Showing papers by "Ramanan Laxminarayan published in 2016"

Antibiotic resistance is the quintessential One Health issue.

Abstract: International Livestock Research Institute, Nairobi, Kenya; Institute of Animal Science, Chinese Academy of Agricultural Sciences, Beijing, China; Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Université Libre de Bruxelles, Brussels, Belgium; Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA; Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Oxford, UK; Research Group for Preventive Technology in Livestock, Faculty of Veterinary Medicine, Khon Kaen University, Khon Kaen, Thailand; Public Health Foundation of India, Delhi, India; Kenya Medical Research Institute, Nairobi, Kenya; Center for Disease Dynamics, Economics and Policy, Washington DC, USA; Food and Agriculture Organization of the United Nations, Rome, Italy; Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden; National Institute of Veterinary Research, Hanoi, Vietnam; Institute of Integrative Biology and Center for Adaptation to a Changing Environment, Swiss Federal Institute of Technology, Zurich, Switzerland; Centre for Immunity, Infection & Evolution, University of Edinburgh, Edinburgh, UK

Antibiotic Resistance in India: Drivers and Opportunities for Action.

Abstract: Ramanan Laxminarayan and Ranjit Roy Chaudhury examine the factors encouraging the emergence of antibiotic resistance in India, the implications nationally and internationally, and what might be done to help.

Achieving global targets for antimicrobial resistance

Abstract: After decades of neglect, antimicrobial resistance (AMR) has captured the attention and concern of the public health community and global leaders. In September 2016, a high-level meeting of the United Nations General Assembly (UNGA) will discuss how countries can cooperate to preserve global access to effective antimicrobials. This will be only the fourth health issue (and the first One Health issue, integrating human, animal, and environmental health) to bring together heads of state at the UNGA for a rare opportunity to set a global agenda to combat the crisis. We believe that (i) setting targets for reducing drug-resistant infections, (ii) adequate financing for global action, and (iii) defining the global health architecture to address AMR should be elements of a UN plan.

Health and economic benefits of public financing of epilepsy treatment in India: An agent-based simulation model.

Abstract: OBJECTIVE: An estimated 6-10 million people in India live with active epilepsy, and less than half are treated. We analyze the health and economic benefits of three scenarios of publicly financed national epilepsy programs that provide: (1) first-line antiepilepsy drugs (AEDs), (2) first- and second-line AEDs, and (3) first- and second-line AEDs and surgery. METHODS: We model the prevalence and distribution of epilepsy in India using IndiaSim, an agent-based, simulation model of the Indian population. Agents in the model are disease-free or in one of three disease states: untreated with seizures, treated with seizures, and treated without seizures. Outcome measures include the proportion of the population that has epilepsy and is untreated, disability-adjusted life years (DALYs) averted, and cost per DALY averted. Economic benefit measures estimated include out-of-pocket (OOP) expenditure averted and money-metric value of insurance. RESULTS: All three scenarios represent a cost-effective use of resources and would avert 800,000-1 million DALYs per year in India relative to the current scenario. However, especially in poor regions and populations, scenario 1 (which publicly finances only first-line therapy) does not decrease the OOP expenditure or provide financial risk protection if we include care-seeking costs. The OOP expenditure averted increases from scenarios 1 through 3, and the money-metric value of insurance follows a similar trend between scenarios and typically decreases with wealth. In the first 10 years of scenarios 2 and 3, households avert on average over US$80 million per year in medical expenditure. SIGNIFICANCE: Expanding and publicly financing epilepsy treatment in India averts substantial disease burden. A universal public finance policy that covers only first-line AEDs may not provide significant financial risk protection. Covering costs for both first- and second-line therapy and other medical costs alleviates the financial burden from epilepsy and is cost-effective across wealth quintiles and in all Indian states.

Multidrug- and Carbapenem-Resistant Pseudomonas aeruginosa in Children, United States, 1999-2012.

