National Child Health Programme

1. National Child Health Programme Dr Baya Kishore Assistant Commissioner (Child Health), Department of Family Welfare, Ministry of Health and Family Welfare.

2. National goals & MDG context

3. Under 5 Mortality Rates

6. Percentage of infant deaths and cumulative percentage of infant deaths

7. 2005 2000

8. Proportion of 1-year old children immunized against measles (%) Immunization of children of 12-23 months of age as per NFHS-II (1998-99) against measles was 50.7% as compared to 42.2% during NFHS-I (1992-93).As per NFHS III (2005-06), immunization level has further increased to 58.8 %. 1998-99 2005-06

9. Immunization 2005-2006

10. MDG4- Reduce child mortality • Reduce by two thirds the mortality rate among children under five (measured against baseline year 1990)

11. INDIA’S CHILD SURVIVAL FACTS • Globally India accounts for 23% of all deaths of children under 5 years. • Infant Mortality of 58 per 1000 live births. • More than 1.5 million infant deaths every year. • 64% of infant deaths occur in the first 30 days. • More than 50% occur in first 3 days.

12. Child Health Programmes 1978- Expanded Programme of immunization (EPI) 1984- Universal Immunization Programme (UIP) For prevention of deaths due to 6 VPDs 1985- Oral Rehydration Therapy Programme for prevention of deaths due to diarrhoea 1990- UIP and ORT universalized in all districts 1990- ARI Programme taken up as a pilot in 26 districts 1992- CSSM 1997- RCH-1 2005- NRHM and RCH II • The focus is a District • District Action planning • Effectiveness of policy & • coordination at District

13. National Rural Health Mission RCH Program FP MH NH-CH ADH

14. MMR decline is likely to have impact on IMR

15. RCH II: Child Health strategy IPHS Standards Capacity building Health system strengthening IMNCI Strengthening the existing interventions ASHA/HW HBNC Care at birth Facility / Home Pre Service Improved Referral Care of New born & sick children BCC AND COMMUNITY MOBILIZATION

16. Improving the Health care delivery System CHCs • IPHS prescribed(Indian Public Health Standards) • 2000 CHCs being upgraded to IPHS • Block pooling of doctors & management support

17. IMNCI-Approach in RCH-II • The IMNCI approach is the centrepiece of newborn and child health strategy in RCHI II.

18. Child Health-Approach in RCH-II • The IMNCI approach is the centrepiece of newborn and child health strategy in RCHI II. A component on the management of sick neonates and children in the inpatient setting at PHCs, CHCs FRUs will be added. Health system strengthening will be addressed effectively to ensure effective implementation

19. Causes of infant mortality in India Primary causes of neonatal deaths in India (Source: National Neonatology Forum and Saving Newborn’s lives, 2004)

20. Evidence based interventionsEstimated U5 Deaths Prevented With Universal Coverage Preventive interventionsProportion of all deaths (%) • Breastfeeding 13 • Insecticide treated materials 7 • Complementary feeding 6 • Zinc 5 • Clean delivery 4 • Water, sanitation, hygiene 3 • Newborn temperature management 2 • Tetanus toxoid 2 • Vitamin A 2 • Measles vaccine 1

21. Evidence based interventionsEstimated U5 Deaths Prevented With Universal Coverage Treatment interventionsProportion of all deaths (%) • Oral rehydration therapy 15 • Antibiotics for sepsis 6 • Antibiotics for pneumonia 6 • Antimalarials 5 • Zinc 4 • Newborn resuscitation 4 • Antibiotics for dysentery 3 • Vitamin A <1

22. Child mortality • Child mortality (CMR) has two distinctive components • Neonatal mortality – (deaths during first month of life) – account for 63% of CMR • Post neonatal mortality - (deaths from 1-12 months of life) – accounts for 37% of CMR • It is important that both components are addressed.

23. Neonatal mortality • Over half (56.4%) neonatal deaths occur in the first three days of life. • Almost three fourths (73.3%) of neonatal deathsoccur in the first week of life.

24. Adaptation of IMCI as IMNCI (Integrated Management of Neonatal and Childhood illnesses)

25. Operational Guideline for Implementation of Integrated Management of Neonatal and Childhood Illness (IMNCI) SECTION-A: The Package SECTION-:B Institutional Arrangements SECTION-C: Training in IMNCISECTION-D:Funding arrangements for IMNCI Training

26. IMNCI Package • 100% birth registration & birth weight recording. • 6 visits for LBW with weight monitoring. • 3 visits for normal weight baby. • Physical check up for all infants up to 2 months. • Visit to every sick child under 5 for check up & classification of illness. • Local treatment for all minor illness by AWW / ANM. • Timely Referral of severely sick child. • Record keeping & monitoring of each sick child.

