A.

Background
The Need for a Focus on Child Health and Nutrition

Amrit Pal Singh/CARE India

“The lives of children and women are the truest indicators of

the strength of communities and nations.”

— Carol Bellamy, Executive Director, UNICEF

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 THE PROBLEM: How many children die? When do they die?

TOO MANY More children die in India than in any More than 70% of child deaths in India
CHILDREN ARE other country in the world — India are infant deaths.

DYING contributes three times more child

deaths than Nigeria, the country with About 70% of infant deaths are
the next highest number of deaths. neonatal deaths.

Of every 1000 children born alive, As infant mortality rate (IMR) falls, an
India has the most
barely 900 make it past their 5th increasingly greater proportion of the
number of child deaths
in the world. birthday. In Sri Lanka 980 children remaining deaths are neonatal deaths.
survive, and in East Asia and the Unless neonatal mortality can be taken
There are significant Pacific region 960 children survive care of, IMR will not fall much further
differences between to their fifth birthday. below 70 (Figure 3).
states, and between
rural and urban areas. Who are the children who die? In pockets where IMR is still high,
deaths in the postnatal age group are
Most number of child National figures hide vast differences still prominent. In this case, there are
deaths occur in the first within states and regions. two distinct clusters of deaths — those
year of life. Of these, in the first week or month and those in
two thirds occur in the There are many more child deaths in the second half of the first year.
neonatal period.
some states than in others (Figure 1).
How healthy are the children
Malnutrition is a major
More children die in villages and in who do not die?
contributing factor to
urban slums (Figure 2).
child deaths, as well as
ongoing morbidity and About half of all children who survive

disability. Girls are more vulnerable than the first month become progressively
boys, particularly in rural settings. more malnourished during the first

FIGURE 1 FIGURE 2
Regional Disparities in Under-five Mortality Rates Gender Disparities in Under-five Mortality Rates
(1998-99) (1998-99)

138
Under-five Mortality Rate

Under-five Mortality Rate

140 – 123 140 –

115 117
120 – 104 105 120 – 106
95
100 – 86 100 –
80 – 80 – 68 63
60 – 60 –
40 – 40 –
19
20 – 20 –
0– 0–
Kerala AP India Orissa Bihar Rajasthan UP MP Male Female Male Female

State Rural Urban

Note: Deaths per 1,000 live births for a five-year period Note: Deaths per 1,000 live births for a five-year period
preceding the survey preceding the survey
Source: NFHS-2, 1998-99. Source: NFHS-2, 1998-99.

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 FIGURE 3
Trends in Infant Mortality — All India, Urban and Rural (1981-1997)

140 –

120 –
Deaths/1000 Live Births

100 –

80 –

60 –

40 –

20 –

0–
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

YEAR

Rural All India Urban

Source: Socio-Economic Differences in Health, Nutrition and Population, The World Bank, 2000.

year. By 18 months, all the damage has The causes of death among neonates immunization rates are low. These are
been done and there is little or no are very different from that among all dealt with in the next section.
chance of recovery. children dying later.
Where post-neonatal deaths are
The malnourished have higher risks of Neonatal deaths are mainly due to prominent, pneumonia, diarrhea,
illness and death throughout severe infections, asphyxia, and the measles, pertussis and malaria are the
childhood, perhaps even into complications of being born main killers. Most of these deaths are
adulthood. Malnutrition also has a prematurely or with low birth weight. preventable.
significant impact on cognitive ability, Tetanus is an important cause wherever
therefore a long-term impact on Malnutrition is an important
educational outcomes and FIGURE 4 contributory cause of child deaths,
productivity. Childhood Malnutrition in India about 60% of these children would not
have died if they were normally
What do they die of? 54 –
nourished (Figure 4).

52 –
Percent of Children

The health of the mother and child are 52 HIV/AIDS has contributed to the very
50 –
inextricably linked. Poor maternal high child mortality rates in sub-
48 –
health and nutrition contribute Saharan Africa. A similar epidemic in
47 47
46 –
substantially to child death and 42 India would have a devastating impact
disability. 44 – on child deaths.
42 –

Poverty/food insecurity, poor access to 40 – The urban poor are often worse
health services, and the complex role Underweight Stunted off than the rural poor
of gender, which includes (but is not 1992-93 1998-99
limited to) discrimination against the The urban poor suffer even higher
Source: National Health and Family
girl child, all play an important part in Survey (NFHS, 1992-93 and 1998-99) mortality and malnutrition than the
child deaths. rural poor. As can be seen from

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 FIGURE 5
Infant Mortality Rates by Urban/Rural Areas and by Economic Level (1992-93) Nevertheless, there are several
successful examples of interventions
140 – with a focus on child survival that have
121
Infant Mortality Rate

120 – 109 107 been evaluated from the developing

94
100 – 85 90 world. Data from Brazil, Egypt,
80 – 67 65 Philippines and Mexico show that the
60 – 42 51
large scale implementation of diarrhea
40 –
control and oral rehydration programs
20 –
have been accompanied by reductions
0–
Urban Rural in child mortality. Training community
health workers in the management of
Poorest Second Middle Fourth Richest
common childhood illnesses with locally
Source: Socio-Economic Differences in Health, Nutrition and Population,
adapted protocols was also successful in
The World Bank, 2000.
Guatemala.

Figure 5, the child death rates are
higher among the poorest urban
families as compared to the poorest
rural families. There has been a steady
increase in urban slum populations in
41 cities with populations of over 1
million, as well as in mid-size cities
and towns. Their health and nutrition
needs are not being met.
Public health interventions
delivered at community level
Tackling problems of such magnitude
affecting the health of our children
requires a public health approach.
Achieving population coverage
interventions at such scale can only
work with community-based
approaches.
Delivering community-based
interventions requires a challenging
and multi-pronged approach: engaging
the community, using health workers
and volunteers from the community,
capacity-building and training at
multiple levels, collaborative and
inter-sectoral planning and work.
Although research on interventions,
particularly hospital-based
interventions is plentiful, little is
known about the characteristics of
delivery strategies for successful
community-based interventions.
The SEARCH study from Gadchiroli in
Maharashtra (see the Newborn Care
Section) showed that village health
workers could be trained successfully to
dramatically reduce newborn deaths.
Similar approaches to training health
workers, traditional birth attendants,
volunteers and empowering local
communities to access appropriate care
have been used successfully by many
agencies (government and non-
government).
Simple, focused health interventions
delivered through the existing network
of health and development services,
can make a significant impact on child
health.

The State of Health Services in India

Further Reading
• India has one of the largest networks of health services. Through Primary
Health Centres (PHCs) and Integrated Child Development Services (ICDS), 1. National Family Health Survey (NFHS-2),
essential public health services can reach virtually every rural doorstep India; 1998-1999.
in the country, free of cost. Hardly any other developing country can
claim such a wide government funded health care network. 2. The State of the World’s Children 2003;
• Yet, for various reasons, the health services have been able to make a UNICEF.
rather limited impact on the health situation. One such reason is that,
in trying to be comprehensive in reach, the health interventions have 3. Bryce J, Arifeen S, Pariyo G et al, and
not been sufficiently focussed to make a deeper impact. the Multi-Country Evaluation of IMCI
• There are other major problems, like limitations in available resources, Study Group, Reducing child mortality:
poor working conditions, and poor motivation levels. Can public health deliver? Lancet 2003;
362: 159-164.