Missing Little Indians

Infant Mortality Rate (IMR) is defined as the number of infant deaths per 1,000 live births in a community during a particular calendar year. This index is considered the most important measure of how well the government distributes available resources for health, education, status of women and public spending. According to experts, deprivation among people of a particular region, class or ethnic group within a country is likely to show in the form of an increased IMR.

A country like Sri Lanka, riddled with civil war, has managed to keep it at 17 per 1,000, compared to India’s 60. Even Bangladesh is improving at a faster rate than India. Kerala, with an IMR of 16, is the only state with a figure similar to developed countries. Certain areas in Madhya Pradesh, Orissa and Rajasthan have an IMR figure of above 90-100.

Why worry?
RECENT research shows that the maximum number of deaths of children occur before they are 28 days old. This, the neonatal mortality death, is 40 for every 1000 children born (see box, Dying Young). Its rate of fall has not been substantial at all —it was 51 in 1991. This means that the existing health strategies are missing this critical stage.

Two, as the UN Human Development Report 2005 points out, the fall-rate was substantial in the 1980s but stagnated in the ’90s. So, while government interventions worked in the ’80s, something went awry in the ’90s.

Both these points indicate there is a gaping hole in the mother-child care programme that needs to be plugged.

The ’90s norm
IN hindsight, it can be said that the interventions in the ’70s and ’80s were very effective but, in the ’90s, the government became ambitious and launched giant, umbrella programmes without the supporting infrastructure that would make an impact on the ground.

In 1979, the Expanded Programme of Immunisation was established to provide tetanus vaccines to pregnant women and BCG, DPT, polio and measles vaccines to children. The Universal Immunisation and oral rehydration were both launched in the mid-’80s.

The results were evident. The IMR improved: from 114 in 1980 to 80 in 1990.

In the early ’90s, the government launched the ambitious Child Survival and Safe Motherhood programme, including ORS, immunisation, nutrition counselling, vitamin A, antenatal care and family planning. In the urge to focus on the big picture—and the mother—newborns started getting ignored.

‘‘These vertical, direct interventions attacked the largest killer diseases till the ’80s but in the ’90s the focus became broader,’’ said Sangeeta Saxena, assistant commissioner, Child Health, Ministry of Health and Family Welfare, acknowledging the need for a re-think.

While the mother-focus is a great concept—her health is directly linked to the child’s—the programme overlooked the fact that the same village nurse or dai would have to include additional services in her daily duties.

Moreover, there was a freeze on the number of AMNs (auxilliary midwife and nurse) that could be hired and the existing ones apparently couldn’t cope with the bouquet of services they had to offer. Despite the population boom, no additional ANMs were recruited when ideally there should be one for each 1,000-strong population cluster.

Additionally, the national emphasis shifted to polio campaigns and immunisations. While the survival rate of children aged five and less improved, the figure of infants dying within 40 days of birth had little reason to cheer about.

Further, research shows that 66 per cent of the children dying do so within 28 days of their birth. With such clarity in the target group, the government should have been able to turn around the programme quickly but the bureaucratic wheels are still dithering.

‘‘At this rate, the IMR and child mortality projected up to 2016 shows that India may not be able to achieve the set target of an IMR of 30 by 2010 without making concerted efforts to improve the content and quality of health services,’’ said Arvind Pandey, director, Indian Council of Medical Statistics.

It takes a village
WITH 42 per cent of all deliveries still happening at home, research emphasises that the community is very important in preventing neo-natal deaths. ‘‘It has more to do with behavioral details rather than biological ones,’’ said Pandey.

The community role is vital in detecting the first signs of illness in a child. With a little bit of training, they can amend some age-old practices that increase chances of children dying. For example, some communities traditionally wash the child after it is born, the mother is not allowed to breast-feed for four days and she is not allowed to step out for 40 days.

A few community projects have been launched and have shown dramatic results, to the extent of halving the IMR in some tribal communities. Dr Abhay Bang and Rani Bang published their findings in a study in acclaimed medical journal Lancet. Two small contraptions they introduced made all the difference (see The Big Bangs Theory).

Dr Vishwajit Kumar, too, is working with the community in Uttar Pradesh, slowly changing habits that make the child vulnerable. ‘‘The community is extremely important and it is unfortunate that this resource has not been tapped earlier,’’ said Kumar, active in nearly 300 villages in Rae Bareilly district.

Though few, these efforts show how quickly a substantial difference can be made. In spite of promises to scale the Bang model in four states, the government has not even begun.

Survival strategies
As evident from the map, some areas have an IMR far above the national average of 60. So far, the government has not been able to move from a state-centric approach. No attempts have been made to target areas like Southern Orissa, Vindhyas in Madhya Pradesh or central Uttar Pradesh.

But, according to Dr Saxena, the government is considering innovative strategies that factor in a freeze on funds. The National Rural Health Mission, for one, has introduced ASHA—an acronym for Accredited Social Health Activist—who will have a minimum education till class VIII, be a member of the community and be paid by the community for her services. While she won’t be a government employee, she will get training and kits for her work.

At present, there has been little coordination among government departments on the healthcare front, resulting in duplication of efforts. An effort is being made in this direction. For example, the Ministry of Health’s ASHAs will be present in the Anganwadis, which is a programme run by the Department of Women and Child Welfare.

If there’s a silver lining in this dark cloud, it’s that the IMR has been falling since 2003. The latest figures are 60, down from 63 in 2002. But this figure is not good enough to hide India’s shame, brighter in the light of the country’s economic boom.