The Future of DFID’s Programme in India

Written evidence co-submitted by the Centre for International Health and Development (CIHD) at University College London’s Institute of Child Health, Ekjut (India), Society for Nutrition, Education and Health Action (India) and Women and Children First (UK).

Summary

This submission is co-submitted by the Centre for International Health and Development (CIHD) at University College London’s Institute of Child Health, Ekjut (India), Society for Nutrition, Education and Health Action (India) and Women and Children First (UK). This submission focuses on the urgent need to maintain commitment and action to achieving Millennium Development Goals 4 and 5 [1] in India and the key role that DFIDI needs to continue to play to support the Government of India to meet these goals and improve the health and wellbeing of India’s women and children. The following key issues for the inquiry are addressed: the positive impact of DFIDI’s current programme in India, DFIDI’s role as a catalyst for other donors and the positive influence that DFIDI’s programme has on India’s national priorities and implementation. Specific recommendations for DFIDI are included, covering issues around the quality of health care; maternal, newborn and child health ODA and efficiency; health system strengthening; health sector governance, community mobilisation and accountability; equity; links with the other sectors e.g. education, gender, nutrition; and the need for monitoring and evaluation of DFIDI programmes. A full evaluation of DFIDI’s country programme is overdue and would be timely.

1. Recommendations for DFIDI

Building on what DFIDI does well and to address the fundamental gaps in improving the health of women and children in India, DFIDI should:

1. Maintain its focus on maternal, newborn and child health and MDGs 4 and 5.

2. Continue to ensure that its programme is in line with national priorities and that it supports national schemes which are primarily financed by GOI.

3. Continue to support state governments.

4. Increase maternal, newborn and child health ODA and efficiency and provide ODA specifically for this, targeting the poorest and most marginalised.

5. Provide overall health sector programme support.

6. Increase support to GOI to deliver universal access to a minimum package of good quality essential services for women and children.

7. Support GOI to increase the number of skilled birth attendants and to ensure that Accredited Social Health Activists are fully trained and supported.

8. Support the introduction of effective regulation systems to improve the quality of private sector health services and to ensure greater accountability.

9. Encourage greater commitment to maternal, newborn and child health, cohesion around and cooperation between different donors and Ministries.

10. Persuade other donors, especially the EC, UN agencies and the World Bank, to provide greater quality financial support to maternal, newborn and child health in India.

11. Cultivate political will for maternal, newborn and child health at the national level and maintain pressure at the international level.

12. Support health sector governance, community mobilisation and accountability especially at the local level.

13. Use its position of influence to support the GOI at the state level to improve targeting of the poorest women.

14. Promote linking the different ministries, strategies and laws addressing health, gender, education, marriage and nutrition.

15. Undertake rigorous impact evaluation of components of GOI schemes that it is supporting.

16. Invest in ensuring that evidence generated in India translates into policy and practice.

2. The CIHD, Ekjut, SNEHA and WCF Partnership

Centre for International Health and Development (CIHD) at UCL’s Institute of Child Health, Ekjut, SNEHA (Society for Nutrition, Education and Health Action, India) and Women and Children First are currently working together to improve MNCH in urban and rural areas of India - in Mumbai, Maharastra, and the eastern states of Jharkhand and Orissa.

CIHD works to promote the health, nutrition and welfare of children and their families in less developed countries. Research undertaken aims to develop the scientific basis for improvement in clinical practice and public health using robust epidemiological, laboratory and social science methodologies. CIHD is committed to capacity-building with partner organisations in developing countries to disseminate work as widely as possible.

Set up in 2002, Ekjut is a voluntary organisation working towards building healthier communities. Ekjut works with women’s groups to devise effective health promotion strategies during pregnancy, delivery and the postpartum period. In 2008, Ekjut piloted the community based monitoring of health services, an initiative mandated by the NRHM. This involved Ekjut facilitating a process to bring together communities, VHCs and government functionaries to develop collective ownership of the public health services and to jointly solve community health problems. Ekjut’s current work covers a population of 600,000 in eight districts of Jharkhand and Orissa. Ekjut advocates for improved health services at the district, state and national levels and is represented on the national ASHA mentoring group.

