INTERVIEW

India has prevented one million child deaths due to disease since 2005. More needs to be done

Prabhat Jha, lead author of a new study on India’s declining child mortality, tells us how government health schemes have made this possible

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.

We welcome your comments at letters@scroll.in.
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“My body instantly craves chai and samosa”

German expats talk about adapting to India, and the surprising similarities between the two cultures.

The cultural similarities between Germany and India are well known, especially with regards to the language. Linguists believe that Sanskrit and German share the same Indo-Germanic heritage of languages. A quick comparison indeed holds up theory - ratha in Sanskrit (chariot) is rad in German, aksha (axle) in Sanskrit is achse in German and so on. Germans have long held a fascination for Indology and Sanskrit. While Max Müller is still admired for his translation of ancient Indian scriptures, other German intellectuals such as Goethe, Herder and Schlegel were deeply influenced by Kalidasa. His poetry is said to have informed Goethe’s plays, and inspired Schlegel to eventually introduce formal Indology in Germany. Beyond the arts and academia, Indian influences even found their way into German fast food! Indians would recognise the famous German curry powder as a modification of the Indian masala mix. It’s most popular application is the currywurst - fried sausage covered in curried ketchup.

It is no wonder then that German travellers in India find a quite a lot in common between the two cultures, even today. Some, especially those who’ve settled here, even confess to Indian culture growing on them with time. Isabelle, like most travellers, first came to India to explore the country’s rich heritage. She returned the following year as an exchange student, and a couple of years later found herself working for an Indian consultancy firm. When asked what prompted her to stay on, Isabelle said, “I love the market dynamics here, working here is so much fun. Anywhere else would seem boring compared to India.” Having cofounded a company, she eventually realised her entrepreneurial dream here and now resides in Goa with her husband.

Isabelle says there are several aspects of life in India that remind her of home. “How we interact with our everyday life is similar in both Germany and India. Separate house slippers to wear at home, the celebration of food and festivals, the importance of friendship…” She feels Germany and India share the same spirit especially in terms of festivities. “We love food and we love celebrating food. There is an entire countdown to Christmas. Every day there is some dinner or get-together,” much like how Indians excitedly countdown to Navratri or Diwali. Franziska, who was born in India to German parents, adds that both the countries exhibit the same kind of passion for their favourite sport. “In India, they support cricket like anything while in Germany it would be football.”

Having lived in India for almost a decade, Isabelle has also noticed some broad similarities in the way children are brought up in the two countries. “We have a saying in South Germany ‘Schaffe Schaffe Hausle baue’ that loosely translates to ‘work, work, work and build a house’. I found that parents here have a similar outlook…to teach their children to work hard. They feel that they’ve fulfilled their duty only once the children have moved out or gotten married. Also, my mother never let me leave the house without a big breakfast. It’s the same here.” The importance given to the care of the family is one similarity that came up again and again in conversations with all German expats.

While most people wouldn’t draw parallels between German and Indian discipline (or lack thereof), Germans married to Indians have found a way to bridge the gap. Take for example, Ilka, who thinks that the famed differences of discipline between the two cultures actually works to her marital advantage. She sees the difference as Germans being highly planning-oriented; while Indians are more flexible in their approach. Ilka and her husband balance each other out in several ways. She says, like most Germans, she too tends to get stressed when her plans don’t work out, but her husband calms her down.

Consequently, Ilka feels India is “so full of life. The social life here is more happening; people smile at you, bond over food and are much more relaxed.” Isabelle, too, can attest to Indians’ friendliness. When asked about an Indian characteristic that makes her feel most at home, she quickly answers “humour.” “Whether it’s a taxi driver or someone I’m meeting professionally, I’ve learnt that it’s easy to lighten the mood here by just cracking a few jokes. Indians love to laugh,” she adds.

Indeed, these Germans-who-never-left as just diehard Indophiles are more Indian than you’d guess at first, having even developed some classic Indian skills with time. Ilka assures us that her husband can’t bargain as well as she does, and that she can even drape a saree on her own.

Isabelle, meanwhile, feels some amount of Indianness has seeped into her because “whenever its raining, my body instantly craves chai and samosa”.

Like the long-settled German expats in India, the German airline, Lufthansa, too has incorporated some quintessential aspects of Indian culture in its service. Recognising the centuries-old cultural affinity between the two countries, Lufthansa now provides a rich experience of Indian hospitality to all flyers on board its flights to and from India. You can expect a greeting of Namaste by an all-Indian crew, Indian food, and popular Indian in-flight entertainment options. And as the video shows, India’s culture and hospitality have been internalized by Lufthansa to the extent that they are More Indian Than You Think. To experience Lufthansa’s hospitality on your next trip abroad, click here.

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This article was produced by the Scroll marketing team on behalf of Lufthansa as part of their More Indian Than You Think initiative and not by the Scroll editorial team.