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Decentralised funding is the only way to reduce Southasia’s continued skyhigh infant mortality.
There has recently been some triumphalism in Indian government circles over reports that the
National Rural Health Mission (NHRM) has been successful in reducing maternal mortality and
infant mortality. Yet while the reduction in maternal mortality – from 301 to 254 for every 100,000
live births – does provide some cause for cheer, the reduction in child mortality – from 58 to 53 for
every 100,000 live births – still leaves much to be desired. This is particularly so when some Indian
states continue to lag behind far poorer countries including, Nepal and Bangladesh. The NHRM is
now slated to receive an eightyear extension from its current target year of 2012, by which time it
was supposed to have achieved a range of farreaching goals of direct consequence to this issue. At
this point, however, even this significant extension does not look set to help the two million Indian
children under the age of five who die every year. The fact of the matter is that the NHRM simply
does not have a clear roadmap by which to take any significant step forward on the matter. As such,
it will almost certainly continue to muddle along, even as children continue to die preventable
deaths – by the current count, one every 15 seconds.
There is a clear place to start in this undertaking. At the moment, deaths occurring within the first
month of birth – socalled neonatal deaths – constitute half of all fatalities in children under five
years old. This is a significant number, and over twothirds of infants continue to die within their
first month in today’s India, 90 percent of whom expire due to easily preventable causes such as
pneumonia and diarrhoea. Yet even within what appear to be clearcut parameters, the official effort
to deal with this phenomenon – the NRHM’s Navjat Shishu Suraksha Karyakram, which trains
health workers in the basic care and resuscitation of newborns – has yet to take off.
Across Southasian countries, a common and complicating feature of child and infant mortality today
is that the deaths are not evenly distributed across the countries. Instead, these take place in specific
geographic locations and among particular population groups. These especially include 50 districts
in five Indian states, a few districts in two provinces of Pakistan, and a few districts in Nepal,
Afghanistan and Bangladesh. Together, these areas contribute to the highest global burden of
preventable infant mortality. Alongside this, other Indian states have quite low levels of infant
mortality, comparable even to the numbers in developed countries. Consider, for instance, the 2007
data from the Ministry of Health and Family Welfare: with 13 deaths per 1000 live births, Kerala
has the lowest infant mortality rate in India, while Madhya Pradesh, with 72, has the highest. A
closer analysis shows that high infant and childmortality rates are invariably a reality among
historically marginalised population groups and locations, with low levels of female literacy,
recurring drought, rampant migration and poor local governance being common features across
these areas.
To date, some of these more indirect causes for such high mortality rates, particularly poor
governance and lack of accountability, have not received adequate examination. In addition, one
aspect that is very rarely discussed is the sheer apathy that exists on the part of local, government
and international agencies – the ‘dutybearers’ who are vested with the responsibly of ensuring the
survival of each and every child. Yet thus far, only limited efforts have been made to understand the
role of dutybearers in preventing avoidable child deaths, particularly the ‘opportunity cost’ of
inaction and inappropriate action. In Southasia, such inaction or inappropriate action is directly
contributing to the daily ‘murder’ of about 5000 children.
Clueless
The focus of the international health community for ensuring child survival is currently on the
provision of vaccines, access to trained healthcare providers, institutional delivery and nutrition,
and other interventions such as cash transfers. Interestingly, childmortality rates in the West
decreased substantially during the first three decades of the 20th century without the help of any
such interventions. In most of the West, prior to the 1930s, declining fertility, better nutrition and
housing, accompanied by a rising standard of living, played important roles in reducing infant
mortality. Industrialisation, the growth of the welfare state, and feminist and secular initiatives are
also generally acknowledged as having led to low levels of infant mortality in the West. Along the
same lines, the relatively low infantmortality rates in Kerala indicate that a high level of economic
development is not a prerequisite for child survival. Instead, what is needed is an improvement in
the social and economic determinants of neonatal and infant health.