SNEHA was founded in 1999 by a group of doctors and social workers. The organisation dedicates its energies, expertise and resources to ensure quality nutrition, education and health care of women and children. Its mission is to impact quality of care and influence urban health policies through innovative solutions to problems in nutrition, education and health in urban communities. It builds sustainable and replicable models of intervention and partnerships that empower women to change their lives and those around them. SNEHA creates change agents, working to empower women and slum communities to be catalysts of change. SNEHA works with existing systems to create sustainable change: with the Municipal Corporation of Greater Mumbai (MCGM) to improve the quality of perinatal care; with the Integrated Child Development Scheme (ICDS) to improve nutrition in children from the slums; with private health practitioners to standardise quality of maternal and newborn care. SNEHA is the only NGO on the Mumbai Reproductive and Child Health committee.

Women and Children First is a UK based international NGO at the forefront of working to achieve MDGs 4 and 5. Through promoting safe motherhood and newborn care, WCF develops effective and sustainable solutions to MNCH problems and strengthens accessible and appropriate health services. As well as helping to improve MNCH services WCF works with local communities, raising women’s knowledge of how best to take care of themselves during pregnancy and improving skills in newborn care. This is done through both strengthening health services and mobilising communities through establishing women’s groups where the women are supported to identify the problems they face, then develop and implement strategies to solve them. Building on experience in the field, WCF is also engaged in an evidence-informed advocacy programme, striving to bring about changes related to the continuum of care in MNCH that make a real difference to people’s health and welfare.

3. Maintain Focus on Maternal, Newborn and Child Health and MDGs 4 and 5

Ill health and poverty are interlinked and mutually reinforcing – poor people are more likely to become ill, suffer from higher incidence of disease, have limited access to health care and be forced to sell assets or to borrow at high rates to deal with health crises (UNDP, 1998). The burden of poverty and ill health falls disproportionately on women and girls. It has been estimated that the poor health of women and children leads to US$15 billion in lost potential productivity globally (WHO, 2009). As The World Health Organisation (WHO) has recently demonstrated investing in MNCH makes absolute economic sense and can also generate huge economic returns, benefitting women and children themselves, their families, communities and society as a whole (WHO, 2009). Healthy mothers can work more productively (informally or formally) and households with healthier and better nourished mothers and children spend less on healthcare. Reducing unexpectedly large and catastrophic out-of-pocket expenses for women and children is particularly important for the poor, ensuring that they can hold on to their savings, enabling them to improve their own lives and contribute more positively to the wider economy.

The Millennium Development Goals have galvanized unprecedented efforts to meet the needs of the worlds poorest but there is still an urgent need to stimulate further commitment and action to achieving MDGs 4 and 5 in particular. A remarkable increase in global commitment to improving women and children’s health has been demonstrated in recent years, with the UK government and DFID playing a lead role globally. After the UK general elections in May 2010, the new coalition government pledged to "push hard in 2010 to make greater progress in tackling maternal and infant mortality" [2] . This promise was followed in June 2010 with the UK commitment of £490m for 2010 and 2011 to accelerate progress towards MDGs 4 and 5 at the Muskoka Summit [3] . More recently, Deputy Prime Minister Nick Clegg demonstrated much-needed leadership at the MDG Summit in New York at the launch of the UN Global Strategy for Women’s and Children’s Health [4] . As part of a total $40 billion (£25.5 billion) pledge for women’s and children’s health by governments, NGOs and businesses the UK committed to doubling its annual support for maternal, newborn and child health by 2012, and sustaining that level to 2015. The UK committed to providing an annual average of £740 million (US$1.1 billion) for maternal, newborn and child health from 2010 to 2015, meaning that over this period the UK will spend an additional £2.1bn on maternal, newborn and child health, an additional £1.6bn to the Muskoka commitment (above).

