Even as seemingly avoidable child deaths at government hospitals continue to make news across the country, a new study puts the spotlight on India’s significant progress in reducing child mortality in the last 15 years.

Published in the journal Lancet, the study draws upon interviews of 13 lakh households, which were selected randomly across India. The interviews were done as part of the Million Death Study by non-medical surveyors with the Registrar General of India, which seeks to investigate deaths in developing countries by speaking to families and not relying on hospital data. Through the interviews, data was collected on children below five who died between the years 2001 and 2013.

The researchers then extrapolated estimated mortality rates backward to 2000 and forward to 2015. This showed the mortality rate in children under the age of five fell from 45.2 in the year 2000 to 19.6 in 2015 – a decline of 5.4% each year. The numbers at at variance with data from the National Family Health Survey, which shows that under five mortality fell from 74 in 2005-’06 to 50 in 2015-’16. The Lancet study results show that the mortality rate per 1,000 live births among neonates – babies who are within the first 28 days of life – fell from 45 in 2000 to 27 in 2015, a 3.3% decline every year. Data from the government’s Sample Registration System also maintained by the Registrar of India shows a similar trend.

The verbal autopsies were independently examined by two physicians to establish the most likely cause of death. The study found that the leading causes of death were pneumonia, diarrhoea, low birth weight, and malaria. In 15 years, deaths of children due to pneumonia fell by 63%, deaths due to diarrhoea fell by 66% and deaths due to measles and tetanus fell by 90%.

The authors of the paper attribute this decline in mortality to the introduction of two major national programmes in 2005 – the National Rural Health Mission, which is now the National Health Mission, and the Janani Suraksha Yojana. While the National Rural Health Mission was implemented to improve the entire rural healthcare system, the Janani Suraksha Yojana was implemented to encourage women in both rural and urban areas to deliver babies in hospitals and not at home.

Between 2005 and 2010, the health budget also increased from 0.9% of GDP to 1.3%. In 2016, it stood at approximately 1.2% of GDP.

“A modest improvement in investment in public health has resulted in declines in child mortality, largely in the central states,” said Rajesh Kumar, dean of Post Graduate Institute of Medical Education and Research, Chandigarh and one of the authors of the study. “The decline rate was stagnant in the 1990s to 2000. This shows that the public system delivers. If we can improve spending, the gains may be much more.”

The lead author of the paper, Prabhat Jha, who is the head of the Centre for Global Health Research India Foundation and Professor at St Michael’s Hospital at the University of Toronto, spoke to Scroll.in about the major take-aways of the study and how it can impact policy decisions.

What are the key findings of the study?
What it says is that child mortality has come down substantially in india and, importantly, it has come down faster from 2005 and particularly fast in the last five years.

The United Nations estimates that between 2000 and 2015, based on actual data from the census and the Registrar General’s data, 29 million children under the age of five died of all causes.

What our study shows is that the annual decline in mortality accelerated after 2005 because of attention to particular programmes and introduction of National Health Mission and Janani Suraksha Yojana. That is the most likely explanation.If that acceleration had not occurred after 2005, there would have been one million more deaths. There would have been 30 million instead of 29 million. The faster rates of progress have saved an extra million children in india.

This is good national representative data that shows that access to quality care can increase maternal and neonatal outcomes.

Prabhat Jha, professor at St Michael’s Hospital, University of Toronto. (Photo: HT Photo)
Prabhat Jha, professor at St Michael’s Hospital, University of Toronto. (Photo: HT Photo)

How do you think the two programmes and government policy helped in the decline of child mortality below five years?

The Janani Suraksha Yojana that has really increased the number of women giving birth in hospitals has led to reduction in birth complications from breathing (birth asphyxia caused by obstruction to the infant’s airways) and infections. The emphasis on making sure there is free access to basic treatment for pneumonia and diarrhoea has led to more than 60% decline in pneumonia and diarrhoea deaths. And then some focused immunisation programmes on measles and tetanus have led to 90% decline in deaths. The way to think about this is that more spending on healthcare helped. But the things that got national attention is where the greatest progress is.

But in areas such as controlling the mortality related to low birth weight, there has been no decline. Why?
In areas that had less attention, there was less progress. The most important one is that neonatal deaths of low birth weight babies who were delivered at full term rose in the last 15 years in the poorer states and rural areas but not in the richer states or in the urban areas. They fell in those areas. This is because the Janani Suraksha Yojana is very much set up for getting women delivered in hospitals in rural areas. But it is not set up to handle a low birth weight baby. Neonatal Intensive Care Units or incubators or other things are not part of the standard package.

At the same time, there are other factors that need more research. There might be undetermined maternal factors such as maternal anaemia, or even tobacco chewing among women in the poorer states that helps explain this.

Another disease that has served as a control in this study is malaria. Malaria deaths in children have come down, but not nearly at the same rate. They have come down about 44% during the 15 years whereas for many other conditions have come down well over 60% or 70%. What that reflects is relative inattention to malaria prevention and treatment, particularly in getting newer treatments.

Earlier more girls used to die as compared to boys. Now the divide has narrowed rapidly. What do you think are the reasons?
We had some evidence that as recently as 2008 that mortality rate in girls at ages 1-59 months was about 40% higher than in boys. What we have shown, however, is that the increase in access to free treatment cuts the bias against the girls. Or perhaps, it does not give the excuse for the bias to be implemented such as “I only have a bit of money. If I have to go to a hospital and I have to pay. So, I am not going to pay for my girl but will pay for my boy.”

When the service is free of cost and available easily, people do avail of the service.

There are other factors. For instance, the severity of infection in diarrhoea has come down. This means there is more treatment access. This is also related to increasing literacy, especially among women. A literate mom will know what drugs to give a sick child.

I think the main driver of the narrowing of the inequalities is expansion of free good treatment for pneumonia and diarrhoea in particular for all.

What about the the divide between urban and rural areas, and rich and poor states? What does the study find?
What is particularly striking is that in children at ages 1- 59 months, the death rates between rural and urban areas have converged. The rural areas are making faster progress than urban areas, particularly in tackling pneumonia and diarrhoea, birth asphyxia and birth trauma.

But, when we look at the first month of life, the story is different. There is no narrowing of rural urban gap in the first month of life overall. The reason is that there are more low birth weight babies in the rural areas than in urban areas. Rich and poor states follow the same story more or less with low birth weights increasing in poorer states.

After the Gorakhpur tragedy where the oxygen was cut for a few hours in the intensive care units of the pediatric wards, what should government set out to do? How can we improve our data collection on these deaths?
Gorakhpur was a tragedy that could have helped the government learn a lot more. The gap that was there was the same gap is the motivation for million death study. We do not know how people die and we do not issue proper death certificates. It is a deficiency in almost all hospitals in India.

The World Health Organisation death certificate is the norm now in places like China and Thailand. It is a simple form to try understand the cause of death.

The Gorakhpur incident suggests that, along with understanding rural deaths, we also need to understand urban deaths in the hospitals better.

Apart from increasing spending in health, what kind of policy decisions can the government take based on your research which can reduce the child mortality further?
About 2,25,000 deaths below age of five are from pneumonia, diarrhoea, malaria and measles. There are 7,000 measles deaths and there are only 600 neonatal deaths from tetanus in 2015. You can eliminate measles deaths and have that as a goal. The government can expand the vaccination programme.

We will now be working with Indian Council for Medical Research to do more detailed description of what is happening in the first month of life. Then we will do more detailed work at state level so that every state has a blueprint for better health.