmes such as Kishori Shakti Yojana and Janani Suraksha Yojana. The beginning for addressing LBW and malnutrition which peaks at around 18 months can be effectively made by focusing on the 'golden window of opportunity' from birth to 18 months by promoting early and exclusive breastfeeding till six months of age followed by continued breastfeeding as long as possible with adequate complementary feeding and continued feeding during common illnesses such as diarrhea, ARIs and fevers and increased food intake during convalescence. Child under nutrition and infectious diseases act in a synergistic and cyclical manner resulting in child death and pose a major threat to achieving child survival goals in India. The majority of these deaths can and must be prevented by scaling up coverage with well known, affordable, effective, high impact interventions which have been available for several decades. The evidence for their effectiveness has been documented well in Lancet series on child survival and neonatal survival.  Coverage of some of these interventions (given in parenthesis) is unacceptably low in India. The interventions to address these killers include cross cutting interventions which are effective in preventing deaths from more than one killer i.e. exclusive breastfeeding (46%), vitamin A (53%) and disease specific interventions such as oral rehydration therapy (ORT) in children <5 years with diarrhea (33%) and Measles vaccination (70%). 
| What Can be Done in India|| |
There is a need to create a sense of urgency from national to community level. The program should focus on community level actions for behavior change to scale up locally identified priority interventions to address the major killers of children. This can be done by undertaking the following activities:
Planning to reach every beneficiary from village and urban slums upwards
This should start with strengthening micro plan under District Health Action Plan of NRHM. It should enumerate every under-five child and pregnant woman in every village and slum area including names of persons from local community who will help in reaching every beneficiary through social mobilization. The village plan should be made by village level functionaries (ANM, AWW, ASHA) with active engagement of Village Health and Sanitation Committee and other local self government institutions. Each ward member should be given the overall responsibility for engaging local formal and informal leaders to cover every child and pregnant woman. We need to build on the experience of micro planning for immunization in late 80's and recently for polio eradication. The villages plans are consolidated to become a sub centre plan to be consolidated at primary health centre, block and district level with allocation of resources, plan for development of required skills in health functionaries and social mobilizers, clear role of other sectors to achieve universal coverage and supportive supervision. The district planning process in NRHM offers an excellent opportunity for targeting and reaching every beneficiary through micro planning provided it is done and implemented properly.
Analyze and address barriers for each of the identified interventions for major killers
We need to identify demand and supply side barriers and address these to achieve near universal coverage of locally identified priority interventions for major killers. For example immunization program has been in place for more than three decades but leaves around 40% children not fully immunized. According to 2009 Coverage Evaluation Survey,  7.6% children did not receive even one dose of any vaccine. Though 92.4%received at least one dose but only 61% completed their immunization. Around four fifth of them were not reached due to demand side barriers (did not feel need, not knowing about vaccines, not knowing where to go, time not convenient, fear of side effects, do not have time, wrong advice and cannot afford the cost). At the same time supply side barriers (vaccine not available, place not convenient, ANM absent, long waiting time, place too far and service not available) account for about 20%. 
The demand side barriers can be addressed through communication and social mobilization at community level through about 2.5 million AWWs, Helpers and ASHAs with active participation of other sectors such as panchayati raj institutions, school children and others. The supply side bottlenecks should be addressed by the health care delivery system. A similar analysis needs to be done at district level for all priority interventions. The impact of actions to address the barriers should be regularly monitored and strategy refined accordingly.
Engage private health facilities/providers
Private health care providers play an important role by providing services to a substantial proportion of beneficiaries but are not given adequate attention in health care programs. For example they provided health care to 77.5% of children with ARI, 48.4% for diarrhea and 10.2% for immunization  compared to 20.9%, 20.3% and 89% by public health care providers respectively. The private health care providers need to be actively engaged in the government plans to achieve universal coverage with identified priority interventions. Many of the health care providers fall in the unorganized sector and may fall under the category of 'quacks'. There is a need to address this sensitive issue in view of the government's anti-quackery drive and develop a strategy of their engagement with focus on providing maximum benefit to the children.
