Why Should 5,000 Children Die in India Every Day? Major Causes of Death and Managerial Challenges

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1 PERSPECTIVES presents emerging issues and ideas that call for action or rethinking by managers, administrators, and policy makers in organizations Why Should 5,000 Children Die in India Every Day? Major Causes of Death and Managerial Challenges KV Ramani, Dileep Mavalankar, Sanjay Joshi, Imran Malek, Tapasvi Puvar and Harish Kumar Executive Summary Globally, more than 10 million children, under five years of age, almost all in poor countries, die every year (20 children per minute), mostly from preventable causes. The major causes of child death include neonatal disorders (death within 28 days of birth), diarrhoea, pneumonia, and measles with malnutrition being a major contributing factor for childhood illnesses. India alone accounts for almost 5,000 deaths of under-five years children (U5) every day. In 1975, the Integrated Child Development Scheme (ICDS) was launched in the country to provide integrated health and nutrition services focusing upon the holistic development of children at the village level. Yet by 2005, 50 per cent of the children in India were still malnourished. India s neonatal mortality, which accounts for almost 50 per cent of the U5 deaths, is one of the highest in the world. India launched the Universal Immunization Programme (UIP) in Yet full immunization in India had reached only 43.5 per cent by , as per the NFHS 3 1. This paper, besides discussing the status of mortality of children and the situation of child health services, examines the managerial challenges of the child health programmes in India. There is a need for improving the management capacity amongst health service providers, specifically the planning and implementation of child health programmes such as immunization, control of diarrhoea, and pneumonia. KEY WORDS Neonatal Mortality Infant Mortality U5 Mortality Malnutrition Immunization Childhood Illnesses MDG4 Management Capacity The analysis of the trends of the past decline shows that during , India achieved a decrease in infant mortality rate (IMR) at a very low annual average rate of 1.9 per cent. To achieve Millennium Development Goals (MDG) 4, between , the rate of reduction of IMR needs to be increased to a very high level - at 6.74 per cent every year. This means that the government and the private sector need to improve the effectiveness and efficiency of the child health programmes substantially. Incremental improvement over business-as-usual will not help in achieving MDG 4. Effective and efficient management of child health programmes would require focused political and administrative attention and managerial capacity. 1 National Health Family Survey (NFHS) is a Government of India initiative. The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India. Three rounds of the survey have been conducted since the first survey in The survey provides state and national information for India on fertility, infant and child mortality, the practice of family planning, maternal and child health, reproductive health, nutrition, anaemia, utilization and quality of health and family planning services. VIKALPA VOLUME 35 NO 2 APRIL - JUNE

2 CHILD HEALTH: THE GLOBAL SCENARIO Globally, more than 10 million children under five years of age, almost all in poor countries, die every year (20 children per minute), mostly from preventable causes. A few countries account for a large proportion of child deaths and India tops this list. In the year 2000, eight countries in the world accounted for 60 per cent of all child deaths as can be seen from Table 1, while 42 countries accounted for 90 per cent of the child deaths (Black, Morris and Bryce, 2003). It can be seen from Table 1 that 40 per cent of the child deaths occurred in the four Asian countries, namely, India, China, Pakistan, and Bangladesh. Table 1: Countries with Highest Number of Child Deaths in 2000 (in million) Country Total Annual Number of Population Births Child Deaths India Nigeria China Pakistan D R Congo Ethiopia Bangladesh Afghanistan Total Source: Black, Morris and Bryce (2003). Figure 1 shows the major causes for under-five year (U5) mortality with malnutrition as a major contributing factor for the disease burden in children. It can be seen that diarrhoea and pneumonia together account for almost 45 per cent of all under-5 (U5) child deaths, and neonatal deaths (children under one month of age) account for almost 1/3rd of all the child deaths, with birth asphyxia as the major cause of neonatal deaths. What is highly unfortunate is the fact that most of these deaths are preventable through simple preventive or treatment interventions. Jones, et al (2003) have offered international research evidence on effectiveness of interventions towards curbing the major causes of under- 5 mortality. They have shown that at least one proven intervention is available for preventing or treating each main cause of death among the under-5 children, except birth asphyxia (see Exhibit 1). We have, therefore, enough knowledge about interventions to reduce child mortality, but children continue to die because these effective interventions are not reaching them due to various problems with the health service organizations including their low accessibility. Child Mortality Indicators in India Child mortality is usually measured using three indicators: Neonatal Mortality Rate (NMR less than one month), Infant Mortality Rate (IMR less than one year), and Under-5 Mortality Rate (U5MR). Table 2 lists the States and Union Territories in India, which have very high neonatal, infant, and U5 mortality rates. India is a large and diverse country with wide variations across the states on NMR, IMR, and U5MR. On the one hand, we have states like Kerala and Tamil Nadu having excellent indicators of child health, comparable with those of many developed countries. On the other hand, we have states like Orissa, Madhya Pradesh, UP, Rajasthan, and Bihar, whose child health indicators are very poor. These five states put together account for almost 40 per cent of India s total population and 60 per cent of the child deaths (Exhibit 2). Figure 1: Causes of Under-Five Mortality Others 14% Measles 1% Malaria 9% Tetanus 24% Others 15% Pneumonia 21% Malnutrition Neonatal Disorders 33% Sepsis 24% Pre-term Delivery 24% Diarrhea 22% Birth Asphyxia 31% 10 WHY SHOULD 5000 CHILDREN DIE IN INDIA EVERY DAY?

