There has recently been some triumphalism in Indian government circles over reports that the National Rural Health Mission (NHRM) has been successful in reducing maternal mortality and infant mortality. Yet while the reduction in maternal mortality – from 301 to 254 for every 100,000 live births – does provide some cause for cheer, the reduction in child mortality – from 58 to 53 for every 100,000 live births – still leaves much to be desired. This is particularly so when some Indian states continue to lag behind far poorer countries including, Nepal and Bangladesh. The NHRM is now slated to receive an eight-year extension from its current target year of 2012, by which time it was supposed to have achieved a range of far-reaching goals of direct consequence to this issue. At this point, however, even this significant extension does not look set to help the two million Indian children under the age of five who die every year. The fact of the matter is that the NHRM simply does not have a clear roadmap by which to take any significant step forward on the matter. As such, it will almost certainly continue to muddle along, even as children continue to die preventable deaths – by the current count, one every 15 seconds.
There is a clear place to start in this undertaking. At the moment, deaths occurring within the first month of birth – so-called neonatal deaths – constitute half of all fatalities in children under five years old. This is a significant number, and over two-thirds of infants continue to die within their first month in today's India, 90 percent of whom expire due to easily preventable causes such as pneumonia and diarrhoea. Yet even within what appear to be clear-cut parameters, the official effort to deal with this phenomenon – the NRHM's Navjat Shishu Suraksha Karyakram, which trains health workers in the basic care and resuscitation of newborns – has yet to take off.
Across Southasian countries, a common and complicating feature of child and infant mortality today is that the deaths are not evenly distributed across the countries. Instead, these take place in specific geographic locations and among particular population groups. These especially include 50 districts in five Indian states, a few districts in two provinces of Pakistan, and a few districts in Nepal, Afghanistan and Bangladesh. Together, these areas contribute to the highest global burden of preventable infant mortality. Alongside this, other Indian states have quite low levels of infant mortality, comparable even to the numbers in developed countries. Consider, for instance, the 2007 data from the Ministry of Health and Family Welfare: with 13 deaths per 1000 live births, Kerala has the lowest infant mortality rate in India, while Madhya Pradesh, with 72, has the highest. A closer analysis shows that high infant- and child-mortality rates are invariably a reality among historically marginalised population groups and locations, with low levels of female literacy, recurring drought, rampant migration and poor local governance being common features across these areas.
To date, some of these more indirect causes for such high mortality rates, particularly poor governance and lack of accountability, have not received adequate examination. In addition, one aspect that is very rarely discussed is the sheer apathy that exists on the part of local, government and international agencies – the 'duty-bearers' who are vested with the responsibly of ensuring the survival of each and every child. Yet thus far, only limited efforts have been made to understand the role of duty-bearers in preventing avoidable child deaths, particularly the 'opportunity cost' of inaction and inappropriate action. In Southasia, such inaction or inappropriate action is directly contributing to the daily 'murder' of about 5000 children.