Child Health in India
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Transcript of Child Health in India
Child Health in India By Vikash
Moderator: Dr. Chetna Maliye
• Introduction & History: History of Child health services in
India.Major Milestones for child health in
India.
• Child Health Statistics: Indicators of SurvivalMortality Statistics:
• National Programmes for child Health in India.
• Future Strategies.
The story of India is one of growth, gains and gaps. With an economy that is going from strength to strength, benefiting from the demographic dividend of a young and growing workforce, this largest democracy of the world is also home to the largest number of children in the world. With this growth come real gains for India’s children and women.
The situation of Children in India - A Profile, UNICEF, India, May 2011
Introduction & History:
• India: Country of Great Contrast & Complexity.
• Not only Rich vs. Poor.• Disparities b/w : Geographic regions,
Social groups, Income levels and b/w Sexes.
Introduction:• The First Five Year Plan (1951-56): Maternal and
child health Services in India.
• First country in the world to launch family planning programme .
• Till 1977 Major health activity was family planning.
• Family welfare programme included Maternal and Child Health an integral part. Vision : Reduction in birth rate has a direct relationship
with reduction in infant and child mortality .
Introduction Cont…..
• National Health Policy 1983:– Envisioned significant reduction in IMR, NMR &
U5MR by 2000.• 1985:
– Universal Immunization Programme against six preventable diseases introduced in a phased manner which covered whole India by 1990.
• 2000: Millennium Development Goal 4• 2000: National Population Policy.• 2002: National Health Policy.
MILES STONE IN MCH CARE• 1946 - Bhore Committee Recommendation
on Comprehensive & Integrated Health Care• 1951 –Family Planning Programme• 1956 – MCH Centers Become Integral Part Of
PHC.• 1961 - Department Of Family Planning
Created.• 1971 – MTP Act.
• 1974 – Family Planning Services
Incorporated MCH Care
• 1975 – ICDS Launched
• 1977 – Renaming Family Planning To Family
Welfare
• 1978 – Expanded Programme on Immunization.
• 1983 – National Health Policy envisioned significant reduction in
IMR, NMR & U5MR
• 1985 – Universal Immunization Programme
• 1990 - The ARI Control Programme was started.
• 1992 – Child Survival& Safe Motherhood Programme
• 1996 – Target Free Approach
• 1997 – Reproductive & Child Health Programme Phase-1 (15.10.
1997)
• 2000: MDG 4
• 2000: National Population Policy
• 2002: National Health Policy
• 2005 – RCH Programme Phase-2 (01-04-2005)
• 2005 – National Rural Health Mission.
Child Health: Vital Statistics
• Indicators of Child Survival:• Birth Weight.• Breast Feeding• Immunization coverage.• Child Morbidities Statistics.• Nutritional Status
• Mortality Statistics:• Neonatal Mortality• Infant Mortality• Under 5 Mortality
Indicators of Child Survival:• Birth Weight:
Figure 1: proportion of LBW
National Family Health survey – 3, IIPS, Mumbai, 2006.
NFHS 3 Overall Urban Rural10
20
30
40
50
60
70
80
90
100
21.5 19.323.3
78.5 80.776.7
< 2.5 kg.≥ 2.5 kg.
• Initiation of Breast Feeding:
Figure 2:Proportion of ever Breast fed and initiation of breast feeding (NFHS -3)
Breast feeding Practices:
Ever Breast Fed
Within Half an Hour
Within One Hour
Within A day10
20
30
40
50
60
70
80
90
100
95.7
23.6 24.3
55.3
Inititiation of Breast feeding
Percentage of children
Pre-lacteal Feeding:
Figure – 3: types of prelacteal feeding (NFHS -3)
Figure- 4: Infant and Young children Feeding
Immunization Coverage:
Figure- 5: Immunization coverage
Fully Immun-ized
Measles BCG Immunization Card Available
0
10
20
30
40
50
60
70
80
90
100
42
50.7
71.6
33.7
43.5
58.1
78.1
37.5
61
74.1
86.9
51.5NFHS - 2 NFHS - 3CES - 2009
Figure -6: Immunization status wealth quintile (CES-2009)
Figure 7: Immunization status state wise (CES -2009)
Child Morbidity Statistics:Figure -8: ARI, Fever and Diarrhea cases
ARI Fever Diarrhea05
101520253035404550
19.3
29.5
19.2
5.8
14.9
9
18.815.5
NFHS - 2NFHS - 3CES - 2009
Nutritional Status:
Figure – 9: Percentages of underweight, wasted and Stunted Children
Figure-10: Proportion of Children Underweight, stunted or wasted according to age.
