Reducing child mortality in India in the new millennium.

Reducing child mortality in India in the new millennium Mariam Claeson,1 Eduard R. Bos,2 Tazim Mawji,3 & Indra Pathmanathan4 Globally, child mortality rates have been halved over the last few decades, a developmental success story. Nevertheless, progress has been uneven and in recent years mortality rates have increased in some countries. The present study documents the slowing decline in infant mortality rates in India; a departure from the longer-term trends. The major causes of childhood mortality are also reviewed and strategic options for the different states of India are proposed that take into account current mortality rates and the level of progress in individual states. The slowing decline in childhood mortality rates in India calls for new approaches that go beyond disease-, programme- and sector-specific approaches. Keywords: infant mortality, trends; child, preschool; infant, low birth weight; infant, premature; health services; child health services, utilization; child nutrition disorders, prevention and control; maternal health services, utilization. Bulletin of the World Health Organization, 2000, 78: 1192–1199. Voir page 1197 le re´sume´ en franc¸ais. En la pa´gina 1198 figura un resumen en espan˜ol. Introduction In 1998, about 2.5 million under-5-year-olds died in India, the highest total of any country (1). India’s health goals for the year 2000 included reducing: the national mortality rate for children under 5 years of age to less than100per 1000 livebirths; the infantmortality rate to less than 60 per 1000 live births; and the perinatal mortality rate to less than 85 per 1000 live births. Between the mid-1980s and early 1990s, significant progress was made toward these goals and national targets appeared to be within reach, despite large disparities in mortality levels, rates of decline and child health determinants among the various Indian states. However, recent data indicate that the decline in child mortality rates is slowing. In this study we examine, inter alia, the trend in infant mortality rates since 1981. Thedata support thehypothesis that thedecline inchild mortality rates is slowing, and we suggest factors that could be important when formulating child health policy in India over the next decade. Has the decline in childhood mortality rates slowed in India? Several indicators of childhood mortality are used to measure levels and trends, including the neonatal and postneonatal mortality rates, the infant mortality rate, the child mortality rate, and the under-5 mortality rate. Over the 15-year period before the 1992–93 National Family Health Survey (NFHS), all measures of childhood mortality declined in India at rates slightly greater than the average for other low-income countries, excluding China (2). Fig. 1 summarizes the decline of several childhood mortality indicators measured in the NFHS. The decline in the under-5 mortality rate in India was comparable with those of 20 other countries with Demographic and Health Surveys (DHS) data (3). A comparison of the under-5 rate for India with seven DHS countries is given in Fig. 2. Another source of infant mortality data is the Indian Sample Registration System (SRS), whose annual estimates are consistent with those of the NFHS (4). The SRS was started in a few states in 1965, with coverage extended to all states in 1970, and tracks births through the use of continuous enumeration and biannual surveys. Infant mortality rates and child deaths are published annually, but not child mortality rates. The continuous registration and survey results are matched and verified in the field to minimize duplication and omission. At the national level, the results are generally believed to be quite accurate. Improvements in the accuracy of the data are likely to have occurred in some states over time, whichmay underestimate the pace of decline; but this is not likely to affect the estimation of national trends. A 1980 survey into omissions of vital events found that death rates were underestimated by about 3% nationally; by 1985, this had improved to 2.5%. We have compared SRS estimates of the annual infant mortality rate for themost recent 5-year period (1993–97) with retrospective data going back to 1981 (Fig. 3). Throughout this interval the rate of decline in 1 Principal Public Health Specialist, Health, Nutrition and Population, Human Development Department, The World Bank, 1818 H Street NW, Washington, DC 20433, USA (email: mclaeson@worldbank.org). Correspondence should be addressed to this author. 