In line with these global commitments DFID India (DFIDI) has recognised that maternal and child mortality rates in India are appalling and has been championing MNCH as a priority area in India (DFID, 2008). This support for MNCH is most welcome and is one of DFIDI’s major strengths. Despite recent average economic growth of almost 8 per cent a year, India has struggled to translate gains in income into improved life chances for children with more children under five dying in India every year than in any other country. A record that is worse than that of neighbouring countries such as Bangladesh and Sri Lanka (Save the Children, 2010). Globally, India accounts for 21 per cent of all child deaths (under 5 years), and 25 per cent of all neonatal deaths (Goldie et al., 2010; Tripathy et al., 2010) and India is home to one third of the worlds undernourished children (Save the Children, 2010). India’s current rate of reduction in under-five mortality is just 40 per cent of what is neede d to achieve MDG 4 by 2015 (ibid. ).

India’s children continue to die from diarrhoea and pneumonia but the newborn period remains the area of greatest concern. Newborn deaths account for 55 per cent of all under five deaths, from causes such as infection, preterm birth and asphyxia (Countdown 2015, 2010). All of which are inextricably linked with the health of their mothers.

Table 1: MDG 4 Status in India

Source: IGME 2009, Countdown 2015 (2010)

India accounts for around a quarter of maternal deaths worldwide and is off track to meet MDG 5 (Countdown 2015, 2010). A reported 117,000 women died of maternal causes in 2005 (Campbell and Scott, 2010). Progress being made on improving maternal health is too slow, at only around 4 per cent since 1990 [5] , with similarly slow improvements in most reproductive health indicators (ibid.). India’s women are doomed to a 1 in 70 lifetime risk of maternal death, deliveries attended by skilled health personnel have only marginally increased from 34 to 47 per cent since 1993, the adolescent birth rate (per 100,000 women) remains relatively high at 45 per cent and access to quality post natal care is severely lacking (Countdown 2015, 2010). It is highly likely that these figures mask reality in many areas of the country and a massive acceleration of progress in reducing maternal deaths is needed.

The main causes of maternal death in India are haemorrhage, hypertension, botched abortion and sepsis infections, all of which are preventable and with a functioning health system, easily treated.

Table 2: MDG 5 Status in India

Source: Countdown 2015.

The subcontinent of India is, however, a country of vast regional and socio–economic inequalities, impacting negatively on access to health information and services in the poorest areas. Nowhere is this clearer than maternal mortality, where India’s 117,000 annual maternal deaths and morbidities occur primarily among poor women (Campbell and Scott, 2010). The official figures are also likely to underestimate the scale of the problem. A far higher MMR, in pockets of underserved areas of Jharkhand and Orissa, of 722 per 100,000 live births has been reported (Barnett et al., 2008). This is far higher than the national average (MMR of 450) places two of India’s poorest states on the same level in terms of MMR as Congo, Ethiopia and Haiti (see figures in Countdown 2015, 2010). In addition to these unacceptable rates of mortality millions more women suffer serious damage to their health, including high rates of maternal depression (Jones, 2010). This situation is of particular concern for poorer sub-populations, such as rural people, lower castes, tribal groups and those in less developed states including where there is growing insurgency. India is rapidly urbanising and the explosive urbanisation of poverty is a health disaster in the making. Slum populations also rank among the poorest most underserved and most vulnerable groups in terms of health indicators (see (Shah More et al., 2010, to be published). Although urban India has a relatively strong health and nutrition infrastructure its utilisation is sub-optimal due to a range of interrelated socioeconomic and cultural determinants of health such as caring practices, the status of women, the nature of livelihoods, food security and social capital (ibid.).

It is vital that the UK government commitments on MNCH remain a priority focus area for DFIDI’s support to GOI.