Abstract: Background Pseudomonas aeruginosa is a common cause of healthcare-associated infection. Multidrug-resistant (MDR) (>3 classes) and carbapenem-resistant (CR) P aeruginosa are significant threats globally. We used a large reference-laboratory database to study the epidemiology of P aeruginosa in children in the United States. Methods Antimicrobial susceptibility data from the Surveillance Network were used to phenotypically identify MDR and CR P aeruginosa isolates in children aged 1 to 17 years between January 1999 and July 2012. Logistic regression analysis was used to calculate trends in the prevalence of MDR and CR P aeruginosa. Isolates from infants (<1 year old) and patients with cystic fibrosis were excluded. Results Among the isolates tested, the crude proportion of MDR P aeruginosa increased from 15.4% in 1999 to 26% in 2012, and the proportion of CR P aeruginosa increased from 9.4% in 1999 to 20% in 2012. The proportion of both MDR and CR P aeruginosa increased each year by 4% (odds ratio [OR], 1.04 [95% confidence interval (CI), 1.03-1.04] and 1.04 [95% CI, 1.04-1.05], respectively). In multivariable analysis, both MDR and CR P aeruginosa were more common in the intensive care setting, among children aged 13 to 17 years, in respiratory specimens, and in the West North Central region. In addition, resistance to other antibiotic classes (aminoglycosides, fluoroquinolones, cephalosporins, and piperacillin-tazobactam) often used to treat P aeruginosa increased. Conclusions Rates of MDR and CR P aeruginosa infection in children are rising nationally. Aggressive prevention strategies, including instituting antimicrobial stewardship programs in pediatric settings, are essential for combating antimicrobial resistance.

Use antimicrobials wisely

Abstract: The United Nations must reframe action on antimicrobial resistance as the defence of a common resource, argue Peter S. Jorgensen, Didier Wernli and colleagues.

Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume.

Abstract: Reproductive, maternal, newborn, and child health (RMNCH) has been a priority for both governments and civil society in low- and middle-income countries (LMICs). This priority was affirmed by world leaders in the Millennium Development Goals (MDGs) that called for countries to reduce child mortality by 67 percent and maternal mortality by 75 percent between 1990 and 2015. Although substantial progress on these targets has been made, few countries achieved the needed reductions. The United Nations (UN) Secretary-General’s Global Strategy for Women’s and Children’s Health, launched in 2010 and expanded in 2015 to include adolescents, is an indication of the continued global commitment to the survival and well-being of women and children (Ban 2010). Annual official development assistance for maternal, newborn, and child health has increased from US$2.7 billion in 2003 to US$8.3 billion in 2012, when there was an additional US$4.5 billion for reproductive health (Arregoces and others 2015). A continued focus on RMNCH is needed to address the remaining considerable burden of disease in LMICs from unwanted pregnancies; high maternal, newborn, and child mortality and stillbirths; high rates of undernutrition; frequent communicable and noncommunicable diseases; and loss of human capacity. Cost-effective interventions are available and can be implemented at high coverage in LMICs to greatly reduce these problems at an affordable cost.RMNCH encompasses health problems across the life course from adolescent girls and women before and during pregnancy and delivery, to newborns and children. An important conceptual framework is the continuum-of-care approach in two dimensions. One dimension recognizes the links from mother to child and the need for health services across the stages of the life course. The other is the delivery of integrated preventive and therapeutic health interventions through service platforms ranging from the community to the primary health center and the hospital.This volume presents the levels and trends of RMNCH indicators, proven interventions for prevention of mortality, costs of these interventions and potential health service delivery platforms, and system innovations. Other volumes in the third edition of Disease Control Priorities also cover topics of importance to women and children that are related to the RMNCH health services packages (box 1.1). These topics include the following: Trauma care; obstetric surgery; obstetric fistula; surgery for family planning, abortion, and postabortion care; and surgery for congenital anomalies (Volume 1, Essential Surgery) Breast cancer, cervical cancer and precancer, childhood cancer, and cancer pain relief (Volume 3, Cancer) Childhood mental and developmental disorders (Volume 4, Mental, Neurological, and Substance Use Disorders) Cardiovascular and respiratory disorders (Volume 5, Cardiovascular, Respiratory, and Related Disorders) HIV/AIDS and other sexually transmitted infections, tuberculosis, and malaria (Volume 6, HIV/AIDS, STIs, Tuberculosis, and Malaria) Road traffic injury and interpersonal violence (Volume 7, Injury Prevention and Environmental Health) Child (older than five years) and adolescent development (the subject of the entire Volume 8, Child and Adolescent Development).

