Can health spending of 2.5% of GDP only by 2025 help achieve the goals set by India’s National Health Policy?


The National Health Policy wants to reduce infant mortality rate to 28 per 1,000 live births by 2019.

The long awaited National Health Policy announced a few days ago proposes to raise public health expenditure as a percentage of GDP from the current 1.15% to 2.5% by 2025. The resource allocation to individual States will be linked with their development indicators, absorptive capacity and financial indicators. “There will be higher weightage given to States with poor health indicators and they will receive more resources. The Policy aims to end inequity between States. But at the same time, States will be incentivised to increase public health expenditure,” says Manoj Jhalani, Joint Secretary — Policy, Ministry of Health and Family Welfare.

The catch

While public health expenditure as a percentage of GDP will reach 2.5% only by 2025, many of the goals listed in the Policy have a deadline of 2025 and some of them even earlier.

The Policy stresses on preventive healthcare by engaging with the private sector to offer healthcare services and drugs that are affordable by all. It wants to reduce out-of-pocket “catastrophic” health expenditure by households by 25% from current levels by 2025.

The focus is on providing free, comprehensive care in primary care for the most prevalent communicable and non-communicable diseases, and increased affordability of care at secondary and tertiary care services by a combination of public and not-for-profit private providers wherever necessary. It wants to increase the utilisation of public health facilities by 50% from the current levels by 2025.

Health card roll out

The Centre is working on introducing a health card — an electronic health record of individuals. “The health card will be for retrieving and sharing health data by lower [PHC] and higher [secondary and tertiary] healthcare facilities. It will be helpful when patients move from primary to secondary or tertiary healthcare facilities,” says Mr. Jhalani. “It will be launched in six months to one year’s time. It will be launched in those States that show interest to roll it out in certain districts or across the State.”

Disease control and elimination

Like the Health Ministry’s National strategic plan for tuberculosis elimination 2017-2025 report, the Policy wants to reduce incidence of new TB cases to reach elimination by 2025. In a similar vein, the policy has set 2017 as the deadline to eliminate kala-azar and lymphatic filariasis in endemic pockets, and 2018 in the case of leprosy. In the case of chronic diseases such as diabetes, cancer, cardiovascular diseases, it envisages a 25% reduction in premature mortality by 2025.

The Policy “aspires” to provide secondary care right at the district level and reduce the number of patients reaching tertiary hospitals. For the first time, there is any mention of public hospitals and facilities being periodically measured and certified for quality.

Pipe dream

The Policy has sharpened its war on tobacco by indicating a 15% relative reduction in tobacco use prevalence by 2020 and 30% by 2025. But the most ambitious target is providing access to safe water and sanitation by all by 2020. As per January 2016 Ministry of Drinking Water and Sanitation country paper, sanitation coverage was only 48%.

Reducing IMR and MMR

Other challenging targets set by the Policy include reducing infant mortality rate to 28 per 1,000 live births by 2019 and under five mortality to 23 per 1,000 live births by 2025. According to the National family Health Survey 4, IMR was 41 in 2015-16; it took 10 years to reduce IMR from 57 to 41. Similarly, under five mortality was 50 in 2015-16 and it took 10 years to reduce it from 74. Over 38% children under five years were stunted according to the NFHS-4 report. The Health Policy wants to reduce this by 40% by 2025.

Increasing immunisation coverage

As against 62% children 12-23 months old who were fully immunised in 2015-16 according to the NFHS-4 data, the Policy has set a target of 90% by 2025. “Going up to 70% coverage is hugely a challenge of reaching the community. But beyond 70% coverage, other factors come in and it becomes a very big challenge,” says Dr. Pradeep Haldar, Deputy Commissioner — Immunisation, Ministry of Health. According to J.P. Nadda, the Union Health Minister, the Mission Indradhanush has increased the annual increase in full immunisation from 1% to 5-7%.

Published in The Hindu on March 19, 2017

Why rural children in India die of diarrhoea and pneumonia

The reason why a large number of children under the age of five years die of diarrhoea and pneumonia, generally in rural India and especially in Bihar, has become abundantly clear. The results of a study were published a couple of days ago in the journal JAMA Pediatrics.

Diarrhoea and pneumonia are the biggest killer diseases in children aged under five years in India. With 55 per 1,000 live births, Bihar has the highest infant mortality rate in the country. But 340 health-care providers who were studied in rural Bihar rarely practised what little they knew about treating children suffering from these two diseases.