3 Table 2: States with High IMR, NMR and Under-5 Mortality Rates Name of the State NMR IMR U5 MR (SRS 2006) (SRS 2007) (NFHS-III, 2005) Madhya Pradesh Orissa Uttar Pradesh Assam Rajasthan Chhattisgarh Bihar Haryana Andhra Pradesh Gujarat Meghalaya NA Jammu and Kashmir Himachal Pradesh Jharkhand Karnataka Punjab Uttarakhand NA Arunachal Pradesh NA NA: Not Available Source: Sample Registration System (SRS) and National Family Health Survey (NFHS) III, GOI. The National Family Health Survey (NFHS) shows substantial difference in child mortality in terms of urban and rural residence, sex of the child, mothers education, caste, and socio-economic status (IIPS, 2007). This indicates gross inequity in child health conditions in the society. Immunization Programme Immunization is one of the most cost-effective interventions for preventing a series of major childhood illnesses, particularly in environments where children are undernourished and may die from vaccine-preventable diseases. Immunization has been one of the priority programmes since independence in The Government of India initiated BCG immunization against Tuberculosis in 1948, and DPT immunization of infants and pre-school children against Diphtheria, Pertussis (Whooping Cough), and Tetanus during the Fourth Five Year Plan period, (Gaudin and Yazbeck, 2006 a, b). Immunization against Polio was introduced in and against Measles in As a signatory to the UNICEF Declaration in the 40th Anniversary of the UNO, India launched the Universal Immunization Programme (UIP) in October 1985 with the goal to achieve complete immunization of children against the abovementioned six vaccine-preventable diseases by To eradicate Polio, India launched the Pulse Polio Immunization (PPI) campaign in 1995 as a vertical programme with a high degree of political commitment. In spite of this long history of immunization programmes, it is unfortunate that we have been able to achieve only 43.5 per cent complete immunization (complete immunization means a child receiving DPT, Polio, BCG, and Measles vaccines) up to Table 3 gives the coverage of immunization by each vaccine obtained from NFHS. The campaign mode of PPI is sometimes cited as one of the causes for the under-achievement of UIP goals (Bonu, Rani and Baker, 2003) Table 3: Trend of Vaccination Coverage in India: Survey-based Estimates Immunization/ Immunization Coverage Vaccination (NFHS-1) (NFHS-2) (NFHS-3) BCG DPT DPT DPT OPV OPV OPV OPV Measles All Basic Vaccines No Vaccination Source: IIPS: NFHS-1 (pp 252 ), NFHS-2 (pp 209) and NFHS-3. What is important for the success of the immunization programme is to make people aware, get them interested, and ultimately motivate them to get their children protected against the six major Vaccine Preventable Diseases (VPD). To achieve the goal of protecting the target population and reduce the incidence of diseases, it is necessary to generate demand and also to make potent and effective vaccine and immunization services available and accessible. Parents need to be convinced that immunization is valuable; they should know where and when services are available and should understand when their children VIKALPA VOLUME 35 NO 2 APRIL - JUNE