2 Demographer, The World Bank, Washington, DC, USA. 3 Consultant, The World Bank, Washington, DC, USA. 4 Senior Public Health Specialist, Health, Nutrition and Population, South Asia Department, The World Bank, Washington, DC, USA. Ref. No. 00-0788 Special Theme – Child Mortality 1192 # World Health Organization 2000 Bulletin of the World Health Organization, 2000, 78 (10) the infant mortality rate tended to stagnate for brief periods, and was often followed by a subsequent rapid decline. During the most recent 5-year period, however, the marked reduction in the rate of decline has been sustained, and the observed estimates (with 95% confidence intervals) are now significantly above the 1981–93 trend line. Based on the longer- term trend, the predicted value for the 1997 infant mortality rate was 63.5 per 1000 live births, whereas the observed rate was 71 per 1000 live births. In terms of numbers, this means that about 200 000 more infants died in 1997 than would have been the case had the longer-term trend continued. As infant and child mortality rates fall, further gains become more difficult to achieve. However, childhood mortality rates in India are still at elevated levels, and the observed reduction in the decline is not readily explainable. The failure to reduce infant mortality during this period means that India will not achieve its year 2000 health goals. Why is the decline in child mortality rates slowing? Determinants of child mortality in India Child mortality trends, differentials, and determi- nants in India have been the subject of many studies (5–15). One of the studies attempted to account for the pace of decline in the infantmortality rate over the period 1968–78 and provided a framework for analysing factors that contributed to it (5). These included proximate factors (such as nonmedical factors and medical care during the antenatal period, care at birth, and preventive and curative care in the postnatal period); maternal factors (age, parity, and birth intervals); and household- and community-level factors (water, sanitation and housing). Then, as now, opinions differed as to the relative importance of socioeconomic development and health services in reducing the infant mortality rate. The study concluded that a substantial decline in infant mortality rate is possible without significant im- provement in economic development, even though the relative importance of various determinants could not be assessed. It made a case for increased access to a minimum package of essential services that would significantly reduce high infant mortality rates: reproductive health services; perinatal care; improved breastfeeding practices; immunization; home-based treatment of diarrhoea; and timely introduction of supplementary foods. Several other studies laid out intervention strategies and directions based on similar analyses and assumptions (9, 16–19). Income as a determinant of child mortality The infant mortality rate often serves as a key development indicator, reflecting the combined effects of economic development, technological change, including health interventions, and the sociocultural environment. Several studies have attempted to evaluate the impact of individual determinants on this rate. For example, studies of infant mortality rate and child mortality trends in Kerala showed that socioeconomic factors explained only a small percentage of the differentials in the rate at the household level (6, 7). The role of other 1193Bulletin of the World Health Organization, 2000, 78 (10) Reducing child mortality in India socioeconomic determinants, such as availability of flush or pit toilets, clean cooking utensils, fuel and ownership of household goods have been examined in a 1998 NFHS report (20). A recent World Bank report supported the previously documented inverse relationship between per capita income and infant mortality rate in India (15). However, even though increases in income have reduced the infant mortality rate, the income effect is stronger on total fertility rates; and non-income factors play an even more significant role than income in lowering the infant mortality rate. For example, the effect of technological progress on the decline in infant mortality rate was estimated at 20% over the period 1975–90, the greatest effect occurring in 1985–90. However, public health expenditures did not significantly lower the rate. The World Bank report noted that although the poorest states in India performed worst in terms of both infant mortality and total fertility rates, the richest states did not perform best. The best state performers in India had relatively low per capita income levels, but achieved relatively good results for those levels. The percentage difference between the expected infant mortality rate for a given level of income and time and the actual rate gives the ‘‘relative performance rate.’’ As shown in Table 1, over the period 1980–90 the rate of decline of the infant mortality rate in Indian states varied significantly, as did their relative performance, and under-5 mortality levels in 1992. To fully explain the profile for each state, additional information on programme inputs and recent trends is needed. As with countries in demographic and epidemiological transition, some states in India are finding it difficult to prevent or reverse a slowdown in the decline of the under-5 mortality and infant mortality rates. The decline in infant mortality rate may be slowing because current child survival interventions are more effective at reducing high under-5 mortality rates when there is a relatively large proportion of postneonatal mortality, than when postneonatal mortality is already low and when neonatal mortality plays an increasingly important role. Another possible reason is that the coverage rates of preventive and curative child health services are declining or levelling off. Child health programmes and child mortality reduction Table 2 summarizes the available data on selected child health programme indicators in India, grouped by states with similar under-5 mortality rates. The data indicate a positive relationship between reduced under-5 mortality rates and key child health inter- ventions, such as oral rehydration therapy, care seeking for acute respiratory infections, and immu- nization rates. Data from various sources (multi- indicator cluster surveys (MICS) and (NFHS) show that non-income factors also played a significant role in lowering infant mortality and under-5 mortality rates in recent years. However, the data do not permit directly attributing mortality declines to maternal and child health programmes. Determinants of perinatal and neonatal mortality Although concerted global and national efforts have been made to improve child mortality, especially in the postneonatal phase, less attention has been given to determinants of perinatal and neonatal mortality. Neonatal mortality has gradually increased as a percentage of total child mortality, because of a faster decline in the postneonatal mortality rate (Registrar General India, 1972–95). The SRS and NFHS data referred to above show a similar pattern. As expected, the decline in perinatal mortality rates also lags behind the overall decline in child mortality. Although problems in the perinatal and neonatal phases have been reported in India (21–32), little progress has been made towards implementing large-scale solutions to these problems. Effective interventions to address risk factors areavailable (suchasessentialnewborncare) and their implementation could result in a rapid reduction in perinatal and neonatal mortality rates (23, 33–35). Maternal determinants Perinatal mortality studies point to the link between the health of the mother and the birth outcomes. The high perinatal mortality rates in India reflect the poor status of women, including poor nutritional status (malnutrition and anaemia), low rates of literacy, lack of autonomy and early marriage and childbirth. In addition, low rates of antenatal care, low utilization of obstetric and other health services and large numbers of deliveries by untrained personnel result in poor maternal health and poor birth outcomes, such as low birth weight and prematurity (36, 38–43). Further- more, the effects of maternal characteristics are not limited to the perinatal period. As Table 3 shows, the under-5 mortality rate also differs significantly by maternal background characteristics. Improving female education (20) and nutrition, and increasing the use of health services during pregnancy and delivery, are all important for reducing childhood mortality rates. Gender differentials Gender disparities in health and education are higher in South Asia, including India, than anywhere else in the world, and have been the subject of many studies (36, 38–43). For example, a girl in India is 30–50% more likely to die between her first and fifth birthdays than is a boy; thus, eliminating gender gaps inmortality rates would significantly reduce infant and child mortality overall. One reason for gender differences in child mortality is a preference for sons, and after the first month of life other factors come into play, including environmental and behavioural factors, such as