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:

1. World Population Prospects: 2008 Revision.2. Child Health Programmes in India- Major Milestones. Downloaded From URL:3. mohfw.nic.in/WriteReadData/l892s/6342515027file14.pdf4. Patra A. When will they ever learn?’: The Great Indian experience of universal

immunisation programme. Downloaded from URL: www.isid.ac.in/~pu/conference/dec_09_conf/Papers/NilanjanPatra.pdf

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

• HUNGaMA Report 2011. Downloaded from http://www.naandi.org/CP/HungamaBKDec11LR.pdf