May 2008

(Draft)

Millennium Development Goals – Fact

Goal 4: Reduce Child Mortality
 Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate

The Millennium Development Goals (MDGs) were formulated in 2000 at the United
Nations Millennium Summit as a response to the world’s main development
challenges. There are eight goals to be achieved by 2015. MDG4 aims to reduce
child mortality.

Definitions
 Under-5 mortality rate: Probability of dying between birth and exactly five
years of age expressed per 1,000 live births1.

 Infant mortality rate: Probability of dying between birth and exactly one year
of age expressed per 1,000 live births.2

 Neonatal mortality rate: Probability of dying within the first 28 days of life.3

MDG 4 progress
Description Target
20154
Latest
Available
Status
Under five mortality rate 41 72 (2007)5

Infant mortality rate 27 55 (2007)6

Proportion of 1 year old children n/a 67 (2007)7

immunized against measles
Sheet Series

 According to the Planning Commission, India is unlikely to achieve the

targets for child mortality and infant mortality by 2015.

 Malnutrition contributes to over 50% of child deaths.8

 India has the highest number of births (20%) and neonatal (first 28 days of
birth) deaths (30%) in the world.9 Neonatal mortality (39 per 100,000 live
births in 2005-2006)10 constitutes nearly about two thirds11 of infant
mortality and over half of all deaths under-5 years of age.

 Over three-fourths of neonatal deaths occur among infants who are born
with low birth weight (weighing less than 2.5 kg at birth). In India, one-
third of all neonates (children 28 days or younger) are underweight.

 In 2005-06, 59% of children aged 1-year received measles vaccination in

India.12

 Of every four children that die before reaching the age of five years, one dies
in the first three days since birth.
 May 2008

The Millennium Development Goals (MDGs) were formulated in 2000 at the UN Millennium Summit as
a response to the world’s main development challenges. There are eight goals to be achieved by 2015.
MDG4 aims to reduce child mortality. The following table lists some of the other goals and targets at
global, regional and national levels.
Goals/Targets Indicators/Approach

Target 4A: Reduce by two-thirds,  Under five mortality rate

between 1990 and 2015, the under-five  Infant mortality rate
mortality rate.  Proportion of 1 year old children immunized against measles

MDG #4

 Universal immunization of children

Goal: Child health13
SAARC  Universal practice of breast feeding

 11th Plan 2007-2012

 Reduce malnutrition among children of age group 0-3 years
11th Plan 2007-2012: Reduction of to half its present level
Infant Mortality Rate (IMR) to 28 per
 Reduce infant mortality rate to 28 and maternal mortality
1000 live births.
ratio to one per thousand live births.
 Reduce anaemia among women and girls by 50% by the
National Plan end of the plan.

Common
 Expand nutrition programmes on a significant scale,
Minimum Protect the rights of children14
especially for the girl child
Programme

The Indian government follows the definitions used by the UN for measuring child mortality rate and infant
mortality rate.
Term UN Definition Government Definition
Under-5 mortality rate Probability of dying between birth and exactly five years of Same as UN definition
age expressed per 1,000 live births.
Probability of dying between birth and exactly one year of
Infant mortality rate Same as UN definition
age expressed per 1,000 live births.

MDG Target and Status

Indicator 2015 Projected By Govt. definition (Year)
Status16 By UN. Definition (Year)17
Target15 value 2015
Under-5 mortality 41 54.8 Off track 74 (2006)18 72 (2007)
rate
Infant mortality 27 48.1 Off track 55 (2007)19 54 (2007)
rate
Proportion of 1 n/a n/a n/a 59 (2005-06)20 67 (2007)
year old children
immunized against
measles
 May 2008

Some Ingredients for Reduction of Infant and under-5 Mortality

Target: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate.
According to the 2005 India’s progress report on the UN MDGs, a number of factors will help reduce the
prevalence of infant and child mortality:

• Adequate maternal and newborn care: The first few days and weeks of life are the most risky.
20% of under-5 child deaths occur on the first day, 25% within the first 3 days, and 37% within the first
week. Neonatal mortality (40 per 100,000 live births in 2002) constitutes 60% of infant mortality and
over 50% of under-5 child mortality. Success in this area involves convergence of multiple efforts in
many sectors other than health and family welfare.

• Prevent neonatal diseases: The principal causes of neonatal deaths and neonatal disorders (bacterial
infections (52%), asphyxia (20%), prematurity (15%) and neonatal tetanus), pneumonia, diarrhoea,
and measles. Birth injuries are an additional cause.