4. Strengthen the Overall Health System

Healthy health systems translate into healthy mothers, newborns and children. The poor face huge barriers to accessing healthcare in India including high informal fees for healthcare; long distances to travel to health facilities with limited transport; too few, under qualified, untrained and/ or demotivated healthcare staff, and a lack of medicines. Increased supply side investment in India’s health system to ensure health information and services are accessible will be key to delivering MNCH services in India. Maternal health cannot be achieved without access to affordable high quality sexual and reproductive health services which encompass three main areas: contraceptive services, maternal health services (including safe abortion, treatment for incomplete and botched abortion and Emergency Obstetric Care (EOC)) and services related to the diagnosis and treatment of sexually transmitted infections (including HIV). Preventive interventions which will improve MNCH are relatively simple and extremely cost-effective but require a functioning health system, for example the provision of basic family planning, antenatal care, skilled birth attendance, and the prevention and management of common illnesses among newborns and children.

DFIDI should be commended for its work supporting state governments and this is evident in its support for national public programmes and support to specific focus states (Bihar, Madhya Pradesh, Orissa and Uttar Pradesh). At the national level DFIDI is a key supporter of the Reproductive and Child Health II (RCH2) programme, contributing £252 million (2006-2011). This programme aims to reduce the maternal mortality and infant mortality rates and has national reach. DFIDI also provides substantial support to the National Polio Eradication Programme and the Revised National Tuberculosis Control Program II. In the DFIDI focus states DFID is working with the state governments to improve the entire health system, including staffing, medicine and infrastructure. DFIDI is supporting health sector reform in West Bengal through Sector Budget Support (Health Systems Development Initiative £100m, 2005-2010), which strengthens the capacity of the delivery system to enhance provision, access and equitable utilisation of health services and state-level health sector support is also provided in Orissa (£50m), Madhya Pradesh (£60m) and Andhra Pradesh (£40m). DFIDI should be commended for ensuring that its programme is in line with national priorities and that it supports national schemes which are primarily financed by GOI. This health system support must continue if gains towards meetings the MDG 4 and 5 goals are to be made.

However, significant gaps in the availability, accessibility, acceptability and quality of health service provision remain. Support for human resources, infrastructure and other building blocks of the health system are all needed and if the well-documented failures of public delivery in India are not addressed, rural Indians will continue to rely on fee-for-service, unqualified providers ( blog of Rajeev Ahuja, World Bank India ). The national and state governments urgently need support to intensify efforts to maintain and improve the quality of care available to women in health facilities, including obstetric care, to reduce maternal, newborn and child deaths (Lim et al., 2010) in rural and urban areas. DFIDI is well placed to increase support to GOI to deliver universal access to a minimum package of good quality essential services for women and children. This can be done by ensuring there is an extensive training programme to increase the number of skilled birth attendants and to ensure that ASHAs (see below) are also fully trained and supported.

As the World Bank’s Health Economist Rajeev Ahuja has recently blogged, the private sector is the dominant player in the Indian health sector and most financing is out-of-pocket (at 66 per cent of total expenditure on health, Countdown 2015, 2010), and often catastrophic for families. In urban slum areas of Mumbai there is evidence suggesting that poorer families may have been reducing consumption of food and other essentials to finance maternal care (Shah More et al., 2010, to be published). The qualified private sector is also mostly absent in distant rural and tribal areas where most Indians rely on unqualified and unregulated private providers (Ahuja, 2010). Residents in these areas often have a limited choice - between "quacks" and often nothing at all (ibid.). DFIDI has a key role to play in supporting the introduction of effective regulation systems to improve the quality of private sector health services and to ensure greater accountability.

