A large number of children dying in Uttar Pradesh (84 in Gorakhpur followed by 49 children dying in Farrukhabad) and another 24 dying in the Vidisha district of Madhya Pradesh has attracted plenty of media and public attention.
The state governments and the health officials have been castigated for their neglect in providing adequate medical facilities including oxygen and essential medicines.
The nation feels anguished at the loss of innocent lives, the public health experts are outraged and the politicians have jumped to doing what they do the best: Politicising the death of children.
It is a replay of a similar outrage after several children died in a government hospital in West Bengal a few years ago.
The media attention meanwhile has shifted to other headlines despite their promise to follow the story. The politicians likewise are busy scoring brownie points on TV debates, some forming new mahagathbandhans (Grand Alliances) and others consolidating the votes for 2019 elections.
India's inability to improve health outcomes is among the major reasons of not meeting the millennium goals of sustainable development despite rapid growth.
But evidence from the latest round of the National Family Health Survey (NFHS) suggests that this may be changing. The infant mortality rate (IMR) is an important measure of a country’s health.
There has been a marked improvement over the past decade with IMR declining from 57 per 1,000 live births in 2005-06 to 41 per 1,000 live births in 2015-16. The improvement over the past decade has been much faster than in the rest of the post-liberalisation era. The IMR declined at a nearly constant pace of 2.5 percent per annum between 1992-93 and 2005-06. But the pace of decline accelerated over the past 10 years, with the IMR registering an annual decline of 3.24 percent per annum.
The faster decline in India's IMR over the past decade has also been lauded by the UNICEF. However, the decline cannot be attributed merely to faster growth alone but also to greater public expenditure in health. For decades, India spent a woeful 1 percent or less of the GDP on health care. The budget allocations have improved from 1.1 to 1.35 percent of GDP with this year’s budget promising to raise it to 2.5 percent in the coming years. Public health experts would like to see it around 3 percent of GDP in order to make meaningful interventions in otherwise struggling government health care sector.
Amitabh Kant of NITI Aayog emphasised recently how the eastern states have been impediments to what could have been a happy story of growth and development. It is noteworthy that some states such as Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh comprise the unflattering BIMARU (sick) states and along with Odisha have lagged behind and still record high IMR of 50, 47, 56 and 51 respectively (NITI Aayog - 2013 figures). Uttar Pradesh, India’s most populous state has slid past Madhya Pradesh and Chhattisgarh to record the country’s worst infant and under-five mortality rate, according to newly released health data.
Why Uttar Pradesh?
Although Uttar Pradesh’s IMR has improved from 73 deaths per 1,000 live births to 50 over 10 years, some analysts still put it around 64 per 1000 live births, same as in strife torn countries like Burkina Faso or Afghanistan. This dismal picture indicates the failure of governance even as other BIMARU states made some serious efforts to improve the health services.
Ahead of the swearing in of a new government in Uttar Pradesh, data released from the National Family Health Survey, 2015-16 (NFHS-4) show that India’s most populous state now also has India’s worst under-five mortality rate of 78 deaths per 1,000 live births. Serious analysts, therefore, need to look beyond the politics of Yogi Adityanath of BJP or Akhilesh Yadav of Samajwadi Party or the others before them.
According to World Data, infant mortality rate of India declined from 149.88 deaths per thousand live births in 1966 to 40 deaths per thousand live births in 2015. Similarly, NITI Aayog gave the figures on IMR from 2002 to 2013 as in Uttar Pradesh 50 (67), Madhya Pradesh 56 (70), Odisha 51 (69) Rajasthan 47 (64) and Bihar 46 (56) (figures in brackets are for 2002). IMR for India according to latest figures show further reduction to 37.81.
Kerala, on the other hand, remained steady at 12 for many years and is now on par with developed countries like the US recording IMR of six, (IE2017). What has been achieved in Kerala is attributed to a sound primary health care and total literacy especially of girls resulting in the true empowerment of women who demand and get good healthcare. High literacy with affordable good health care has kept the birth rate low sans coercion. This should have been the model that other states could have replicated with resultant healthy educated mothers and healthy children.
BIMARU states, in contrast, are reflective of the years of neglect that education and health care suffered since Independence under successive governments. Two major areas of neglect in independent India have been education and healthcare (Ratna Magotra, Bhavan’s Journal 15 August 2017). This neglect led to the burgeoning population that remained impoverished and backward.
Despite growth and improvement in economic indicators, there are just too many to share the pie; undernourished children fall prey to infections like encephalitis. The poor become a captive vote bank increasingly dependent on government schemes including health care. The mix of caste, religion and politics deprived them of all self-belief denying them an opportunity to become proud and equal citizens of the country.
Coming to the large number of children dying of encephalitis or other infections it is well known that the malnourished, anemic, low weight and most vulnerable children are admitted to government hospitals, often in critical condition. The patient overload in these referral hospitals has resources stretched even at times when there is no epidemic.
By the time they reach the hospital, they have nearly lost the battle. The hospital preparedness, medical expertise, availability of life care equipment like ventilators, monitors, essential quality medicines are indeed important to save lives but not the only thing experts and authorities need to take into account if the systems are to be overhauled.
Several well meaning individuals come forward to establish state of art facilities as has happened in Gorakhpur. Varun Gandhi, a parliamentarian, has promised to donate Rs 5 crore from his Members of Parliament Local Area Development Scheme (MPLAD) to set up a pediatric hospital in his constituency. Such gestures are worthy of appreciation but fact remains that we need to focus on the primary health care, education and reproductive health of future mothers. Also, children born to impoverished, underweight, undernourished and anemic mothers with poor antenatal and hospital care start with a great handicap. The population has to be manageable for optimal resource management.
Smaller families where young mothers can look after and provide for their children will change the picture that we see in villages or towns of Uttar Pradesh, Madhya Pradesh or Bihar. In a study from Columbia in the 80s, a very advanced neonatal care was set up in a deprived area with high neonatal and infant mortality. The neonatal intensive care was top end with trained experts and survivals of sick babies improved significantly. The hospital discharge data was promising and soon comparable to the best. Unfortunately, late survivors were few as these babies went back to their squalid homes with no proper sanitation or clean drinking water.
Policy makers, public health experts and the governments can draw their own lessons. Primary education and primary health care need to come back on the drawing board with useful public-private partnerships where necessary. Improved, timely and structured referral system will bring sick babies to tertiary care hospitals in better condition and give them a fair chance to fight the battle.
All efforts should be on strengthening the education and reproductive health to build skills and confidence of young mothers to take care of their newborns and indeed their entire family.
The author is a Mumbai-based cardio-vascular surgeon.
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Updated Date: Sep 11, 2017 10:36:41 IST