The number of children under-five dying has fallen by 30% since 2012, from 1.4 million to 989,000. Over the same period, infant deaths (dying before reaching their first birthday) fell by 26% (1.09 million to 802,000) and neonatal deaths (dying in the first 28 days) by 22% (779,000 to 605,000).

These data indicate a continuing high mortality risk in the first year of life for Indian children.

These are the findings of a report released on September 18, 2018, by the The United Nations Inter-Agency Group for Child Mortality Estimation. The United Nations Children’s Fund, World Health Organization and World Bank were some of the parties involved in generating country-specific estimates of child mortality.

By addressing the most common risk factors for child mortality with prevention methods such as access to diarrhea and pneumonia treatment, measles and tetanus vaccinations and increasing hospital births, the number of child deaths have been able to decline, according to this 2017 paper, published in The Lancet, a global journal.

India’s infant mortality rate in 2017 was 32 deaths per 1,000 live births, compared to the global average of 12. Neonatal mortality rates show a similar gap–24 per 1,000 live births for India, compared with the global average of 18.

The gender gap between under-five mortality rates has also narrowed, with female mortality rates now just 2.5% higher than males (39 deaths per 1,000 live births for males and 40 for females). This is a 7.5-percentage-point decrease from 2012 when the gap was 10% (54 deaths per 1,000 live births for males and 59 for females).

However, within India, large disparities between states on health indicators such as infant mortality show high levels of inequality in access to healthcare and sanitation levels.

While some wealthy states such as Goa and Kerala have infant mortality rates similar to European countries, low-income states such as Madhya Pradesh and Odisha mirror rates found in war and disaster-affected Afghanistan and Haiti, IndiaSpend reported in July 2018.
Child mortality rates are often used as an overall measure of population health, as well as to determine levels of social and economic development. The number young children dying can indicate the ability of communities to access basic healthcare, adequate nutrition and clean water and sanitation.

India and its neighbours
Though India may now match the global average for under-five mortality rates at 39 deaths per 1,000 live births, three countries within South Asia already have rates lower than this figure, outperforming India on this key development indicator.

The mortality rates of Bangladesh and Nepal, both countries with a lower per capita income than India’s $1,939 ($1,546 and $835, respectively) are 32 and 34, compared to 39 for India. Sri Lanka, which tops the South-Asian rankings with a rate of 9, also has the highest per capita income in the region: $3,790.

Bangladesh and Nepal had higher under-five mortality rates in 1990 than India (144 and 140 respectively vs 126 in India) but pulled ahead around a decade later in 2000. India’s under-five mortality rate was 88 deaths per 1,000 live births in 2000, whereas Bangladesh recorded 84 deaths per 1,000 and Nepal 83.

The same three countries also have the lowest infant mortality rates (IMR). However, India has shown the biggest improvement, with the largest reduction (27%) of IMR among South Asian countries since 2012.

Over a five-year period, India’s IMR has fallen 27% from 44 deaths per 1,000 live births in 2012 to 32 in 2017. Afghanistan follows with a 26% reduction, then Bangladesh (18%), Nepal (17%) and Pakistan (11%). Sri Lanka’s IMR has not changed from an already low rate of 8 in 2012.

Similarly, Sri Lanka has maintained an exceptionally low neonatal mortality rate at 6 deaths per 1,000 live births, significantly under the global average of 18 and far ahead of any other country in South Asia.

India’s neonatal rate, while decreased by 22% since 2012 (the second highest reduction after Bangladesh with a 25% decrease), remains higher than the global average at 24.

Health and sanitation challenges
“Children are dying because of who they are and the environments into which they were born,” said the report, citing studies that indicate children in the poorest households are nearly twice as likely to die before the age of five as those from the richest, as well as those whose mothers lack any secondary or higher education.

In India, high rates of anemia (affecting 50% of pregnant women nationally), low nutrition levels (23% of mothers are underweight) and over-burdened government and private health facilities are part of the challenge in delivering healthy children.