Clearly, the current strategies are not working. While the arena of advocacy for child survival (as
this issue is generally known) is a crowded one, with a plethora of multilateral and bilateral agencies
in the business, the results have not been proportional to the efforts. At the same time, throughout
our region, ensuring the survival of children is essentially the duty of the state, and no specific
agency is tasked with the job. Even when specialised agencies – such as a child rights commission
and childwelfare NGOs – do exist, there are no institutionalised accountability mechanisms to
ensure that these bodies fulfil their stated roles. The institutional mechanisms that do exist,
meanwhile, are often little more than tokenism. Incredibly, not a single one of the statutory child
rights institutions in India has taken up the issue of high levels of child mortality. Indeed, many
members of Parliament from such areas are not even aware that their constituencies have higher
levels of child mortality than most, and none of these parliamentarians has been held accountable
for his or her failure to address the issue.
Unfortunately, just as political leaders are influenced by political outcomes, civil society is often
influenced by funders’ priorities. Consequently, even as many NGOs, particularly the international
players, engage in a great deal of sloganeering on infant mortality, it is becoming evident that these
pious sentiments are little more than doublespeak. While publicly calling for a ‘revolution’ to ensure
child survival, these groups are often motivated by vested interests – fundraising for their own
survival at the headquarters level – and are not even willing to ensure basic progressive values, such
as cultural diversity among their staff, even at the country level. An amazing number of Western
expatriate experts provide advice to countrylevel programmes in addressing infant mortality.
Advocacy for child survival has become just another way to capture media space and ‘build the
brand’ for international and national NGOs, with even the corporate sector getting involved. For
instance, CocaCola is today one of the major sponsors of childmortalityreduction programmes in
Southasia.
Localising health
At the same time, there are several empirically validated efforts to improve child survival that are
being implemented in most Southasian countries today. Their activities are being carried out by
dedicated health workers, working in isolation and with limited resources. Lessons from India,
Pakistan and Bangladesh indicate that the best communitybased approach for reducing infant
mortality is a combination of community mobilisation and home visits by communitybased health
workers. In this, it seems, both the timing of visits and treatment interventions are critical. It is
imperative that governments and NGOs learn from the positive experiences and insights of these
health activists, who could provide models for scaling up efforts to ensure greater child survival.
Yet the reality is a general reluctance to work within a coalition – for instance, of likeminded NGOs
– based on a common plan of action for a particular region to improve the condition of children.
Instead, turf wars and brinksmanship regularly undermine the need for building strong partnerships.
Equally worryingly, NGO policies and programmes are generally not grounded on existing data and
empirical evidence, but rather are influenced by the ‘big man’ ideas of NGO managements. For
instance, though it has long been known that the most common causes of death in China for children
under five were pneumonia, birth asphyxia and preterm birth complications, a leading international
childwelfare agency carried out a campaign to promote handwashing as a key strategy to reduce
infant mortality. Only later was it discovered that a multinational corporation involved in the sale of
detergents and soaps was behind the promotion of the handwashing drive. No rationale was ever
provided for the campaign, and none of the expatriate staff who initiated this opportunistic
campaign were held accountable.
Even while such irrelevant programmes continue to be implemented, the localised causes behind
child mortality have yet to be fully explored. For instance, there has been no analysis of the manner
in which local belief systems and existing social exclusion contribute to higher infant mortality.
After all, concepts of ritual pollution associated with childbirth – the expulsion of pregnant mothers
to cowsheds to give birth, for example – continue to contribute massively to infant deaths. Without
such specific knowledge, it will be impossible to design effective solutions.
A call for a greater share of budgetary resources is in some ways the cornerstone of contemporary
campaigns for ensuring child survival. While this is certainly an important issue, a far more
informed analysis of the indirect and local causes of high mortality rates, as well as more targeted
and decentralised financing, are necessary. Ultimately, a nationally initiated and centrally
administered programme is unlikely to be more effective than one administered by local
governments. To ensure transparency and accountability, local governments and states need to be
given a greater role in financing child survival. In turn, holding all agencies and local
administrations involved in child survival accountable for their promises is absolutely critical. In the
end, only by training more health workers, employed through local governments and who are also
able to tackle problems of malnutrition, will infant mortality be reduced in Southasia.
Joe Thomas is a public health commentator, teacher and researcher who teaches Public Health at
the Jodhpur National University.