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

BLOG - NHP

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

Non-communicable diseases killed more Indians in 2015

 

stethoscope

Cardiovascular diseases were the leading cause of deaths in males and females in India in 2015. And high systolic blood pressure was the number one risk factor.

In 2015, India, like other developed countries, had more number of deaths caused by non-communicable diseases. In the case of males, deaths due to non-communicable diseases (3.6 million) were more than double that caused by communicable diseases (1.5 million), while it was nearly double in females (2.7 million due to non-communicable diseases and nearly 1.4 million deaths due to communicable diseases, neonatal, and nutritional diseases). Globally, 70 per cent (40 million) of deaths in 2015 were due to non-communicable diseases.

Cardiovascular diseases were the leading cause of death in both sexes in India — 1.6 million in males and 1.1 million in females. The next biggest cause of deaths was chronic respiratory diseases — 0.68 million in males and 0.5 million in females.

These are some of the Global Burden of Diseases results (here, here, here, here, here, here,  and here) published in seven papers in The Lancet on October 6.

Injuries killed 0.6 million males and 0.3 million females in 2015 alone. India had the highest number of suicide deaths in the world last year, with nearly 132,000 deaths in men and over 76,000 deaths in women. At 0.36 and 0.31 million, neonatal disorders killed nearly equal number of males and females. The other leading causes of deaths last year in both sexes were ischemic stroke, haemorrhagic stroke, TB, lower respiratory infections and diarrhoea.

India had the highest number of suicide deaths in the world in 2015.

Slower reduction in MMR

Along with Nepal and Bhutan, India has registered a slower reduction in maternal mortality rate (MMR). The MMR was reduced by a little over 50 per cent in 25 years (1990 to 2015), from over 130,000 deaths in 1990 to nearly 64,000 deaths in 2015.

In 2015 alone, the number of under-5 deaths in India was 1.26 million. The number of stillbirths alone was 0.53 million. “India recorded the largest number of under-5 deaths in 2015, at 1.3 million (1.2–1.3 million), followed by Nigeria (726,600) and Pakistan (341,700),” says a paper in The Lancet. Neonatal pre-term birth complications, lower respiratory infections, diarrhoeal diseases and measles were some of the leading causes of under-5 mortality.

The rate of under-5 deaths was 48.9 deaths per 1,000 live births. For every 1,000, live births there were 29.06 neonatal deaths (0-27 days after birth), 20.25 stillbirths, 11.74 post-neonatal (28 days to 1 year) deaths, and 8.80 deaths during the 1-4 years.

The Janani Suraksha Yojana conditional cash transfer programme was established when increasing number of women sought reproductive health services. “[The programme] has been successful at increasing reproductive health-care services, but even despite its popularity this programme has not been as effective at reaching poor rural women, the sociodemographic group that is already at highest risk of adverse pregnancy outcomes,” a paper notes.

Leading risk factors

For both sexes, the leading risk factors are high systolic blood pressure, fasting plasma glucose, ambient particulate matter, household air pollution, and unsafe water. According to The Lancet, smoking is a bigger risk factor for Indians than even cholesterol and iron deficiency. Childhood under-nutrition and lack of whole grains figure in the list.

Iron-deficiency anaemia is the leading cause for years lived with disability in the case of India, followed by lower back and neck pain, sense organ diseases, and depression.

Published in The Hindu on October 6, 2016

‘There is fantastic immunisation coverage in India’

WHO

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.

Why?

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

Bangladesh: women’s education cuts maternal, child mortality

Bangladesh is a classic case of how a low- and middle-income country can achieve something which others have failed to. It reduced its maternal mortality by 66 per cent between 1990 and 2010; the reduction was 40 per cent between 2001 and 2010 alone.

These were achieved by lowering the maternal mortality rate (the number of maternal deaths per 100,000 live births) from 574 to 194 during the period 1990 to 2010. The reduction was substantial even in a short span of eight years (1990 to 1998) — 574 to 322 per 100,000 live births. As per the 2012 WHO estimates, the average annual rate of decrease was 5.9 per cent during the period 1990 to 2010, which is more than the Millennium Development Goal 5 target of 5.5 per cent or more.

