This initiative  was launched in 2015 as a collaborative effort between the Indian Council of Medical Research, Public Health Foundation of India, Institute for Health Metrics and Evaluation, and a number of other key stakeholders in India, including academic experts and institutions, government agencies and other organizations, under the aegis of the Ministry of Health & Family Welfare. Over 300 leading scientists and experts representing about 100 institutions across India are engaged with this collaborative work. Key findings: 

· The under-5 mortality rate (U5MR) and neonatal mortality rate in the first month of life (NMR) have dropped substantially in India since 2000, but there is a 5-6 fold variation in the rates between the states and 8-11 fold variation between the districts of India.

· While U5MR and NMR have been decreasing in almost all districts of India, the progress in this decline has been highly variable because of which the inequality in these rates has increased between districts within many states.

· 68% of the under-5 deaths in India can be attributed to child and maternal malnutrition, 83% of the neonatal deaths to low birth weight and short gestation.

· Child growth failure, measured as stunting, wasting and underweight has improved in India since 2000, but their rates vary 4-5 fold between the districts of India and the inequality between districts within many states has increased.

· If the trends observed up to 2017 were to continue, India would meet the SDG 2030 U5MR target but not the SDG 2030 NMR target; 34% of the districts in India would need higher U5MR reduction and 60% districts would need higher NMR reduction to individually meet the SDG targets.

· The district-level child mortality and child growth failure trends in this report arrived at by using all accessible data sources from India provide the most comprehensive reference so far for further planning to improve child survival across India.

New Delhi, 12 May 2020 – At this time when India is focussed heavily on how to deal with COVID-19, two important scientific papers on child survival are published today by the India State-Level Disease Burden Initiative. These publications remind us that while we must do all that we can to control COVID-19, other crucial health issues in India should also continue to receive attention commensurate with their contribution to health loss in India.

The paper in The Lancet reports the first comprehensive estimates of district-level trends of child mortality in India from 2000, and the paper in EClinicalMedicine reports detailed district-level trends of child growth failure. The findings show that although the child mortality and child growth failure indicators have improved substantially across India from 2000 to 2017, the inequality between districts has increased within many states, and that there are wide variations between the districts of India. The child mortality and child growth failure trends reported in these papers utilized all accessible georeferenced survey data from a variety of sources in India, which enabled more robust estimates than the estimates based on single sources that may have more biases. The district-specific findings described in these scientific papers highlight the extent of the effort needed in each district to achieve the national and global targets for the child mortality and child growth failure indicators.

Prof Vinod Paul, Hon’ble Member NITI Aayog on the release of the findings said, “These research findings have shown that India has made positive strides in protecting the lives of new-borns over the last two decades. Introduction of contextually relevant multi-sectoral actions by the Government of India and the State Governments like maternal nutrition programmes during pregnancy, access to skilled health providers during childbirth, and family/community-based care through postnatal home visits have shown to have made a difference. The district-level data from this study will help in the planning and implementation of local action plans and set the course for further improvements in child mortality and child growth failure in India.”

Prof Balram Bhargava, Secretary to the Government of India, Department of Health Research, Ministry of Health & Family Welfare, and Director General, ICMR said, “This is India’s first comprehensive consolidated and detailed analysis of sub-national trends of child mortality and growth failure for all the districts and states in India. It is reassuring news for India that with the various governmental and other efforts under-five mortality rate has halved from 2000 to 2017. The district-level trends reported in these papers provide useful guidance for identifying priority districts in each state that need the highest attention. This approach can facilitate further reduction in child mortality in India.”

Prof Rakhi Dandona, Professor at the Public Health Foundation of India and the lead author of the child mortality paper said, “Comparison of child mortality trends in each of the 723 districts of India with the National Health Policy and SDG targets has identified the districts with high gap where more targeted attention is needed. Bringing down death numbers among newborn babies in the first month of life by addressing specific causes of death is crucial. Malnutrition continues to be the leading risk factor for child death across India. Low birth weight is the biggest component in this risk factor. Focus on maternal nutrition during pregnancy needs to be a priority to improve birthweight of babies. The health system needs to track every pregnant women and every newborn effectively to substantially reduce child deaths in India.”

Dr R Hemalatha, Director, National Institute of Nutrition, ICMR and the lead author of the child growth failure paper said, “India has had significant improvements in stunting, wasting and underweight among children since 2000. However, there continues to be a 5-fold variation in the prevalence of these indicators between the districts of India. The relative inequality of this prevalence between districts has increased within several states, indicating that efforts targeting poorly performing districts as identified by our analysis can potentially help hasten overall improvements in child growth failure in India.”

The Director of the India State-Level Disease Burden Initiative, Prof Lalit Dandona, who is National Chair of Population Health at ICMR, Professor at PHFI, and senior author of these two papers said, “Over the past couple of years, the India State-Level Disease Burden Initiative has been reporting scientifically strong analyses of key diseases and risk factors for every state to inform health policy formulation. The district-level analyses of child mortality and child growth failure reported today are next in this series, providing robust evidence for policy to further improve child survival in India.  Continuing this work, this year we are undertaking a comprehensive analysis of the disease burden caused by COVID-19 across India as well as district-level analyses of other indicators that are important for decentralized health planning to which India aspires.”