“Vignette” interviews were conducted to assess how they would diagnose and treat children with these diseases. Later, the actual treatment offered by the health-care providers was assessed by sending “patients” pretending to suffer from the same symptoms as in the interviews.

If the providers exhibited “low levels” of knowledge about the two diseases during the interviews, it was even worse during practice. Cheap, life-saving, widely available oral rehydartion salts (ORS) with zinc supplementation is the correct treatment for diarrhoea (2013 WHO recommendation).

During the vignette interviews, a paltry 3.5 per cent of providers offered the correct treatment for diarrhoea. Another 69 per cent offered ORS, but it was in addition to other unnecessary treatments. Some even prescribed antibiotics.

Shockingly, no health care provider prescribed the correct treatment for the “patients” with diarrhoea — only ORS. It was a few shades better in the case of pneumonia where the figure stood at 13 per cent.

Again, if nearly 21 per cent of practitioners prescribed potentially harmful treatment (including antibiotics) without ORS during the interviews, an alarming 72 per cent offered dangerous cocktails that included antibiotics during practice. Antibiotics have no role to play in the treatment of diarrhoea.

In the case of pneumonia, while 12 per cent prescribed antibiotics for pneumonia during interviews, the figure went up marginally to 15 per cent during practice. Severe pneumonia requires treatment with appropriate antibiotics.

“Our ongoing studies aim to understand why providers who know they shouldn’t be prescribing antibiotics for conditions like simple diarrhoea continue to do so,” Dr. Manoj Mohanan from Duke University, North Carolina said in a release.

Besides wrong treatment, the researchers found that the health-care providers asked very few pertinent questions that would enable correct diagnosis and understanding of the severity of the diseases during practice than they did during interviews.

Even the most basic diagnostic question of frequency of stools was asked only by 46 per cent during interviews and 30 per cent during practice. Similarly, in the case of pneumonia, only 27 per cent of the providers asked about rapid breathing and 25 per cent about signs of respiratory distress during practice.

Most distressing was that during practice, 76 per cent of practitioners offered treatment despite not seeing the “sick” child with diarrhoea. It was 79 per cent in the case of pneumonia.

Eighty per cent of the providers in the study did not have a medical degree from any system of medicine — allopathy, ayurveda, homeopathy or unani medicine. While those with formal medical training did have large gaps between what they knew and what they practised, they were “significantly less likely” to prescribe harmful drugs, the study found.

Published in The Hindu on February 17, 2015

Editorial: Strengthening care of the newborn

Tamil Nadu has come to realise in a most tragic manner the high mortality risk faced by preterm babies (those born before 37 completed weeks of gestation), and its unfinished task of saving these lives. Of the 13 neonates who died recently in district hospitals in Dharmapuri and Salem, five were preterm. Both preterm and low birth weight babies have died of the usual causes, such as respiratory distress syndrome, intrauterine growth restriction, birth asphyxia and sepsis. Incidentally, with 27.3 deaths per 1,000 live births, the State has achieved the WHO’s Millennium Development Goal 4 of reducing the number of deaths in children younger than five years, well before the December 2015 deadline. It can further reduce the number of under-five deaths by adopting a two-pronged approach of bringing down the number of babies born preterm and providing crucial care to such babies during the most critical phase. There is a compulsion to adopt both measures simultaneously as birth complications in preterm babies are among the leading causes of neonatal (0-27 days) deaths. Of the estimated 15 million babies born preterm annually across the world, over 3.6 million are in India; of them, over 3,00,000 die each year. Globally, one million preterm babies die every year. According to an October 2014 study published in The Lancet, during 2013, for the first time, preterm birth complications became the leading cause of death in children under five, across the world.

Though there are several reasons for preterm delivery, the common, preventable causes are early induction of labour, teenage pregnancy, multiple pregnancies, diabetes and high blood pressure. In a commendable move in July 2013, the Ministry of Health and Family Welfare authorised auxiliary nurse midwives to administer a pre-referral dose of antenatal corticosteroids to women and injectable antibiotics to babies for suspected sepsis. Since immaturity of the lungs is one of the main reasons for preterm baby deaths, the steroid administered before delivery can vastly improve lung maturity. Similarly, the Ministry’s focus on the well-proven and cost-effective kangaroo mother care in health facilities and at home after discharge can greatly improve survival rates of preterm and low birth weight babies. These measures can potentially save many preterm babies (32 to less than 37 weeks of gestation) even in the absence of expensive incubators and ventilators. There is no reason why Tamil Nadu cannot set these as standard health practices at all its public health centres and hospitals. The lives of at least some of the 13 babies could probably have been saved had the State already adopted them. These deaths should prompt the government to act swiftly.

