a. Department of Social Work, Faculty of Social Sciences, Jamia Millia Islamia University, New Delhi, India
The commentary critically examines the key issues related to the current status and future challenges of child health in India. The paper consists of three sections; the first section of this paper describes the situational analysis of child health in India. The second section deals with an analytical review of the role of multilateral and bilateral agencies in formulation and implementation of child health programmes. And the last section provides a critical review of situational analysis of child health programmes in India.
In the early 1990s, the public policy reforms paid particular attention to social policy-policies related to health, education, employment, housing and social welfare benefits etc, and they all underwent significant transformation in the process. The research questions of the paper are why do poor children die earlier?, why the socially deprived children do has poor access to healthcare services?, despite the governance effort, why does child malnutrition persists in India particularly in rural India?. Many empirical studies suggests that the socio economic factors are the main factors determining healthcare of the poor people, and draw a link between healthcare and the role of the socio economic factors. In many cases, socio- economic factors such as; poverty, income, occupation, class are the determining factors of healthcare.1,2 Multilateral and bilateral agencies have played significant role in formulation and implementation of public health programmes in both the industrialized and emerging economies. They provide funds on certain conditionality to promote target oriented, output- based programmes in public funded health systems.3 Condition based donor organizations grants played significant role in shaping the third phase of the maternal and child health programme in India.
Health and Nutritional Status of Children in India
Around 11 million child deaths occur per year, across the globe and this is considered to be one of the biggest public health challenges worldwide.4 There are four major diseases leading to child death in the emerging economies. First, Diarrhea; In India one fifth of child deaths occur due to malnutrition, lack of safe drinking water, lack of sanitation, lack of infrastructure, and lack of access to healthcare facilities. The second most important reason for child death is Pneumonia; which is further compounded by malnutrition (poor breast feeding), lack of immunization, and lack of access to healthcare services. The third disease Measles occurs due to lack of access to and or failure to outreach through healthcare services in any subsystem, and lastly, the Neonatal period which includes: unsafe delivery, incorrect breast feeding practices, unhygienic conditions, overcrowded environment, unsafe drinking water and lack of access to sanitation.5
Table 1 shows the slow pace of progress in child health immunization, treatment of childhood diseases, child feeding practices, and nutritional status of children from 1992 to 2006. There are many reasons associated with this predicament; slow increase in women’s literacy rate; poor level of health awareness and poor accessibility and availability of healthcare services. Table 2 shows high rate of Infant Mortality Rate (IMR) among the Scheduled Caste/Scheduled Tribes (SC/STs) in comparison with the general population. There are many unreported deaths; for instance, natural deaths are not reported in this survey. The data shows huge variations between regions, castes, class etc. In 1998-1999, Kerala had 18.8 per 1000 live births but in Madhya Pradesh it was 137.6 per 1000 live births, and most of the child deaths in India occur in the rural areas and the urban slum population.7
The universal immunization programme against six preventable diseases viz., Diphtheria, Pertussis, Childhood Tuberculosis, Poliomyelitis, Measles, and Neonatal Tetanus was introduced in a phased manner in 1985.9 The universal immunization programme was taken up in 1986 as national mission and became operational in all districts in the country during 1989-1990. The universal immunization programme also became a part of the Child Survival and Safe Motherhood (CSSM) Programme in 1992 and Reproductive and Child Health Programme (RCH) in 1997. Under the immunization programme, infants are immunized against Tuberculosis (TB), Diphtheria, Pertussis, Poliomyelitis, Measles and Tetanus. The Acute Respiratory Infection (ARI) prevention programme for children was started in India in 1990. The RCH-II activities were proposed to implement in an integrated manner with other child healthcare interventions. The CSSM programme jointly funded by the World Bank and United Nations Children’s Emergency Fund (UNICEF) was started in 1992-1993. The programme was to improve the health status of infants, children and reduce maternal morbidity and mortality. The RCH programme 1997- 1998 in the IX plan aimed at integrating CSSM programmes with other child health services. The RCH programme was partially funded by the World Bank, UNICEF, United Nations Population Fund (UNFPA) and European Commission etc., and broadly promotes breast feeding; exclusive breast feeding of the infants especially in the first six months of life; preschool children’s programme and vitamin A supplement strategy. The National Health Policy 2002 made the provision of curative care at the Primary Health Centre (PHC) level, and reduction of IMR to 30 per 1000 and Maternal Mortality Rate (MMR) to 100 per lakh by 2010. The Integrated Management of Neonatal and Childhood Illnesses (IMNCI) aim to prevent and manage five major childhood illnesses: ARI, Diarrhea, Measles, Malaria and Malnutrition. It focuses mainly on preventive, promotive, and curative aspects. India is a signatory of the Millennium Development Goals (MDGs); the 4th MDG aims at reduction of child mortality, the mortality rate of children under five and the target for this is to reduce by 2/3rd between1990 and 2015. This is reflected in the 11th five year plan (2007-2012), which states that IMR is to be reduced to 45 per 1000 by 2007 and 28 per1000 live births by 2012. The National Rural Health Mission (NRHM) focuses mainly on: nutrition; to increase public expenditure on health; to reduce regional imbalances; improve access to quality healthcare for people in rural areas and tribal areas, especially women and children; to reduce the IMR and MMR and to promote female Accredited Social Health Activist (ASHA). The ASHA’s would act as a bridge between the Auxiliary Nurse Midwife (ANM) and the villages.
