Why infant mortality rate matters

The worrying trend is that the decline in the IMR has slowed down in the last five years in several states

Madhya Pradesh Chief Minister Shivraj Singh Chouhan says cow dung and urine can help boost the economy. What would boost child survival in his state? One eagerly waits to hear his thoughts.

Meanwhile, in the state with the worst infant mortality rate (IMR) in the country, four infants recently died in a fire that swept through the children's ward in a Bhopal hospital. Ten more children died later, and hospital authorities maintain this was due to reasons not linked to the blaze.

Contrary to how Chouhan put it, it was not the "untimely departure of children from the world". These were preventable deaths and are part of the big picture of child survival in this country.

Infant mortality, defined as the number of infant deaths (less than one year) per thousand live births in a given period and for a given region, is not just a marker of the health of infants. It is as much a pointer to the overall health of a country or a region and indicates health disparities between different populations, both within and between countries.

Infant deaths also signal deeper social problems such as malnutrition or poor sanitation and compromised immunisation of both mother and child. The latest official data (Sample Registration System, 2019) tells us that India's infant mortality rate (IMR) is 30 (i.e. 30 infant deaths per thousand live births for the year 2019). This is about one-fourth of what it was in 1971. That is the good news.

The bad news is that the national average masks huge disparities. The IMR in Nagaland and Mizoram is 3; for Kerala, the corresponding figure is 6, almost as good as many countries in Europe. Madhya Pradesh's IMR, in stark contrast, is a shameful 46. Worse than a war-torn nation like Yemen, as has been pointed out many times.

The other equally worrying trend is that the decline in the IMR has slowed down in the last five years in several states. For example, in 2008, Uttar Pradesh had an IMR of 67. That dropped to 50 in 2014. In 2019, however, the rate of progress has slowed down to 41. Madhya Pradesh's IMR was 70 in 2008; it plunged to 54 in 2014, but once again, the rate of progress has turned sluggish in recent years, and the latest official data put the state's IMR at 46.

What is contributing to the slowdown of the decline in IMR in many states?

Health experts flag a mix of factors linked to the political and economic factors, which have further strained an overstretched and under-resourced health system. Poorer states have been hit harder.

"It depends a lot on political priorities," says Sulakshana Nandi, National Joint Convener, Jan Swasthya Abhiyan (Peoples' Health Movement) and a Chattisgarh-based health activist.

"In recent years, the central government has paid less attention to social welfare schemes and tangible services. We found district administrations and departments focused on improving coverage of initiatives like the so-called JAM (Jan Dhan accounts, Aadhaar cards and mobile phones). Frontline workers were busy meeting targets on these. Indicators such as percentage of Aadhar coverage or bank linkage became the main discussion points during review meetings at the district and state levels instead of issues such as whether mid-day meals were being provided in schools and anganwadis," says Nandi.

The National Rural Health Mission (NRHM) set up in 2005, she points out, focused on maternal and child health, especially on improving primary health care services such as immunisation and ante-natal care. "States like Chhattisgarh saw significant reductions in IMR in the early 2000s due to the work of Mitanins (precursor of ASHA) and other social welfare measures. The low-hanging fruit was reached through these efforts. But what did not get attention was the quality of facility-based care required for more complicated cases and conditions. There continues to be

an inadequate investment for secondary and tertiary care in the government sector. Instead, private hospitals are being brought in to provide these services through publicly-funded health insurance schemes such as PMJAY(Pradhan Mantri Jan Arogya Yojana, part of the Modi government's flagship Ayushman Bharat scheme). The focus of the Modi government on public-private partnerships instead of strengthening the government health system has made things even worse," Nandi adds.

The Modi government's welfare schemes include the much-talked-about Pradhan Mantri Ujjwala Yojana, which aims to provide women below the poverty line with free or subsidised gas cylinders to wean them from unhealthy cooking fuel. There is also the grand scheme now to provide households with piped water connections. These are laudable initiatives, but we need more data on their impact on child survival.

A performance audit of Reproductive and Child Health under the NRHM by The Comptroller and Auditor General of India (CAG) released on July 21, 2017, made damning observations. It said that surveys of selected health facilities across 29 states/UTs disclosed that even the basic equipment required for reproductive and child health (RCH) services such as labour table, normal delivery kit, emergency obstetric care equipment, X-ray facility were not available in various health facilities. Non-availability of essential drugs and idling of equipment deprived the patients of the intended health care under NRHM. Mobile Medical Units (MMUs) were also not operational in four states and only partially functional in 10 states.

