The fourth National Family Health Survey, conducted in between January 2015 and December 2016 shows that most public health metrics have improvement. For instance, the number of infants dying per thousand live births – a critical measure of human development index – has gone down sharply from 57 in 2005 to 41 in 2016.

Quite significantly, infant mortality rate has declined in all 15 states and union territories surveyed, except one: Mizoram. According to data released as part of the survey, the rate in Mizoram went up from 34 in 2006 to 40 in 2016, an increase of almost 18%.

Is this an indication that Mizoram is facing an impending public health? If so, what is fuelling it?

According to H Lhungdim of the Population Centre of India, who was part of the team that carried out the survey in the state, the primary reason behind the higher number was the use of district-level samples. “Since robust data samples from each of the districts were collected this time the poor performance of the southern districts, particularly Saiha, reflects in the state average,” he explains.

Lhungdim, however, insists that it may not be the best idea to compare the survey of 2006 and 2016 as there were no district-level samples taken in the former. Lhungdim’s explanation indicates that Mizoram’s high infant mortality rate may not be a new phenomenon but was not detected earlier because of bad data and poor representation from the historically backward and minority-populated southern districts.

The centralisation of health facilities in the state capital Aizawl, said Lhungdim, has led to people in the southern districts being deprived. “Most of Mizoram is rural and since the terrain is difficult, quality healthcare fails to reach these people,” he said.

A Scroll.in ground report from Saiha district in 2015 corroborates Lhugdim’s contention. Aizawl’s apathy has pushed Saiha to the margins and the neglect is all-pervasive in the area.

In neighbouring Manipur, almost all district headquarters are bustling centres with comparatively decent healthcare facilities, according to Lhugdim. Manipur has the lowest infant mortality rate in India.

State government in denial

The Mizoram state government, though, does not seem to think that there is a problem. The state’s coordinator for maternal and child health Dr Zochhuan Awmi told Scroll.in over the phone from Aizawl that the data was not accurate and it “depicted Mizoram in a bad light”.

“According to our own live data, the rate has been steadily coming down – it is 22 now,” said Awmi. “We are completely surprised at how they have arrived at these numbers. It seems they didn’t go to the field at all.” Awmi pointed out that even census data, released earlier this year, pointed towards a lower rate: 32.

The data Awmi is referring to is Sample Registration System data of the Registrar General of India. A two tier-approach is employed by the to collect these numbers. A local enumerator keeps record of all births and deaths in a sample set of villages or urban blocks and an independent supervisor carries out a survey every six months retrospectively. While Mizoram’s infant mortality rate was indeed 32 at the end of 2015, according to this data set, it has risen by more than 80% since 2000, when the rate was just 17.5.

A study from Mizoram University in 2015 diagnosed that the high infant mortality rate in Saiha was a direct consequence of food insecurity and malnutrition. The study showed that per capita calorie intake in the region was 1703 kilocalories. The recommended amount is 2400 kilocalories.

Awmi, however, contended that the situation was under control. “Since April 2015, we have been distributing Vitamin D supplements and we have seen deaths come down by almost 50%,” she said. “We refuse to accept the National Family Health Survey.”

Broken system

T Sundararaman, dean of the School of Health Systems Studies at the Tata Institute of Social Sciences in Mumbai, said the National Family Health Survey seemed fairly robust and believable. “State governments tend to underreport data for obvious reasons,” said Sundararaman, who was also till recently the executive director at the National Health Systems Resource Centre in New Delhi.

However, he added, infant mortality rates should always be understood in relation to other metrics like nutrition prevalence since better nutrition levels usually lead to low infant mortality rates.

“The data looks believable because it’s in the same range as the census data and the previous survey,” Sundararaman says. “What happens is simple interventions like women’s education, sanitation, nutrition, etc. can bring down infant mortality rates from say the 60s to the 30s, but to decrease it beyond that requires higher level scientific and medical interventions and special facilities. Since it is unlikely that Mizoram can afford such interventions, the number has probably stagnated or increased, but it has definitely not decreased.”

Mizoram has been on the verge of a health crisis for some time now, owing largely to its over-reliance on central funds in the absence of any other real source of revenue. Even the Janani Suraksha Yojana, a scheme to reduce neonatal and maternal deaths, has suffered major cutbacks due to non-availability of funds.

It is evident that Mizoram’s healthcare system, particularly its maternal and child health services, is broken and requires immediate attention. The government would do well to acknowledge it.