As part of the Sustainable Development Goals set out by the UN, India has committed to reaching an under-five mortality rate of 25 deaths per 1,000 live births by 2030. India’s own National Health Profile has set an aim of 23 by 2025.

Tackling the diseases and conditions associated with the quality of care around the time of childbirth will help tackle newborn deaths, the report said. This will depend on strengthening health services and ensuring more births take place in hospitals and are attended to by trained staff.

(Sanghera is a writer and researcher with IndiaSpend.)

Courtesy: India Spend
 

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The SNP is the most popular service under the national child-support system–the Integrated Child Development Services (ICDS)–as it is used by 35.6% of urban and 53% rural residents, according to data from the National Family Health Survey 2015-16 (NFHS-4). As many as 55% and 61% of India’s lowest and second-lowest income classes, respectively, depend on the ICDS.
 
The fall in funding could jeopardise not just child health but, as a consequence, future productivity and economic growth; these cuts come three years after the Centre increased the states’ share of net tax revenues from 32% to 42% and at a time when two out of three nutritional parameters improved over 10 years to 2016. The greater share of net tax revenues to the states followed the recommendations of the 14th Finance Commission in 2015.
 
The funding cuts made to the SNP by the 14 states range from 3% to 55% over a year to 2016-17, according to a February 2018 budget brief published by the Accountability Initiative, a division of the Centre for Policy Research, a think tank.
 
The other six states–Haryana, Uttar Pradesh, Madhya Pradesh, Himachal Pradesh, Sikkim and Karnataka–increased funding to the SNP over the same period (by 3% to 22%), data from the brief revealed.
 
The states that cut funding are: Jammu and Kashmir, West Bengal, Gujarat, Maharashtra, Punjab, Assam, Bihar, Jharkhand, Tripura, Orissa, Kerala, Telangana, Chhattisgarh and Nagaland.
 

Source: Budget brief, Accountability Initiative
Note: Change is for 2015-16 and 2016-17
 
Children are better off than before, but progress is slow
 
Spending on child health is central to making Indian children healthier–India currently trails not just emerging economies but many poorer countries on most parameters–the country’s future workforce being more productive and increasing economic growth, IndiaSpend reported in March 2018.
 
India has slowly improved its ranking on a global healthcare access and quality index from 153 in 1990 to 145 in 2016, yet it ranks lower than neighbouring Bangladesh and even sub-Saharan Sudan and Equatorial Guinea, we reported on May 23, 2018.
 
Over 10 years to 2015-16, the proportion of Indian children stunted–short for their age–went down from 38% to 28%, underweight (relative to their age) from 43% to 36%, but wasting–thin for their weight–rose from 20% to 21%, according to NFHS-4 data.
 
The child-care funding cuts come at a time when the central government reduced its allocations to the ministry of women and child development over two years to 2016-17, before increasing it over the following two financial years.
 
The allocations for anganwadis (day-care centres) fell over two years to 2016-17 before rising again over the next two, according to the budget brief.

 
Funding cuts impacting anganwadis
 
Bihar’s anganwadis were the worst affected, with no more than 80% working, while Sikkim, Maharashtra and Kerala were the least affected with 99% anganwadis operational.
 
As many as 76% of child development project officers and additional child development project officers posts were vacant on March 2017 in Maharashtra, while there were no vacancies for the same positions in Bihar and Mizoram, according to the budget brief.  
 
West Bengal has the most anganwadi supervisor posts vacant (63%) while Madhya Pradesh has the least (17%). Nationally, vacancies were unchanged between March 2015 and March 2017, data show.
 
(Pallapothu, an MSc student at the Symbiosis School of Economics, Pune, is an intern with IndiaSpend.)

Courtesy: India Spend
 
 

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Despite the improvement in mortality, diarrhoea remained among the leading causes of death in Indian children below the age of five, killing an estimated 321 children every day in 2015, according to data from the World Health Organization (WHO).
 
