NEW DELHI: India’s strategies to reduce child mortality rates, among the world’s highest, need to be reassessed notes a newly conducted study.

More than 90% of treatments for childhood diarrhoea and pneumonia, the leading causes of death among Indian children, are incorrect. Instead, largely unqualified medical practitioners, unfamiliar with relatively simple life-saving medications, prescribe antibiotics and other potentially harmful drugs, said the recent study published in JAMA Paediatrics (JAMA stands for Journal of the American Medical Association).

The results indicate that India’s strategies to reduce child mortality rates – among the world’s highest – need to be reassessed and modified. Among 15 high-burden countries, India ranks third from bottom for its use of life-saving intervention for children at risk of dying from diarrhoea and pneumonia, this 2014 study noted. The number of children under five years of age, dying from diarrhoea and pneumonia was the highest, with 318,000 deaths in 2013.

“Only 20% of the providers in our sample had medical qualifications,” said Manoj Mohanan, author and professor at Duke University’s Sanford School of Public Policy. “However, it is also important to note that this is not unusual in rural settings.” The Duke study involved 340 healthcare providers in Bihar, which has India’s highest mortality rate for children between one and four years of age: 55 die for every 1,000 live births. Child mortality in India has declined 55% over the past 24 years, as it was previously reported at international level, but too many children still die. India lags behind in the majority of the world’s countries, including poorer neighbours Bangladesh and Nepal.

Whether trained or not, medical practitioners examined in the study fared badly in interviews and worse in practice. “Less than 10% of practitioners prescribed the correct treatment and referral for cases of watery diarrhoea and pneumonia, and inappropriate and potentially dangerous medications were prescribed for a significant proportion of the standardised patients,” noted an accompanying editorial in JAMA Paediatrics, written by James Tielsch, chair of the Department of Global Health at George Washington University.

“For simple diarrhoea, where the only medication necessary was ORS (oral rehydration salts) and zinc without any antibiotics or other unsafe drugs, providers gave the exact treatment,” said Mohanan. None of the dummy patients asked for antibiotics or other drugs. Only 17% of practitioners prescribed (ORS), a low-cost, easily available and efficient treatment, although 72% said they would use ORS, but obviously did not.

Practitioners, who did give ORS, also prescribed dangerous or needless drugs, such as antibiotics, resistance to which is spreading across India and putting millions at risk. Other factors in over-prescribing antibiotics could be that providers underestimate the emergence of drug resistance, long-term adverse effects on patients or simply believe that guidelines on antibiotic use somehow do not apply to local conditions.

Since the study was conducted in Bihar, do the findings apply across India? “Our previous studies using standardised patients collected data from urban Delhi and rural areas of Madhya Pradesh, and the patterns in quality of care were very comparable,” said Mohanan. “I cannot say it can be generalised across all parts of the country, but it is plausible that our findings are generalisable to rural India, where most health care is provided by untrained practitioners.”

Tielsch wrote that the study was ‘a stark reminder that there remains a large, difficult-to-address, unfinished agenda for child health and survival in under-served populations around the world’. Better understanding of how comprehensive strategies can address the know, do, and quality gaps across a range of practice environments is needed to prepare for the ambitious upcoming sustainable-development goals that call for elimination of preventable mortality among women and children.