care-seeking practices. Girls are often brought to health facilities in more advanced stages of illness than boys, are taken to less qualified doctors when they are 1194 Bulletin of the World Health Organization, 2000, 78 (10) Special Theme – Child Mortality ill, and less money is spent onmedicines for them than for boys (39). A recent analysis confirmed that girls are less likely to receive treatment than boys (42), and a study conducted in Punjab showed that during the first two years of life (the peak years for child mortality), expenditure on health care was 2.3-times higher for sons than for daughters (44). Nutritional determinants Malnutrition is a factor in an estimated 54% of all childhood deaths globally (41). Despite significant progress, more than half of all under-4-year-olds in India are still moderately or severely malnourished, 30% of newborns are significantly underweight, and 60% of Indian women are anaemic (46). Malnutrition has been identified as the main factor retarding improvements in human development and hindering further reductions in infant mortality in India (47). Also, despite differences in sociocultural practices and lifestyles between states, nutritional deficiencies underlie child and infant mortality throughout India. Furthermore, in most urban and rural locations the proportion of malnourished children among sched- uled castes and tribes is consistently higher than the average (46). Themajor nutritional disorders are deficiencies of iron, vitamin A and iodine. Micronutrient deficiencies influence child survival and the health and development of surviving children, including cognitive development. Although potentially cost- effective and affordable interventions are available, existing food supplementation and micronutrient programmes in India have not achieved significant reductions in nutritional deficiencies at state or national levels, a factor contributing to the slowing decline of childhood mortality rates. The problems that beset micronutrient programmes include shortages in supplies, logistical difficulties and the lack of community motivation and education (47). These shortcomings need to be addressed in order for these programmes to be scaled up and sustained. Low birth weight is a key predictor of malnutrition and an important determinant of child mortality. National efforts have been made to collect representative estimates of birth weights from institutional and community deliveries, but the findings vary greatly. In a study of fifteen centres across India, theNationalNeonatology Forum found a prevalence of low birth weight of 33%, of which 32% were premature births. The 1992–93 NFHS found that small birth size— a proxy for birth weight — carries a risk of infant death 2.5-times higher than the risk for average or large birth size. Low birth weight has also been identified as a factor in the retardation of motor, adaptive, social and language development, as well as in the susceptibility of adults to diseases.One of themost detrimental outcomes of low birth weight is growth retardation in young girls, which perpetuates a vicious cycle of female malnu- trition through adulthood and into the next genera- tion (48). Conclusions Infant and child mortality in India have declined substantially over the past 15–20 years. According to SRS and NFHS data, infant mortality declined by 35% over the past 15 years and under-five mortality by 25% between 1978–83 and 1988–93. The available data indicate that non-income factors, such asmaternal and child health interventions, have played a significant role in lowering both infant mortality and under-5 mortality rates in India, although the data do not Table 1. Decline in infant mortality rate (IMR), infant mortality rate relative performance, and under-5 mortality (U5M) rate for selected Indian statesa State Decline in Relative U5M rate IMR, 1980–90 performance in 1992 (%)b of IMR (%)c (per 1000) Kerala 45 103 32 Karnataka 38 22 87 Tamil Nadu 32 7 86 Haryana 27 – 16 98 Bihar 20 5 127 West Bengal 19 5 99 Orissa 19 – 34 131 Punjab 18 – 5 68 Assam 7 – 11 142 Gujarat 7 – 23 104 Rajasthan 2 – 16 102 a Only those states for which data were available on all three indicators are shown. b See Fig. 1. c Percentage difference between the expected infant mortality rate for a given level of income and time period and the actual rate. Table 2. Selected child health programme indicators, 1992–93 (by clusters of states according to under-5 mortality (U5M) levels)a Cluster of states U5M range Median EPI Median ORT Median ARI (per 1000) ratesb use ratesc ratesd All India 109.3 35.4 30.6 66.3 Assam, Orissa, Uttar >100 20.2 22.9 62.3 Pradesh, Bihar, Gujarat, (10.7–49.8)e (20–41) (54.3–73.3) Rajasthan Maharashtra, West Bengal, 100–50 57.7 33.3 73.3 Haryana, Karnataka, (34.2–64.9) (19.5–74.7) (67.4–88.1) Tamil Nadu, Punjab Goa, Kerala <50 64.6 39.6 81.8 (54.4–74.9) (37.8–41.4) (81.3–82.3) a Source: NFHS, 1992–93. b EPI rates = % of children fully immunized using Expanded Programme on Immunization schedule. c ORT use rates = % of children with diarrhoea given oral rehydration therapy or recommended use of home fluid. d ARI rates = % of children with cough and fast breathing taken to health facility/provider. e Figures in parentheses are the ranges. 