Diarrhoea, which results in dehydration–is also a leading cause of malnutrition globally. In 2016, India ranked 114 of 132 nations on stunting (low height for age).
 
In 2015, deaths from diarrhoea in Indian children under five accounted for 10% (117,285) of all deaths in the age-group, higher than 7% (3,273 children) in Myanmar, 7% (5,442 children) in Kenya and 9% (39,484 children) in Pakistan–countries with lower per capita incomes–as IndiaSpend reported on July 29, 2017.
 
Between 2000-2012, India’s under-five mortality declined by an average of 3.7% annually, according to this September 2013 study published in the Lancet. “Even though the deaths among children under five years have declined, the proportional mortality accounted by diarrheal diseases still remains high,” said this 2015 paper referring to the Lancet study.
 
More affected children received rehydration therapy
 
This reduction in deaths, as we said, was driven by the inception and success of many programmes for immunization, and control of diarrhoeal diseases through promotion of oral rehydration salts (ORS), improving breastfeeding practices and institutional births, explains the Lancet study quoted above.
 
India has adopted the Integrated Action Plan for Prevention and Control of Pneumonia and Diarrhoea (IAPPD) in 2014 to address the gaps.
 
Besides strengthening existing approaches, IAPPD aims to achieve higher coverage of interventions including appropriate infant and young child feeding, provision of safe drinking water and improved sanitation, Vitamin A supplementation, measles vaccination, Hib vaccination to prevent pneumonia and meningitis, hand washing and personal hygiene and provision of ORS, zinc.
 
ORS is a mixture of clean water, salt and sugar which is absorbed in the small intestine and replaces the water and electrolytes lost through faeces. Zinc supplements reduce the duration of a diarrhoea episode by 25%, and are associated with a 30% reduction in stool volume, according to the WHO.
 
In 2015-16, 60% children with diarrhoea received some form of oral rehydration–through ORS packets (51%) or gruel (28%) or increased fluids (7%)–up from 43% in 2005-06, NFHS-4 data show.
 
The proportion of children with diarrhoea who received rehydration therapy from ORS packets increased from 26% in 2005-06 to 51% in 2015-16. Yet, India did worse than neighbours Pakistan and Bangladesh in providing ORS and zinc tablets to children, as IndiaSpend reported on November 18, 2016.
 
No more than 38% of children with diarrhoea received continued feeding and oral rehydration, as recommended, according to the report.
 
In 2015-16, advice or treatment was sought from a health facility or provider for 68% of children with diarrhoea, up from 60% a decade ago.
 
More than 90% of treatments for childhood diarrhoea are incorrect, as IndiaSpend reported on February 18, 2015. Largely unqualified medical practitioners, unfamiliar with relatively simple life-saving medications, prescribe antibiotics and other potentially harmful drugs, the report said.
 
Sanitation gaps keep prevalence of diarrhoea high
 
In 2015-16, 9.2% Indian children below the age of five had diarrhoea–up from 9% in 2005-06, according to NFHS-4 data.
 
The prevalence fell 2 percentage points among children aged 6-11 months, “when complementary foods and other liquids are introduced”, while it fell 0.8 percentage points among children aged 12-23 months, “when children begin to walk and are at increased risk of contamination from the environment”.

 
Improved sanitation is a key measure to prevent diarrhoea, according to this May 2017 WHO factsheet.
 
In 2015-16, states that had low usage of sanitation facilities such as Jharkhand, where 24% of households used improved sanitation facilities, Bihar (25%) and Odisha (29%), also had high proportion of children under five who suffered from diarrhoea–7%, 10%, and 10%, respectively–according to data from NFHS-4, as IndiaSpend reported on July 29, 2017.
 
Improved sanitation refers to a household with its own toilet, connected to a piped sewer system or flush to septic tank, flush to pit latrine, ventilated improved pit/biogas latrine, pit latrine with slab, twin pit/composting toilet, which is not shared with any other household.
 