Financing Mechanisms of Child Health Programmes in India
In general, social sector expenditure in India is tax financed, but a small proportion of the financial support is from bilateral and multilateral agencies with conditionality promoted reforms in the provision of healthcare services. Over the years, a massive personal and public health infrastructure was created, consisting of about 1,37,000 sub-centers; 28,000 dispensaries; 23,000 PHCs; 3,500 urban family welfare facilities; 3,000 Community Health Centers (CHCs) and an additional 12,000 secondary and tertiary hospitals.10 In this situation, there are studies conducted by Non Governmental Organizations (NGOs) which are the funded by World Bank called the public health system as inefficient, inadequate, and poor quality along with a suggestion of promoting Public-Private Partnership (PPP) in the existing healthcare service delivery system. There are evidences across globe to prove that after PPP there is no further improvement in the system; instead poor people are paying more money to access medical care service. This kind of practice brought into operation a user-friendly system to those who can efficiently utilize these services along with the added advantage of affordability. Finally such kinds of practices end up with the major question of accountability (for what? for whom and how long will it sustain?). The government of Tamil Nadu contracted out ambulance services to the NGOs in order to reduce the IMR and MMR. The Government of Gujarat had introduced Chiranjeevi Yojana, which functions through private gynecologists and government centers in order to reduce IMR and MMR. There is insufficient evidence to prove the effectiveness, efficiency and epidemiological impact of the above schemes.
There are evidences to suggest the significant variations in Antenatal Care (ANC); ANC coverage was below five percent in the districts of Bihar, Uttar Pradesh, Madhya Pradesh and more than 80 percent in districts of Kerala, Tamil Nadu, and Karnataka. Although the IMR in India is 64 per 1000 live births, Kerala has an IMR of 10 per 1000 live births, whereas Orissa, Madhya Pradesh and Utter Pradesh have more than 80 per 1000 live births. Variations are also observed between urban and rural areas and between SCs and STs population as compared to other groups. Health inequalities are the consequences of the imposition of the World Bank and International Monetary Fund (IMF) led polices of structural adjustment and the accompanying health sector reforms.11 We can draw certain conclusion with regard to child health; there is a need for coordination of different programmes by integration of different services. Public policies should aim to reduce social inequalities with main focus on empowerment of vulnerable sections of the society. There is also the need to strengthen the existing system by expanding infrastructure including that of human resources. There is also the need to promote access to health care to the poor, especially those who reside in rural, tribal, and remote areas. Further, there is a need for strengthening state level, district level, and local level health facilities with full support from the government, instead of promoting the PPP arrangements or handing over service to provision to NGOs. The management of common childhood illnesses should be undertaken with locally adopted protocols. We need to strengthen health information systems for further policy. Monitoring should be done not only in terms of measuring the impact on mortality and morbidity rates but also the methods adopted to bring in this change. Finally, political will is required for planning and implementing child health programmes.
Conflict of Interest: None declared
- Banerji D. A Forgotten Path to Health Service Development. Health and Development, 2005: 1(2 &3):7-11
- Case A, Paxson C, Vogl T. Socioeconomic status and health in childhood: a comment on Chen, Martin and Matthews, “Socioeconomic status and health: do gradients differ within childhood and adolescence?” (62:9, 2006, 2161-2170). Soc Sci Med. 2007 Feb;64(4):757–61.
[Pubmed] | [Crossref]
- Sigamani P. Innovative Technologies in Access to Essential Medicine, Diagnostics in India: Lessons for Emerging Economies. New Delhi, Bloomsbury; 2013
- Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003 Jun 28;361(9376):2226–34
[Pubmed] | [Crossref]
- Srinivasan K, Shekhar C, Arokiasamy P. Reviewing reproductive and child health programmes in India. Economic and Political Weekly. 2007 Jul 14:2931-9
- IIPS. National Family Health Survey (NFHS I II III). Mumbai, International Institute of Population Sciences, 2006
- Choe MK, Chen J. Potential for reducing child and maternal mortality through reproductive and child health intervention programmes: An illustrative case study from India. Asia Pacific Population Journal. 2006 Apr 1; 21(1):13
- Nayar KR. Social exclusion, caste & health: a review based on the social determinants framework. Indian J Med Res. 2007 Oct;126(4):355–63.
- Jain AK. Determinants of regional variations in infant mortality in rural India. Population studies. 1985 Nov 1; 39(3):407-24
- Government of India. A Report; Working Groups on Development of Children for the Eleventh Five Year Plan (2007-2012). New Delhi, Ministry of Women and Child Development: 2007
- Rao M, Nayar KR. Public Health in Private Hands?. Medico 320-friend 321 circle bulletin. 2006 Mar; 2007:56