1195Bulletin of the World Health Organization, 2000, 78 (10) Reducing child mortality in India permit directly attributing the mortality decline to programme efforts. Furthermore, the decline in child mortality in urban areas has been slower than in rural areas, and as a result urban–rural mortality differentials have become smaller. Under-five mortality has declined because of reductions in the neonatal, postneonatal and child mortality rates. Proportion- ately, postneonatal mortality has declined more than neonatal mortality, increasing the relative importance of perinatal and neonatal mortality. This successful record now appears to be in jeopardy. In the past, periods of 2–3 years of slower declines in the infant mortality rate have been preceded and followed by years of very rapid declines. However, the current period of slower decline has lasted 4 years, during which time the rate has dropped by only 3 per 1000 live births. As a result, the infantmortality rate is increasingly departing from the longer-term trend observed in India since 1981, indicating a period of stagnation (Fig. 3). Factors contributing to this slowing decline include the lower social, cultural and health status of women in India. Thus, improving female education and nutrition, as well as increasing the use of health services during pregnancy and delivery, would lower child mortality. The level of child morbidity and mortality is higher for girls aged 1 month to 5 years than for boys, and girls receive less health care; eliminating gender differences in mortality rates would significantly reduce infant and child mortality overall. Malnutri- tion among Indian children is also very prevalent and contributes to mortality from many causes. The slowing decline in India’s child mortality rate calls for new approaches to the problem of child mortality.Future child health policies should build on past lessons from child health programmes in India, sustain the achievements that have already been made, enhance quality and efficiency and address specific gaps in neonatal care. These goals can be accomplished as discussed below. First, a new strategic framework for childhood illness, health and development is needed. The government of India needs to reassess the country’s current child mortality reduction goals and proceed with integrated approaches for child health and Table 3. Childhood mortality rates by maternal characteristica IMRb CMRc U5M rated (per 1000) (per 1000) (per 1000) Mother’s educational level Illiterate 101 44 141 Literate, did not complete middle school 63 23 84 Middle school completed 56 9 65 High school and above 37 6 43 Medical maternity care No antenatal care 97 54 146 Either antenatal or delivery care 64 23 85 Both antenatal and delivery care 44 13 57 Place of delivery Public health facility 59 19 77 Private health facility 39 4 42 Home 78 40 114 Mother’s age at birth (years) <20 107 38 141 20–29 76 35 108 30–39 91 34 122 40–49 112 58 163 Previous birth interval (months) < 24 130 55 178 24–47 68 35 3 >48 42 16 57 Birth order 1 93 26 117 2 77 32 106 3 72 37 107 6 98 40 134 7 120 54 168 a Source: NFHS, 1992–93. b IMR = Infant mortality rate. c CMR = Child mortality rate (the probability of dying between first and fifth birthday). d U5M rate = Under-five mortality rate (the probability of dying before the fifth birthday). Box 1. Policy options for stratified state child health policies in India States with high under-5 mortality/infant mortality rates and slow rates of decline need to: . Address priority maternal and child health problems by strengthening health systems (e.g. by improving the availability of drugs, monitoring and surveillance). . Prioritize the essential elements of child health and nutrition services (e.g. by strengthening immunization programmes and other preventive measures; and integrate approaches to clinical management of acute respiratory infections, malnutrition, diarrhoea and other