What is more surprising is that the reduction in MMR (maternal deaths per 100,000 live births) was almost the same in both the urban and rural areas.

At the current rate of (MMR) reduction, Bangladesh is well on its way to reaching the MDG 5 target of 143 per 100,000 live births this year — a year ahead of schedule. India too reduced maternal mortality by 65 per cent from 569 to 190 per 100,000 live births between 1990 and 2013.

Yet, with only 4.5 per cent annual reduction in MMR, India is bound to miss the MDG 5 target of 5.5 per cent or more decrease rate before 2015.

So how did Bangladesh, one of the poorest countries in the world with the highest population density and where 75 per cent of the population lives in rural areas, achieve it? “It’s a difficult question to answer. Several different things happened and they were interlinked,” said Prof. Shams El Arifeen, Centre for Children and Adolescent Health, ICDDR, B, Shaheed Tajuddin Ahmed Sharani, Dhaka.

“If you were to highlight the factors, the status and value of women have improved. They are more educated and have access to finance. Discrimination against women has come down… there is quite a bit of evidence of that.” Education has in turn increased women’s willingness and ability to seek health care. “Education for women in the 15-24 years age group is particularly important… there is a revolution happening with 80 per cent literacy in women. It is the time when they are starting their reproductive life and having families and babies. A big factor is that the government is consistent in encouraging education regardless of which political party is in power,” he explained.

“In villages can see more girls are educated compared with boys.” One of the biggest benefits of education is seen in reduced fertility. Each individual is replacing himself. “Every couple produces no more than two children. I couldn’t have imagined this 20 years ago,” he pointed out. The family planning norm has changed. Couples used to have more children but that norm has changed. Most couples have 2 or less children. With increased use of contraceptives, fertility rate reduced by 0.7 child per women.

On average, the fertility is currently 2.3. “The desired fertility is 1.6. That gap can be reduced by reducing fertility,” he said. Besides reduced fertility, one third to one half of women who deliver are first time mothers. “Twenty years ago, each couple would have had five children,” Prof. Arifeen said.

It is known that mothers have a greater risk of dying when they have greater parity. “So we don’t see high risk deliveries happening now. There are fewer chances of maternal mortality.

There is a shift from high parity high risk to low risk low parity,” he noted. According to a paper published today (June 30) in The Lancet (Prof. Arifeen is the first author), the fertility reduction led to MMR reduction through two mechanisms. While there was 21 per cent deaths averted through reduction in the number of births, a shift towards more younger women (aged 20-34 years) and those with fewer children delivering babies contributed an additional seven per cent reduction in MMR.

It is a “valid, nationally-representative household survey-based statistical evidence of progress towards MDG 5,” the journal notes. This is just one of the many factors that differentiate Bangladesh from India. The first survey in 2001 included 100,000 households and the second in 2010 covered 174,000 households. Bangladesh witnessed a 40 per cent reduction in maternal mortality during the period the 2000 and 2010. A three-fold increase in deliveries by medically trained healthcare providers was one of the important factors; deliveries attended by midwifery were, however, low (3 per cent).

While there has been an improved access to and use of health facilities, most often people turn to the private sector. There has been only a fair bit of investment in the public health sector. “The private sector is more expensive,” Prof. Arifeen admits.

“The problem is that the ultra-poor don’t benefit. So have to worry [about] how to provide help to that stratum. We definitely need to provide affordable care to everybody.” He does see the Indian model of more public care spending as an advantage to the socioeconomically backward class. “There is a lot to learn from India’s experience,” he admitted. “We are talking about universal health coverage. Affordable service is a part of health coverage. We must provide some sort of safety net for the poor.”

(The Correspondent participated in the Partnership for Maternal, Newborn and Child Health Forum in Johannesburg at the invitation of the Global Health Strategies, New Delhi.)

