CHILD HEALTH STRATEGY RCH II/NRHM

National goals & MDG context

19901990 CurrentCurrent NPPNPP

20102010

MDGMDG

20152015

Infant Infant Mortality RateMortality Rate

8080 5555(2007)(2007)

<30<30 <27<27

Neonatal Mort Neonatal Mort raterate

5353 3737(2005)(2005)

<20<20 <20<20

U5M Rate U5M Rate 107107 7474(2005)(2005) -- <36<36

39.043.448.6

57.0

78.5

67.6

1

74.3

94.9

109.3

0

20

40

60

80

100

120

NFHS 1(92-93) NFHS 2(98-99) NFHS 3(05-06)

Neo- natal mortality Infant mortality #REF! Under f ive mortailty

Perceptible decline in U5MR (Needs acceleration to >7 points to achieve NRHM goals)

Slow decline in IMR Slower decline in the neonatal mortality

NFHS

69 70 67 67 66

60 60 58 57 5653 51 50

47 48 47 46 45 45 4439 37

0

10

20

30

40

50

60

70

801980

1982

1984

1986

1988

1991

1993

1995

1997

1999

2004

NMR

NeonatalNeonatalMortality RateMortality Rate

Source: SRS dataSource: SRS data

15%15%

25%25%

1980-19901980-1990

1991-20001991-2000

About half of child deaths occur in the neonatal About half of child deaths occur in the neonatal period (ICMR Study 2003)period (ICMR Study 2003)

When do neonates die When do neonates die die?die?

3.1

10

12.6

2.8

2.8

5.5

6.2

10.2

7.3

39.3

74.1

0 10 20 30 40 50 60 70 80

Week 4

Week 3

Week 2

D7

D6

D5

D4

D3

D2

D1

Week 1

Percent (%)

DayDay U5 Child U5 Child deathsdeaths

1st day 20%

By 3rd day 25%

By 7th day 37%

By 28th day

50%

Child/Neonatal deaths and the Millennium Development Goal 4

Millennium Development Goal 4 can only be achieved if neonatal deaths are addressed - missing from current programmes

050

100

150

Glo

bal m

orta

lity

per 1

000

birt

hs

1960 1980 2000 2020Year

Under-5 mortality rate

Late neonatal mortality

Early neonatal mortality

Target for

MDG-4

IMR

tre

nd

s`

IMR

tre

nd

s` RCH II

The challengeThe challenge

80 80 79

74 74 7472 71 70 70

6866

64

55

48

0

10

20

30

40

50

60

70

80

90

1990 1992 1994 1996 1998 2000 2005 2010 2015

IMR

per 1

000

live

birt

hs

Present trend

Desired trend for NPP goal

Desired trend for MDG

MDGExpectation

NPPGoal

6360

58

2002

UP26.1%

MP13.0%

Bi11.8%

Rj7.2%

AP6.4%

Mh5.6%

Or4.7%

Guj4.5%

WB4.5%

Kn4.1%

TN3.8%

As2.9%

Hr1.8%

Pb1.3%

Kr0.5%

HP0.4%

Rest1.5%

Neonatal Mortality burden in major states

Estimation based on data from National Human Development Report 2001 & SRS 2000

UP:Uttar Pradesh;MP:Madhya Pradesh;Bi:Bihar;Rj:Rajasthan;Mh:Maharashtra;Or:Orissa;WB: West Bengal; Kn:Karnataka,TN:Tamil Nadu;As: Assam;Hr:Haryana;Pb:Punjab;Ke:Kerala;HP:Himachal Pradesh

State-wise burden of neonatal State-wise burden of neonatal deathsdeaths

UP

Mh

APRj Bi

MPOr

Gj

WB

Kn

TNAs Hr Pb

Estimation based on data from National Human Development Report 20017 & SRS 2001

MOST CHILD DEATHS ARE PREVENTABLEMOST CHILD DEATHS ARE PREVENTABLEUniversal coverage with Universal coverage with a few a few interventions can prevent interventions can prevent over over

1.2 million deaths this year1.2 million deaths this year

Prevention Intervention

Deaths prevented as proportion of

all child deaths

Breastfeeding 13%

Insecticide-treated materials

7%

Complementary feeding 6%

Zinc 5%

Hib vaccine 4%

Water, sanitation, hygiene

3%

Vitamin A 2%

Source: Jones et al Lancet CS series

MOST CHILD DEATHS ARE PREVENTABLEMOST CHILD DEATHS ARE PREVENTABLEUniversal coverage with Universal coverage with a few a few interventions can prevent interventions can prevent over over

1.2 million deaths this year1.2 million deaths this year

Treatment Intervention

Deaths prevented as proportion of

all child deaths

Oral rehydration therapy 15%

Antibiotics for pneumonia

6%

Antimalarials 5%

Zinc 4%

Antibiotics for dysentery 3%

Source: Jones et al Lancet CS series

New Born & Child Health Key Strategies

1. Increase coverage of skilled care at birth for newborns in conjunction with maternal care

2. Implement, by 2010, a newborn and child health package of preventive, promotive and curative interventions using a comprehensive IMNCI approach

New Born & Child Health Key Strategies under RCH II/NRHM

3. Strengthen and augment existing services (care at birth/Essential New born /care, ARI and diarrhea control) in areas where IMNCI is yet to be implemented.

