There has recently been some triumphalism in Indian government circles over reports that the National Rural Health Mission (NHRM) has been successful in reducing maternal mortality and infant mortality. Yet while the reduction in maternal mortality – from 301 to 254 for every 100,000 live births – does provide some cause for cheer, the reduction in child mortality – from 58 to 53 for every 100,000 live births – still leaves much to be desired. This is particularly so when some Indian states continue to lag behind far poorer countries including, Nepal and Bangladesh. The NHRM is now slated to receive an eight-year extension from its current target year of 2012, by which time it was supposed to have achieved a range of far-reaching goals of direct consequence to this issue. At this point, however, even this significant extension does not look set to help the two million Indian children under the age of five who die every year. The fact of the matter is that the NHRM simply does not have a clear roadmap by which to take any significant step forward on the matter. As such, it will almost certainly continue to muddle along, even as children continue to die preventable deaths – by the current count, one every 15 seconds.
There is a clear place to start in this undertaking. At the moment, deaths occurring within the first month of birth – so-called neonatal deaths – constitute half of all fatalities in children under five years old. This is a significant number, and over two-thirds of infants continue to die within their first month in today’s India, 90 percent of whom expire due to easily preventable causes such as pneumonia and diarrhoea. Yet even within what appear to be clear-cut parameters, the official effort to deal with this phenomenon – the NRHM’s Navjat Shishu Suraksha Karyakram, which trains health workers in the basic care and resuscitation of newborns – has yet to take off.
Across Southasian countries, a common and complicating feature of child and infant mortality today is that the deaths are not evenly distributed across the countries. Instead, these take place in specific geographic locations and among particular population groups. These especially include 50 districts in five Indian states, a few districts in two provinces of Pakistan, and a few districts in Nepal, Afghanistan and Bangladesh. Together, these areas contribute to the highest global burden of preventable infant mortality. Alongside this, other Indian states have quite low levels of infant mortality, comparable even to the numbers in developed countries. Consider, for instance, the 2007 data from the Ministry of Health and Family Welfare: with 13 deaths per 1000 live births, Kerala has the lowest infant mortality rate in India, while Madhya Pradesh, with 72, has the highest. A closer analysis shows that high infant- and child-mortality rates are invariably a reality among historically marginalised population groups and locations, with low levels of female literacy, recurring drought, rampant migration and poor local governance being common features across these areas.
To date, some of these more indirect causes for such high mortality rates, particularly poor governance and lack of accountability, have not received adequate examination. In addition, one aspect that is very rarely discussed is the sheer apathy that exists on the part of local, government and international agencies – the ‘duty-bearers’ who are vested with the responsibly of ensuring the survival of each and every child. Yet thus far, only limited efforts have been made to understand the role of duty-bearers in preventing avoidable child deaths, particularly the ‘opportunity cost’ of inaction and inappropriate action. In Southasia, such inaction or inappropriate action is directly contributing to the daily ‘murder’ of about 5000 children.
The focus of the international health community for ensuring child survival is currently on the provision of vaccines, access to trained health-care providers, institutional delivery and nutrition, and other interventions such as cash transfers. Interestingly, child-mortality rates in the West decreased substantially during the first three decades of the 20th century without the help of any such interventions. In most of the West, prior to the 1930s, declining fertility, better nutrition and housing, accompanied by a rising standard of living, played important roles in reducing infant mortality. Industrialisation, the growth of the welfare state, and feminist and secular initiatives are also generally acknowledged as having led to low levels of infant mortality in the West. Along the same lines, the relatively low infant-mortality rates in Kerala indicate that a high level of economic development is not a prerequisite for child survival. Instead, what is needed is an improvement in the social and economic determinants of neonatal and infant health.