5. Increase Maternal, Newborn and Child Health ODA and Efficiency

Globally, aid for MNCH has been increasing and the UK stands out (along with the USA) as by far the largest bilateral donor to MCNH (Pitt et al, 2010). This trend is evident in India where ODA to MNCH increased from 345.2 to 372.8 million US$ from 2007 to 2008 (Pitt et al., 2010) and DFID is a significant contributor to the health sector (see above). However, this increasing trend of MNCH funding has tended to only keep pace with, and does not exceed, increases in ODA to the health sector generally (Pitt et al., 2010). Total ODA to child health per child was a mere 1.8 US$ in 2008 (barely increasing from previous years) and total ODA to maternal and newborn health per live birth remains low at 5.4 US$ [1] . In relation to the size of the Indian economy and India’s total population, MNCH aid to India remains a drop in the ocean. Public health spending averaged 0.9 per cent of GDP in India between 2001 and 2005 (Save the Children, 2010), a shockingly low figure in comparison with the UK which allocates 15 per cent of central government expenditure to health (UNICEF, 2010). The big poor states of India (several of which have population sizes similar to or bigger than countries) have a small tax base and despite increases in resources being allocated to state governments for health many states remain resource starved (ibid.). DFIDI has an important role to play in providing ODA specifically for MNCH and in supporting the GOI in its attempts to raise public expenditure on health as a percentage of GDP. Only this way can the public health system improve, ensuring that the poorest of the poor, who cannot pay for (unregulated) private health services, are reached.

Another challenge (globally) concerns the volatility of MNCH aid and that despite the Paris Declaration commitments [2] more than 90 per cent of funding to MNCH continues to be disbursed through project-based modalities (Pitt et al, 2010). DFIDI should be commended for providing overall health sector programme support. However, GOI reliance on just one or two bilateral donors for such a large proportion of funding also risks exposing India to future aid volatility (Pitt et al, 2010). In this case DFIDI has a role to play in persuading other donors, especially the EC, UN agencies and the World Bank, to provide greater quality financial support to MNCH in India. DFIDI should also encourage greater commitment to MNCH, cohesion around and cooperation between different donors and Ministries by ensuring jointly agreed work plans and outcomes as one criteria of good performance. As part of this role, and in line with DFID’s position as the leading international advocate for MNCH, DFIDI has a key role to play in cultivating political will for MNCH at the national level and to maintaining pressure at the international level, to ensure that political will translates in to policy and reality at the state level and for India’s women and children.

6. Support Health Sector Governance, Community Mobilisation and Accountability

As well as the overall health system and quality of care issues outlined above, another area of particular concern is health sector governance and accountability in government health services. By virtue of their proximity to service users local government officials need to be more accountable and it is essential that DFIDI supports participation, transparency and accountability efforts at the local level. The GOI National Rural Health Mission (NRHM) was launched in 2005 seeking to improve access to equitable, affordable, accountable and effective primary health care in rural India. To address the inaccessible and poorly staffed and equipped healthcare services the NRHM supports a new community based volunteer cadre, the Accredited Social Health Activist (ASHA) [3] and seeks to strengthen Village Health Committees to address local health issues and monitor health services. ASHAs are local women who are trained, among other things, to promote antenatal care and institutional births. They are to be a bridge between communities and government healthcare also creating awareness about the social determinants of health. In many areas Village Health Committees are not functioning and despite the potential of the ASHA programme to help biomedical care becoming more accepted by poor communities the programme is undermined by a dearth of dialogue between medical staff and ASHAs. In addition, when community members take their ASHAs advice and visit health centres, the poor quality of care afforded often undermines the ASHAs work and leads to distrust (Scott and Shanker, 2010). The outcome based remuneration also motivates ASHAs to achieve short term quantifiable goals, rather than long term change in women’s abilities to take control of their health (Campbell and Scott, 2010).

DFID should support the strengthening of Village Health Committees and the ASHA programme as an important potential change agent but this must go hand in hand with increased access to better quality services (as above) and as well as demand creation.

Community-based interventions on the demand side can play a significant role in improving MNCH care. Research undertaken in two of the poorest states in India (Jharkhand and Orissa) demonstrates that even where services are poor and under-utilised, women coming together in groups to talk about ante-natal care and childbirth can reduce the numbers of newborn deaths by 45 per cent and rates of maternal depression by 57 per cent (Tripathy et al., 2010).