Sense of urgency, close monitoring of progress and accountability
Child survival needs to be given urgency by defining clear targets to scale up identified interventions. This can be done if the role of each functionary from health and other sectors from bottom to top is identified and clear targets assigned Each one of them should be held accountable for achieving these targets. India has 3.3 million civil society organizations. 
Many of them can play a very important role to support activities at grass root level. Their role should be identified and included in the micro plan for both urban and rural areas. The role for social mobilization needs to assign to local panchayati raj institutions with support from health functionaries.
Address inequity, social determinants of health for sustainable long term impact
Many other sector programmes such as BPL, Antyodaya, Mahatma Gandhi National Rural Employment Guarantee Act (MNREGA), PRIs, Water hygiene and sanitation, and other programmes for elimination of gender discrimination are in operation and contribute to improving care and education of girl children and women empowerment, elimination of social inequity etc. Strong linkages with these programmes will help in sustainable progress in reducing child mortality.
There is ample evidence that child mortality can be reduced significantly in India and targets of MDG 4 can be achieved by scaling up available, affordable and high impact interventions with focus on killer conditions. What is required is political commitment, resources and sound strategies by mobilizing all possible sectors, civil society organizations on an unprecedented scale to save the most vulnerable segment of our population - the children.
| References|| |
|1.||UNICEF. The State of The World's Children 2011. Adolescencean Opportunity, UNICEF, 3 UN Plaza, New York. Feb 2011. |
|2.||WHO. Sound Choices- Enhancing Capacity for Evidence-informed Health Policy. Geneva, Switzerland:WHO Press, HO;2007. |
|3.||IIPS.National Family Health Survey -3, 2005-2006: International Institute for Population Sciences and Macro International, India. Volume I, 2007. |
|4.||Nandan D. Editorial National Rural Health Mission: Turning into Reality. Indian J Community Med 2010;35:453-4. |
|5.||UNICEF 2006. Global Data Sheet. Available from:http://www.unicef.org/india/media_3896.htm. [Last accessed on 2011 Apr 17]. |
|6.||SRS Bulletin January 2011, Sample Registration System, Registrar General of India, New Delhi 2011. |
|7.||GOI 2010. Millennium Development Goals - India Country Report 2009. Mid-Term Statistical Appraisal. Central Statistical Organization, Ministry of Statistics and Programme Implementation, Government of India. |
|8.||Lancet child survival series 2003. Available from:http://www.who.int/child_adolescent_health/documents/lancet_child_survival/en/ and Lancet neonatal survival series 2005.Available from:http://www.who.int/child_adolescent_health/documents/lancet_neonatal_survival/en/[Last accessed 2011 Apr 18]. |
|9.||Reddy KS,van Den Hombergh H. Synthesizing Evidence for Improving Child Health in India. Indian Pediatr 2011;48:181-2. |
|10.||UNICEF 1987. Cash R, Keusch GT, Lamstein J, editors. Child Health and Survival - The UNICEF GOBI-FFF Program. Routledge & Kegan Paul Books, London; 1987 |
|11.||WHO/CHERG 2010 as quoted in Countdown to 2015. Taking stock of maternal, newborn and child survival. Decade Report 2000-2010. WHO and UNICEF 2010. |
|12.|| UNICEF 2009 Coverage Evaluation Survey, All India Report, GOI, MoHFW UNICEF House 73, Lodhi Estate, 2010. |
|13.||TOI 2011. Watch the watchdog. Times of India, 18 April, 2011. |
|This article has been cited by|
||Planning and preparation of VHND through convergence: Sharing experiences from Uttarakhand
| ||Vartika Saxena,Ranjeeta Kumari,Praveer Kumar,Bhola Nath,Ranabir Pal |
| ||Clinical Epidemiology and Global Health. 2014; |
|[Pubmed] | [DOI]|
||Health promotion: An effective tool for global health
| ||Kumar, S. and Preetha, G.S. |
| ||Indian Journal of Community Medicine. 2012; 37(1): 5-12 |