Published in The Hindu on July 3, 2014

Finally, neonatal mortality prevention gains attention

 

WHO

Dr. Flavia Bustreo, Assistant Director-General for Family, Women’s and Community Health, WHO. – Photo: R. Prasad

Following the approval of the Every Newborn Action Plan by the ministers last month in the World Health Assembly, a new global action was launched on June 30 in the Partner’s Forum in Johannesburg to bring in significant new financing, policy and service delivery commitments that could save the lives of newborns and mothers.

The need for such focus arises as about three million women and newborns die every year from preventable and treatable conditions like prematurity, complications around birth and severe infections. All the 194 countries that attended the World Health Assembly last month agreed to a commitment to support and implement measures that would save these lives.

“The WHO remains committed to support countries and work with partners as the plan gets implemented and to the accountability agenda, which included the reporting on progress achieved every year until 2030,” Dr. Flavia Bustreo, Assistant Director-General for Family, Women’s and Community Health at WHO said in a release.

UN

Photo: R. Prasad

While the number of maternal and newborn (0-27 days) deaths has shrunk significantly over the last two decades, the number of newborn deaths and still birth has been depressingly high. Nearly three million (2.9 million to be precise) newborn deaths are still seen, and another 2.6 million are stillborn globally every year.

At 779,000, India has the highest neonatal deaths in the world, and 56 per cent of all under-five year deaths in India happen during the neonatal period.

That newborn death now accounts for 44 per cent of all under-5 deaths worldwide every year is a poignant reminder of the unfinished work. Also, babies face the greatest risk of dying during the first 24 hours. First day of birth is the most risky period for both mother and newborn. In India, over 300,000 newborns deaths take place in the first 24 hours, the highest for any country.  These deaths account for 29 per cent of the global total.

If death on the first day contributes to around half of world’s newborn deaths annually, 50 per cent of 290,000 maternal deaths occurring each year across the world is also during the first day of delivery. Clearly, reductions in neonatal mortality have lagged behind those of maternal, infant, and child mortality due to less attention and investment.

It is to prevent these deaths that 40 commitments have been made by the private sector, few countries, philanthropic institutions and NGOs. The private sector, which is supporting the “Every Woman Every Child” movement, is responsible for supporting 17 of the 40 commitments.

Johnson & Johnson will through its $30 million commitment “work with partners to implement evidence-based interventions and innovative technologies designed to improve the health-knowledge of pregnant women and mothers.”

Similarly, Laerdal has made a financial commitment of $35-50 million through 2017 “to develop and provide on a non-profit basis, innovative products and programs for high-interventions for saving lives at birth,” said Tore Laerdal, Chairman and Managing Director of Laerdal Global Health in a release.

The Well Being Foundation, Novartis, Pfizer, McCann Health, Merck & Co are among others who have made financial commitment from the private sector.

The Islamic Development Bank has a made a huge $90 million commitment to address one of the most neglected but very important areas – building midwifery schools, training health workers in maternal and neonatal care and establishing health information system, including birth registration. On the sub-Saharan countries would stand to benefit.

Five governments – Bolivia, Cameroon, Malawi, the United Sates and Oman — have made commitments.

Four philanthropic institutions and other funders have pledged their support. These institutions are: Bill & Melinda gates Foundation, Sanofi Espoir Foundation, The Children’s Investment Fund Foundation and The Wellbeing Foundation.

Of the several non-governmental organisations, the Family Planning Association of India (FPA India) is one of them. It commits to promote and advocate for universal access to sexual and reproductive health services by continuing to serve the poor, marginalized, socially excluded, and the underserved.

(The Correspondent is participating in the Partnership for Maternal, Newborn and Child Health Forum in Johannesburg at the invitation of the Global Health Strategies, New Delhi.)