• Access to quality healthcare and institutional deliveries (birth in hospitals or health centres).
There is a correlation across states between the proportion of non-institutional deliveries and IMR and
NMR rates. Kerala has the lowest IMR (14 per 1000 live births) with nearly universal institutional
deliveries, whereas Uttar Pradesh has less than 25% institutional deliveries and IMR of 73. Nurses also
play a crucial role in neonatal care, and improving nursing skills is a priority and a challenge.

• Decrease malnutrition. Malnutrition contributes to over 50% of child deaths. Given the high
prevalence of malnutrition among children, the government is promoting exclusive breastfeeding up to
the age of 6 months and breastfeeding and complementary feeding until 2 years of age.

• Birth weight. Over three-fourths of neonatal deaths occur among infants who are born low birth
weight (weighing less than 2500 g. at birth). In India, one-third of all neonates (28 days or younger)
are underweight.

• Reducing the neonatal mortality rate. According to the National Planning Commission, the country
cannot achieve its 10th Plan target of reducing the IMR to 45 per 1,000 live births by 2007 and 28 by
2012 unless it simultaneously achieves the enabling goal of bringing down the NMR to below 19 per
1,000 live births by 2010. They note that this fact does not seem to be considered in programme
design.

Infant Mortality Rate is higher in rural areas than urban, and higher for girls than boys

Infant MortalityRate (2005)

IMR has been steadily declining in India from 146 in 1951 to 58 in 2005. However, the
rate of decline in IMR slowed after 1993. Before 1993, the rate decreased at about 3 points
Urban per year, but after 1993 the rate decreased at 1.5 points per year. Since 1995, the rate of
decline has improved to 2.25 points per year.
IMR varies among gender as well as among urban and rural populations. The IMR for the
Rural girl child is worse than the IMR for the boy child in both rural and urban areas. In rural
areas, the girls’ IMR is 66 per 1,000 live births compared to the IMR for boys of 62. In
urban areas, girls’ IMR is 43, whereas the IMR for boys is 37.
India
Source: http://www.undp.org.in/index.php?
option=com_content&view=article&id=73&Itemid=157
0 20 40 60 80 NFHS – 3, 2005 -2006
Total Male Female

Source: Sample Registration System, October 2005; PRS.

 May 2008

Infant Mortality Rates

Malnutrition contributes to over half of all child deaths in

India. (http://www.mospi.nic.in).
In 2009, India’s Infant Mortality Rate (30) was higher than
other countries in the region including Sri Lanka (19),
Vietnam (23) and China (20).
(https://www.cia.gov/library/publications/the-world-
factbook/rankorder/2091rank.html).
Of every four children that die before reaching five years
of age, one dies within the first 3 days of birth.
 May 2008

Measles Immunization

• In 2006, 59% of children aged 1-year received measles

vaccination in India.
(http://www.unicef.org/sowc08/docs/sowc08_table_Statistica
lTables.pdf). Failure to deliver at least one dose of measles
vaccine to all infants is the primary reason for continuing
high childhood measles morbidity and mortality.

• According to the World Health Organisation the number of

reported cases of measles in India has been increasing – from
39,000 in 2000 to 48,000 in 2008 (
http://www.who.int/immunization_monitoring/en/globalsum
mary/timeseries/TSincidenceByCountry.cfm?C=IND).

•
 May 2008

Some Ingredients for Increasing Immunization against Measles

Target: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate.
Measles and other vaccine preventable diseases account for many under-5 and infant deaths. Under the Global
Plan for Reducing Measles Mortality (2006-10), WHO and UNICEF have identified India as one of 47 priority
countries that make-up 95% of global measles death. According to the WHO, the number of reported cases of
measles in India has been increasing since 2000. In 2000, 38,800 cases were reported, whereas in 2006 close
to 61,000 cases were reported. According to the Comptroller Auditor General (CAG), the Ministry of Health and
Family Welfare and multi-lateral agencies, there are a number of factors that help achieve universal
immunization:

• Effective immunization: According to WHO, failure to deliver at least one dose of measles vaccine to
all infants is the primary reason for continuing prevalence of childhood measles and mortality.
According to the Ministry of Health and Family Welfare, immunization sessions are not being held
regularly in the community. The Ministry also cited “reporting of actual number of children vaccinated”
as an implementation issue.

• Improved delivery of services: MHFW also attributes staff vacancies, particularly of the health
workers in the sub-center, lack of training and orientation of staff, inadequate mobility of health workers
and problem of delivery of vaccines to failures in immunization. The UN also cites ensuring cold chain
and vaccine storage services as important requirements for effective implementation of vaccination
programmes.