Published in The Hindu on November 24, 2014

Tamil Nadu has come to realise in a most tr

‘India has the potential to end all preventable child deaths’



India is changing very quickly, says Dr. Mickey Chopra, Global  Head of UNICEF. – Photo: R. Prasad

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)

Published in The Hindu on October 15, 2014

Coverage of antenatal care in India has to be increased: WHO



India has little more than 50 per cent of antenatal coverage, says Dr. Flavia Bustreo. – Photo: R. Prasad

In 2013, globally, preterm birth complications were responsible for 15 per cent (0.96 million) of deaths in children under five years of age. It is a leading cause of death in neonates (0-27 days after birth). According to WHO, about 15 million babies are born preterm (before 37 completed weeks of gestation) every year. Such births are seen both in the developed and developing countries.

India ranks first in the list of 10 countries that account for 60 per cent of all preterm births; the U.S. is ranked sixth in the list.

“India has little more than 50 per cent of antenatal care coverage. So in order to face the issue of premature births, low birth weight babies and stillbirths, the first aspect is to increase the coverage of antenatal care,” Dr. Flavia Bustreo, Assistant Director General at WHO told this Correspondent. “During antenatal care, health workers can detect whether progress of foetal growth is happening normally, pregnant mother’s nutrition is good or look out for any other complications.”

What is evident in the latest data is that across the world, nearly 30 per cent of maternal deaths are linked to indirect causes like gestational diabetes and obesity — especially among young mothers, and the influence of communicable diseases on maternal deaths.

“So antenatal care is very important as health workers can detect mothers who are obese or have diabetes. These are specific risks during pregnancy and should be given particular care,” Dr. Bustreo said. “This is not happening in India. India has to particularly care for mothers for what we call as pre-existing conditions.”

Pregnant mothers who have diabetes, are obese or have preeclampsia (high blood pressure) are less likely to complete full term and babies will be born with low birth weight. Therefore, antenatal care becomes all the more important.

Of course, babies who are born before full term can still survive as simple interventions and treatments are available. For instance, corticosteroid given to mothers before delivery can greatly facilitate the development of the babies’ lungs. It can also be given to babies soon after their birth in cases when delivery takes place even before the steroid can be given to pregnant mothers. The steroid greatly reduce the possibility of neonatal deaths. Similarly, kangaroo mother care can go a long way in keeping babies warm and improve their chances of survival.


More to do

“India has to still progress. What is available as special care facilities for babies that are low birth weight and premature are not sufficient in number. What I have seen happening is that some of the facilities in private hospitals have moved very fast especially in the cities. But when you come to rural areas in North India, this is something that is still missing,” Dr. Bustreo said. “So this leads to loss of babies who are born too early or born too small. This is part of India’s challenge.”

Within reach

While being critical of the shortcoming of the Indian government, she is still very optimistic. “Our latest data show that India is just an inch away from reaching the MDG4 (child morality) and MDG5 (maternal mortality) targets. [The current under-five mortality rate is 56 and should reach 42 before December 2015. The MMR is 190 and should drop to 140 before the end of next year.] It’s just a matter of the curve accelerating a little bit. I am hopeful that if the new government concentrates constructively on the challenges and focuses on the strengths of immunisation programme then India can achieve the MDG4 target,” she stressed.

One big challenge that stares the country in the face is the reach of antenatal care. According to the 2014 data, antenatal care in rural areas is about 50 per cent for more than one visit and about 10 per cent for more than four visits. The availability of skilled attendant at the time of delivery is only about 20 per cent in rural areas.

Yet, Dr. Bustreo remains confident. “These data are retrospect. We don’t measure them in real time. I can tell you some countries that have seen huge progress when they applied themselves to the task. For example, in the case of child mortality, we have seen annual rate of reduction of seven per cent, nine per cent and even 10 per cent in the case of Ethiopia, Rwanda and Malawi,” she said. “So if India applies specific measures, I am quite confident that it would really come close to meeting the goals and it would surprise everybody.”