As of March 20, 2018, individual household toilets were constructed in 52.16% of the targeted 12 million rural Indian households under the ministry of drinking water and sanitation’s Swachh Bharat Abhiyan (Grameen), data show.
 
Fewer children received recommended diet, liquids during a diarrhoea episode
 
In 2015-16, only 7% of Indian children under five years with diarrhoea were given more liquids than usual, as recommended by WHO–down from 10.2% in 2005-06, NFHS-4 data show.
 
While 31% children received the usual amount of liquids, 57% children with diarrhoea were given less to drink–up from 37% a decade ago.
 
“To reduce dehydration and minimise the effects of diarrhoea on nutritional status, mothers are encouraged to continue normal feeding of children with diarrhoea and to increase the amount of fluids,” the NFHS-4 report said.
 
In 2015-16, only 31% Indian children with diarrhoea were fed according to the recommended practice of giving the same or more food to the sick child–down from 39.4% in 2005-06.
 
In comparison, 56% sick children were given less food than usual during an episode of diarrhoea–up from 41.8% a decade ago.
 
(Tripathi is a principal correspondent with IndiaSpend)

Courtesy: India Spend
 

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As many as 11 states and four union territories (UTs) have not announced any change in the additional salary paid to anganwadi (courtyard shelter or creches) workers (AWWs) and anganwadi helpers (AWHs) since 2015, according to government data.
 
India utilises the services of 1.18 million AWWs and 1.16 million AWHs under anganwadi services in the Integrated Child Development Scheme (ICDS), an early childhood care and development programme to improve health and nutritional status of children between 0-6 years. The number of AWWs dropped 7% to 1.18 million in 2016 compared to 2013.
 
AWWs and AWHs are part time “honorary workers” from the local community who provide government services to children, pregnant and nursing women.
 
AWWs and AWHs are already overburdened and underpaid for the various services that they are expected to render under ICDS. AWWs have been forced to shell out money from their own pockets due to delays.
 
Nearly 40% of anganwadi workers surveyed in 2014 in six states had to use their personal money to run the anganwadi centre and 35% of them had not been paid on time, according to Progress of Children Under Six, 2016, report. In some states like Tamil Nadu, where the ICDS is robust, honorarium paid to the AWHs is higher than AWWs in Uttar Pradesh, added the report.
 
The central government enhanced the honorarium of AWWs and AWHs by Rs 1,500 and Rs 750 per month–to Rs 3,000 and Rs 1,500 per month, respectively–with effect from April 1, 2011.
 
States and UTs provide additional salary to AWWs and AWHs out of their resources.
 
Kerala, Tripura and West Bengal have not increased salary paid to AWHs or AWWs, according to data made available as of March 2015 and December 2017 to the Rajya Sabha (upper house of Parliament). Uttar Pradesh, with nearly 170,000 AWWs and 150,000 AWHs, increased payments to Rs 1,000 and Rs 500 per month, respectively, as of December 2017, from Rs 200 and Rs 100 per month
 
Delhi increased the total salary (including centre’s allocation) to Rs 9,678 for AWWs and Rs 4,839 to AWHs, the Times of India reported on July 22, 2017.
 
The state government has also provided an additional Rs 500 and Rs 250, respectively, for internet/mobile charges, the Hindu reported on July 22, 2017.
 

Source: Rajya Sabha (2017 and 2015); Data as of December 21, 2017
 
While Odisha hiked the remuneration of anganwadi workers from October 2017, Karnataka increased the salaries after protests by anganwadi workers.
 
The wage increase in news report for states like Odisha and Kerala does not reflect in the government response in Parliament.
 
Despite two email requests and as many calls over three weeks to the Ministry of Women and Child Development and the state government of Kerala on clarification of wages, we have not received any response. We will update the copy if and when we receive it.

This article was first published on IndiaSpend.
 

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