The new government has a historic opportunity to register an early, grand success which would make India proud, and bring global recognition to the country.
Like all other countries, India is a signatory to the millennium development goals (MDGs). The fourth MDG (MDG 4) requires each country to reduce by 2015 the under-five child mortality rate by two-thirds in comparison to the level prevailing in 1990. For India, this translates into achieving an under-five child mortality rate of 42 per 1,000 live births by 2015 (the 1990 rate being 125). The present projections, including the one a few weeks back by a global think tank, indicate that we are not on track to reach our MDG 4 target.
However, we believe India has a real chance to prove the pundits wrong. With political resolve and determined effort, it is within our reach to save millions of additional children, and thereby attain the MDG 4 target next year.
The latest official estimate of the country’s under-five mortality rate is a high 52 per 1,000 live births in the year 2012. This compares poorly with that of China (14), Brazil (13), and even Bangladesh (41) or Nepal (42). Incidentally, all these countries have reached their respective MDGs 4, unlike India.
The end 2015 dateline means that we have less than 20 months to make an all-out effort. We propose intensified action on four fronts.
First, dramatically reduce mortality due to diarrhoea, responsible for 176,000 under-five deaths each year. Bangladesh has nearly eliminated diarrhoeal deaths by ensuring a very high coverage of oral rehydration solution (ORS) which corrects the life-threatening dehydration due to diarrhoea. In India, less than half the children with diarrhoea receive ORS, whereas this rate is 78% in Bangladesh. We can also record a similar win. Nationwide awareness generation through all channels of communications targeting the poorest and the marginalised is the need of the hour. This should be matched by distribution of ORS packets to each household with a child and demonstrating use, making ORS available in rural/peri-urban shops, and galvanising referral and facility care to treat children with severe dehydration. Zinc treatment, which reduces the duration of diarrhoea and averts adverse nutritional effects, needs to be universalised. Efforts must be intensified in a campaign mode during the summer months. We believe it is possible to reduce diarrhoeal deaths by over 50% by next year with such an effort.
Second, an urgent priority is to tackle pneumonia, the number one killer of children, responsible for 326,000 under-five deaths each year. Pneumonia is treated with antibiotics which can be given at home if the illness is mild, and in injectable form in the facilities if it is severe. The country has already trained most of the Accredited Social Health Activist (Asha) workers, anganwadi workers and auxiliary nurse midwives in treating mild pneumonia in home settings, and to refer the rest. After successful introduction in nine states, the government is planning to roll out the Hib vaccine nationwide that would reduce pneumonia cases. With the intensification of early care-seeking, community level action and facility care, it is within our grasp to reduce pneumonia mortality by 20-25% by next year.
The third action is to nearly eliminate measles, responsible for about 40,000 under-five child deaths. Building on a relatively high coverage of the first dose of measles vaccine at nine months, the country immunised 120 million children with the second dose at 18 months since 2010. It is quite conceivable to expect a two-thirds reduction in measles deaths if we can give a further push to these impressive efforts.
The fourth strategy is to focus on home-based newborn care. Under this programme, Asha workers are expected to provide care to newborns and detect illness through multiple home visits. Although most of the 800,000 Asha workers have since been trained in this task, the uptake of the programme is very low. If we could cover about half our birth cohort in 2015 under this initiative, and continue to strengthen ongoing initiatives for neonates (skilled care at birth and facility-based care), an additional 8-10% newborn deaths can be prevented by 2015. Home-based newborn care needs to be coupled with an effective community/facility based care of sick young infants, and it is here that innovative, bold steps are required.
Together, the above four strategies can save enough children for us to achieve MDG 4. But the translation of these strategies into impact is possible only through executional brilliance.
Here are six suggestions on a brisk and effective execution of accelerated action for mortality decline in children: Focus on the high-mortality districts (about 180 in number); place an efficient techno-managerial enabling team down to block level in each one of them; operationalise mechanisms to monitor progress; establish an empowered task force for facilitation and speedy problem-solving, make child survival a people’s movement and assign accountability to functionaries at all levels. The latter should include child death reviews by the district magistrates.
The acceleration plan may require a few hundred crores of additional flexi-budget that should be made available. The target for the first 100 days of the government should be to operationalise the ‘accelerating child survival endeavour’ in the country. Attaining the MDG 4 would mean survival of millions of our children. India’s success would also drive the world closer to the global MDG 4. Above all, gifting MDG 4 to the country would be symbolic of the firm commitment of the new government to children and the health sector, as promised in the election manifesto of the BJP.
Vinod Paul is professor and head, department of pediatrics, All India Institute of Medical Sciences, New Delhi, and Maharaj Bhan is a former secretary, department of biotechnology, Government of India
The views expressed by the authors are personal.