Indications and Types of Antibiotic Agents Used in 6 Acute Care Hospitals, 2009-2010: A Pragmatic Retrospective Observational Study.

Abstract: BACKGROUND To design better antimicrobial stewardship programs, detailed data on the primary drivers and patterns of antibiotic use are needed. OBJECTIVE To characterize the indications for antibiotic therapy, agents used, duration, combinations, and microbiological justification in 6 acute-care US facilities with varied location, size, and type of antimicrobial stewardship programs. DESIGN, PARTICIPANTS, AND SETTING Retrospective medical chart review was performed on a random cross-sectional sample of 1,200 adult inpatients, hospitalized (>24 hrs) in 6 hospitals, and receiving at least 1 antibiotic dose on 4 index dates chosen at equal intervals through a 1-year study period (October 1, 2009-September 30, 2010). METHODS Infectious disease specialists recorded patient demographic characteristics, comorbidities, microbiological and radiological testing, and agents used, dose, duration, and indication for antibiotic prescriptions. RESULTS On the index dates 4,119 (60.5%) of 6,812 inpatients were receiving antibiotics. The random sample of 1,200 case patients was receiving 2,527 antibiotics (average: 2.1 per patient); 540 (21.4%) were prophylactic and 1,987 (78.6%) were therapeutic, of which 372 (18.7%) were pathogen-directed at start. Of the 1,615 empirical starts, 382 (23.7%) were subsequently pathogen-directed and 1,231 (76.2%) remained empirical. Use was primarily for respiratory (27.6% of prescriptions) followed by gastrointestinal (13.1%) infections. Fluoroquinolones, vancomycin, and antipseudomonal penicillins together accounted for 47.1% of therapy-days. CONCLUSIONS Use of broad-spectrum empirical therapy was prevalent in 6 US acute care facilities and in most instances was not subsequently pathogen directed. Fluoroquinolones, vancomycin, and antipseudomonal penicillins were the most frequently used antibiotics, particularly for respiratory indications. Infect. Control Hosp. Epidemiol. 2015;37(1):70-79.

Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders

Abstract: This volume of the third edition of the Disease Control Priorities (DCP) project addresses mental, neurological, and substance use (MNS) disorders. MNS disorders are a heterogeneous range of disorders that owe their origin to a complex array of genetic, biological, psychological, and social factors. Although many health systems deliver care for these disorders through separate channels, with an emphasis on specialist services in hospitals, the disorders have been grouped together in this volume to guide policy makers, particularly in low-resource settings, as they prioritize essential health care packages and delivery platforms (box 1.1).MNS disorders are grouped together because they share several important characteristics, notably: They all owe their symptoms and impairments to some degree of brain dysfunction. Social determinants play an important role in the etiology and symptom expression for many of these disorders (box 1.2). The disorders frequently co-occur in the same individual. Their impact on families and society is profound. They are strongly associated with stigma and discrimination. They often observe a chronic or relapsing course. They all share a pitifully inadequate response from health care systems in all countries, particularly in low- and middle-income countries (LMICs). Our grouping of MNS disorders is also consistent with programs intended to address their health burden, exemplified by the Mental Health Gap Action Programme (mhGAP) (WHO 2008), and with the goals of the third edition of Disease Control Priorities (DCP3) of synthesizing evidence and making recommendations across diverse health conditions. As we emphasize in this volume, these shared characteristics shape the response of countries in addressing the burden of MNS disorders. For example, a strong case is made for an integrated public health response to these conditions in all countries, but particularly in LMICs because of the paucity of specialist services in these settings. Such services have been the hallmark of the health system response to these conditions in high-income countries (HICs).DCP1 had only addressed a few MNS disorders: psychosis and bipolar disorder. DCP2 had focused on the cost-effectiveness of specific interventions for burdensome disorders, organized separately for mental disorders, neurological disorders, alcohol use disorders, illicit drug use disorders, and learning and developmental disabilities. In this third edition, we have considered interventions for five groups of disorders—adult mental disorders, child mental and developmental disorders, neurological disorders, alcohol use disorder, and illicit drug use such as opioid dependence—and suicide and self-harm-health outcomes strongly associated with MNS disorders. Within each group, we have prioritized conditions associated with high burden for which there is evidence in support of interventions that are cost-effective and scalable.Inevitably, such an approach does not address a significant number of conditions, for example, multiple sclerosis as a neurological disorder and anorexia nervosa as an adult mental disorder. However, the recommendations in this volume, particularly regarding the delivery of packages for care, could be extended to other conditions not expressly addressed. In addition, some important MNS disorders or concerns are covered in companion volumes of DCP3, notably, nicotine dependence, early childhood development, neurological infections, and stroke.This volume addresses four overall questions and themes (box 1.3): First, we address the question of why MNS disorders deserve prioritization by pointing to and reviewing the health and economic burden of disease attributable to MNS disorders. We build on the 2010 estimates of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD 2010) in two important ways: by examining trends in the burden over time, and by estimating the additional mortality attributable to these disorders. Second, we address the question of what by reviewing the evidence on the effectiveness of specific interventions for the prevention and treatment of a selection of MNS disorders. Third, we consider how and where these interventions can be appropriately implemented across a range of service delivery platforms. Fourth, we address the question of how much by examining the cost of scaling up cost-effective interventions and the case for enhanced service coverage and financial protection for MNS disorders. This chapter also considers how some countries have attempted to incorporate this body of evidence into scaled-up programs for MNS disorders. The chapter discusses lessons on barriers and strategies for how these will need to be addressed for successful scaling-up.The primary focus of the volume—and DCP3 as a whole—is on LMICs. We include HICs in the section on global disease burden, and we draw liberally on the concentration of available evidence on intervention effectiveness from these countries.

Current costs & projected financial needs of India's Universal Immunization Programme.

Abstract: Background & objectives: India's Universal Immunization Programme (UIP) is one of the largest programmes in the world in terms of quantities of vaccines administered, number of beneficiaries, number of immunization sessions, and geographical extent and diversity of areas covered. Strategic planning for the Programme requires credible information on the cost of achieving the objectives and the financial resources needed at national, State, and district levels. We present here expenditures on immunization services in India in 2012 (baseline) and projected costs for five years (2013-2017). Methods: Data were collected from the Immunization Division of the Ministry of Health and Family Welfare, Government of India, and immunization partners, such as the World Health Organization and UNICEF. The cost components were immunization personnel, vaccines and injection supplies, transportation, trainings, social mobilization, advocacy and communication activities, disease surveillance, Programme management, maintenance of cold chain and other equipment, and capital costs. Results: Total baseline expenditure was ₹ 3,446 crore [1 crore = 10 million] (US$718 million), including shared personnel costs. In 2012, the government paid for 90 per cent of the Programme. Total resource requirements for 2013-2017 are ₹ 34,336 crore (US$ 5, 282 million). Allocations for vaccines increase from ₹ 511 crore in 2013 to ₹ 3,587 crore in 2017 as new vaccines are assumed to be introduced in the Programme. Interpretation & conclusions: The projections show that the government immunization budget will be double in 2017 as compared to 2013. It will increase from ₹ 4,570 crore in 2013 to ₹ 9,451 crore in 2017.

The unintended effects of cash transfers on fertility: evidence from the Safe Motherhood Scheme in India

Abstract: India launched the Safe Motherhood Scheme (Janani Suraksha Yojana or JSY) in 2005 in response to persistently high maternal and child mortality rates. JSY provides a cash incentive to socioeconomically disadvantaged women for childbirth at health facilities. This study explores some unintended consequences of JSY. Using data from two large household surveys, we examine a policy variation that exploits the differential incentive structure under JSY across states and population subgroups. We find that JSY may have resulted in a 2.5–3.5 percentage point rise in the probability of childbirth or pregnancy over a 3-year period in states already experiencing high population growth.