Effective demand side strategies, particularly through such community mobilisation approaches, empower women to recognise and press for their right to quality health services and increase resilience to community health challenges, and are as important as the requirement to improve and make health services more accessible on the supply side. Community mobilisation enables communities to come together to plan, carry out, and evaluate strategies to make sustained improvements to their health. Community mobilisation can make deep and lasting improvements to the health and well-being of community members by increasing their health knowledge and enabling them to identify and address important healthcare needs. Women’s groups develop low cost strategies to meet their healthcare needs, for example: e mergency funds, improved healthcare facilities, stretcher schemes and clean home delivery kits. Women’s groups enable women to identify and prioritise MNCH issues, have the support to find local and low cost solutions and build links with local health services. Women’s groups are a cost effective and evidence based intervention, which have the potential to be scaled up to reach out to all women and make a significant impact on their lives, their children’s lives and the lives of wider community members. Evidence from community mobilisation work in Nepal suggests that even after external funding is withdrawn 75 per cent of women’s groups continue to meet to address their community MNCH challenges.

In line with a rights based approach DFIDI should continue support for India’s vibrant and active civil society, supporting the inclusion of communities in decision making processes through the strengthening of Village Health Committee’s and by supporting community mobilisation efforts more generally.

7. Address Equity

DFID should be commended for focussing its programmes and emphasis on the three faces of development in India - global, developing and poorest India. However, DFID should strengthen its current efforts on targeting aid to the poorest and most marginalised across all states by placing an even greater focus on equity.

The lack of progress across all states in India has been a struggle because it is inextricably linked with complex social and economic factors related to health beliefs and practices, culture, education and poverty. Efforts to reach all Indian people equitably, including those who are regionally excluded, need to be intensified. Socio-economic inequalities in MNCH outcomes and determinants are an important concern. Inequalities in MNCH outcomes are caused by inequalities in the health care system as well as by social determinants of health. Health system inequalities are stark and, according to Save the Children, India has made slow or no progress regarding child mortality and inequity. In India, child mortality in the poorest quintile is almost three times higher than in the richest quintile (Save the Children, 2010). In some areas, such as Jharkhand, where a large percent age of the population belong to scheduled tribes, as many as 80 per cent of women delivered their newborns at home without skilled attendance [4] (Rath et al., 2010). In support of this one recent study showed that in India, despite significant overall reductions in income poverty, people from minority ethnic groups are more likely to suffer from health problems, and are less likely to be covered by health programmes or to receive vital vaccinations (Macdonald, 2010).

In response to the slow and varied progress in improving maternal and newborn health across the country GOI launched the Janani Suraksha Yojana (JSY) safe motherhood scheme – a national conditional cash transfer scheme – and the largest in the world in terms of the number of beneficiaries (Lim et al., 2010), which goes someway in addressing health inequities. The ultimate goal of the programme is to reduce the number of maternal and neonatal deaths by promoting institutional deliveries through the provision of cash incentives to all women irrespective of socioeconomic status and parity [5] . JSY has appeared to have achieved some of its stated goals with large increases in the proportion of births occurring in a health facility occurring in the same states that had a large uptake of JSY (Lim et al., 2010). However, the scheme does not seem to be reaching the poorest women at the highest rate (ibid.) and coverage has varied greatly between states and districts with a slow uptake in underserved areas (Rath et al., 2010). Lim et al. (2010) ascertain that the results for JSY uptake indicate the central part that state authorities play in the implementation of national health programmes in India. DFIDI, therefore, should use its position of influence to support the GOI at the state level to improve targeting of the poorest women, for example through improved communication about the scheme and by supporting evaluations through an equity lense. DFIDI should also support GOI to improve the quality of obstetric care in health facilities (as above), especially considering that some studies have suggested that JSY led to increased workloads and reduced quality of care in health facilities (e.g. early discharge after delivery) (ibid.). DFID should also provide support to build the capacity of health facilities to cope with increased demand and workloads to ensure that all women receive benefits equitably.

