“Better Than Average” Is Not Good Enough: Accelerating Child Survival in India

This is a joint post with Rachel Silverman. Last week, the Government of India held a star-studded National Summit on child survival, “co-convened”* with USAID and UNICEF.  The high-profile meeting featured politicians (the Minister of Health & Family Welfare, the US Ambassador to India), heavy-hitters in global child health (Bob Black, Zulfiqar Bhutta, Mickey Chopra, Geeta Rao Gupta) along with some Indian stars of child health (Vinod Paul, Abhay Bang, Yogesh Jain), and even a Bollywood actress/“child rights activist” Nandana Sen (daughter of Nobel Laureate and Professor Amartya Sen), to name a few. Underlying this national attention was an ambition to tout India’s progress in child survival, particularly that the country’s child mortality rate has “declined much faster than the global average.” Indeed, any publicity is good publicity for child survival (yes, even today children still die from preventable causes). But aside from bringing some fleeting political and media attention, one cannot help but be concerned how child survival in a country as large as India will ultimately accelerate. To understand the context for my concerns, some background is important. For roughly the past ten years, global health funders have paid relatively little attention to the kids (see figure below), with resources overwhelmingly tied up in the fights against HIV/AIDS, tuberculosis, and malaria (although, of course, those diseases also affect children, but are not the main causes of child death). For this reason, last summer’s call to action for child survival – led by the US, Ethiopia and India – seemed to be an encouraging sign, but its failure to put money where its mouth was (i.e. lack of substantial new funding commitments) left many to fear that it would be just a summer fling (see here and here). Perhaps for this reason I hope that last week’s summit will translate to practical changes. Such an event inevitably grabs the attention of donors and policymakers to pay attention to child health, at least temporarily. But attention alone, while important, is not a sufficient strategy to reduce child mortality. And, holding such a summit could actually be worse than not at all, if all the praise of achievement and being “better than average” mortality reduction leads to complacency. In the case of India, being “better than average” also happens to be “worse than Bangladesh” — a neighboring country with far lower incomes than India but with far higher outcomes in child health (a fact that can seem far fetched to many Indians). But if Bangladesh had settled on being “better than average,” it would never have achieved the results it has seen today. One could argue that any “national summit” may miss the opportunity create subnational policy changes. Indeed, health is a “state subject” in India – that is, an area that is the responsibility and purview of Indian states, though in recent years the central government has given an extra (soft) nudge through the National Rural Health Mission. And for a country as large as India, with its states as large as any given country, big national meetings often can’t get into the details on state-specific challenges. Admittedly, I didn't attend the summit, so I'd love to hear more about specific and concrete policy changes at state and district level that were discussed. So how might India develop a successful strategy to accelerate gains in child health? As any national plan needs to be made useful to states and districts, for starters it will be important to continue measuring performance at the state level (e.g. Commonwealth Fund’s US scorecard on child health), and more regularly than every decade (as is done by Indian’s national human development report). Even better, if they haven't already, they could commit to district-level measurement and scorecards, as seen by a really awesome project on designing district scorecards led in part by the Office of the Registrar General and Census Office and my colleague Onil Bhattacharyya from the University of Toronto. This would strengthen, if not expand, the existing measurement work in conducting annual health surveys already being done by India’s amazing statistical team at the Office of the Registrar General and Census (see page 117 here) as well as the District-Level Health Survey. More generally, while measurement is important (as Bill Gates recently highlighted), mere measurement does not automatically provide accountability. Here I think that the central government and the Ministry of Health & Family Welfare can play a crucial role in pushing states and districts to improve. In particular, the government can deploy financial incentives such as results-based financing and cash-on-delivery approaches, between the center and the state, or between the state and the district. But even the use of such incentives will not be enough. No doubt, there is no shortage of new ideas to try, pilot, and test, drawing on inspiration and experience both within and outside of India. Business as usual will not be enough to accelerate the rate of progress in child survival seen in India today, and we should not be content to let it remain merely “better than average.” India needs new approaches and innovations to push forward and improve. To do that, we need to experiment, evaluate, (even fail!), and ultimately learn from all of those experiences. This kind of learning is something that not only India must do, but also the US and global health funding agencies. Now that the Indian summit has grabbed attention, it’s time to push forward a strategy backed by the political commitment and resources that India’s children deserve. The follow-up to this summit will be critical, and I look forward to observing these health policy changes in India (hat tip here). The authors thank Amanda Glassman and Jenny Ottenhoff for excellent comments. *Footnote: As an aside, admittedly the US could probably also benefit from its own National Summit on Child Health for children in the US, since, unfortunately, child health in the US is not exactly a model for other industrialized countries – see excellent work done by Commonwealth Fund here and here. But I guess it would be a bit awkward, at least to the Americans, if the American National Summit was “co-convened” with India and UNICEF.