Dr Hendrik J Bekedam, WHO Representative to India said, “The complementary programmes –  National Health Mission, National Nutrition Mission and Swachh Bharat Abhiyaan – have helped in addressing the immediate and underlying causes of child mortality and child growth failure.  Importantly, improving health indicators together with other socio development indicators through the Aspirational District Programme will result in greater reduction of child growth failure and resulting mortality in underperforming districts."

Prof K Srinath Reddy, President, Public Health Foundation of India said, “Reductions in under-5 child mortality and neonatal mortality are promising as we move towards the SDG targets. Even neonatal mortality which was previously slow to change is now showing improvement. This decline needs to be further accelerated. Child malnutrition is a major determinant along with maternal malnutrition for these deaths and should be accorded highest priority for corrective action. While stark inter-state and inter-district differences in health and nutrition continue to be challenges, these gaps must be quickly bridged through effective and equitable social development, nutrition and environmental health programmes. Our pre-occupation with Covid19 should not let these development imperatives slip in to the shadows.”

“These studies clearly indicate that, nationally, India has made impressive and substantial progress in reducing the rates of under-5 mortality, however there remain discrepancies in those rates among and within district-level geographies,” said Prof Christopher J L Murray, Director of the Institute for Health Metrics and Evaluation at the University of Washington’s School of Medicine. “Health policymakers throughout India will gain critical insights from these studies to help address those discrepancies as the nation seeks to meet the United Nations’ Sustainable Development Goals.”

The findings reported in the papers published today are part of the Global Burden of Disease Study 2017. The analytical methods of this study have been refined over two decades of scientific work, which has been reported in over 16,000 peer-reviewed publications, making it the most widely used approach globally for disease burden estimation. These methods enable standardized comparisons of health loss caused by different diseases and risk factors, between different geographies, sexes, and age groups, and overtime in a unified framework.

Key findings from the child mortality paper published in The Lancet:

India State-Level Disease Burden Initiative Child Mortality Collaborators. Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–2017. Lancet. 12 May 2020.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30471-2/fulltext

State-level child mortality variations

· U5MR in India reduced by 49% from 83 in 2000 to 42 per 1000 live births in 2017, and NMR reduced by 38% from 38 to 23 per 1000 live births during this period.

· There were 1.04 million under-5 deaths in India in 2017, of which 0.57 million were neonatal deaths, down from 2.24 million under-5 deaths including 1.02 million neonatal deaths in 2000.

· The highest number of under-5 deaths in 2017 were in the state of Uttar Pradesh (312,800 which included 165,800 neonatal deaths) and Bihar (141,500 which included 75,300 neonatal deaths).

· U5MR and NMR was lower with the increasing level of development of the states. In 2017, there was 5.7 fold variation in U5MR ranging from 10 per 1000 live births in the more developed (high SDI) state of Kerala to 60 in the less developed (low SDI) state of Uttar Pradesh, and 4.5 fold variation for NMR ranging from 7 per 1000 live births in Kerala to 32 in Uttar Pradesh.

· The annual rate of reduction from 2010 to 2017 for U5MR ranged among the states from 2.7% in a small north-eastern state of Nagaland to 6.5% in the middle SDI state of Telangana, and for NMR from 1.8% in Nagaland to 5.5% in the high SDI state of Tamil Nadu.

· The annual rate of reduction of NMR was lower than that of U5MR in all states during 2010-2017, but this varied considerably between the states.

District-level child mortality variations

· U5MR varied 10.5 times between the 723 districts of India in 2017, ranging from 8 to 88 per 1000 livebirths, and NMR varied 8.0 times, ranging from 6 to 46 per 1000 livebirths. The highest district-level U5MR and NMR in 2017 were comparable to the highest rates globally among some Sub-Saharan Africa countries.

· U5MR was 40 or more per 1000 livebirths in 88% of the districts in the less developed (low SDI) states, but only in 2% of the districts in the more developed (high SDI) states.

· Similarly, NMR was 20 or more per 1000 livebirths in 93% of the districts in the low SDI states, but only in 13% of the districts in the high SDI states.

· The annual rate of change 2010-2017 varied widely among the districts from 9.0% reduction to no significant change for U5MR, and from 8.0% reduction to no significant change for NMR.

· Inequality between the districts within the states, measured as coefficient of variation, varied extensively in 2017, ranging 11-fold for U5MR and 13-fold for NMR among the states.

· Despite the decrease in U5MR and NMR in most of the districts from 2000 to 2017, the inequality in these rates increased in 74% of the states for U5MR and in 77% states for NMR.