major causes of childhood illness). . Develop and expand community participation in the prevention and treatment of childhood illnesses (e.g. by strengthening care-seeking, compliance and preventive behaviours at the household level). States that have reached lower levels of under-5 mortality/infant mortality rates but are experiencing a slowdown in reduction in these rates, need to: . Sustain all of the programmes outlined above. . Emphasize improved referral services (including obstetric emergencies).a . Emphasize effective strategies for reducing perinatal/ neonatal mortality (including strategies for comprehen- sive reproductive health services and for improving women’s nutritional status, and newborn care).a . Implement early child development programmes. States with a large proportion of urban poor need to: . Include policy options for innovative approaches to heath services delivery (e.g. use private providers and NGOs to increase access to quality services). a Where maternal mortality rates are high, attention needs to be paid to reproductive health services, regardless of the level of childhood mortality rates. 1196 Bulletin of the World Health Organization, 2000, 78 (10) Special Theme – Child Mortality nutrition. Existing child health programmes and strategies, including initiatives for the eradication and elimination of vaccine-preventable childhood dis- eases, and specific health and nutrition interventions, need to be examined in the context of a child health framework that goes beyond disease-, programme- and sector-specific approaches. Second, a better understanding of the main determinants of the health and nutrition cycle for mothers and children— the life cycle — is central to developing more effective strategies for child survival, health and development. Socioeconomic, environmental, behavioural, health and nutritional determinants influence this cycle; the challenges over the next 10 years will be to jointly address the most important determinants and gaps in the cycle with affordable, cost-effective and culturally appropriate interventions. These should take into account both demand and supply factors, and involve local communities in identifying needs and priorities. Third, because of state differences in infant and child mortality levels and performance in India, stratified child health policies are needed that take into account state-specific epidemiological and demographic patterns and key determinants, as shown in Box 1. n Acknowledgements The study was a collaborative effort involving World Bank staff at headquarters and in the New Delhi Resident Mission; Indian government officials; and the UNICEF country office. We are grateful toGNV Ramana, Suneeta Singh, Rashmi Sharma, Fred Arnold, Anthony Measham, Peter Heywood, V. Manchandra and James Tulloch for useful inputs and helpful comments. A longer version of the study, including supporting tables and an extended biblio- graphy is available in the World Bank informal Health, Nutrition and Population Discussion Series (Claeson M, Bos E, Pathmanathan I. Reducing child mortality in India; keeping up the pace. Washington, DC, The World Bank, 1999 (Health, Nutrition and Population Discussion Series). Re´sume´ Re´duire la mortalite´ infanto-juve´nile en Inde au troisie`me mille´naire En Inde, la mortalite´ infanto-juve´nile a beaucoup diminue´ au cours des 15 a` 20 dernie`res anne´es. Selon les donne´es de l’Indian Sample Registration System et de la National Family Health Survey, la mortalite´ a baisse´ de 35 % chez les nourrissons au cours des 15 dernie`res anne´es et de 25 % chez les moins de 5 ans entre 1978- 1983 et 1988-1993. Les renseignements disponibles indiquent que des facteurs autres que les revenus, comme les interventions en sante´ maternelle et infantile, ont joue´ un roˆle important dans cette baisse, meˆme si aucune donne´e ne permet d’attribuer directement la diminution de la mortalite´ aux actions des programmes. De plus, la baisse a e´te´ plus lente en zone urbaine qu’en zone rurale, ce qui a re´duit la diffe´rence entre les taux de mortalite´ en ville et a` la campagne. La mortalite´ des moins de 5 ans a diminue´ a` cause de la re´duction des taux de mortalite´ ne´onatale, postne´onatale et de l’enfant. En proportion, la mortalite´ postne´onatale a enregistre´ une baisse plus grande que la mortalite´ ne´onatale, faisant augmenter ainsi l’importance relative de la mortalite´ ne´o- et pe´rinatale. Il semble a` pre´sent que ces bons re´sultats soient remis en cause. Dans le passe´, les pe´riodes (2 a` 3 ans) de baisse plus lente e´taient pre´ce´de´es puis suivies