The Ministry of Health and Family Welfare issued a press release last weekend announcing that India had registered a “significant reduction” in infant mortality rate or IMR as per latest data from the Sample Registration Survey. The IMR has declined three points from 37 deaths per 1000 live births in 2015 to 34 deaths per 1000 live births in 2016, which is an 8% decline.
The drop in the number of infant deaths is, of course, good news. But while the health ministry is hailing the numbers as “remarkable achievements in merely one year”, public health experts point out that the numbers only confirm the downward trend in infant mortality across the country over the past decade. Meanwhile, a large number of children continue to die in India – about 9,30,000 died in 2015 and 8,40,000 died in in 2016.
Dr Mohan Rao professor at the Centre for Social Medicine and Community Health at Jawaharlal Nehru University in Delhi, said that the decline is unremarkable as it only confirms the declining trend. Since 2006, IMR has declined by at least two to three points every year and the same has happened again between 2015 and 2016.
IMR is an important indicator of community health and is sensitive to general structural factors such as socio-economic development and basic living conditions. The same factors that increase an infant’s susceptibility to death – poverty, disease, lack of sanitation, lack of education – are the factors that affect health and productivity of adults as well. Moreover, the biggest improvements in life expectancy and health come from reduction in infant and child mortality.
“We are benefitting from technological advancements, perhaps a better vaccination programme, better hospital procedures during childbirth,” said Amit Sengupta, associate global coordinator of the People’s Health Movement. “It does not indicate that social indicators are better. We still have many children with low birth weight and many young mothers. We are benefitting from picking these low hanging fruit.”
Another recent study – the Million Death Study that looked at causes of child mortality – attributed the decline of infant mortality from 2000 to 2015 to the creation of the National Health Mission aimed at improving primary healthcare in the country, and the Janani Suraksha Yojana which incentivised institutional deliveries.
“The focus on primary health care and antenatal care [of schemes implemented in 2005] may have caused a persistent accelerated impact [over the past decade],” said Dr T Sundararaman, Dean of School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai. “The build up to [2016 IMR rates] is not particularly because of the current government but because of the concerted action in this area over the years.”
Meanwhile, as Rao pointed out, IMR in Uttar Pradesh, Bihar, Madhya Pradesh have been declining significantly but remain unacceptably high.
Uttarakhand is the only state with an unfortunate increase in IMR, especially in the rural areas. While the total IMR in Uttarakhand has risen from 34 to 38, its rural areas have seen a sharp 10 point rise from 31 to 41 in one year. The other states showing a rise in IMR are Arunachal Pradesh, Tripura, Manipur and the union territory of Daman and Diu.
Another significant comparison with regards to to infant mortality is that that India’s neighbouring countries, which are economically more backward, have fewer deaths.
As per the United Nations Inter-agency Group for Child Mortality Estimation figures of 2015, neonatal mortality – mortality within 28 days of birth – in Nepal and Bangladesh were 22.5 and 23.3 respectively. India’s neonatal mortality was 27.7.
“India’s social indicators including infant mortality rates are higher than countries such as Nepal and Bangladesh,” said Sengupta. “I am not even considering Sri Lanka which is way ahead of India on health indicators.”
One reason for this difference, according to Sengupta, is that while social indicators have become better among richer household in India, they have only stagnated or become worse for the poor.
“After liberalisation [of the economy in 1991], the global evidence shows that while people got richer, the difference between the rich and poor increased,” he said.
This is borne out by the infant mortality rates in rich states like Andhra Pradesh, Telangana, Haryana and Gujarat which have higher infant mortality rates as compared to the poorer state Jharkhand. This is because, infant mortality in rural areas in the richer states is worse than in rural areas of Jharkhand.
The gender gap
The Sample Registration Survey also shows that difference between the female and male infant mortality has reduced by more than 10%. The government has attributed the this improvement to the Beti Bachao Beti Padhao scheme launched in January 2015, which is aimed at improving the child sex ratio, early survival of the girl child and girls’ education.
But like infant mortality, the improvement in child sex ratio is also more likely to be a continuation of a decade-long trend.
The Million Death study noted significant reductions in the gap between male and female child mortality between 2000 to 2015. The authors of the study were reluctant to attribute it to any single reason, but speculated that the availability of health services, and overall social indicators may have contributed to it.
Experts said that more studies need to be done to understand this phenomenon before jumping to the conclusion that a single programme has helped reduce the gender divide.
“I do not see any specific intervention making such a big difference to reduce the gender divide between the male and female IMR,” said Sundararaman.