Self-enforcing regional vaccination agreements

Abstract: In a highly interconnected world, immunizing infections are a transboundary problem, and their control and elimination require international cooperation and coordination. In the absence of a global or regional body that can impose a universal vaccination strategy, each individual country sets its own strategy. Mobility of populations across borders can promote free-riding, because a country can benefit from the vaccination efforts of its neighbours, which can result in vaccination coverage lower than the global optimum. Here we explore whether voluntary coalitions that reward countries that join by cooperatively increasing vaccination coverage can solve this problem. We use dynamic epidemiological models embedded in a game-theoretic framework in order to identify conditions in which coalitions are self-enforcing and therefore stable, and thus successful at promoting a cooperative vaccination strategy. We find that countries can achieve significantly greater vaccination coverage at a lower cost by forming coalitions than when acting independently, provided a coalition has the tools to deter free-riding. Furthermore, when economically or epidemiologically asymmetric countries form coalitions, realized coverage is regionally more consistent than in the absence of coalitions.

Health and economic benefits of scaling up a home-based neonatal care package in rural India: a modelling analysis

Abstract: Approximately 900 000 newborn children die every year in India, accounting for 28% of neonatal deaths globally. In 2011, India introduced a home-based newborn care (HBNC) package to be delivered by community health workers across rural areas. We estimate the disease and economic burden that could be averted by scaling up the HBNC in rural India using IndiaSim, an agent-based simulation model, to examine two interventions. In the first intervention, the existing community health worker network begins providing HBNC for rural households without access to home- or facility-based newborn care, as introduced by India's recent programme. In the second intervention, we consider increased coverage of HBNC across India so that total coverage of neonatal care (HBNC or otherwise) in the rural areas of each state reaches at least 90%. We find that compared with a baseline of no coverage, providing the care package through the existing network of community health workers could avert 48 [95% uncertainty range (UR) 34-63] incident cases of severe neonatal morbidity and 5 (95% UR 4-7) related deaths, save $4411 (95% UR $3088-$5735) in out-of-pocket treatment costs, and provide $285 (95% UR $200-$371) in value of insurance per 1000 live births in rural India. Increasing the coverage of HBNC to 90% will avert an additional 9 (95% UR 7-12) incident cases, 1 death (95% UR 0.72-1.33), and $613 (95% UR $430-$797) in out-of-pocket expenditures, and provide $55 (95% UR $39-$72) in incremental value of insurance per 1000 live births. Intervention benefits are greater for lower socioeconomic groups and in the poorer states of Chhattisgarh, Uttarakhand, Bihar, Assam and Uttar Pradesh.

Reducing stunting in India: what investments are needed?

Abstract: India has among the highest rates of child malnutrition rates in the world, but these rates have been declining rapidly during the past decade. Between 2006 and 2014, stunting rates for children under five in India have declined from 48 to 38% (Global Nutrition Report, 2014). Despite this progress, child undernutrition rates in India are among the highest in the world, with nearly one-half of all children under 3 years of age being either underweight or stunted. India is still home to over 40 million stunted children and 17 million wasted children (Global Nutrition Report, 2014). In addition, the rates of decline have been highly variable across India’s states. Some states, including Arunachal Pradesh, Mizoram and Delhi, had large rates of reduction in stunting, but overall levels of undernutrition remained high because of high baseline rates. Meanwhile, in Uttar Pradesh, Jammu and Kashmir, Manipur and Jharkhand the situation has not changed significantly (Raykar et al., 2015). Similar variability is observed in the prevalence of anaemia rates as well, which range from 38% in Goa to 78% in Bihar (IIPS & Macro International, International Institute for Population Sciences (IIPS) and Macro International, 2007). Global evidence shows that childmalnutrition is only weakly correlated with income. In fact, a quarter of Indian children from the top income quintile were stunted in 2006. Stunting is a marker for poor environmental, maternal and child factors, including poor sanitation, intrauterine growth restriction, micronutrient deficiencies, and sub-optimal infant and young child feeding practices. Current global recommendations for achieving 20% reduction in stunting and 61% reduction in severe wasting include delivery of a set of nutrition-specific interventions at 90% coverage level (Bhutta et al., 2013). These interventions span the continuum of care and include food and micronutrient supplements before and during pregnancy, counselling for initiation of breastfeeding and food and micronutrient supplementation formothers in the newborn period and breastfeeding counselling, food and micronutrient supplementation along with routine immunization for the under five children (Fig. 1). Available data indicate that less than 50% of mothers and children in India are exposed to a majority of these interventions. The shortfall is greater for iron folic acid supplementation, food supplementation and minimum diet diversity, whereas exclusive breastfeeding and immunization have improved in recent years (Fig. 2).