Published in The Hindu on June 30, 2014

Ten countries that were on a fast-track to achieve the MDG 4 & 5 goalss

 

Shyama

Each country had a unique pathway but had certain commonalties like family planning and immunisation, says Dr. Shyama Kuruvilla. – Photo: R. Prasad

While a majority of low- and middle-income countries (LMICs) are struggling to meet the Millennium Development Goal 4 and 5 of reducing child mortality and improving maternal health, in 2012 ten countries with similar resources were on the “fast-track” of achieving the targets, notes a June 30, 2014 Partnership for Maternal, Newborn and Child Health, WHO report.

These countries (in alphabetical order) — Bangladesh, Cambodia, China, Egypt, Ethiopia, Lao PDR, Nepal, Peru, Rwanda, and Vietnam — “deployed tailored strategies and adapted quickly to change” to achieve the desired results. “Each country had a unique pathway but had certain commonalities like family planning and immunisation,” said Dr. Shyama Kuruvilla, Senior Technical Officer, Knowledge for Policy, Partnership for Maternal, Newborn and Child Health, WHO, Geneva. She is also a coordinating author of the “Success Factors for Women and Children’s Health” report.

The reason why these 10 countries are doing better than other low- and middle income countries turns the spotlight on the core issue – it was not the amount of money they spent but how they spent it that mattered. “These countries identified evidence-based high-impact interventions like immunisation, family planning and quality care at the time of birth. And these were carried out the interventions in a novel way and adapted to suit the particular country’s conditions,” she said.

As a result, the immunisation coverage shot up from 2 per cent to 85 per cent between 1985 and 2010. “They have a very good monitoring system. You need to focus on the results of investment and not just how much money is put in. These [10] countries have, what we call, a triple planning — investment, investing to sustain progress and identifying the challenges that require change,” Dr. Kuruvilla explained.

These countries did work outside health as well, like girl’s education; women’s participation in labour force and politics; rapid increase in safer water availability and sanitation; and economic development and good governance. “All the 10 countries are doing better than other countries in all these areas. We need combined progress in all areas, not just health. That’s the challenge for India,” Dr. Kuruvilla stressed.

China made universal primary education compulsory in 2000. It made nine years education compulsory for eliminating illiteracy among young people. And in 2011, the net enrolment of primary school-age children was 99.8 per cent. It achieved universal education in 2011, much ahead of 2015. “So the strongest population point is China. It achieved 99.8 per cent enrolment of children [although] the population is 1.37 billion,” she said dismissing the excuse of a large population in India standing in the way of vastly and quickly improving the health indicators.

Between 1990 and 2013, India reduced maternal mortality by 65 per cent (569 to 190 per 100,000 live births). But it still accounts for 17 per cent (50,000) of the global maternal deaths, the highest in the world. Though it brought down under-five mortality from 2.5 million to 1.4 million between 2001 and 2012, 22 per cent (the highest in the world) of deaths took place in India in 2012. Of the three million neonatal (0-27 days) deaths in 2012, 779,000 happened in India. Also, globally there were 2.6 million stillbirths the same year, of which 600,000 were in India.

In the case of Nepal, increased provision of maternal and neonatal services like free delivery scheme and cash incentives for antenatal care visits have ensured that women deliver safely and babies have a better start to life. The number of skilled birth attendance has shot up from less than 10 per cent in 2001 to 36 per cent in 2011.

Many government strategies and policies connected to safer motherhood, neonatal health, nutrition and gender are “underpinned by principles of human rights.” Reproductive, maternal, newborn, and child health have become a political priority. Between 1991 and 2011, Nepal witnessed a 66 per cent reduction in under-five mortality (from 162 to 54 per 1,000 live births) and 80 per cent reduction in maternal mortality (from 850 to 170 per 100,000 live births). Nepal has shown that political instability is not a limiting factor. “Despite severe economical and political challenges, all these [10] countries have done well,” she added

“There is greater participation and ownership by community and female health volunteers in Nepal,” Dr. Kuruvilla said. In the case of Bangladesh, the co-ordinated efforts by community workers and NGOs helped save the lives of many under-five children. “In Bangladesh and Nepal somebody takes leadership. We must have leadership from somewhere. The only problem [in India] is we need a critical mass. There are hundreds of NGOs but all do different things,” she highlighted.