Talking about the huge number of adolescent marriages and women’s role in the society and education, she noted that positive results can be obtained despite certain determinants that impact on maternal and child mortality taking a long time to change.

“What we are arguing at this juncture is that India can strengthen the provision of care so even if you have a young adolescent pregnant mother or if a pregnant mother is affected by gestational diabetes or is biologically not matured and delivers a preterm baby, she and the baby can be saved,” she noted. “Some determinants will take a generation to change but providing critical care will not take a generation.”

(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)

Published in The Hindu on October 1, 2014

Preterm births and pneumonia kill most children under five years in India


Pneumonia - Wikimedia Commons

Pneumonia caused 0.14 million deaths in neonates. 

Of the 6.3 million deaths in children under the age of five years, nearly 44 per cent of deaths during 2000-2013 occurred during the neonatal period (0-27 days after birth). Preterm birth complications, pneumonia and intrapartum-related complications have been found to be the three main causes of death in children globally.

The results are published today (October 1) in the journal The Lancet. According to Li Liu from the Institute of International Programs and the first author of the paper, there will be 4.4 million deaths in children younger than five years even in 2030 if the present trend continues.

In 2013, India, Nigeria, Pakistan, the Democratic Republic of Congo and China together accounted for half of deaths in the world in children aged under five years, and 52.5 per cent of all neonatal deaths. In the case of India and Pakistan, the three leading causes were preterm birth complications, pneumonia and intrapartum-related complications, in that order. In the case of China, the order was different — intrapartum-related complications, preterm births complications and pneumonia were the three leading causes.

Globally, preterm birth complications caused 15 per cent (0.96 million) of child deaths in 2013. This was closely followed by pneumonia. While pneumonia caused only 0.14 million deaths in neonates, at 0.8 million, it was the second major cause of death across the world in children aged 1-59 months. The two periods together accounted for 0.93 million deaths caused by pneumonia in children aged under five years. As expected, diarrhoea killed more children after the neonatal period — 0.02 million during the neonatal period and nearly 0.59 million during the period 1-59 months.

Case management of pneumonia and diarrhoea can be easily implemented and large number of deaths can be prevented with minimum intervention at little cost. Use of antibiotics to treat pneumonia and timely oral rehydration therapy in the case of diarrhoea can prevent deaths in children under five years.

“Deaths due to pneumonia and diarrhoea can be reduced in India. The coverage [of antibiotics and oral rehydration therapy] is not wide enough in India … it’s not sufficient,” Prof. Robert E. Black from the Johns Hopkins Bloomberg School of Public Health and the Corresponding author of the paper told this Correspondent. “Pneumonia [occurs] during and after neonatal period and diarrhoea [occurs] mainly after neonatal period.”

For pneumonia less than 30 per cent of children in India receive antibiotics, and over 600 million defecate in the open and have very poor access to clean drinking water resulting in most cases of diarrhoea.

“Compared to managing premature babies which involves sometimes months of intensive care, complex medical treatments and follow-ups, treatment for pneumonia (early diagnosis and three-day antibiotic treatment costing about Rs.25) and diarrhoea (oral rehydration therapy) are relatively straight forward and will save a lot more lives in the short term,” Dr Nicholas Furtado Attending Paediatrician, University of Illinois Hospital and Health Sciences System, Chicago said in an email to this Correspondent. Dr. Furtado was not involved in the study.

“In the long term, prevention of pneumonia by immunisation, acute diarrhoea by improving water supply and sanitation, and decreasing prematurity through quality care before, during and after birth would be the most important ways to decreased under five mortality rate,” Dr. Furtado noted.

Explaining why pneumonia cases are more common than diarrhoea, Dr. Furtado said: “During the neonatal period the lungs are immature and more prone to infection.”

Simple measures like exclusive breastfeeding for six months can further cut the number of diarrhoeal episodes and deaths in children. However, only about 46 per cent of children in India were exclusively breastfed for six months during 2005-2006.

It is to be noted that reduction in pneumonia, diarrhoea and measles during the period 2000-2013 has led to nearly 50 per cent decrease in deaths in children under five years.

