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India has avoided about one million deaths of children under the age of five since 2005, driven by significant reductions in mortality from pneumonia, diarrhea, tetanus and measles, according to new University of Toronto research.

But nearly three times that number could have been saved if national progress in child health matched that reached in some states, Dr. Prabhat Jha, a professor in the U of T's Dalla Lana School of Public Health and head of the Centre for Global Health Research of St. Michael’s Hospital.

The study was published in .

A steeper decline in the number of girls dying narrowed a previously observed girl-boy mortality gap, said Jha. An almost equal number of boys and girls under the age of five died in 2015.

This research is part of the Million Death Study, one of the largest studies of premature deaths in the world. Jha is the lead investigator of the survey, based in India, where most deaths occur at home and without medical attention. Hundreds of specially trained census staff in India knocked on doors of more than 1.3 million homes to interview household members about deaths. Two physicians independently examined these “verbal autopsies” to establish the most probable cause of death.

Dr. Prabhat Jha, a professor in U of T's Dalla Lana School of Public Health and head of the Centre for Global Health Research of St. Michael’s Hospital.

 “You get the truth when you knock on doors and talk to parents,” said Jha. “We knocked on the doors of 100,000 homes where children died. If the health system failed these families, they will tell you all about it. These are far more reliable numbers than models or projections from small studies.”

The study found a 3.3 per cent annual decline in mortality rates of neonates (infants less than one month old) and 5.4 per cent for those ages one month to 59 months. The declines accelerated starting in 2005 and were fastest between 2010 and 2015, and in urban areas and richer states.

Per 1,000 live births, the mortality rates among neonates fell from 45 in 2000 to 27 in 2015. The one-59 month mortality rate fell from 45.2 to 19.6.

Looking at specific causes of death, mortality rates from neonatal tetanus and measles fell by at least 90 per cent; neonatal infection and birth trauma fell more than 66 per cent. For children ages one to 59 months, mortality rates from pneumonia and diarrhea fell more than 60 per cent.

About six million children die around the world each year and progress in reducing that number depends greatly on India, which accounts for about a fifth of the deaths. About 29 million Indian children died between 2000 and 2015. Had the mortality rates of 2000 continued unchanged, about 39 million children would have died.

The authors noted that in the last decade the government of India has modestly increased its traditionally low level of public spending on health. The government launched a program to encourage women to give birth in hospitals and for children to have a second dose of measles vaccine.

Jha said that to meet the United Nations' sustainable development goals of halving its child mortality rates by 2030, India must maintain its current trajectory for children ages one to 59 months and accelerate declines in neonatal mortality.

Reducing the number of neonatal deaths will require efforts to reduce deaths caused by premature delivery and low birthweights, especially in poorer states, he said. Both are strongly linked to largely modifiable maternal and prenatal factors, such as health care during pregnancy, education, nutrition, anemia and tobacco use.

, leading scientists from Bangladesh and Tanzania wrote that the “Million Death Study can be a model for other countries where vital registration systems are still fragmented.”

This work received funding from the U.S. National Institutes of Health, the Disease Control Priorities Network, the Maternal and Child Epidemiology Estimation Group and the University of Toronto.

 Leslie Shepherd is a writer with , where this article originally appeared.