• Decrease malnutrition: According to WHO, severe measles is particularly likely in poorly nourished
young children. Those particularly prone to a severe case are children who do not receive sufficient
vitamin A, or whose immune systems have been weakened by HIV/AIDS or other diseases.

• Avoid complications from measles: Children usually do not die directly from measles, but rather
from its complications, more common among children below the age of five years. Complications
include blindness, encephalitis, severe diarrhea, ear infections and severe respiratory infections.

• Government targets for immunization must be relevant to demographics: According to the

Comptroller Auditor General, targets fixed for immunization of children had no relationship to the
demographic profile, and were not based on any baseline survey.

A lower proportion of children from disadvantaged groups are vaccinated against measles

Measles Vaccination (%) among 1-yearoldChildren (2005-06)

In 2005-06, 59% of children aged one-year
received measles vaccination. Measles
Scheduled Caste
vaccination varied among social groups. There
was an 11 percentage point difference in
Scheduled Tribe vaccination between Scheduled Tribe children
(46%) and Scheduled Caste children (57%).
OBC
This number also varied by income. Among the
lowest fifth of the population, 39% of children
Other
received measles vaccination, whereas 85% of
the highest fifth of the population (wealth-wise)
All-India
were vaccinated.

0 10 20 30 40 50 60 70

Source: NFHS-3; PRS.

 May 2008

Major National Initiatives

There are a number of national initiatives that aim to reduce infant and under-5 mortality. The umbrella
scheme under which most of the other schemes fall is the Reproductive and Child Health Programme. The
National Health Policy has prioritized the implementation of the National Immunization Programme. The
cornerstone of the child health care system is the immunisation of children against six preventable diseases:
tuberculosis, diphtheria, pertussis, tetanus, polio and measles. The Expanded Programme on
Immunisation (EPI) was started by the Government of India in 1978 with the objective of reducing the
prevalence, mortality and disabilities from these six diseases by providing free vaccination to all eligible
children. Vaccination against measles began in 1985-86. A number of initiatives aim to reduce child and
infant mortality.
Budget Allocation and Expenditure Trends and Achievements
RCH Phase II approach: integrated management of
Neonatal and Childhood Illnesses (IMNCI), home
Central government budget 2009 – 2010: based newborn care, promotion of breastfeeding and
Reproductive complementary feeding, control of deaths due to Acute
Rs. 99.50 crore21
and Child Health Respiratory Infections (ARI), control of deaths due to
Programme diarrhoeal diseases, supplementation with
micronutrients Vitamin A and iron, universal
immunisation programme.

Integrated As of 2006-07, 75 districts across the country have

Management of This scheme falls under the RCH head. initiated implementation of IMNCI.
Neonatal and
Programme is to be introduced throughout the country
Childhood
in a phased manner.
Illnesses

Universal Introduced in country in 1985, became part

Immunization of RCH in 1997.
Programme

There are a number of other schemes, including the Diarrhoeal Disease Control Programme, the Acute
Respiratory Infection (ARI) control programme (both merged under the Child Survival and Safe
Motherhood Programme), and the Border District Cluster Strategy. The IMNCI programme was initiated
to achieve the National Population Policy’s goal of attaining an IMR of 30 per 1,000 by 2010. Under
IMNCI, baseline workers are trained in the management of measles, malaria, pneumonia, diarrhoea and
malnutrition in a holistic manner with appropriate health facilities. Also, the community is to be involved
in the recognition of the sick child so that there is no delay in seeking treatment.

The Border District Cluster Strategy provides focused interventions for reducing infant and maternal
mortality rates by 50% over the next 2-3 years in 49 districts in 16 States of the country. The Diarrhoeal
Disease Control Programme was started in 1978 to prevent death due to dehydration caused by diarrhoeal
diseases among children under 5 years or age. The Union Budget also provides for routine immunisation
against six vaccine preventable diseases: In 2009-10, Rs 388 crores was allocated, compared to Rs 233
crores in the (revised) 2008 – 2009 budget.22
 May 2008

What has worked: Integrated Management of Neonatal and Childhood

Illnesses (IMNCI)
A group of women – all frontline health and nutrition workers -- are listening attentively to a medical
officer from a rural primary health centre as he explains how mothers in one of the poorest rural
communities in India can be taught to save their newborns, including low birth weight, sick ones, when
the nearest doctor is far away. The accent is on developing skills so the trainees learn by doing: 50% of
the 8-day training session is devoted to actual case management of young infants (0 – 2 months) in
hospital and community settings.

