Elsevier

The Lancet

Volume 377, Issue 9762, 22–28 January 2011, Pages 332-349
The Lancet

Series
Reproductive health, and child health and nutrition in India: meeting the challenge

https://doi.org/10.1016/S0140-6736(10)61492-4Get rights and content

Summary

India, with a population of more than 1 billion people, has many challenges in improving the health and nutrition of its citizens. Steady declines have been noted in fertility, maternal, infant and child mortalities, and the prevalence of severe manifestations of nutritional deficiencies, but the pace has been slow and falls short of national and Millennium Development Goal targets. The likely explanations include social inequities, disparities in health systems between and within states, and consequences of urbanisation and demographic transition. In 2005, India embarked on the National Rural Health Mission, an extraordinary effort to strengthen the health systems. However, coverage of priority interventions remains insufficient, and the content and quality of existing interventions are suboptimum. Substantial unmet need for contraception remains, adolescent pregnancies are common, and access to safe abortion is inadequate. Increases in the numbers of deliveries in institutions have not been matched by improvements in the quality of intrapartum and neonatal care. Infants and young children do not get the health care they need; access to effective treatment for neonatal illness, diarrhoea, and pneumonia shows little improvement; and the coverage of nutrition programmes is inadequate. Absence of well functioning health systems is indicated by the inadequacies related to planning, financing, human resources, infrastructure, supply systems, governance, information, and monitoring. We provide a case for transformation of health systems through effective stewardship, decentralised planning in districts, a reasoned approach to financing that affects demand for health care, a campaign to create awareness and change health and nutrition behaviour, and revision of programmes for child nutrition on the basis of evidence. This agenda needs political commitment of the highest order and the development of a people's movement.

Introduction

India has a unique opportunity now to improve the health and nutritional status of its people. The country is in a position to invest increasing amounts of resources in social sectors as a result of economic progress. With recognition of the importance of health and nutrition for national development, the prospects for improved and equitable health and nutrition are now better than they have ever been.

Reproductive health, and child health and nutrition are core priorities for any country, more so for India with the world's greatest burden of maternal, newborn, and child deaths. In 2008, 1·8 million children (age <5 years), including 1 million neonates, died,1 and 68 000 mothers died.2 India also has the greatest number of undernourished children, with about 52 million stunted children (age <5 years).3 Progress in reproductive health, and child health and nutrition does not compare favourably with some other countries in Asia that gained independence at about the same time as India (webappendix p 7). India still has a long way to go to reach its declared goals (table 1).3, 4, 5, 6 We review the current situation of reproductive health, and child health and nutrition in India, identify policy and programmatic gaps, and suggest a way forward. To maintain focus on the main themes, we do not cover some equally important and related issues such as child development and micronutrient malnutrition. The description of methods used in this report is provided in the webappendix p 1.

Key messages

  • With 1·8 million deaths among children (age <5 years) and 68 000 deaths among mothers every year, and 52 million children who are stunted, India's burden of reproductive health, and child health and nutrition is greater than that in any other country.

  • The pace of improvement has been slow and falls short of the national and Millennium Development Goal targets. For instance, the national goal for 2010—ie, an infant mortality rate of less than 30—will not be attained in rural India as a whole, and all except five states, even in 2015. The reason is that the coverage for priority interventions remains insufficient, and the content and quality of existing programmes suboptimum, further complicated by unacceptable inequities.

  • The underlying cause of insufficient progress is weak health systems; substantial inadequacies exist in planning, financing, human resources, infrastructure, supply systems, governance, and monitoring.

  • Adequate importance has not been given to the first 2 years of a child's life that are critical for prevention of undernutrition and its consequences; the focus of the nutrition programmes has become supplementary nutrition and preschool education for children aged 3–6 years.

  • The only way forward is to transform health systems. Effective stewardship, decentralised planning in districts, effective service delivery in communities and health facilities, a reasoned approach to demand-side financing, a sustained campaign to change household behaviours, and creation of centres of excellence for health and nutrition policy research are essential for change.

  • Child nutrition programmes need to be changed with focus on the vulnerable first 2 years of life.

  • For long-term gains, investments in sexual and reproductive health of young people are essential.

Section snippets

Trends in key indicators

The estimated population of India is 1·16 billion individuals7 and is projected to be 1·48 billion people by 2030, surpassing China as the world's most populous nation.7 The total fertility rate in 2005–06 was 2·7,3 versus 3·4 in 1998–99.8 It is now 2·1 (replacement level) in urban areas, and 3·0 in rural areas.3 In 2005–06, 56% of married women were using contraception3 compared with 41% in 1990–929 and 48% in 1998–99.8 The estimated maternal mortality ratio showed a 36% reduction from 398 per

Scope of current programmes

The main national programmes are the Reproductive and Child Health Programme, National Rural Health Mission (NRHM; panel 1), and the Integrated Child Development Services (panel 2).32, 33, 34, 35, 36, 37 Janani Suraksha Yojana, a conditional cash transfer scheme to promote deliveries in institutions, is another major initiative that is part of NRHM.38, 39 Health and nutrition are multidimensional and cross the traditional boundaries between sectors and ministries, requiring improvements in

Child health

In this section, we identify the programmatic gaps in reproductive health, and child health and nutrition. A summary of specific suggestions to address these gaps is presented in webappendix pp 3–5. Integrated Management of Neonatal and Childhood Illnesses, the Indian adaptation of the generic strategy for Integrated Management of Childhood Illness, was introduced in 2005. It includes home visits in the first week of life by anganwadi workers. Postnatal home visits, a strategy that was

Governance

Technical leadership in India and its states is weak. Bureaucrats with little experience in public health make decisions about reproductive and child health, whereas technical advisors are relegated to the fourth level of the central hierarchy. Nationally, for the entire maternal or child health programme, there are five or six senior technical professionals. This problem was recognised early, but little improvement has occurred.89 Expert technical committees are established for specific tasks,

Transformation of health systems

In India, inadequate progress in reproductive health and child health is due largely to underdeveloped, under-resourced, and underperforming health systems. A health system with weak foundations cannot support the interventions and strategies needed to attain the goals presented in policy documents. The results are inadequate coverage of most interventions and behaviours, and widespread inequities. However, an unprecedented effort has been made to reform the health sector through NRHM, and the

Search strategy and selection criteria

Since several global systematic reviews are already available, we restricted our search to India, and reports published in English. We created three groups and used the following terms to search PubMed: “India” (group 1); “maternal”, “child”, “neonate”, “newborn”, “infant”, “mother”, or “pregnancy” (group 2); and “nutrition”, “infection”, “mortality”, “morbidity”, or “growth” (group 3). Of 16 695 citations in the past 10 years preceding March, 2009, 2960 publications were judged to be relevant

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