Recent: Hunger and Malnutrition (HUNGaMA)Report• By the Naandi Foundation. Recently released by the Prime
Minister.• Sample Size: Survey of more than one lakh children
across six States.• 112 rural districts (included 100 Focused) (Bihar,
Jharkhand, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh).
• Key Findings:• 42% of under-five children severely or moderately
underweight. Decreased from 53 to 42% in last 7 years.• 59% of underweight children moderate to severe stunting• About half of stunted are severely stunted. • About half of all children are underweight or stunted by two
years.
• Prevalence of malnutrition is significantly higher among children from low-income families, Muslim or SC/ST
• Birth weight is an important risk-factor for child malnutrition. The prevalence of underweight among LBW is 50%.
• Among Birth weight above 2.5 kg is 34%.
• Nutrition advantage girls have over boys in the first months of life gets reversed over time as they grow older.
Figure-11: Coverage along the Continuum of care (CES-2009)
Mortality Statistics:Figure- 12A & B: Trends of Neonatal Mortality (Source -
8)
1980
1985
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
0102030405060708090
100
6960
53 51 50 47 48 48 47 46 45 45 44 40 40 37 37 37 37 36 35
Neonatal Mortality rate
1980
1985
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
01020304050607080
6960
53 51 50 47 48 48 47 46 45 45 44 40 40 37 37 37 37 36 35
Neonatal Mortality rate
Figure- 13A & B: Trends of Infant Mortality Rate
1980
1985
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
0
20
40
60
80
100
120 114
97
80 80 79 74 74 74 72 71 72 70 68 66 63 60 58 58 57 55 53
Infant MortalityRate
1980
1985
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
020406080
100120 114
9780 80 79 74 74 74 72 71 72 70 68 66 63 60 58 58 57 55 53
Infant MortalityRate
Figure -14: Infant Mortality rate by demographic criteria
Figure -15A & B: Trend of Under 5 Mortality
1970 - UNICEF- WHO
1990 - UNCEF - WHO
2000- SRS 2006 - NFHS 2009- SRS0
40
80
120
160
200 186
11893
74 66 U5MR
1970 - UNICEF- WHO
1990 - UNCEF -
WHO
2000- SRS 2006 - NFHS
2009- SRS0
20406080
100120140160180200
186
11893
74 66 Series1
Child Health Programmes India:
National Family Planning Programme:
• Launched in 1951.• Emphasised on Population control Measures.• Specific objective :
– "Reducing the birth rate to the extent necessary to stabilize the population at a level consistent with the requirement of the National economy”
• Approaches: Before 1961 census:
• Clinical approaches: Facilities for provision of services were created.
After 1961:• Extension and Education Approach:
1969: To reduce birth rate from 35 per thousand to 32 per thousand by the end of 4th Five year plan.
• V plan (1974-79):– Birth rate to 30 per thousand by the end.– Integration of family planning services with those of
Health, Maternal and Child Health (MCH) and Nutrition. • 1975-77:
– Emergency declared in the country and forceful and coercive measures used for sterilization.
• 1977 – Programme Renamed as Family Welfare
Programme:– Maternal & Child Health Became one of the
Components.
There after the programme continually ran as voluntary programme.
• Started in 1978.• Objective: To prevent death due to dehydration caused by diarrheal
diseases among children less than 5 years of age.• Oral Rehydration Therapy (ORT) program was started in
1986-1987.• Later on Diarrheal Disease control is part of child health
strategies all along.