Clearly, the current strategies are not working. While the arena of advocacy for child survival (as this issue is generally known) is a crowded one, with a plethora of multilateral and bilateral agencies in the business, the results have not been proportional to the efforts. At the same time, throughout our region, ensuring the survival of children is essentially the duty of the state, and no specific agency is tasked with the job. Even when specialised agencies – such as a child rights commission and child-welfare NGOs – do exist, there are no institutionalised accountability mechanisms to ensure that these bodies fulfil their stated roles. The institutional mechanisms that do exist, meanwhile, are often little more than tokenism. Incredibly, not a single one of the statutory child-rights institutions in India has taken up the issue of high levels of child mortality. Indeed, many members of Parliament from such areas are not even aware that their constituencies have higher levels of child mortality than most, and none of these parliamentarians has been held accountable for his or her failure to address the issue.
Unfortunately, just as political leaders are influenced by political outcomes, civil society is often influenced by funders’ priorities. Consequently, even as many NGOs, particularly the international players, engage in a great deal of sloganeering on infant mortality, it is becoming evident that these pious sentiments are little more than doublespeak. While publicly calling for a ‘revolution’ to ensure child survival, these groups are often motivated by vested interests – fundraising for their own survival at the headquarters level – and are not even willing to ensure basic progressive values, such as cultural diversity among their staff, even at the country level. An amazing number of Western expatriate experts provide advice to country-level programmes in addressing infant mortality. Advocacy for child survival has become just another way to capture media space and ‘build the brand’ for international and national NGOs, with even the corporate sector getting involved. For instance, Coca-Cola is today one of the major sponsors of child-mortality-reduction programmes in Southasia.
At the same time, there are several empirically validated efforts to improve child survival that are being implemented in most Southasian countries today. Their activities are being carried out by dedicated health workers, working in isolation and with limited resources. Lessons from India, Pakistan and Bangladesh indicate that the best community-based approach for reducing infant mortality is a combination of community mobilisation and home visits by community-based health workers. In this, it seems, both the timing of visits and treatment interventions are critical. It is imperative that governments and NGOs learn from the positive experiences and insights of these health activists, who could provide models for scaling up efforts to ensure greater child survival.
Yet the reality is a general reluctance to work within a coalition – for instance, of likeminded NGOs – based on a common plan of action for a particular region to improve the condition of children. Instead, turf wars and brinksmanship regularly undermine the need for building strong partnerships. Equally worryingly, NGO policies and programmes are generally not grounded on existing data and empirical evidence, but rather are influenced by the ‘big man’ ideas of NGO managements. For instance, though it has long been known that the most common causes of death in China for children under five were pneumonia, birth asphyxia and pre-term birth complications, a leading international child-welfare agency carried out a campaign to promote hand-washing as a key strategy to reduce infant mortality. Only later was it discovered that a multinational corporation involved in the sale of detergents and soaps was behind the promotion of the hand-washing drive. No rationale was ever provided for the campaign, and none of the expatriate staff who initiated this opportunistic campaign were held accountable.
Even while such irrelevant programmes continue to be implemented, the localised causes behind child mortality have yet to be fully explored. For instance, there has been no analysis of the manner in which local belief systems and existing social exclusion contribute to higher infant mortality. After all, concepts of ritual pollution associated with childbirth – the expulsion of pregnant mothers to cowsheds to give birth, for example – continue to contribute massively to infant deaths. Without such specific knowledge, it will be impossible to design effective solutions.
A call for a greater share of budgetary resources is in some ways the cornerstone of contemporary campaigns for ensuring child survival. While this is certainly an important issue, a far more informed analysis of the indirect and local causes of high mortality rates, as well as more targeted and decentralised financing, are necessary. Ultimately, a nationally initiated and centrally administered programme is unlikely to be more effective than one administered by local governments. To ensure transparency and accountability, local governments and states need to be given a greater role in financing child survival. In turn, holding all agencies and local administrations involved in child survival accountable for their promises is absolutely critical. In the end, only by training more health workers, employed through local governments and who are also able to tackle problems of malnutrition, will infant mortality be reduced in Southasia.
~ Joe Thomas is a public health commentator, teacher and researcher who teaches Public Health at the Jodhpur National University.