Preterm births

India is one of the 10 countries with an estimated 100,000 to 250,000 preterm births in 2010. Preterm births cause about 50 per cent of neonatal mortality. “The causes of preterm births are not known. Conditions like high blood pressure in pregnant mothers and infections during pregnancy are some of the reasons. In a majority of cases no cause can be attributed. It’s hard to prevent preterm births,” said Prof. Black.

“Preterm birth complications will probably remain the leading cause of neonatal and under five deaths,” the paper notes.

But measures like supported infections control, kangaroo care (skin to skin contact of the baby with the mother to keep the baby warm) and use of incubators will go a long way in preventing deaths even when the baby is preterm. “We can’t prevent preterm births but can treat them and prevent most of the deaths,” Prof. Black said.

“In this analysis we didn’t include small for [gestational] age as a risk factor,” he said. Most small-for-gestational-age infants are born in India, Pakistan, Nigeria, and Bangladesh.

A July 2013 Comment piece in The Lancet notes: “In 2010, an estimated 32·4 million infants were born [at term but] small for gestational age in low- and middle-income countries (27 per cent of live births).”

Published in The Hindu on October 1, 2014

‘There is fantastic immunisation coverage in India’


Dr. Flavia Bustreo says there is lack of people with skills to assist childbirth. – Photo: R. Prasad

Both child and maternal mortality have reduced by 50 per cent since 1990, and compared with previous decades, the average rate of reduction in child mortality during this decade has more than doubled. Dr. Flavia Bustreo , Assistant Director General at WHO explained to me that the reasons why the Millennium Development Goal ignored newborn mortality reduction while concentrating on maternal and child mortality.

Unlike reducing maternal and child mortality, why was reducing newborn mortality ignored?

When we started in 1990, there were 30 million children under five years of age who died every year. At that time the proportion of newborn deaths was less than 30 per cent. As we were successful in reducing the child deaths by half, the proportion of newborn deaths kept increasing. We were successful in things that were simpler like treatment of diarrhoea and treatment of pneumonia.

We didn’t recognise the importance of mother and child at the critical time during and after birth. This was partly because providing care at birth was difficult because these births are happening at many places at home. So you don’t have people with skills to assist. The awakening now has come partly because of the large number of newborn deaths and also the importance of recognising that deliveries should happen at places where skilled workers are present.

Why was newborn mortality missed out despite it being 30 per cent of all deaths?

It was not missed. It was an area where we had less ability to do action fast because as I said the births were happening at many places. Now the situation has changed. So there is more opportunity to reduce newborn deaths. It is also clearly linked to the status of the women. In many countries, assisting a woman at the time of birth is not considered as something that is right for a woman to do. It is demeaning… That has taken so much of our time.

What is the role and importance of midwives in providing care to pregnant women?

Midwifery cadre is absolutely important both for the mother during pregnancy and at the time of delivery. Midwives have the right skills and have the right closeness with the mothers to provide care in a more sensitive manner in many countries. So midwives are critical. When we released the midwifery report in June [2014], we called for increasing the number of midwives across the world. This is a cadre that is very important. But this is the cadre we don’t have in many countries.

Within what time frame can newborn death reduction be achieved?

There is a strategic plan till 2020, 2025 and 2030. The hope is if countries adhere to the plan, we will arrive at a world in 2030 where there are less than 12 deaths per 1,000 live births. That’s the horizon we are projecting in 15 years.

But 15 years is a long time…

It will take time to build the cadre, to build infrastructure, the skills and the provision of care.

How is India’s response?

India has been absolutely unbelievable. I had worked with the Indian government in 2005. At that time there was really no focus on women and children. Progressively, India took initiatives through the National Rural Health Mission and other schemes to bring women to health facilities. There is also fantastic immunisation coverage. India is on the brink … additional push will help India to reach the Millennium Development Goal 4.

Do you really think so?

I am hopeful that if the new government takes it up and addresses this with force, then it can be done. And if India makes it, it changes the situation for the world. It would be a huge change.

What about India meeting the MDG 5 goal of reducing maternal mortality?

Meeting MDG 5 goal would be more difficult, more challenging.


I think because that the care for the women at the time of delivery requires longer time to establish. One, women should have access to facilities, then the quality of care at the facility to provide care to women when they have complications like post-partum haemorrhage or when women have serious infections like sepsis. All of these are elements of strength of the health system. And the health system takes a bit longer to establish and strengthen. There has been great progress but not sufficient to reach MDG5 goal.

Published in The Hindu on September 25, 2014