DIARRHEAL DISEASE CONTROL PROGRAMME:
Universal Immunization Programme:• 1975: WHO launched “ Expanded Programme on
Immunization. (EPI)”• 1978: Alma Atta conference ; Immunization recognized as a
strategy for “Health For All”.• Government of India launched EPI in 1978.• 1985: UNICEF pledged for “Universal Child Immunization”• 1985-86 : Govt. of India launched “Universal Immunization
Programme”.• Objective:
– To cover at least 85 percent of all infants against the six vaccine preventable diseases by 1990.
– To achieve self-sufficiency in vaccine production and the manufacture of cold-chain equipment
• UIP become a part of the Child Survival and Safe Motherhood (CSSM) Programme in 1992 and Reproductive and Child Health (RCH) Programme in 1997.
• Started in 1990. • Sought to introduce scientific protocols for case management
of pneumonia with Co- trimoxazole.• Since 1992 the Programme implemented as part of CSSM
and later with RCH. • Under RCH-II : Implemented in an integrated way with other
child health interventions. • IMNCI, ARI is managed according to IMNCI Guidlines.
ARI control Programme:
Child Survival and safe Motherhood Programme:• Launched in 1992. • Objectives:
– Increase child survival.– Promote safe motherhood, including establishing first
referral units (FRUs) for secondary-level care of mothers and their newborn.
– Strengthen the delivery of services by improving institutional capability.
• Results: – The overall objectives were partially met. – Discontinuation of practice of setting fertility reduction
targets and increased emphasis on MCH. – Not only were ongoing MCH activities sustained, but the
range of services increased.
Reproductive and Child Health Programme:
• 1997: RCH Programme launched.• Integration of Child Survival and Safe Motherhood (CSSM)
Programme with other reproductive and child health (RCH) services.
• Aims & Objectives: Overall aim is to reduce infant, child and maternal mortality, Specific objectives:
• Improve management performance by "participatory planning approach“ and institutional strengthening for timely, coordinated utilization of resources;
• Improve quality, coverage and effectiveness of existing FW services.
• Expand the scope and content of existing FW services to include more elements.
• Selected disadvantaged districts and cities, increase access by strengthening FW infrastructure while improving its quality.
Outcome regarding Child Health Components: RCH Programme
IMR NMR Immunization - RHS
Insitutional Deliveries
0
10
20
30
40
50
60
70
80
90
100
71
4649.5
34
62
40
54.249.5
19972002
2000: Millennium Development Goals:• GOAL 4: Reduce Child Mortality• Target:
4 a: Reduce by two thirds, between 1990 and 2015, the mortality rate of children under five.
Under-five mortality rate. Infant mortality rate. Proportion of 1 year-old children immunised against
measles
• National Population Policy 2000: Reduce IMR to 30/1000 live births• National Health Policy 2002: Reduce IMR to 30/1000 by the year 2010.
Reproductive and Child Health Programme 2:• launched 1st April, 2005. • Objective:
– Reducing total fertility rate, infant mortality rate and maternal mortality rate.
• Child Health Interventions of RCH 2:– Guiding principles:
• Evidence-based interventions.• Integrated approach.• Equity-driven implementation and monitoring.• Rational mix of family-centered (home based), population
centered (outreach) and individual-centered (clinical) interventions.
• Decentralized priority setting and phasing at the state and district levels.
• Participation from private sector
The objectives of the newborn and child health strategy:
– Increase coverage of skilled care at birth.
– Implement, by 2010, a newborn and child health package of preventive, promotive and curative interventions using comprehensive IMNCI approach at:
• Sub-centres.• Primary health centers.• Community health centers.• First referral units
– At the household level in rural and poor peri urban settings in at least 125 districts (through AWWs / LVs / ASHAs)
• Implement the medium-term strategic plan for the UIP (Universal Immunization Program).
• Strengthen and augment existing services in areas where IMNCI is yet to be implemented.