4. Implement the multi year strategic plan for the UIP (Universal Immunization Program)

CHILD HEALTH INTERVENTIONS

• Essential new born Care• Integrated management of neonatal

and Child hood Illness• Exclusive Breast Feeding and Timely

introduction of complimentary Feeding

• Immunization

CHILD HEALTH INTERVENTIONS

• Vitamin A and Iron and folic acid supplementation

• Early detection and management of ARI/ diarrhoea and other infections

• referral care • pre service training

CHILD HEALTH Interventions Essential New born Care

•Initiation of early breast feeding.

•Rooming/ keeping baby warm

•Resuscitation.•Infection prevention

•Immunization

CHILD HEALTH Interventions- Breast Feeding

•Early Initiation•Excusive

feeding till 6 months•Starting

Complementary feeding at 6 months

CHILD HEALTH Interventions - Diarrhoeal disease

•Increase ORS Use rate /addition of Zinc

•Prevention of diarrhea

(Safe Water, Contd. feeding)

•Rational drug usage

CHILD HEALTH Interventions - ARI Management

•Early recognition of fast breathing•Cotrimoxazole

administration for Pneumonia

•Rational drug usage

CHILD HEALTH Interventions - Immunizations

•Complete Immunization

schedule in first year

•Supplementation of Vitamin A and Iron

CHILD HEALTH Interventions – Integrated Management of Neonatal and childhood Illness

•Appropriate care of sick new born and sick child.

•Recognition of Danger Signs•Counseling

on Breast Feeding and Nutrition

CHILD HEALTH Interventions – Referral / Facility Care

•Care of Sick New born /Child

•Emergency Assessment /Care.•Management of

Malnutrition.Pilot in MP

Interventions – Home Based Care

•Care of Sick New born at Home

•Based on Gadchiroli Model.•Pilot in UP, Bihar, Orissa,

Rajasthan and MP

Child health Indicators 1. Infant Mortality Rate/Under five

mortality Rate.

2. % of children visited within 24 hrs of and on 3rd and the 7th day of delivery by a trained provider.

3. % of children who were breast fed within 1 hr of delivery and exclusively for 6 months.

4. % of children fully immunized.

Child health Indicators 6. % of children with Anaemia and who

received IFA syrup.

7. % of children with ARI and % of children with ARI who received antibiotic and were referred to health centre.

8. % of children with diarrhoea who received ORS and were referred to health centre.

9. % of children who have received Vit A all nine doses

Methodology

• Analysis of: NFHS I, II, III, DLHS III, MIS, on CH indicators

• Assessment of field visits to States.– Visits to health facilities (District Hospitals,

CHC/FRU, PHC, SC– Meetings with health providers at State and district

level– Meetings with NGO’s and other stakeholders.– Meeting with beneficiaries and community

TRENDS IN CHILD HEALTH

States:Early initiation of Breast Feeding

5.8 10.620.8

7.420.3

10

-10.1

24.2 19.3

-7.6

28.3

-1.9

8.5 11.3

-20

0

20

40

60

80

100

Initiation Breast Feeding DLHS-3 (2007-08) Initiation Breast Feeding DLHS-2 (2002-04)

Initiation Breast Feeding Difference

Exclusive Breast Feeding• All states show improvement except UP, Goa and AP • 3 better performing States

Exclusive B-fd » Jharkhand (49.7%)» Chhattisgarh (43.2%) » Orissa (43.1%)Performance of other States» Kerala ( 22 % )» T.N (23 %)» A.P. ( 33%)» Goa (28%)» Puducherry (26 %)

• Bihar reported least exclusive breast fed children (12%)

No state has achieved rate of 50%

Fully Vaccinated Children (13-24 months)

0

10

20

30

40

50

60

70

80

AndhraPradesh

Bihar Chhattisgarh Jharkhand MadhyaPradesh

Orissa Rajasthan Uttar Pradesh

Per

cent

age

DLHS-2 (2002-04)

DLHS-3 (2007-08)

Immunization indices are improving

Immunization Drop out RatesBCG - Measles

0

5

10

15

20

25

30A

ndhr

a P

rade

sh

Bih

ar

Chh

attis

garh

Jhar

khan

d

Mad

hya

Pra

desh

Ori

ssa

Raj

asth

an

Utt

ar P

rade

sh

Per

cent

age

High drop out rates(>15%)

remains critical issue in Bihar, MP and UP

Training - Child health

TRAINING SATES DISTRICTS NO. TRAINED

IMNCI 28 145 135000

PRE SERVICE IMNCI

6 STATES-60 MEDICAL COLLEGES

4000

Home visits for New Born across several districts*

63% Home visits on day-1 of reported births61% 3 home visits in first 10 days

*

Implementation information available from limited districts

Initiatives in Pipeline

• F-IMNCI (IMNCI and Facility based care in the process of finalization)

• Newborn Health Care strategy on the anvil

• School Health Programme• Pentavalent Vaccine

Innovative Schemes• District Child Health Co-ordinator (Rajasthan,

MP, Orissa)• ISO certification of District Hospitals. Standard

Protocols for New Born and Sick New Born at District Hospitals (Gujarat)

• New Born Care Kits (2 Baby Mattresses; 4 Baby Jackets; 3 Baby Caps; 3 pairs of Gloves; 12 Baby Diapers and 8 Baby Blankets) (AP)

• Health information help line

Way Forward

• Strengthen Care at birth (Essential Newborn care) at all facilities (logistics and capacity)

• Scale up IMNCI

• Training pace (In Service / Pre Service )• Implementation ( in districts )• Supportive supervision • Reporting & monitoring

• Accelerate facility based care for sick newborn and children with standard protocols

• Intensify BCC for Child Health: feeding practices, ORT, ARI, newborn care practices

• Training of health providers in non-IMNCI districts on newborn care, ARI and Diarrhea