d’anne´es de baisse tre`s rapide ; or la pe´riode actuelle de baisse plus lente dure depuis quatre ans, avec une diminution des taux de mortalite´ infanto-juve´nile de seulement 3 pour 1 000 naissances vivantes. On peut donc observer que ce taux s’e´carte de plus en plus de la tendance a` long terme qui se maintenait depuis 1981, signe d’une ve´ritable stagnation. Les facteurs contribuant a` ce ralentissement de la baisse sont lie´s au niveau social, culturel et sanitaire infe´rieur des femmes en Inde. Par exemple, les taux de morbidite´ et de mortalite´ sont plus e´leve´s chez les filles entre 1 mois et 5 ans que chez les garc¸ons, et elles rec¸oivent moins de soins. Par conse´quent, c’est en supprimant les diffe´rences entre les sexes, c’est-a`-dire en ame´liorant l’e´ducation et l’alimentation des filles et aussi en encourageant les femmes enceintes a` recourir davantage aux services de sante´ pendant leur grossesse et lors de l’accouchement, que l’on pourrait faire encore baisser la mortalite´ infanto-juve´nile. La malnutrition chez les enfants est e´galement largement pre´valente et contribue a` accroıˆtre la mortalite´ imputable a` de nombreuses autres causes. De nouvelles approches sont ne´cessaires pour contrer le ralentissement de la baisse des taux de mortalite´ infanto-juve´nile en Inde. En matie`re de sante´ de l’enfant, les politiques devront s’appuyer sur l’expe´rience des programmes dans ce domaine, maintenir les re´sultats obtenus, renforcer la qualite´ et l’efficience et combler les lacunes propres aux soins ne´onatals. Pour y parvenir, trois e´tapes seront ne´cessaires. Premie`rement, un cadre strate´gique pour les maladies, la sante´ et le de´veloppement de l’enfant s’impose. Le Gouvernement indien doit re´e´valuer les objectifs actuels en matie`re de re´duction de la mortalite´ infanto-juve´nile et agir en adoptant des approches inte´gre´es au niveau de la sante´ et de la nutrition de l’enfant. Les programmes et strate´gies existantes, y compris les initiatives pour l’e´radication et l’e´limination des maladies de l’enfance e´vitables par la vaccination, de meˆme que les interventions en matie`re de sante´ et de nutrition, doivent s’inscrire dans le cadre plus ge´ne´ral de la sante´ infanto-juve´nile, qui de´passe les approches particulie`res adopte´es pour des maladies, des program- mes ou des secteurs. Deuxie`mement, il importe de mieux comprendre les principaux de´terminants du cycle de la sante´ et de la nutrition pour les me`res et les enfants afin d’e´laborer des 1197Bulletin of the World Health Organization, 2000, 78 (10) Reducing child mortality in India strate´gies plus efficaces visant la survie, la sante´ et le de´veloppement de l’enfant. Ces de´terminants sont de nature socio-e´conomique, environnementale, compor- tementale, sanitaire et nutritionnelle. Au cours des dix prochaines anne´es, la difficulte´ pour les acteurs de la sante´ et du de´veloppement de l’enfant consistera a` traiter conjointement les principaux de´terminants et lacunes de ce cycle au moyen d’interventions abordables, d’un bon rapport couˆt/efficacite´ et culturellement adapte´es. Ces interventions devront tenir compte a` la fois de l’offre et de la demande, tout en associant les communaute´s locales a` la de´finition des besoins et des priorite´s. Troisie`mement, compte tenu des diffe´rences qui existent entre les Etats concernant les taux de mortalite´ infanto-juve´nile et les re´sultats obtenus, il faudra des politiques de sante´ infanto-juve´nile stratifie´es pour prendre en compte les sche´mas e´pide´miologiques et de´mographiques ainsi que les facteurs cle´s propres a` chaque Etat. Resumen Reduccio´n de la mortalidad infantil en la India en el nuevo milenio La mortalidad de lactantes y de nin˜os pequen˜os en la India ha disminuido sustancialmente durante los u´ltimos 15-20 an˜os. Segu´n demuestran los datos del Sistema de Registro de Muestras (SRS) y de la Encuesta Nacional de Salud Familiar (NFHS) de la India, la mortalidad de lactantes ha descendido un 35% durante los u´ltimos 15 an˜os, y la mortalidad de menores de 5 an˜os cayo´ un 25% entre 1978-1983 y 1988-1993. Los datos disponibles indican que factores distintos de los ingresos, como las intervenciones de salud maternoinfantil, han contribuido de forma significativa a la disminucio´n de la mortalidad de lactantes y de menores de 5 an˜os en la India, si bien los datos no permiten atribuir directamente esa disminucio´n a actividades programa´ticas. Adema´s, la reduccio´n de la mortalidad de nin˜os pequen˜os en las a´reas urbanas ha sido ma´s lenta que en las zonas rurales, y en consecuencia