Newborn Intervention:• Scenario-based approach on prioritizing newborn
health strategies:• Key Issues in Managing Sick Newborn and children:
– Promote early recognition of sickness, including severe malnutrition
– Promote healthy household practices and avoid harmful practices
– Promote early care seeking– Ensure access at the community level to a provider who
can manage/refer sick neonates/and children– Promote community/home-based care of mild to
moderate illnesses that require no referral
– Promote appropriate referral and ensure safe transport of neonates/children with severe disease
– Make ORS more widely available, close to the source of demand
– Involve AWWs as the first contact provider for sick neonates/children
– Enable AWWs to treat children with diarrhoea and ARI with ORS and cotrimoxazole, respectively
– Enable ANMs to use gentamicin to treat neonatal sepsis– Ensure functional PHCs, CHCs and FRUs to cater to the care of
sick– neonates/children– Ensure care of sick neonates/children of BPL families in private
facilities
Breastfeeding and complementary feeding:Promotion of Exclusive Breast Feeding and appropriate
Complementary feeding.
IMNCI ‘Plus’
• Need to add the inpatient care component for facilities.• IMNCI package would still not cover the vital care of the
neonates at birth in home and facility settings.• IMNCI approach includes only counselling for immunization. • The implementation of immunization in India cannot be
adequately done by the IMNCI contacts alone. Therefore, a comprehensive immunization plan will be
required. • ‘The IMNCI Plus’ to combine the wider, comprehensive
range of interlinked interventions that form the newborn and child health component of the RCH Phase II program.
Navjaat Shishu Suraksha Karyakram:• High Neonatal Mortality Rate despite
substantial reduction in childhood and infant mortality
• Nearly two-thirds infant deaths each year occur within the first four weeks of life, and about two-thirds of those occur within the first week.
• A new programme on Basic Newborn Care and Resuscitation.
• Training course of 2 Days on :– Basic newborn resuscitation -1Day.– Basic newborn care-1Day.
• Medical officers, Nurses & ANMs: responsible for conducting deliveries and managing newborn babies
• Based at health centres (CHCs/FRUs/24x7 PHCs) and small hospitals (not referral hospitals)
Child Health Strategy Under RCH 2.
ASHA /HW
IPHS / Capacity Building Of Staff
Trained Person
at Instituti
onal
Key Strategies Under RCH 2:
• Skilled care at birth• IMNCI• Training for IMNCI• Health System Issues: Strengthening facilities for care of newborn infants and
children CHCs and FRUs will be strengthened.• Ensuring referral of sick neonates and children• Permitting ANMs and AWWs to administer selected antibiotics• Other health system issues Strengthening of health infrastructure Uninterrupted availability of drugs and supplies High quality supervision and monitoring Ownership of the state and district level program managers• Efficiency of the administrative/ financial system
Where We stand Now?
Target Under 5 MR
Current Status 2011
IMR Current Status
MDG 39 by 2015
66 28 by 2015
50 (SRS 2011)
NPP 200 < 30 by 2010
50
NRHM < 30 by 2012
50
Future Strategies:• Child Health Strategies for 2011 – 15: MOHFW, GOI.
• STRATEGIC APPROACH-1: – Expand household and community care of newborns and
children:– Expand role of community health workers on community based
care of newborns and children: – Set up sub-center clinics on fixed time to ensure ambulatory
management of sick newborns and children.– Design and Implement a behavior change communication
(BCC) plan for newborn and child health and nutrition. – Expand coverage of VHNDs and basket of services for newborn
and child health.– Orient RMPs & AYUSH practitioners on detection and
management of childhood illnesses and growth promotion.– Strengthen community based nutritional interventions.
STRATEGIC APPROACH-2:
• Improve facility based care of newborns and children
– Prepare and implement facility-specific plans for improving quality of care for newborns and children as per the revised Indian Public health Standards (IPHS).
– Build capacity of health providers.– Strengthen referral of newborns.– Equip health facilities to support 48-hr stay of mother-
newborns.– Engage private sector facilities for management of sick
newborns and children. – Integrate newborn and child healthcare in social
insurance schemes.– Develop surveillance sites for monitoring of Perinatal
and neonatal mortality.