The widespread use of mobile phone technology is playing a pivotal role in strengthening the health system in Bangladesh. Collection of real-time data on pregnant women and under-five children, text messages offering advice to registered pregnant women are sent out every week and online registration of births and deaths are driven by information and communication technology.

“The use of mobile phones has increased birth registration [in Bangladesh] from 10 per cent in 2006 to 50 per cent in 2009,” said Dr. Kuruvilla. The country is striving to make government health services fully digital by 2016; rural areas, where 75 per cent of the population lives, got connected by wireless broadband in 2012.

Between 1990 and 2011, Bangladesh witnessed a 65 per cent reduction in under-five mortality (from 151 to 53 per 1,000 live births) and 66 per cent fall in maternal mortality (from 574 to 194 per 100,000 live births).

“Bangladesh and Vietnam adopted economic programmes to employ women,” said Dr. Kim Dickson, Co-Chair of “Every Newborn Action Plan” report and Senior Adviser for Maternal and Newborn Health, UNICEF. “They [women] have more money… can help take decisions.”

Stressing on the importance of breast feeding, Dr. Dickson cited the example of Cambodia where it increased from 11 per cent in 2000 to 74 per cent in 2010. “There was a campaign focussed on media awareness, including TV soap operas,” Dr. Dickson said.

In many countries, breast feeding not being done as recommended is not unusual. “Early initiation [in facilities immediately after birth] and exclusive breast feeding for first six months are an issue,” Dr. Kuruvilla said.

(The Correspondent is participating in the Partnership for Maternal, Newborn and Child Health Forum in Johannesburg at the invitation of the Global Health Strategies, New Delhi.)

Published in The Hindu on June 30, 2014

Editorial: No reason to cheer

On the face of it, India may appear to have made great strides in reducing the maternal mortality rate by 65 per cent, from 569 per one lakh live births in 1990 to 190 in 2013. But scratch the surface, and the real picture emerges. In 2013, India had 17 per cent (50,000) of the global maternal deaths. Together with Nigeria at 14 per cent (40,000), the two countries accounted for one-third of total global maternal deaths. The MMR of 190 last year is much higher than the government’s target of below 100 by 2012. Also, India is yet to achieve the expected average annual maternal mortality rate decline of 5.5 per cent or more during the period 1990-2013 to reach the Millennium Development Goal 5 target. With only a 4.5 per cent decline in MMR during the last 23 years, the country falls under the “making progress” category and would fail to meet the MMR target of 109 before 2015. The only silver lining is that India has been making steady progress in reducing the MMR since 1990. But for a country where an estimated 26 million deliveries take place annually, the absolute number of maternal deaths continues to be high.

Besides the medical reasons like severe bleeding and infections after childbirth and high blood pressure levels during pregnancy, one of the factors that is playing a big role in maternal mortality is the lack of skilled care “before, during and after childbirth.” Maternal mortality is counted when deaths occur during pregnancy or in the first 42 days after the birth of the child, caused either directly or indirectly by pregnancy. One way of tackling this is by having more institutional deliveries. India launched a programme in 2005 to facilitate such deliveries on a larger scale than was prevalent, but the results were not encouraging: there was no corresponding decline in the number of deaths. The reason for that is not difficult to find. In 2008, more than 50 per cent of women in Uttar Pradesh and Bihar, and 41 per cent in Rajasthan, continued to deliver at home, according to a United Nations Population Fund-India report. Therefore, a greater focus on increasing the number of well-trained birth attendants should go hand in hand with promoting institutional deliveries. According to a 2008 UNICEF report, the quality of training of such attendants has been found to be “poor” in these three States that fare badly. The 2013 UNICEF report also found many other inadequacies contributing to poor outcomes when deliveries took place in health centres. Insufficient availability of health workers at primary care levels and “gaps” in the availability of equipment and supplies are some of them. The need for India to take up a more serious and multi-pronged approach to bring down the MMR cannot be overemphasised.

Published in The Hindu on May 22, 2014