Dr Mickey Chopra, global head of UNICEF’s health programmes explained to me why he was very encouraged by the efforts taken by the government to reduce child mortality, and how these efforts are paying off, especially in States like Bihar.
How is India doing as far as meeting the MDG 4 target is concerned?
India is changing very quickly. We are seeing very encouraging signs… we are starting to see the fruits of some investments the National Health Mission has been making. For example, [the Mission is] investing much more in rural and poor areas and core public health like vaccines, EPI [extended program on immunisation] and more increasingly on nutrition.
How appreciable is the reduction in child mortality?
The numbers are changing very quickly. As you know, India is a very large country with a relatively weak information system. So getting an accurate measure of mortality is always challenging. But surveys show an increasing acceleration of reduction in child mortality. There is also encouraging leadership, not only at the national level but also at the State level.
State leaders are now prioritising women’s and children’s health. Progress is being made in States such as Bihar. For example, Bihar had been one of the places with the highest rates of child mortality. But we are now seeing an increase in coverage of EPI from less than 10 per cent to almost 50-70 per cent in some parts of the State.
But there is a huge disparity between South and North India…
That’s true. There has been a disparity between North and South India for many reasons, historical and present. But we are seeing success stories even in North India where mortality rates are coming down. The lessons to be learnt from the Tamil Nadus, Keralas and Maharashtras of the world are that even when per capita income is very low, those States can make huge progress in reducing mortality rates in women and children by doing the right things like investing in public health, girl’s education and more equitable income distribution. All these factors can make a huge impact on a child’s survival.
India has central and State governments, and health is a State subject. Do you think this system has been a barrier in achieving results?
It’s a tough one. In theory, having a federal and central system should be strength as you can adapt. It’s also easy to hold leaders accountable at the State level than at the national level. But the problem, not just in India but other large countries like Indonesia and Nigeria, has been that the capacity of public health management and operational management to implement at the sub-national level has been a bottleneck.
The capacity to advocacy in these big countries is quite uneven. In some places we have strong advocacy as we have strong civil society, as in Kerala and Tamil Nadu. Whereas in other States the management is weak and technical skills are inadequate. These two factors can increase inequity. So the potential benefits of having a decentralised system are not always realised.
Despite these shortcomings, do you think India is still making progress and will meet the MDG 4 target in the near future?
Yes, absolutely. Resources are there. What we are learning in all countries is we don’t need to make massive investments to make a big impact. You do need to increase investments but relative to the size of the country and amount of money the government spends on other things, investments in public health services, and women and children services are relatively small and these can make a huge difference and impact.
The key message that we can make to our leaders is that investment in this area has and will lead to immediate results.
So if you look at Bihar, for example, the child mortality rates are dropping, and the EPI coverage rate has gone up —all in a period of five to seven years. So if the government puts its money and focuses, we can get almost immediate results.
Can you cite some targeted efforts taken to reduce child mortality?
The Indian government has stepped up its efforts in bringing down child mortality rate. The government is focussing on the poorest districts or those that have the worst outcomes…170 or 180 deaths [per 1,000 live births]. They have asked the UN and USAID to adopt those districts and help identify the bottlenecks and suggest ways of improving the quality. It has really shown a good leadership role.
I am very encouraged by what I am seeing in India and Indian government, in particular.
When did the government’s focus on reducing child mortality start?
The focus started in 2005-2006. There has been a gradual but significant increase in financing for health, and primary health, in particular. Greater focus on women and children really came in after the Call for Action in 2013. The government really started looking at where the deaths were occurring and prioritising those districts and States.
Do you think the success in polio eradication was a morale booster?
Obviously, the success in polio gave a lot of people the confidence to do more. Don’t forget that polio was surviving in the poorest communities, the communities that were living by the canals and rivers and were the most difficult to reach…yet we were immunising those children seven, eight, nine times a year and finally got rid of polio.
So it gave a sense of confidence that if we can do that in the poorest, most marginalised, most difficult-to-reach villages and communities with polio, maybe we do it with other things as well. So it was an important psychological breakthrough and a feeling that we can achieve much more because we have the technology, management and infrastructure capacity to do it.
Do you think the eleventh hour push is helping?
That’s been one of the advantages of targets — holding everybody accountable. It does add urgency to governments to move faster, put more resources and more attention. So even if India does not achieve it [MDG 4], if it continues to invest in the same way and continues its focus, then the momentum would carry it through, if not by 2015, soon thereafter.
The worst thing that could happen is on the December 31 night of 2015, they say the date has come and gone so we will focus on something different. So wemust make sure we don’t just stop at the end of next year but continue after that.
What kind of pressure would be there for India to continue the focus beyond 2015?
This is where we are saying India has the potential to end all preventable maternal and child deaths. So India can reach a level of 25 per 1,000 live births by 2030. Below a level of 20 per 1,000 live births, most deaths are quite unavoidable. If you can reach a level of 25 to 20, then we can say the child’s chances of survival is no different from that in other parts of Europe and parts of Americas, which is amazing considering where we have come from.
But 15 years is a long time…
We need to set goals in between [too]. So we have to look at 2020 and probably should be at a State level as much as at the national level. We need to set State-level goals, and one of the things we would encourage is looking at an annual rate of change. Say, every State should decrease by 5 per cent or 6 per cent. So we can set short goals and make them visible, particularly at the State level.
Though child mortality rates are coming down the numbers are still very high, especially in the case of India. Why was a reduction in numbers not targeted at?
This where numbers and statistics can mislead. The MDGs aimed at proportionate reduction. The downside is that, it can still lead to high levels of deaths. So we are now advocating for an absolute number by 2035 — 20 child deaths per 1,000 live births.
Why was it not done at the outset?
At that time it was difficult to come to one number. Some countries had 300 child deaths [per 1,000 live births] and some had 60. So if we said everybody should reduce it to 20, it would have been impossible for [countries with] 300 deaths to come down to that level. So that’s why we said proportionate reduction.
But now, the ranges are much narrow. We have done the modelling and we think we can set an absolute number.
At the moment there are 6.3 million children dying every year. One of the things we are looking at is can we say by 2025 or 2030 only three million should be dying. But the trouble with numbers is that it is difficult to know, for instance, if the fertility changes, the numbers can change in different ways. You could get to the [target] number by still having higher rate of deaths but fewer children per mother. So even reducing the fertility rate would lead to lower number, even if the mortality rate is still high in a community. So the trouble with numbers is that it’s very dependenton fertility rate rather than mortality rate.
But reducing fertility rate takes time compared with reducing mortality rate…
So we are looking at having a number as opposed to rate. But within a rate, we should have an absolute rate not a proportionate reduction. That is, every country should achieve 20 per 1,000 and not more than that.
(The Correspondent participated in the events surrounding the United Nations General Assembly, New York as a Partnership for Maternal, Newborn and Child Health Scholarship Journalist at the invitation of PMNCH, Geneva)