Studies show that malnutrition is still a leading cause of death for children under five. Photo: Reuters/Khaled Abdullah
The 2030 Agenda for Sustainable Development set 17 goals – from healthcare and education-based outcomes to social goals. The third of these calls on countries to “ensure healthy lives and promote well-being for all ages”. One of its sub-goals aims to “end preventable deaths” of newborns and children younger than five years. This is crucial for India because some 26 million children are born every year in India; according to the 2011 Census, the share of children aged 0-6 years stood at 13% of the population.
Crucial to meeting this goal is reducing the child diarrhoeal deaths. One 2015 study suggested that diarrhoea accounts for about 3 lakh infant deaths every year in India – which is 13% of the total under-5 mortality.
We have achieved some remarkable results over the past decades on this count, with death rates, infant mortality rates (IMR) and under-5 mortality rates witnessing substantial reductions. As per estimates generated by the UN Inter-agency Group for Child Mortality Estimation in 2021, the median IMR has dropped from 181.45 in 1953 to 27.01 in 2020. Similarly, under-5 child Mortality rates have gone down from 271.90 in 1953 to 32.63 per 1000 live births in 2020.
A similar trend is indicated by the National Family Health Survey (NFHS) over the years. Steep falls have been registered in the past 2 decades, where U5MR has come down from 109.3 in 1992-93 to 41.9 per 1000 in 2018-19, registering a 61% decline. Similarly, IMR has come down to 35.2 in 2018-19.
Other child health indicators have done fairly well too. Stunting measures have also shown considerable falls from 50% to 31% in around 20 years.
India still faces a steep road ahead. COVID-19 has pushed millions into poverty and worsened child health outcomes. Although most states have made considerable progress in improving their child health indicators in NFHS-5 compared to NFHS-4, the numbers still remain way off the desired goals. We should be looking at ‘preventable deaths’ closely for the solution.
Integrated Disease Surveillance Programme under the Ministry of Health and Family Welfare reports weekly outbreaks of diseases at the district level. The highest cumulative outbreaks from 2015 to 2021 are of ADD, amounting to more than 2400 outbreaks across India, i.e. an average of three outbreaks per district in six years.
The most recent results from NFHS-5 suggest that diarrhoea incidence has gone down to 7.3% compared to 9.2% in NFHS-4. It is significant to note that the NFHS survey asks for diarrhoea incidence only in the past two weeks from when the survey is done thus affecting numbers.
Let us dive into the socio-demographic determinants of diarrhoea at the community level, household level and at an individual level.
The figure below elucidates the association between occurrence of diarrhoea and the demographic (social class, religion, wealth quintile), environmental (including quality of water supply) and household characteristics (including social groups and religion, economic well-being, sanitation practices) and health awareness of the caretakers (typically mothers).
Starting with resource-related factors, water contamination is closely and widely associated with diarrhoea but most studies indicate some counterintuitive results revealing higher diarrhea prevalence among households who are using improved drinking water (9.22%) compared to the households using unimproved sources of drinking water (8.04%). While we cannot establish causality without looking into other factors such as methods used for the treatment of drinking water, these figures bring into question the quality of water provided under the label of ‘improved’ drinking water.
Research also revealed higher diarrhoea occurrence for households using unimproved toilet facilities (9.79%) such as pit latrines without a slab or open pit, dry sanitation and pour-flush not to sewer/septic tank/pit latrine. India has a long way to go with merely 64.9% of the rural population using improved sanitation facilities and 70.2% across India. Presence of faeces in the household compound and source of drinking water constitute significant risk factors for diarrhoea and several other waterborne diseases. We have been gratifying in the complacency of the 2019 declaration of ‘Open Defecation Free (ODF) India’ for far too long.
According to some studies, caste and religion seem to be significantly associated with childhood diarrhoea. Children belonging to the Scheduled Tribe (ST) households and other castes are less likely to develop diarrhoea as compared to those in Scheduled Caste (SC) households. Occurrence is revealed to be higher among Muslim children compared to others. This can possibly indicate lower access to improved sources of drinking water and sanitation facilities by SC and Muslim households.
Behavioural factors such as handwashing, eating habits and breastfeeding practices also impact the occurrence of diarrhoea among children. When children consume food without washing their hands after playing in a bacterial environment or after using the toilet, there is a likely possibility of them ingesting germs and bacteria along with food.
Handwashing activities before breastfeeding children and also before meal preparation and cooking are critical factors. As per NFHS 4 (2015-16), a place for washing hands was observed in 97% of the households. However, soap and water were observed in only 60% of the handwashing locations while 16% had only water. This is particularly concerning because it indicates the perception of ‘handwashing’ as a practice of either just pouring water over hands or a futile exercise. In the NFHS 5, these numbers have improved, possibly due to the behavioral changes induced by the COVID pandemic.
Research also indicates that the mothers who have attained a secondary and above level of education are associated with decreased odds of diarrhoea among their children An educated mother is better equipped with the knowledge to facilitate quality health care access, vaccine uptakes, better hygiene at home and most importantly, better education for the children.
First, we need policies aimed at improving the accessibility and quality of drinking water and sanitation facilities. The Jal Jeevan Mission is a step in the right direction, incorporating continuous monitoring of the water supply. This needs to continue along with a renewed effort on promoting toilet usage in households.
Second, educational workshops and programmes are needed to promote behavioural changes like handwashing, breast feeding promotion, etc. Children should be targeted through school and anganwadis, whereas mothers can be reached out through the extensive network of ASHA/ANMs.
Third, a diarrhoea-specific plan is needed which will push through better reporting and management of cases at the primary health centre level thus reducing mortality and severe disease. This plan should have emphasis on targeting vulnerable social groups whose children are more prone to the disease.
Aditya Gulia and Varshita Agarwal are alumni of IIM Indore.