8. Link Health, Gender, Education and Nutrition

India ranks low at 122 out of 168 countries monitored on the Gender Inequality Index (UNDP, Human Development Report, 2010) [6] and the continuing high rates of maternal mortality and morbidity indicate serious gender inequity issues and the low priority afforded to the status of women and women’s reproductive rights in India. Patriarchal norms can place severe restrictions on women. Son preference is common and sex selective abortion is high in some areas contributing to skewed male-t o-female birth ratios (Save the Children, 2010). Girls are often inadequately breastfed or given less food throughout the life cycle and a study of 4,000 children aged between one and two in India found that the likelihood of girls being fully vaccinated was five percent age points lower than tha t for boys (ibid. ). The mobility of many women is decreased with women often prevented from seeking medical help or needing the permission of their husband or parent-in-law before taking their sick child to the doctor (ibid.). As the Human Development Report 2010 highlights reproductive health is the area which loses the greatest because of gender inequality. India has made significant progress over the last two decades in almost halving fertility levels from an average of 5.5 in 1970 to 2.8 in 2008 (UNICEF India). Family planning programmes are established in rural and urban areas but the unmet need for family planning services remains. The focus on family planning is most welcome because a reduction in the number of pregnancies per woman decreases the lifetime risk of maternal morbidity and mortality as well as the probability of complications and death in each pregnancy (Pitt et al., 2010). With a relatively young and ever growing population an increasing number of young people of reproductive age will become the focus of preventive and awareness raising programmes on safe motherhood as well as clients of family planning services. This will make the challenge of accelerating maternal mortality reduction harder, particularly given the relatively high adolescent birth rate (at 45 births per 1,000 women aged 15 to 19 years) and the widespread practice of early marriage.

Considering the association between increased maternal education, household wealth and high odds of receiving at least three antenatal care visits, giving birth in a facility and having a skilled attendant present at the time of delivery (Lim et al., 2010), continued support for girls education is vitally important for improving maternal, newborn and child health outcomes. As such DFID should continue to support the GOI Mahila Samakhya women’s empowerment programme, which aims to increase women’s role in local Government and improve their access to basic services and economic opportunities.

Marriage and childbearing often begins early in India. A new study by the Guttmacher Institute (Santhya et al., 2010) indicates a range of negative associations that compromise the overall lives and reproductive health of young women who marry early, with nearly 63 per cent of the women in the study marrying when they were younger than 18, the minimum legal age for marriage in India. The women who married early were more likely to have had a miscarriage or a stillbirth and were less likely to have used a contraceptive method to delay their first pregnancy or to have delivered their first child in a health facility. Increased risks of early pregnancy also include pre-term birth, birth asphyxia, low birth weight, infections, haemorrhage, anaemia and mortality. Early pregnancy can also have negative impacts upon the education of adolescent girls, limiting choices and potential. Increasing the median age of marriage and child birth in India and ensuring existing laws on the minimum age at marriage are enforced, are central to achieving gender equality of capability and opportunity and to meeting the MDG 4 and 5 targets and will require specific interventions focused on youth and their families.

India is home to more than a third of the world’s stunted children, with 61.2 million . A t current rates of progress, the MDG 1 target for nutrition will only be reached in 2043 with severe consequences for human wellbeing and economic growth (IDS Bulletin, 2009). Recognising the huge nutrition problem, DFID has identified India as one of its six focus countries for nutrition and in doing this DFID has played a key role in supporting GOI in developing the nutrition operational plan to tackle under-five malnutrition, providing very welcome technical support and advice.

The major poor nutrition problem in India also has clear gender dimensions. As UNICEF India emphasises [7] , under nutrition affects women more than it affects men due to the specific nutritional needs of girls and women during adolescence, pregnancy, and lactation. Widespread nutrition deprivation among women perpetuates an inter-generational cycle of nutrition deprivation in children. Undernourished girls grow up to become undernourished women who give birth to a new generation of undernourished children. Women are given the responsibility – but often not the means (empowerment) – to ensure optimal nutrition for their children. A recent study in Andhra Pradesh shows that women with higher autonomy (both financial and physical, for example – the freedom to go to the market) are less likely to have stunted children.