A 2018 analysis by the Centre for Budget and Governance Accountability (CBGA), a think-tank focusing on public policies and government finances, noted that India's policy framework had undergone significant changes over the past few years. Some of the major changes being: (i) the acceptance of the 14th Finance Commission's (FC) recommendations on sharing of the central pool of divisible resources among States; (ii) changes in the structure and funding pattern of the Centrally Sponsored Schemes (CSS); (iii) adoption of the National Health Policy 2017, (iv) transition from Planning Commission to NITI Aayog.

One consequence has been the changes in the Centre-state ratio for centrally-sponsored schemes, including NRHM, now called National Health Mission (NHM), which changed to 60:40 from the erstwhile 75:25.

An analysis of the budgetary allocation for maternal and child health interventions across nine select states (UP, Bihar, Chhattisgarh, Jharkhand, West Bengal, Rajasthan, MP, Odisha and Assam) by the CBGA shows that, in some of the states, there has been a decline for this component. The reduction in state budget spending on maternal, newborn, and child health during the 14th Finance Commission period is seen across most select states. This indicates that states are not prioritising maternal and child health within their respective state

health budgets. This is also evident when we look at maternal, newborn, and child health (MNCH) spending as a share of NHM. In all nine states, there is a declining trend. This drop in allocations towards reproductive and child health has also been witnessed at the Union level and may point towards an overall reduced prioritisation by governments both at the Centre and in the States, it notes.

Several experts have also pointed to dramatic disruptions in the macro-economic situation in the country in recent years, which have impoverished millions of families, affecting child survival. A 2020 report by scholars Jean Dreze and others, "Pauses and reversals of infant mortality decline in India in 2017 and 2018", finds evidence of a slowdown, pauses, and reversals in infant mortality decline in large parts of India in 2017 and 2018. "In urban areas, the infant mortality rate stagnated at 23 deaths per 1,000 births between 2016 and 2018. Worse, overall infant mortality increased in the poorer states of Chhattisgarh, Jharkhand, Madhya Pradesh, and Uttar Pradesh in this period. This occurred despite sustained improvements in household access to sanitation and clean fuel."

One possible interpretation of these findings, the authors say, is that" in addition to their impact on unemployment and poverty, the demonetisation experiment in late 2016 and the subsequent economic slowdown had an adverse effect on child health." The authors point out that between 2005-2016, India experienced a long spell of rapid decline in infant mortality rates, and that coincided with a "period of fast economic growth combined with some major initiatives in the social sector, including the launch of the NRHM in 2005 and the gradual

universalisation of Integrated Child Development Services (ICDS) from 2006 onwards." The report says that "there are many indications of substantial improvement in living conditions in that period, including a decline of close to 50 per cent in multidimensional poverty."

But something went wrong after 2016. The authors point out that the National Sample Survey data for 2017-18, for instance, suggest an unprecedented decline in real per-capita expenditure compared with 2011-12 and "while this may not be due to a decline in the survey year itself, that is certainly a possibility since the Indian economy was doing very well in the intervening period. Another worrying pattern is the virtual stagnation of real wages in rural areas between 2014-15 and 2018-19, in sharp contrast with the preceding ten years when they were rising steadily."

One plausible hypothesis, argue the authors, is that "these setbacks are at least partly attributable to India's startling experiment with wholesale demonetisation in November 2016, when 86 per cent of the currency became worthless overnight."

What should be done?

I spoke to several ASHA workers in states with a higher infant mortality rate than the national average of 30. One common issue that leaps out is the proliferation of new schemes in recent years. Then, there are numerous surveys commissioned by the government, which has led to a massive increase in the ASHA's workload. ASHAs are the footsoldiers of the health system in this country, and they say they are overburdened with so many tasks that they do always find enough time to focus on their core mandate of supporting mothers and children. The pandemic has added to their everyday workload while their demand to be formalised and made permanent workers remains unheeded. This needs to change.

Health activist Amulya Nidhi stresses the need to revive the practice of child and maternal death reviews across the country in right earnest to understand better why infants are still dying in such large numbers. Operational guidelines exist for the same. "Such reviews were taking place between 2005 to 2012; it continued, though with less priority between 2012 to 2017. But since then, it is not happening," says Nidhi. This needs to happen alongside strengthening the primary health care approach and focusing on capacity building of village health and sanitation committee, he adds.

There is a blunt way of explaining the infant mortality rate. The babies who have died before their first birthday in this country won't ever start school, work or become a part of their community or this country's social fabric. Every one of these lives mattered. India's infant deaths need to matter if India matters.

(Patralekha Chatterjee is an independent journalist and columnist)

Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH.