LUCKNOW, India — In this busy, run-down government hospital in India’s northern hinterland, ceiling fans stop whirring in the stifling pre-monsoon heat. Examination rooms descend into darkness. And as patients crowd the corridors, a large puddle seeps across the floor from a leaky ceiling.
Then, as the lights flicker back on, diesel generators in the hallways make a chopper-like ruckus. It is a common sound in this poor district, which gets only six to eight hours of electricity a day.
Before 2005, conditions at this hospital in the town of Colonelganj — about 70 miles from the state capital, Lucknow, in India’s Uttar Pradesh State — were much worse. There was hardly any furniture, equipment, or medicine in the many rooms of this two-story facility, which serves a population of 200,000.
Back then the delivery ward featured only one table, so if more than one woman was in labor at a time, the baby was delivered on the floor. Colonelganj has three nurses and one doctor to deliver babies, but most rural government hospitals in Uttar Pradesh have just one nurse or midwife. Some have none at all.
But as part of the Indian government’s National Rural Health Mission, launched in 2005 to shore up rural health care, generators and medical supplies were added to Colonelganj Community Health Center, wards were renovated, and protocols for vaccinations and new medical training were started. Newborn care launched here in 2011 taught medical staff best practices like cutting umbilical cords with clean blades and keeping infants warm by placing them on their mothers’ abdomens, instead of washing or rubbing them with oil as per folk traditions. This basic “kangaroo mother care” can save babies from dying of hypothermia.
“Even if electricity is not there, the baby can be warm,” says Husnada Khatoon, a 45-year-old nurse. As if on cue, another power cut plunges the room into darkness.
THE BIGGER PICTURE
India is one of the world’s fast-growing economies, but it still claims a staggering 21 percent — or 1.7 million — of the world’s under-5 deaths. Facing the challenge of reaching an enormous, diverse population of 1.2 billion people over a vast area with generally weak governance, India, with a death rate for children under 5 of 61 per 1,000 live births, is widely considered unlikely to meet the UN Millennium Development Goal to reduce that figure to 38 by 2015.
In contrast, neighboring Bangladesh, one of the world’s poorest countries, is on track to reach its UN goal of reducing under-5 deaths by two-thirds from 1990 levels. Global health experts point out that Bangladesh is far smaller than India, more homogenous, and does not have so many layers of fragmented government. They also note that Bangladesh has extensive grassroots networks to reach people. But to many observers, Bangladesh’s success in lowering its child mortality rate provides a stark comparison with its bigger neighbor.
A mother with her 3-year-old daughter, who suffers from chronic diarrhea and tuberculosis, at the District Hospital, Panna, Madhya Pradesh in Central India.
A closer look at India’s struggle to reduce child deaths reveals a mixed picture. In this huge, diverse, and complex country, different states have vastly different social conditions, ranging from dire to impressive.
Six of India’s 28 states and its capital city, Delhi, are on track to meet or have already reached the UN target to reduce child mortality by two-thirds from 1990 levels, according to UNICEF’s Infant and Child Mortality in India report. Added together, the population of these states — Kerala, Tamil Nadu, Punjab, Himachal Pradesh, West Bengal, and Maharashtra — is larger than that of the United States.
Child deaths in the tropical southern state of Kerala, the standout among them, is 15 deaths per 1,000 live births — on par with the rates in Turkey and Venezuela.
But other states, including Uttar Pradesh, are lagging behind in the fight against child mortality. With a population of 200 million, Uttar Pradesh is far larger than the entire country of Bangladesh. Uttar Pradesh's population is even slightly larger than that of Brazil.
Uttar Pradesh is also infamous for corruption, poor governance, and troubling social indicators. Deaths of children under age 5 in the state is 79 per 1,000 live births, according to India’s 2010 Sample Registration System.
And as India’s most populous state, Uttar Pradesh embodies the many challenges — from demographics to governance — that the country faces in combating deaths of children under age 5.
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India’s most basic challenge is its size. It has the world’s second-largest population after China, and many corners of its vast, sprawling terrain are inaccessible. The country is home to inhospitable plains, deserts, jungles and mountains.
In Indian cities, gleaming modern hospitals are available for the wealthy. But many poor people in rural India live far from health clinics and lack access to transportation. Government facilities are also likely to be shabby and inadequately equipped and staffed. Child health in India is also intertwined with other socioeconomic conditions. Leading states tend to have good political governance, better performance in education and literacy (especially for girls), and higher per capita incomes.
“Child survival is symptomatic of the rest of the system,” says Ramanan Laxminarayan, vice president of research and policy at Public Health Foundation of India (PHFI), based in Delhi.
Alkesh Wadhwani, India deputy director of integrated programs at the Bill & Melinda Gates Foundation, adds: “States that have done well – their systems work, and governance is good. Health is one part of the overall picture.”
Although some national health programs are mandated by the central government in Delhi, governance in India is highly fragmented. India’s states and local district governments can drive health and social policies — or let them languish.
Uttar Pradesh is a case in point. During the two-hour drive from Lucknow to Colonelganj, the road changed four times from smooth and well-maintained to crumbled and potholed, marking lines where national, state, and district government jurisdictions changed hands. One of the country’s most intractable problems is poor governance and lack of accountability for basic services, like paving roads, supplying electricity, making sure government doctors and nurses show up at rural hospitals, and monitoring vaccine distribution.
In India, systems without oversight break down, especially in remote areas. Weak protocols and monitoring — not to mention lack of electricity to keep vaccines cold — mean that the national child immunization rate for diphtheria, whooping cough, and tetanus is 72 percent, compared with 96 percent in Bangladesh.
People often do not know when immunizations are taking place at government clinics, and more advanced vaccines are available only in states with good reporting methods, says Dr. Satish Gupta, a health specialist with UNICEF in Delhi.
TRYING TO TURN THE TIDE
A nurse in Colonelganj, Uttar Pradesh practices newborn resuscitation on a doll.
In a no-frills room for newborn care at the Colonelganj Community Health Center, a nurse counts softly to herself in Hindi as she squeezes an airbag affixed to the face of a baby doll. On the worn tiled wall in front of 42-year-old Sarita Tiwari is a chart with instructions on how to resuscitate an asphyxiated newborn with the tiny airbag and mask.
In 2011 Tiwari received special training for treating newborns and pregnant women from the Uttar Pradesh government with help from Maternal Child Health Integrated Program (MCHIP), a collaboration between international nongovernmental organizations such as Jhpiego of Johns Hopkins University, John Snow Inc., Save the Children, and Population Services International. Before the training, the hospital’s staff could not treat neonatal asphyxia, a leading cause of newborn deaths in India.
Tiwari’s face clouds as she recalls a case three years ago when she tried to do mouth-to-mouth resuscitation on a suffocating newborn. Without the simple but specialized equipment used to suck mucus from the baby’s airways, the infant died. The woman’s entire family came to the hospital anticipating the birth of a healthy baby boy, Tiwari says. They left heartbroken.
Tiwari, a 12th-grade graduate, admits that the asphyxia training was difficult. But now she regularly scores about 93 percent on a weekly checklist evaluation of her technique. In the last month alone, nurses at the hospital saved two babies with the airbag and mask.
Nurses at the hospital in Colonelganj say that more women are also coming to the hospital to give birth, rather than delivering at home. After the Indian government poured money into funding the National Rural Health Mission, poor women could receive cash to deliver babies at health facilities.
The rate varies from state to state, but in Uttar Pradesh the government pays women $23 if they deliver in hospitals. A recent initiative to offer free ambulance services to pregnant women has also boosted deliveries.
Institutional deliveries in Uttar Pradesh jumped from 739,000 in 2006 to 1,087,000 last year, according to India’s Annual Health Survey.
Nurses at the hospital in Colonelganj estimate that they deliver as many as 300 babies each month, up from 40 to 50 a month before the incentive program started.
There are other signs of progress in Colonelganj. A simple room with four refrigerators keeps vaccines cold, and maps of local distribution areas hang on the walls. The setup looks modest, but the vaccination program run from Colonelganj’s hospital with MCHIP assistance is a model for the district. Log books tied to the refrigerator handles with twine show meticulous records of temperatures and power cuts each day to ensure the vaccines are properly stored. Charts on the wall indicate the proper way to store various vaccines.
GETTING TO THE PEOPLE
An ASHA holds her baby during training in in Colonelganj, Uttar Pradesh
With its grinding bureaucracy and fragmented jurisdiction across states and districts, India lacks the force of large, widespread NGOs like those in Bangladesh that can mobilize large numbers of community health workers. That last-mile connection is a vital missing link for uneducated, illiterate communities.
Community workers help raise awareness and dispel misconceptions about birth control, immunizations, and basic health.
The lack of awareness and accessibility to birth control means that India has a relatively high birth rate, with women having an average of 2.7 children, compared with 2.3 in Bangladesh. Fertility rates vary dramatically among states. According to India’s 2010 census, the birth rate in Uttar Pradesh is 3.5. In Kerala, it’s 1.8.
In an attempt to fill this missing link, in 2005 India began to deploy community health volunteers called accredited social health activists, or “ASHAs.”
The National Rural Health Mission reports that as of January, there were more than 860,000 ASHAs across India who are trained to raise awareness about basic health such as hand-washing, using latrines instead of defecating in the open, taking iron pills and using birth control. In Uttar Pradesh, ASHAs receive bonuses of up to $10 if a pregnant woman delivers at a hospital, receives prenatal and postnatal care, gets immunized against tetanus and takes iron and folic acid pills, says Dr. Manish Jain, MCHIP’s state representative for Uttar Pradesh. ASHAs are credited with helping to boost institutional deliveries in Colonelganj, but with only one for every 1,000 people, they have their limits.
At the hospital in Colonelganj, about 50 ASHAs in brightly colored saris crowd a sunny, second-story room for a training session. One of these ASHAs, Gita Singh, remembers a woman delivering in a village. A hand came out first instead of the baby’s head, so Singh brought the woman to the hospital. Both mother and child lived.
ASHAs are also benefiting from their own messages. Some of the ASHAs in the crowded room say they have started hand-washing habits at home and are building latrines. Leela Nati, 26, cradles her 1-year-old in her lap during the training session. Her baby was delivered in a hospital, she says.
THE CHALLENGE OF DIVERSITY
Another hurdle is India’s diversity in terms of regional cultural differences, religion, caste and language. A one-size-fits-all approach doesn’t work. More homogenous countries like Bangladesh have fewer cultural complexities to maneuver around. And because India has dozens of major languages and hundreds of dialects, training medical staff and working in far-flung communities can be tricky.
Children of families from minority tribes and low castes have a higher risk of dying — 13 and 18 percent higher, respectively, according to a report from India’s National Institute of Medical Statistics and UNICEF. And states that are more patriarchal and conservative about educating and empowering women tend to lag behind.
The southwest state of Kerala is just the opposite. It has a communist government and a matriarchal society in which, unlike most other Indian states, women have a prominent, respected role. Kerala’s population of 33 million boasts a literacy rate of 94 percent, the highest in the country. India’s national literacy rate is 74 percent.
Statistics show that more and better schooling leads to educated mothers who can understand the importance of prenatal and postnatal care, immunizations, nutrition, breastfeeding and other important measures for keeping babies and children healthy. UNICEF and India’s National Institute of Medical Statistics report that newborns whose mothers have at least eight years of schooling are 32 percent less likely to die in the first 28 days of life, and 52 percent less likely to die after the neonatal stage.
The state’s government has also invested heavily in health facilities and training medical staff. In Kerala, 99 percent of births take place in clinics and hospitals.
"With a good leader, there’s a better chance things are going to happen,” says Richard Cash, visiting professor at the Public Health Foundation of India and senior lecturer at Harvard’s School of Public Health. A prime example of this is Bihar, in India’s northeast. In recent decades, the state was synonymous with poverty.
But Bihar has turned a corner since Nitish Kumar, the current chief minister, came to power in 2005. Under the previous chief minister’s 15-year administration, Bihar was notorious for abject poverty, corruption, crumbling infrastructure and lawlessness. Kidnapping for ransom was a brisk business. Education and health benchmarks were low, and immunization rates hovered at just 11 percent in 1998-1999.
But under Kumar’s leadership, immunization rates have leapt to 67 percent.
Bihar’s collaboration with UNICEF, WHO, and Rotary International was credited with helping India virtually wipe out polio in recent years.
Investment in basic services has been revived, and dilapidated roads and bridges have been repaired.
“In the last 10 years there are big differences in Bihar,” recalls Dr. Gupta of UNICEF. “Traveling 20 kilometers used to take two or three hours. It is very different now.”
Bihar is an example of progress that would have been inconceivable not long ago and shows what is possible for India. Yet Bihar, Uttar Pradesh, and India’s other lagging states still have a long way to go.
Laxminarayan of PHFI boils down the challenge ahead for India to reduce child deaths.
“It takes someone at the top level of government to say, ‘This is important to me,’” he says. “That’s all it takes. Child survival is not rocket science. If Bangladesh can do it, if India has the political leadership, we can do it.”
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