Temporal Analysis of Under 5 Mortality Rate at Sub-National Level in India

Introduction

Mortality is an extremely important indicator for constructing health policy and evaluation of health systems of any state. As per the demographic transition theory, the countries globally had a higher death rate in the past as compared to the current population trend. Over the decades, with the advancement of science and technology and new innovations in health sector, the death rates have considerably declined [1]. This can be accompanied by the fact that the population of the world has also increased over centuries [2].

Death at an early age specifically between the ages of 0 to 5 years is one of the most significant medical issues worldwide [3]. Mortality or death rates of a state is influenced by multiple factors such as health systems, including state and private health expenditure, prevalence and incidence of various chronic diseases, and other socio-demographic characteristics [4].

To continuously reduce the death rates and provide a better environment for humans to live in, it is crucial to know the number of deaths happening around us to construct specific strategies and take appropriate actions to reduce the numbers [5]. For the same, mortality rate is a vital measure that reflects the population health status, and it permits us to compare the various population health components such as Health Systems and interventions [6,7]. One of the measures of mortality is Under Five Mortality Rate (U5MR). U5MR is the probability of dying before the age of five years. It is also included as one of the vital targets (Indicator number 3.2.1) of the Sustainable Development Goals (SDG) of the United Nations. In the Indian scenario, very few studies have been conducted specifically mapping the trend of U5MR and examining its growth rates at the sub-national level. Furthermore, as per the Indian constitution health is a state subject where in the State governments plan out and roll out strategies. Therefore, U5MR is a vital statistic which can help state governments to make strategic and specific plans to check the number of deaths in the age group of 0 to 5 years so as India as a country can move towards the trajectory of achieving the Sustainable Development Goals (SDG) related to U5MR.

For this study, specific objectives have been set:

1. Examining growth rates of U5MR at sub national level
2. Identifying the top 5 and bottom 5 performers in rural and urban India with respect to U5MR.

Methodology

1. Study design – The current study is based on secondary data and involves a time series analysis of Indian states.
2. Study population – The study population includes the twenty Indian states for which the comparable secondary data was available in public domain. The twenty states included in the study are divided into four regions; Northern, Southern, Eastern and Western & Central regions as per the guidelines of RBI [8]. The western and central regions have been compiled into one region so that the size of different regions remain comparable in order to facilitate the subsequent comparative analysis. The states included in the study are those for which the data was available in the public domain.
3. Study data and sources – U5MR data was obtained from Sample Registration System (SRS) for the years starting from 2011 to 2017. The annual reports of Sample Registration System are published by the Office of the Registrar General & Census Commissioner, Ministry of Home Affairs, Government of India.
4. Statistical analysis – The temporal compound annual growth rate (CAGR) were estimated using a semi log linear regression model [9,10]. Negative values of growth rates indicate better performance of the state since mortality is a negative indicator, whereas; a positive value indicates an increase in the U5MR rate. Graphical charts and other descriptive statistical measures, such as mean, standard deviation and coefficient of variation were also computed. Microsoft Excel, 2019, and SPSS version 25 were used for all the statistical analysis.

Findings

Region wise Trend of U5MR for Rural and Urban sector

In the Graph 1, it can be seen that for the rural population, the U5MR values of the Eastern region was more than that of national values, however in 2017 , the U5MR value became less than that of national level. Only the Western & Central region consistently reported higher U5MR values than that of India from 2011 to 2017.

In Graph 2, it can be witnessed that for the urban population, the Northern region reported U5MR values very close to that of national level, whereas; the Southern region registered values less than that of national level. On the other hand, the Eastern and Western & Central regions have a higher U5MR in urban areas as compared to national level.

Discussion

Child mortality rate is a significant indicator for evaluating the health status and development level of any society [11]. In 1998, India recorded about 2.5 million under-5-year-old deaths, the highest number in any country. India included reducing the national mortality rate for children under five years of age to less than 100 per 1000 live births in the health goals for the year 2000 [12]. India is also one of the signatories to the United Nations Convention on the Rights of the Child (UNCRC), which advocates the healthy lives of children by addressing survival, nutrition, and other health care problems [13]. It is the foremost step to estimate the number of deaths and the trend of mortality rate to devise a robust strategy for reducing mortality. One such vital measure of mortality is U5MR, and the present study's objective was to study the growth rate of U5MR. A semi-log linear model was used to carry out the analysis.

