A bottom-up plan

India contributes the highest share of global deaths (about 10.8 lakh, as against China’s 1.7 lakh in 2016) among children under five. Its enormous population and a relatively high under-five mortality rate (U5MR) as an emerging country are key factors. As India’s achievement in reducing child deaths matters a lot at the global level, it can help shape global child mortality indicators. India has shown a consistent decline in mortality rates. Introduction of the National Rural Health Mission (NRHM) accelerated this reduction especially in the post-neonatal period. Yet our recent study shows that the extent of this reduction is still not enough to achieve the Sustainable Development Goals (SDG)-3 goals for the neonatal mortality rate (NMR) and U5MR by 2030. We have found that that over 52% of districts in India are unlikely to meet SDG3 to reduce NMR to 12 (per 1000 live births). Similarly, about a third of the districts in India are unlikely to meet U5MR of 25 (per 1000 live births) by 2030.

Marked differences

Unlike many other emerging countries, India exhibits exceptional regional and socio-economic inequality in demographic and health outcomes. For instance, the U5MR rate for male children varies between 6.3 in the southwest district of the National Capital Territory of Delhi to 141.7 in the tribal-dominated district of Rayagada in Odisha (about 22 times). In general, the majority of high-risk districts for NMR and U5MR are in Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Rajasthan and Uttar Pradesh. Yet, the high-risk districts in NMR are not limited to poorer States but spread across even rich and advanced States such as Andhra Pradesh, Haryana, Gujarat and Telangana, particularly for male neonates. There are two States in particular, namely, Chhattisgarh and Uttar Pradesh, where 97% of districts are unlikely to meet the SDG targets for both NMR and U5MR (irrespective of gender).

Our findings are crucial for policy makers, health professionals, administrative authorities and organisations striving to improve maternal and child health. The government should lay emphasis on local level intensive programmes that cater to the specific needs of individual districts or other population subgroups. More investment is needed for neonatal health. Under the National Health Mission, there are a number of programmes such as the Integrated Management of Neonatal and Childhood Illnesses, Navjaat Shishu Suraksha Karyakram, home-based care of newborns, universal immunisation through the mother-and-child tracking system, and early detection and appropriate management of various diseases.

These programmes have certainly helped to reduce child mortality rates. Yet, to maximise their impact, the focus must shift more intensively to how these programmes are executed in low performing districts. There has to be more awareness about district-level intervention programmes through community-based awareness programmes and educating parents about possible high-risk factors and preventive measures of child health. Second, States should give priority to the improvement of public health facilities by reinforcing institutional deliveries, filling eligible and trained human resources, making available adequate testing machines and infrastructure at sub-centres, primary and community health centres, and district hospitals. We expect that low-performing districts with a high mortality rate would respond faster in mortality reductions if these strategies are adopted. A long-term solution lies in raising the level of education among girls and mothers especially among the poor, rural and deprived sections of society. Apart from child mortality reduction, it will help in the overall health and development of children.

Nandita Saikia is at the Jawaharlal Nehru University, Delhi and the International Institute for Applied Systems Analysis (IIASA), Austria. Jayanta Kumar Bora is with the Indian Institute of Dalit Studies, Delhi and IIASA, Austria