STRATEGIC APPROACH-3:• Strengthen care of girls and women across the life-cycle for
improved newborn and child health.– Improve healthcare and nutrition of adolescent girls and young
women.– Promote spacing of 3 years between two childbirths.– Improve quality of skilled care at birth and expand post-partum
care.
• STRATEGIC APPROACH – 4: Build linkages to address emerging threats to child health
(urbanization and children with special needs)– Improve access and quality of newborn and childcare for urban
poor.– Expand the scope and focus of NCD programmes to include
child health concerns.– Address the special needs of children with congenital heart
diseases, congenital syphilis, Thalassemia, Hemophilia, Rheumatic heart disease and disability.
Enabling actions:• Ensure adequate number and skilled human resources:
– Multi-skilling of MOs for newborn and child health– Engaging AYUSH doctors in newborn and child health:– Empowering nurses for newborn and child health at facilities:– Explore introduction of nursing aides for newborn and child care
in facilities– Building skills and capacities of health providers for newborn
and child health:
• Ensure adequate supplies and equipment:• Improve planning, management, support and oversight
mechanism:• Establish a strong operations research programme • Promote partnerships for child health
• Linkages and Convergence:– Linkages with other health programmes– Linkages with other sectors
Janani Shishu Suraksha Karyakram• Launched on 1st June 2011.Entitlement for Pregnant Women
Entitlement for Sick New Born till 30 Days after Birth
Free and Zero Expense Deliveries and Caesarian Section
Free and zero expense treatment
Free Drugs and Consumables Free Drugs and Consumables
Free Essential Diagnostics (Blood, Urine, USG
Free Essential Diagnostics
Free diet up to stay in Hospital (3 days for normal and 7 days for C. s.)
Free provision of Blood
Free provision of Blood Free transport from Home to Health Centre
Free transport from Home to Health Centre
Free transport to higher centre for referral
Drop Back to home from health centre after 48 hrs. stay
Drop Back to home from health centre.
Free transport to higher centre for referral
Exemption from all user charges
Exemption from all user charges
References:
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5. Newborn and child health in India: Problems and interventions: Downloaded from URL: www.whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_Bg_P2__Newb rn_and_child_heal
6. Child Health — India Development Gateway: Downloaded From URL:7. www.unicef.org/india/children_2355.htm - 18k.8. The situation of Child Health in India- A Report. UNICEF, New Delhi.2011.9. NATIONAL FAMILY WELFARE PROGRAMME: Downloaded from URL:
pbhealth.gov.in/pdf/FW.pdf10. FAMILY WELFARE PROGRAMME: Downloaded from URL:
planningcommission.nic.in/plans/mta/mta-9702/mta-ch17.pdf –11. Child Survival and Safe Motherhood Project: World Bank Report.
web.worldbank.org/external/projects/main?pagePK=64283627&piPK=73230&theSitePK=40941&menuPK=228…
• Oestergaard M Z, Inoue M, Yoshida S W, M Retno, Gore FM. Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities. PLoS Med 8(8): e1001080.
• National Family Health Survey 2. IIPS, Mumbai. • National Family Health Survey 3. IIPS, Mumbai.• Reproductive and child Health Programme 2: National Programme Implementation Plan.• National Rural Health Mission: Mission Document.• Newborn and child health strategies 2011- 15. Ministry of Health and Family Welfare, GOI.
2011.• Navjaat Shishu Suraksha Karyakram Training Manual. MOHFW, GOI.• Bhutta Z A, Chopra M, A Henrik, Berman P, Boerma Ties, Jennifer Bryce et. Al. Countdown
to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival. Lancet 2010; 375: 2032–44.
• National Health Policy 2002: India. • National Population Policy 2000: HUNGaMA Report 2011. Downloaded from• S Ramji. NCMH Background Papers· Burden of Disease in India. • MOHFW, GOI. Guidelines for Janani Shishu Suraksha Karyakram. Downloaded from:
http://202.71.128.172/nihfw/nchrc/index.php?q=content/government-guidelines-guidelines-janani-shishu-suraksha-karyakaram-jssk-new
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