Cost Per DALY Averted in a Surgical Unit of a Private Hospital in India

Abstract: Cost-effectiveness analysis plays an important role to guide resource allocation decisions, however, information on cost per disability-adjusted life year (DALY) averted by health facilities is not available in many developing economies, including India. We estimated cost per DALY averted for 2611 patients admitted for surgical interventions in a 106-bed private for-profit hospital in northern India. Costs were calculated using standard costing methods for the financial year 2012–2013, and effectiveness was measured in DALYs averted using risk of death/disability, effectiveness of treatment and disability weights from 2010 global burden of disease study. During the study period, total operating cost of the hospital for treating surgical patients was USD 1,554,406 and the hospital averted 9401 DALYs resulting in a cost per DALY averted of USD 165. Even though this study was based on one hospital in India, however, the hospital is a private hospital which is expected to have less surgical case load compared to government health facilities, cost per DALY averted for the surgical interventions is much lower than the cost-effectiveness threshold for India (USD 1508 in 2012). This study therefore provides evidence to re-think the common notion that surgical care is expensive and therefore of lower value than other health interventions.

The Impact of a National Early Childhood Development Program on Future Schooling Attainment: Evidence from ICDS in India

Abstract: A central argument for early childhood nutrition is that it improves health, educational, and economic outcomes in later life. Our understanding of the long-term relationship between nutrition and educational attainment in low- and middle-income countries is based on a few small-scale trials that may lack validity in contexts such as India, because the underlying socioeconomic and demographic conditions are different. In this study, we evaluate the effect of India’s Integrated Child Development Services (ICDS), a national program of supplementary nutrition and other health services for children and new mothers, on future educational attainment. Using data from a large national household survey, we determine exposure to the program based on the year ICDS centers were established in villages or city wards. We employ household fixed-effect regression models to find that 15- to 54-year-old men and 15- to 49-year-old women who were fully exposed to an ICDS center during the first three years of life complete on average up to 0.65 additional grades of schooling than those with no exposure. If we also consider partial exposure to ICDS, the effect of the treatment is 0.52 extra grades of schooling . For ICDS centers that are known to provide supplementary nutrition, individuals in the above age groups with full exposure during the first three years of life complete 1.08 additional grades of schooling (0.93 extra years if we also consider partial exposure). Effect size varies by population subgroups, with women and members of Hindu and female-headed households gaining 1.19, 1.17, and 1.16 extra grades of schooling , respectively.

Antimicrobials: access and sustainable eff ectiveness 5 International cooperation to improve access to and sustain eff ectiveness of antimicrobials

Abstract: Securing access to eff ective antimicrobials is one of the greatest challenges today. Until now, eff orts to address this issue have been isolated and uncoordinated, with little focus on sustainable and international solutions. Global collective action is necessary to improve access to life-saving antimicrobials, conserving them, and ensuring continued innovation. Access, conservation, and innovation are benefi cial when achieved independently, but much more eff ective and sustainable if implemented in concert within and across countries. WHO alone will not be able to drive these actions. It will require a multisector response (including the health, agriculture, and veterinary sectors), global coordination, and fi nancing mechanisms with suffi cient mandates, authority, resources, and power. Fortunately, securing access to eff ective antimicrobials has fi nally gained a place on the global political agenda, and we call on policy makers to develop, endorse, and fi nance new global institutional arrangements that can ensure robust implementation and bold collective action.