el diferencial de mortalidad urbano- rural es ma´s pequen˜o. La mortalidad de menores de 5 an˜os ha descendido debido a la reduccio´n de las tasas neonatales, posneonatales y de la nin˜ez. Proporcional- mente la mortalidad posneonatal ha disminuido ma´s que la neonatal, aumentando ası´ la importancia relativa de la mortalidad perinatal y neonatal. Estos progresos parecen ahora peligrar. En el pasado, los periodos de 2-3 an˜os de aminoracio´n de la reduccio´n de la tasa de mortalidad de lactantes se han visto precedidos y seguidos de an˜os de disminuciones muy ra´pidas. Sin embargo, el periodo actual de atenuacio´n de la disminucio´n dura ya 4 an˜os, durante los cuales la tasa de mortalidad de lactantes se ha reducido en so´lo 3 por 1000 nacidos vivos. Como resultado, la tasa se esta´ desviando cada vez ma´s de la tendencia a largo plazo mantenida desde 1981, lo que refleja un verdadero estancamiento. Entre los factores responsables de esa desaceleracio´n cabe citar el menor estatus social, cultural y sanitario de la mujer en la India. Por ejemplo, la morbilidad y la mortalidad es mayor entre las nin˜as de 1 mes a 5 an˜os que entre los nin˜os, y las primeras reciben menos atencio´n de salud. Por consiguiente, la eliminacio´n de las diferencias entre los sexos mediante la mejora de la educacio´n y la nutricio´n de las mujeres y de su acceso a los servicios de salud durante el embarazo y el parto reducirı´a au´n ma´s la mortalidad en la nin˜ez. La malnutricio´n es tambie´n muy frecuente entre los nin˜os de la India, y contribuye a la mortalidad por muchas causas. La menor disminucio´n de la tasa de mortalidad infantil observada en la India es un problema que exige nuevos enfoques. Las futuras polı´ticas de salud infantil debera´n aprovechar las ensen˜anzas sacadas en el pasado de los programas de salud infantil aplicados en el paı´s, mantener los logros conseguidos, fomentar la calidad y la eficiencia, y abordar deficiencias concretas de la atencio´n neonatal. Estas metas pueden alcanzarse del siguiente modo: Primero, hace falta un marco estrate´gico para abordar la salud y el desarrollo del nin˜o. El Gobierno de la India ha de reevaluar las actuales metas del paı´s en lo que atan˜e a la reduccio´n de la mortalidad en la nin˜ez, y abordar con enfoques integrados la salud y la nutricio´n infantiles. Los actuales programas y estrategias de salud infantil, incluidas las iniciativas de erradicacio´n y eliminacio´n de las enfermedades infantiles prevenibles mediante vacunacio´n, ası´ como determinadas interven- ciones de salud y nutricio´n, deben ser examinados en el contexto de un marco de salud infantil que trascienda los enfoques especı´ficos por enfermedades, programas o sectores. Segundo, la profundizacio´n en el conocimiento de los principales determinantes del ciclo de salud y nutricio´n de las madres y sus hijos es fundamental para formular estrategias ma´s eficaces para la supervivencia, la salud y el desarrollo del nin˜o. Los determinantes socioecono´micos, ambientales, conductuales, sanitarios y nutricionales influyen en ese ciclo; para la comunidad que se ocupara´ de la salud y el desarrollo del nin˜o durante la pro´xima de´cada, el reto consistira´ en abordar conjuntamente los determinantes y las deficiencias ma´s importantes de ese ciclo mediante intervenciones asequibles, eficaces en funcio´n de los costos y culturalmente ido´neas. Esas intervenciones debera´n tener en cuenta factores tanto de la demanda como de la oferta, y hacer participar a las comunidades locales en la identificacio´n de las necesidades y prioridades. Tercero, considerando las diferencias entre Esta- dos en lo relativo a los niveles de mortalidad de lactantes y de nin˜os pequen˜os y al desempen˜o en ese sentido, se necesitan polı´ticas de salud infantil estratificadas que reparen en las caracterı´sticas epidemiolo´gicas y demo- gra´ficas y los determinantes ma´s importantes de cada Estado. 1198 Bulletin of the World Health Organization, 2000, 78 (10) Special Theme – Child Mortality References 1. State of the world’s children. New York, United Nations Children’s Fund, 2000. 2. National Family Health Survey (MCH and Family Planning), India, 1992–1993. Bombay, India, International Institute for Population Sciences, 1995. 3. Bicego G, Ahmad O. Infant and child mortality. Calverton, MD, Macro International Inc., 1996 (Demographic and Health Surveys Comparative Studies, No. 20). 4. Registrar General, India. Sample Registration System Bulletin, 1998, 32 (2): 1–3. 5. Jain AK, Visaria P. Infant mortality in India: an Overview. 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