A little less than a week back; Indians woke to yet another screaming headline and ‘breaking news’ story from the media. Every major news outlet (as can be seen in the link) carried the story in bold print. This one was truly alarming – that the latest Unicef report had cited India as having the highest Child Mortality Rate in the world. After the initial horror and dejection waned, and ceded ground to the next horrible thing to hit us, the story continued to gnaw at common understanding of ground realities. Despite the fact that India does have some truly bad public health data; there are still countries doing far worse than us and to have surpassed them all, implied a splendid surge of negative performance that even we, would have struggled to achieve.
Reading the report reveals a complete misreading of the data by the media with the expected misinterpretations. The Unicef report contains no such data, as publicized, and neither has any international publication mirrored the domestic media reports. This then was the over-eager Indian media skewering our reputation in its enthusiasm to be the Ur-harbinger of bad news. Attempts to get them to correct the narrative have fallen on deaf ears (emails and tweets) and this post is written with the hope of correcting the glaring discrepancies in the reportage.
[Pic courtesy: www.indiacsr.in]
No, India does not have the highest child mortality rate. We have the highest number of children that die under the age of five; that number is reflective of the size of our population. A distinction must be made between the total number of children that die under the age of five and the child mortality rate. Since these are two totally different things; it is important to lay bare the difference. While doing so, no attempt is being made to diminish, minimize or molly coddle the appalling figures. For a country with high ambitions of economic superpower-dom and that is called an ’emerging market economy’; these figures are, plain and simple, unacceptable.
To get at the ‘hows and whys’ behind these dismal figures; we must first separate Infant Mortality Rate (IMR) from the Under-five Mortality Rate (U5MR). Causation is different in these two categories. Mortality Rate (MR) refers to the number of children that die per 1000 births. IMR refers to the number of children that die under the age of one. U5MR refers to ALL children who die under the age of five and therefore incorporates IMR figures within it.
U5MR declines globally at a higher rate than IMR. It is far more difficult to grapple with IMR. These are the figures: globally, IMR has low rates of decline: 32% in the past two decades and an annual decline of 1.8%. Compare this with U5MR that, for the same period, records 41% and an annual decline of 2.5%. For South Asia and India, IMR contributes more than 50% to the U5MR figures. And India, independently, contributes 30% to the global IMR. It would be more appropriate therefore to address U5MR as the sum of its two individual components – IMR (birth – 1 year) and CMR (Child Mortality Rate of children between 1 and 5 years). These two categories are very different beasts. The determinants, causation variables and policy outcomes are different and varied in both.
1. CMR operates at a macro-level, is relatively homogeneous and is more easily subject to criteria like access and affordability. These factors make it amenable to standard policy measure that are easy to implement across different strata of experience. Effective and determined deployment of vaccination and access to: safe drinking water, sanitation and basic health facilities significantly alter CMR figures. That we haven’t been able to tackle this component of U5MR is indeed a matter of poor governance. The appalling figures clearly reflect the deficiencies in the drafting and implementation of policy.
2. IMR, on the other hand, is in an entirely different category. IMR is not as readily subject to simple health economics and is strongly affected by culture and gender; two variables that are difficult to regulate by policy alone. It is heterogeneous and operates at the micro-conditional situation of family, individual and communities. The ‘pre-term and post-term causes’ listed in the report, are variables that impact IMR. IMR reflects on both mother and child and is affected by a culture-spread that extends from the treatment of women in a society, to prenatal attention, to delivery/obstetric practices and finally to the postnatal period. Gender discrimination and cultural handling of birth (breast feeding, cord management, etc.,) factor directly into IMR. Health information dissemination and reform of cultural norms have to be critical compositional elements of any policy that targets IMR. To deliver on outcomes through the maze of socio-cultural barriers is not easy and when the deeply diverse nature of our myriad cultures is factored in, it seems a nigh impossible task. Yet, if we invest our collective energies and efforts on effectively tackling IMR, the rewards will accrue on multiple levels, since this one factor encompasses mother, child and all in between.
U5MR data analysis: (figures are from the report)
1. Sierra Leone has the highest U5MR in the world. 185 children die per 1000 live births. Twenty nations have UFMR higher than 100. Of these, nineteen are in Sub-Saharan Africa and one outside Africa, in Asia – Afghanistan. Afghanistan has a U5MR of 101
2. Comparison of Sub-Saharan Africa and South Asia:
a. Sub-Saharan Africa has a higher U5MR than South Asia (1 in 9 as compared with 1 in 15 for the latter. To understand how appallingly bad these figures actually are – in industrialized nations, the ratio is 1 in 167)
b. But, the rate of decline is faster in Sub-Saharan Africa than in South Asia; an encouraging trend for them
c. As of current figures however; a child born in Sub-Saharan Africa still has a 1.8 times greater probability of dying than a child born in South Asia
3. 50% of the ‘total number’ of child deaths (not a rate; but a number) occurred in five countries – India, Nigeria, DRC, Pakistan and China. In *this category, India clocked 24% and was highest
4. A quick comparison U5MR in countries: Sierra Leone 185/ Afghanistan 101. India – 61, Nigeria – 124, DRC – 168, Pakistan – 72, China – 15