Unless such issues around gender, education, early marriage and nutrition are seriously addressed in national plans and implemented at the state and district levels, improvements in MNCH will not be achieved. Greater gender analyses of nutritional levels/ health care access/ provision within the household are needed. DFID has a key role to play in ensuring that the different ministries, strategies and laws addressing health, gender, education, marriage and nutrition are linked and mutually supportive and that different tiers of government are supported to work together.

9. Support Evidence Creation and Monitoring and Evaluation

DFID should be commended for supporting evidence-informed policy formation in India. However, there remains a great need for more comprehensive MNCH data collection and analysis in India. Currently India lacks a complete civil registration system with good attribution of cause of death (WHO, 2010) and only 41 per cent of births are registered (Countdown 2015, 2010). Poor maternal care and maternal deaths in particular tend to be accepted as unfortunate, but inevitable, and often go unreported. The recently published maternal mortality figures and controversy surrounding the reported reductions in maternal deaths demonstrate the challenges of measuring maternal mortality and the uncertainty surrounding interpretation of official data. Identifying a maternal death requires accurate data on the deaths of women of reproductive age, including cause of death, pregnancy status and the time of death in relation to pregnancy or childbirth. More information is also needed on what care is actually provided during antenatal, childbirth and postnatal care. Information about why and how changes in MNCH in India are occurring is even more limited and needs further investigation.

GOI efforts to improve data collection and analysis by strengthening health information and registration systems and undertaking additional surveys which concurrently measure mortality, coverage, funding and other health outcomes should be supported by DFIDI. Further investment in the development and use of the birth registration system and sentinel sites for prospective surveillance data collection and maternal and neonatal death audits should be supported by DFIDI through capacity building and direct funding. To maximise impact, DFIDI should support the collation of death audits, also addressing ‘near misses’, and assist GOI to establish robust mechanisms to guarantee appropriate action based on audit findings, including the meaningful involvement of community representatives as a means of enhancing transparency. This should include supporting the collection of disaggregated data (by gender, wealth, age, and other locally relevant sources of inequity) to inform focused interventions for at risk groups and increase accountability in service provision at the local and national levels.

DFIDI should be commended for supporting impact evaluations of social and health interventions, using robust methods as applicable. However, in doing this DFIDI could be more coherent and systematic in the way evaluation projects are rolled out; ensuring priorities across states are supported. Greater investment in implementation research to identify effective strategies for delivering proven interventions and to quantify their impact is necessary. Greater emphasis on monitoring and evaluation is needed to ensure that the effectiveness of an approach is assessed, that any necessary adjustments are made and that lessons are captured and documented. In many cases the success of approaches to maternal and neonatal health care may be context specific.

An area of particular concern is the lack of equity-oriented research, policy and monitoring. More evidence is needed on how to reach poorer people and how to scale up interventions proven to be effective (including what works in which contexts) to entire populations [8] . Factors influencing the transferability of interventions between contexts should also be mapped [9] .

DFIDI should also undertake rigorous impact evaluation of components of GOI schemes that it is supporting, with a view to checking the effectiveness of targeting in particular, to share lessons (Heath, DFID, 2006) and to ensure impact and value for money.

DFIDI must also invest more in ensuring that evidence generated in India translates into policy and practice. Linking DFIDI’s research more closely to its country programmes, so that lessons learned from research studies can be disseminated and applied is essential.

Investing in dissemination and communication of India-relevant research findings is also important. This includes user-friendly dissemination of research findings and also supporting researchers to critically engage with users of evidence and knowledge. In doing this DFIDI should make a concerted effort to ensure that knowledge collated at the community level, reflecting ordinary peoples experiences, is not discredited or ignored and that specific mechanisms to enable community evidence gathering are developed and supported.

10. Acronyms

November 2010