India may be brimming with optimism about her economy, but she still struggles to save her infants from an untimely death. UNICEF had reported a year ago that about 5,000 children under the age of five die every day in India. Nearly half of all children in India are malnourished. This well-known fact re-emerged on the public radar last December when Nobel Prize-winning economist Amartya Sen commented on it. He said Indian leaders should pay attention to reducing chronic under-nourishment rather than pursuing higher growth targets.
The fight to reduce infant and maternal mortality in India has been largely unsuccessful because of chronic poverty and a weak public health care system. The situation has, however, improved in the past few years as the government began to spend more money on and started paying more attention to the public health care system. India’s infant mortality rate (IMR) fell 3 points in 2009 to rest at 50, according to data released by the Registrar General of India on January 25. Between 2005 and 2009, IMR in rural areas fell 9 points, 3 points more than the decline in towns and cities.
Amarjeet Sinha, a key architect of the National Rural Health Mission (NRHM), says that the mission had a big role to play in this. Launched in 2005, NRHM is a part of the government’s effort to improve the availability of affordable health care to those living in rural areas. NRHM is a state-led programme with scope for innovations and flexibility, says Sinha, who is now principal secretary for health in Bihar, a state that was until recently at the bottom of practically every development index. “It is this character of the mission that has allowed states to think through the challenges of public health.’’ However, he says, allocations are nowhere near the requirements to craft a credible public health system.
Though more resources and better public health infrastructure may have helped, it is difficult to attribute the entire impact to NRHM. Other factors such as better incomes, urbanisation and even better roads may have resulted in access to hospitals and doctors.
Ajay Mahal, who holds the Finkel Chair of Global Health and is professor at Monash University in Melbourne (Australia), says that incomes in India have grown tremendously in the last 5-10 years. “Migration to urban areas, merely being able to afford better health care (even in the private sector) and access urban facilities can make a difference,” says Mahal, whose research focuses on a range of economically relevant questions pertaining to household impacts of health, health financing, ageing, human resources for health and human rights, with a specific focus on India.
He points out that there is no serious evaluation of NRHM or similar government programmes in India, which also affects the authenticity of these numbers. For instance, UNICEF and UNDP had reported the country’s maternal mortality rate in 2009 as 450 while the official government records maintained that it was only 230.
However, there is one factor that may tilt the argument slightly in NRHM’s favour. IMR has fallen 4 points in states such as Bihar, Uttar Pradesh, Rajasthan and Orissa, all of which are high-focus regions for NRHM — none of them had any public health care system worth talking about until a few years ago. That is changing slowly. The change could be faster if India spends more on public health care.