The Benefits of a Universal Home-Based Neonatal Care Package in Rural India: An Extended Cost-Effectiveness Analysis

Abstract: Each year, 27 percent of the world’s newborn deaths— about 748,000—occur in India according to 2013 estimates (UN IGME 2014). India’s newborn mortality rate (NMR) has declined by nearly 43 percent since 1990. However, this decline has been much slower than the decline in the mortality rate for children under age five years, which has dropped by 58 percent during the same period. Consequently, the share of newborn deaths among all under-five deaths in India has risen from 41 percent in 1990 to 56 percent in 2013, highlighting the relative lack of progress made in newborn survival. Conditions associated with neonates—such as preterm birth complications and sepsis—rank among the top 10 causes of all premature mortality in India (CDC 2015). A study in 2005 found that prematurity and low birth weight, infections, birth asphyxia, and birth trauma caused nearly 80 percent of newborn deaths (Bassani and others 2010).India’s NMR of 29 per 1,000 live births continues to be among the highest in the world, underscoring the need for a policy response (UN IGME 2014) (figure 18.1). Although antenatal care and other preventive interventions such as encouraging institutional delivery and improving maternal health care access have been implemented, their impact on newborn survival has been minimal (Hollowell and others 2009; Lim and others 2010; Singh and others 2013). Good quality postnatal care may prevent about 67 percent of all newborn deaths (WHO 2012) in India. However, availability of and access to postnatal care remain low. Data from the District Level Household Survey conducted between 2007 and suggest that only 45 percent of newborns in India underwent a health examination within the first 24 hours (IIPS 2010).In addition to low levels of access to newborn care in general, large regional and socioeconomic differences in access lead to significant variations in outcomes. The mortality among newborns in India’s rural areas is twice that in urban areas—34 and 17 per 1,000 live births, respectively— with mortality rates substantially exceeding the national average in the poorer and larger states of Madhya Pradesh, Uttar Pradesh, Odisha, Rajasthan, Jammu and Kashmir, and Chhattisgarh (Chand and others 2013).In this chapter, we examine the health and economic benefits and the cost to the government associated with scaling up a publicly financed home-based neonatal care (HBNC) package in rural India. We consider two intervention scenarios against a baseline of no HBNC:Box 18.1 provides information on the types of CHWs and the primary health systems in which they operate.

Can Early Childhood Nutrition Improve Adult Educational Attainment in India? Evidence from the ICDS Program

Abstract: A central argument for early childhood nutrition is that it improves health, educational, and economic outcomes in later life. Our understanding of the long-term relationship between nutrition and educational attainment in low- and middle-income countries is based on a few small-scale trials that may lack validity in contexts such as India, because the underlying socioeconomic and demographic conditions are different. In this study, we evaluate the effect of India’s Integrated Child Development Services (ICDS), a national program of supplementary nutrition and other health services for children and new mothers, on future educational attainment. Using data from a large national household survey, we determine exposure to the program based on the year ICDS centers were established in villages or city wards. We employ household fixed-effect regression models to find that 15- to 54-year-old men and 15- to 49-year-old women who were fully exposed to an ICDS center during the first three years of life complete on average up to 0.65 additional grades of schooling than those with no exposure. If we also consider partial exposure to ICDS, the effect of the treatment is 0.52 extra grades of schooling . For ICDS centers that are known to provide supplementary nutrition, individuals in the above age groups with full exposure during the first three years of life complete 1.08 additional grades of schooling (0.93 extra years if we also consider partial exposure). Effect size varies by population subgroups, with women and members of Hindu and female-headed households gaining 1.19, 1.17, and 1.16 extra grades of schooling , respectively.