UNICEF is a key player in the national effort to operationalise an innovative, newborn-centric child survival
strategy called Integrated Management of Neonatal and Childhood Illness (IMNCI) – used to strengthen
the skills sets of community workers. Millions of newborns in India die before their first birthday as they
do not get the basics. This is the glaring gap being addressed by IMNCI. The key components of IMNCI
include: (a) A home visitation programme to promote best practices for the young infant, (b) a special
provision for follow-up of the low-birth weight baby at the village level, (c) reinforcement through
meetings of women’s groups and community-level activities and a linkage between the village and home,
and (d) facility-based assessment at PHC, sub-centres, and hospitals through referrals.

At the heart of IMNCI lies the post-natal home visit by a trained community worker. The idea is not new
but innovation lay in giving it a structure. The most powerful evidence of the IMNCI’s potential is the
energized nutrition worker whose confidence has surged ever since she realized she now has the skill to
save babies. “Earlier, I would give general advice, like telling a mother to breastfeed her baby. Now, I
show her the correct way of doing it,” says Meera Watte, 40, an anganwadi (nutrition) worker.

“I was able to save [the baby] because I could identify the imminent danger and successfully motivate
[his parents] to take him to the hospital” says a trained anganwadi worker in Orissa. The district level
data suggest that Mayurbhanj district now has significantly lower Infant (59.2) and Under-Five Mortality
Rates compared to the state averages. Of the total births reported in the 14 IMNCI blocks, 95.5% were
examined within two months of birth.

First piloted in selected blocks in 6 districts in as many states (Maharashtra, Gujarat, Rajasthan, Madhya
Pradesh, Orissa and Tamil Nadu) in the country between 2002 to 2004, IMNCI is being currently
implemented in nearly 25 districts across the country.

Source: Adapted from a note by UNICEF.

 May 2008

Notes
1
Source: http://www.unicef.org/infobycountry/stats_popup1.html

2
Source: http://www.unicef.org/infobycountry/stats_popup1.html

3
Source: http://www.who.int/healthinfo/statistics/indneonatalmortality/en/

4
Millennium Development Goals India Country Report 2005, Central Statistical
Organization, Ministry of Statistics and Programme Implementation, Government of
India, http://mospi.nic.in

5
Source: http://millenniumindicators.un.org/unsd/mdg/Data.aspx

6
Source: SRS 2007, Registrar General, India

7
Source: http://millenniumindicators.un.org/unsd/mdg/Data.aspx

8
Millennium Development Goals India Country Report 2007, Central Statistical
Organization, Ministry of Statistics and Programme Implementation, Government of
India, http://mospi.nic.in/rept%20_%20pubn/ftest.asp?
rept_id=ssd04_2007&type=NSSO

9
The State of the World’s Children 2008, UNICEF, http://www.unicef.org/sowc08/

10
National Family Health Survey (NFHS – 3) 2005 – 2006, Volume 1, Chapter 7 ‘Infant
and Child Mortality,’ International Institute for Population Sciences, Deonar, Mumbai,
http://www.measuredhs.com/pubs/pdf/FRIND3/07Chapter07.pdf

11
The State of Asia-Pacific’s Children 2008 ‘Child Survival,’ UNICEF,
http://www.unicef.org/publications/files/SOAPC_2008_080408.pdf

National Family Health Survey (NFHS - 3) 2005-2006, International Institute for

12

Population Sciences, Deonar, Mumbai, http://www.nfhsindia.org/pdf/India.pdf

13
Source: http://www.saarc-sec.org/data/pubs/rpp2005/pdfs/Tables/Table-2.26.pdf

14
Source: http://pmindia.gov.in/cmp.pdf

15
Source: Millennium Development Goals India Country Report 2005, Central Statistical
Organization, Ministry of Statistics and Programme Implementation, Government of
India, http://mospi.nic.in

16
Source: http://www.mdgmonitor.org/country_progress.cfm?c=IND&cd=356

17
Source: http://millenniumindicators.un.org/unsd/mdg/Data.aspx

18
Source: http://www.statcompiler.com/country.cfm?ctry_id=57&Ctry_name=India

19
Source: SRS 2007, Registrar General, India
 National Family Health Survey (NFHS - 3) 2005-2006, International Institute for
20

Population Sciences, Deonar, Mumbai, http://www.nfhsindia.org/pdf/India.pdf

21
Source: http://indiabudget.nic.in/ub2009-10/eb/stat22.pdf

22
Source: http://indiabudget.nic.in/ub2009-10/eb/stat22.pdf