27. Service Package provided under IMNCI • Regular assessment including examination and measurement of respiration, temperature and weight to identify sepsis, diarrhoeal diseases and feeding problems as well as other complications. • Intervention includes treatment of hypothermia, superficial infections, sepsis with oral antibiotics, care of low birth weight babies, and referral treatment for pneumonia and diarrhea in children.

28. Improvement in family and community practices • Enhancing Home based New born care • Three home visits are to be provided to every newborn starting with first visit on the day of birth (D 1) followed by visits on D 3 and D 7. • For low birth weight babies, 3 more visits (total of six visits) are to be undertaken before the baby is one month of age. • Home Visits also envisaged under HBNC package of ASHA

29. Home visit schedule under IMNCI

30. Other Districts : Existing Interventions need to be strengthened Promotion of ORT Promotion of Breastfeeding & complimentary feeding-Infant and Young child feeding Case management of Pneumonia Essential Newborn Care Vitamin A prophylaxis All Districts : Care of Newborn at birth (HBNC) **Home Visits for newborn and postnatal mothers Referral care for sick children and Newborn need to be strengthened Implementation of pre service IMNCI Child Health Strategy Districts with IMNCI

31. Convergence with DWCD • AWW involved with IMNCI • IMNCI trained AWW being authorized for using Cotrimoxazole and other oral drugs.

32. Pre Service IMNCI(National Level) • Initial piloting and evaluation was completed with WHO support • Letter sent from Secretary, Health & Family welfare to States for accelerating Pre service activities. • Training material for medical students and nurses finalized • Activities initiated with around 50 medical colleges. • Pilot training done with NCI with Nursing tutors • Under NIPI 5 states to accomplish this in all teaching institutions with WHO Support

33. IMNCI Implementation ( National level) • States started IMNCI activities ~ 20 • Districts started training activities=77 • Districts started implementation= 35 • Medical colleges teaching IMNCI= 5 • Medical colleges where faculty have been trained for pre-service IMNCI=50 (Delhi=3, Karnataka=7, Tamil Nadu=13, Gujarat=10,MP=2 Maharashtra=8 Other States=7)

34. ALL DISTRICTS Care of Newborn at birth (HBNC) **Home Visits for newborn and postnatal mothers Strengthening of Referral care for sick children and New Born 24 Hr PHC Guidelines finalized and disseminated SBA guidelines finalized and disseminated HBNC package in the final stages of development Referral care guidelines being developed and training package piloted

35. Challenge: Slow progress of IMNCI Implementation • Skill development of all health functionaries(1800-2500 Persons/District) • Collaboration/Coordination with other Departments e. g DWCD for AWW • Training site with sick newborns • Facilitator’s • Supportive supervision

36. Challenges in Child Health strategy • Need to accelerate IMR decline(IMR decline from 1980 to 1990 was 34 points (114 to 80) came down to 12 (80 to 68) points during the period 1990 to 2000) • Very slow decline in the neonatal mortality rate (10 points decline in 12 years from 50 in 1990 to 40 in 2002) • Implementing IMNCI and HBNC Package by themselves a major challenge • Resuscitation skills needs to be taught to all SBA’s in all districts • Sustaining and enhancing the momentum of CDD, ARI, IMMUNIZATION, VITAMIN A • Monitoring and feedback on Supportive Supervision

37. NSSO 60TH ROUND • Of those who needed in-patient care, four in five needed care for acute diseases (Fever, Diarrhoea, Cough, injury, minor surgery, dental care etc). • The three major illnesses that contribute to the mortality among children include fever (30%), acute respiratory infection (ARI) (19%), and diarrhoea (19%).

38. Referral care: Current Scenario • Medical officers Lack Knowledge • Equipments not available or not being used • Even those with Pediatric Background have lost skills over the years • Newborns Not being admitted • Malnutrition Management is a weak link • Oxygen and blood availability is an issue in many facilities • Equipments, lab support and drug formulations needs strengthening

39. REFERRAL CARE FOR CHILDREN IN SMALL HOSPITALS: COMPONENTS OF THE PACKAGE ETAT MANAGEMENT OF SICK CHILDREN MANAGEMENT OF YOUNG INFANT

40. Referral Hospital Referral centre CHC District General Hospital Medical college IMNCI & Immunization activities Primary PHC Clinical or Facility-based care SC Outreach Home Based Newborn Care ASHA & IMNCI Family and Community

41. Other areas of Work • On going technical assistance for providing zinc as an adjunct to ORS in the treatment of diarrhoea  in children • Development of Guidelines for managing Newborn and childhood diseases during disasters • Training guidelines for ASHA

42. National Rural Health Mission RCH Program Convergence Water, sanitation Improved Access &Quality Services PPP Public Private Partnership Decentralized Planning PRI Community Participation Medical College Quality Training & Monitoring District Referral services & disease control programmes CHC/FRU Comprehensive Obs & Child health services PHC (1Doctor3Staff Nurse) Village (ASHA, AWW) S.C (ANM)

43. Challenge is to make every mother & child count THANK YOU