Social sector expenditure and child mortality in India: a state-level analysis from 1997 to 2009

Abstract

Background: India is unlikely to meet the Millennium Development Goal for child mortality. As public policy impacts child mortality, we assessed the association of social sector expenditure with child mortality in India.

Methods and findings: Mixed-effects regression models were used to assess the relationship of state-level overall social sector expenditure and its major components (health, health-related, education, and other) with mortality by sex among infants and children aged 1-4 years from 1997 to 2009, adjusting for potential confounders. Counterfactual models were constructed to estimate deaths averted due to overall social sector increases since 1997. Increases in per capita overall social sector expenditure were slightly higher in less developed than in more developed states from 1997 to 2009 (2.4-fold versus 2-fold), but the level of expenditure remained 36% lower in the former in 2009. Increase in public expenditure on health was not significantly associated with mortality reduction in infants or at ages 1-4 years, but a 10% increase in health-related public expenditure was associated with a 3.6% mortality reduction (95% confidence interval 0.2-6.9%) in 1-4 years old boys. A 10% increase in overall social sector expenditure was associated with a mortality reduction in both boys (6.8%, 3.5-10.0%) and girls (4.1%, 0.8-7.5%) aged 1-4 years. We estimated 119,807 (95% uncertainty interval 53,409-214,662) averted deaths in boys aged 1-4 years and 94,037 (14,725-206,684) in girls in India in 2009 that could be attributed to increases in overall social sector expenditure since 1997.

Conclusions: Further reduction in child mortality in India would be facilitated if policymakers give high priority to the social sector as a whole for resource allocation in the country's 5-year plan for 2012-2017, as public expenditure on health alone has not had major impact on reducing child mortality.

Figure 1. Per-capita health, health-related, education, other, and overall social sector expenditure, 1997–2009.

Per-capita expenditure is calculated as the sum of yearly expenditure across all states in our analysis divided by the sum of yearly population in these states and averaged for the five years ending in the index year. Expenditure is shown in constant 2009 prices (USD). Trends are shown for the less developed and more developed state of India and for India as a whole.

Figure 2. Mortality trends among A) infants and B) children aged 1–4 years, 1997–2009.

Trends are shown for the less developed and more developed state of India and for India as a whole.

Figure 3. Observed and counterfactual mortality trends among infants and children aged 1–4 years, 1997–2009.

The observed mortality rate (for infants) or death rate (for age 1–4) is shown in black; the overall social sector expenditure counterfactual shows the predicted mortality/death rates if state per-capita overall social sector expenditure had remained at its 1997 level (blue); the poverty counterfactual shows the predicted mortality/death rates if poverty rates had remained at their 1997 levels (orange). (Note: the effect of overall social sector expenditure on mortality is essentially zero in boys less than one. Hence, the mortality rate under the overall social sector expenditure counterfactual [blue] coincides with the estimated mortality rate [black].)

Figure 4. Averted deaths in 2009 by sex attributable to increased social sector spending since 1997.

Averted deaths per 1,000 population among A) girls and B) boys aged 1–4 years. The population denominator is the sex-specific population aged 1–4 years in 2009. In the analysis, data from Jharkhand was combined with that from Bihar and data from Chhattisgarh with that from Madhya Pradesh. The averted death rates shown in the maps for these four states are therefore the averted death rates obtained for Bihar combined with Jharkhand and Madhya Pradesh combined with Chhattisgarh.