· The highest increases in inequality between districts within states were in Assam and Odisha among the low SDI states, in the small north-eastern states of Meghalaya and Arunachal Pradesh, and in Haryana among the middle SDI states.

Identification of priority districts

· Priority districts for child mortality reduction were identified within states as those that fell in the category of high U5MR and NMR in 2017 and low annual rate of reduction from 2010 to 2017 for the distribution of rates within the states. Using this approach, priority districts for the nationwide distribution of U5MR and NMR and the rate of reduction were also identified to enable a complimentary understanding of the standing of each district with respect to all districts in India.

· In Uttar Pradesh, which had the highest child mortality rate in 2017 among the states, the districts in the highest priority category of high NMR and U5MR and low annual rate of reduction included a cluster of eight districts in the north-central part (Bahraich, Balrampur, Barabanki, Gonda, Hardoi, Kheri, Shravasti, and Sitapur), three districts in the south (Allahabad, Banda and Chitrakoot), and Lalitpur district in the south-west corner of the state.

· In Assam, which had the second highest child mortality rate in 2017, the highest priority category of high U5MR and NMR and low annual rate of reduction was concentrated in the southern handle of the state (Cachar, Dima Hasao, Hallakandi, Karbi Anglong, Karimganj, and West Karbi Anglong)

· In Bihar, the highest priority was scattered in the north-east (Kishanganj and Purnia) and the south-west of the state (Aurangabad and Kaimur).

· Based on the nationwide district-level distribution of child mortality rate, two-thirds of the districts in the less developed low SDI states fell in the high category of U5MR and NMR.

· In Uttar Pradesh, 48% of the districts fell in the highest priority category of high NMR and low rate of reduction for the nationwide distribution of the district-level rates.

Comparison of child mortality trends with targets

· If the trends up to 2017 were to continue, India would not achieve the National Health Policy (NHP) 2025 U5MR target of 23 per 1000 live births or the NHP 2025 NMR target of 16 per 1000 live births. With these trends, India would achieve the SDG 2030 U5MR target of 25 per 1000 live births but not the SDG 2030 NMR target of 12 per 1000 live births.

· In order to achieve these NHP 2025 and SDG 2030 targets individually, most of the less developed low SDI states would need a higher rate of improvement in U5MR and NMR than they had up to 2017.

· Of the 723 districts in India, 34% would need a rate of improvement higher than they had up to 2017 to individually meet the SDG 2030 target for U5MR.

· 59% districts would need a rate of improvement higher than these had up to 2017 to individually meet the SDG 2030 target for NMR; this proportion was 91% in the less developed low SDI states and 21% in the more developed high SDI states.

Causes of child mortality

· Lower respiratory infections (17·9%), preterm birth (15·6%), diarrhoeal diseases (9·9%), and birth asphyxia and trauma (8.1%) were the leading causes of under-5 death in India in 2017.

· Preterm birth (27·7%), birth asphyxia and trauma (14·5%), lower respiratory infections (11.0%), and congenital birth defects (8.6%) were the leading causes of neonatal deaths in India in 2017. 80% of the neonatal deaths were in the early neonatal period of 0–6 days.

· There were wide variations in the percentage of under-5 deaths due to various causes across the states even within the same SDI group. For example, within the low SDI states, the percentage for lower respiratory infections ranged from 15% in Odisha to 27% in Rajasthan, for diarrheal diseases from 6% in Chhattisgarh to 16% in Bihar, and for preterm birth from 11% in Bihar to 19% in Chhattisgarh.

· The rates for most causes of under-5 death in India were lower in the more developed states than in the less developed states.

· The death rate for all major causes of under-5 death reduced in India from 2000 to 2017, with the highest decline in measles (82%), followed by diarrhoeal diseases (69%), and lower respiratory infections (57%) and least for congenital birth defects (15%). There were wide variations in the magnitude of decline between the states, even within the same SDI group.

Risk factors for child deaths

· The dominant risk factor for under-5 death in India in 2017 was child and maternal malnutrition, to which 68% of the deaths could be attributed. The largest contributors to this were low birth weight and short gestation (46%) followed by child growth failure (21%).

· 11% of the under-5 deaths in India in 2017 could be attributed to unsafe water and sanitation and 9% to air pollution.

· For neonatal death, child and maternal malnutrition was the predominant risk factor to which 83% of deaths could be attributed, almost all of which was due to low birth weight and short gestation.

· The proportion of under-5 deaths attributable to child and maternal malnutrition varied between the states from 51% to 73%, unsafe water and sanitation from 1% to 14%, and air pollution from 2% to 14%.

· The proportion of neonatal deaths attributable to child and maternal malnutrition varied between the states from 63% to 87%, unsafe water and sanitation from 1% to 6%, and air pollution from 2% to 9%.

· The contribution of these risk factors to under-5 and neonatal deaths was relatively higher in the less developed low SDI states.

Implications of these findings

· This study provides the most comprehensive understanding of child mortality trends across the states and districts of India over the past two decades, highlighting the enduring disparities in child survival between the states and districts.