The study estimated the growth rate for U5MR of twenty Indian states from 2011 to 2017 and calculated CAGR to identify the top and bottom five performing states. The mean mortality values of Eastern and Western & Central were higher than the other two regions for both rural and urban population. The factors responsible for higher mean mortality values in the eastern region could be low accessibility to health care services due to geographical constraints, economic backwardness, absence of quality education, and shortage of medical professionals [14]. The Western & Central region consists of larger and heavily populated states. The heavily populated states still require additional efforts in terms of efficient resource allocation and management to accelerate the mortality decline [15].

Based on the CAGR, the top five performing states in the rural sector show four states, i.e., Delhi, Jammu & Kashmir, Himachal Pradesh, and Punjab, from the northern region. It merely suggests a trend of the significant reduction in the mortality values of these states and does not mean that the mortality values of the states are low. The decline in mortality rates can be attributed to the rapid growth of healthcare delivery with the help of Auxiliary Nurse Midwife (ANM), Anganwadi workers (AWW), Accredited Social Health Activists (ASHAs) in the northern region [16].

The top five performing states in the urban sector are Himachal Pradesh, Assam, Gujarat, Jammu & Kashmir, and Uttar Pradesh. This depicts that the mortality values of these states have reduced over time which could be a result of biomedical and economic advancements [16]. Though it is seen that the southern states are not in the top five performing states, but most of these states have the lowest U5MR values. The study also displays the U5MR trend for urban and rural areas of the four regions through graphs. The trend line in the graph clearly shows that the U5MR values of the southern region are relatively lower than the national level. Kerala reported the lowest mean mortality value of 13 but is still at the bottom of the performance table. This can be explained by the fact that Kerala has already reached the saturation point of low mortality rates, and only minimal further reduction is possible [17].

Other states in the bottom five of the performance table include Maharashtra, Chhattisgarh in the rural sector and West Bengal, Jharkhand, Bihar, and Odisha in the urban sector. These states are larger and densely populated, resulting in resource constraints. This leads to low accessibility to health services, poor infrastructure, inadequate health care delivery services, and a shortage of medical staff [12, 15]. Another study based on NFHS data [18] states that Maharashtra and West Bengal are poor-performing states regarding child mortality.

Overall, it can be seen that the twenty states included in the study have witnessed a reduction in U5MR rates over the years, which is synonymous with results shown by various studies [12,18,19]. The states in the Eastern region have the highest U5MR rates, which is also reflected in a study conducted by Claeson et al. [12]. Higher U5MR rates in the eastern area could be due to factors like access to health care services in the rural parts due to terrain [20]. The southern region shows the best results in urban and rural sectors as the states' actual values are much lower than other Indian states [12]. It could be because literacy rates in the southern region are high compared to other states, and a strong positive correlation has been seen between U5MR rates and the education level of mothers [21].

There are several policy suggestions offered by the present study. Despite the significant decline in the under-five mortality rates in the last few years, more efforts are still required. The study identifies the top five and bottom five performing states in rural and urban areas. The policymakers should focus on the poor-performing states, which are persistent outliers in the mortality values. The policymakers must also target larger states with the highest population having the maximum potential to reduce under-five mortality values significantly [15].

The limitation of the present study is that all the Indian states could not be covered as data for U5MR was not available for each state. However, it is based on the data obtained from authentic government sources. The methodology adopted in the present study can be utilized for a targeted approach by the respective state governments to monitor the U5MR in the selected Indian states to achieve the long-term targets of Sustainable Development Goals. Furthermore, using this methodology, other mortality indicators could also be studied.

Ethical Approvals

The study involves secondary data analysis based on data freely available in public domain. The study does not involve the collection of primary data and therefore did not require interactions in any form with the participants/human subjects. The study draws upon some portion of the findings of the dissertation work done by Dr. Ankit Bahl during Masters in Public Health, the approvals of which had already been obtained by the institutional ethics committee vide letter INT/IEC/2020/SPH-1079 in the year 2020.

Conflict of Interest

No conflict of interest exists among the authors

Acknowledgement

None

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