4 should receive the vaccines. Different methods and strategies are adopted to undertake the Information, Education and Communication (IEC) and Behavioural Change Communication (BCC) services. NFHS data shows that mothers, if educated, would get their children immunized. Adequate and reliable information on the occurrence of VPD is critical to help the programme managers to effectively plan the programme strategies and take appropriate remedial measures whenever necessary. Information is also required to assess the impact of the programme. The organizational structure of the State Department of Health could also be responsible for under-achievement of UIP targets (Streefland, 1995). Various barriers to high immunization coverage include lack of effective supervision of Primary Health Centre (PHC) staff by district level officers, lack of effective supply of vaccines, weak monitoring, and lack of resources and commitment of staff. Newborn Care 12 The risk of child death is the highest in the first month of life (neonatal period) and exponentially declines after that. Safe childbirth and effective neonatal care are essential for reducing neonatal mortality. Janani Suraksha Yojana (JSY) under the National Rural Health Mission (NRHM) ( ) of the Government of India has led to rapid increase in institutional deliveries; it has also led to an increased load of newborn care especially the sick newborns. For a long time, newborn care has been neglected in India at the community level as well as at the hospital level. But recently, several states have started establishing Sick Newborn Intensive Care Units (SNCU) under the assistance of UNICEF and the Norwegian Government, but the management of these units needs considerable strengthening. Facility planning of SNCU requires a good understanding of the intensive care to be provided (NRHM, 2009). Recruiting and posting highly skilled staff to provide intensive care needs appropriate planning and effective implementation. Equally important is to manage the expectations of the people who look upon SNCU to save all neonates, irrespective of the seriousness of the disease. The recent experience in establishing a SNCU in Rajasthan (Rajasthan Patrika, 2009) warns us against the unintended consequences of opening SNCU without adequate management capacity. Community-based neonatal care is still not organized even though some efforts are being made in that direction by training volunteers called ASHA to visit each neonate at home. Health and Nutrition Poverty is both a cause and an outcome of poor human development, and investments in child nutrition are being promoted as a strategy for economic development (Victoria, et al, 2008). The consequences of child undernutrition for morbidity and mortality are enormous - and there is, in addition, an appreciable impact of undernutrition on productivity so that a failure to invest on combating nutrition reduces potential economic growth. Nutritional adequacy is one of the key determinants of health and well-being of the children. Globally, maternal and child undernutrition is the underlying cause of 3.5 million deaths every year, 35 per cent of the disease burden in children under 5, and 11 per cent total days lost. Under-nutrition occurs due to protein and energy malnutrition as well as micronutrient deficiency. 2 Under-nourishment in children retards physical development and hampers the learning and cognitive processes leading to sluggish educational, social, and economic development. Ignoring undernutrition puts the longterm health and development of population at risk. India has one of the highest percentages of undernourished children in the world. In some districts, the situation of nutrition is dismal. There is frank starvation in some districts reports of starvation deaths keep appearing in national newspapers. Moreover, inequalities in undernutrition between demographic, socio-eco- 2 Protein-energy malnutrition weakens immune response and aggravates the effects of infection, and so, children who are malnourished tend to have more severe diarrhoea episodes and are at a higher risk of pneumonia. Micronutrient deficiencies cause blindness (Vit A deficiency), anaemia (Iron deficiency), and goiter (iodine deficiency). About 10 % of the deaths and DALY (The disability-adjusted life year is a measure of overall disease burden. Originally developed by the World Health Organization, It is becoming increasingly common in the field of public health and health impact assessment (HIA). It extends the concept of potential years of life lost due to premature death to include equivalent years of healthy life lost by virtue of being in a state of poor health or disability. In so doing, mortality and morbidity are combined into a single, common metric) in U5 children are attributable to micronutrient deficiencies, nearly all this burden being due to deficiencies of Vitamin A and Zinc; disease burden from iodine and iron is very less, perhaps due to effective interventions (Bhutta, et al, 2008). WHY SHOULD 5000 CHILDREN DIE IN INDIA EVERY DAY?

5 nomic, and geographic groups increased during the 1990s. In 1975, the Government of India (GoI) launched the Integrated Child Development Scheme (ICDS) to provide an integrated package of services in a convergent manner for the holistic development of children. Because of the important role of the mothers in child development, pregnant and nursing/lactating mothers were also included in the ICDS coverage. ICDS offers a package of services which includes health check-ups, supplementary nutrition, pre-school education, etc. (Exhibit 3). The decline in child malnutrition has been very slow over the last 15 years from 51.1 per cent in (NFHS- I) to 47 per cent in (NFHS-II) to 45.9 per cent in (NFHS-III), as can be seen from Exhibit 4. This slow decline is in spite of ICDS Scheme which has been functional since 1975 and rapid economic growth post Most growth retardation in children occurs by the age of two; this could be because of several reasons including high per cent of low birth weight (about 30 %). 3 The effect of low birth weight is only partly irreversible. The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing under-nutrition and its adverse effects (Jennifer Bryce, et al, 2008). Unfortunately, ICDS has not been successful in providing services to pregnant women and under-3 children. Most ICDS beneficiaries are children in the age group of 3-6 years by which time the damages due to malnutrition already start showing. Also, inequities in undernutrition do exist between the different demographic, socio-economic, and geographic groups in India, as can be seen from NFHS-I, II, and III data. Therefore it may not be possible for India to achieve the nutrition MDGs by 2015 in spite of economic growth, unless urgent measures are taken for more and better investments in child health and nutrition. More investments and better management of programmes are needed if India is to reduce malnutrition. Economic growth alone will not be enough (Gragnolati, et al, 2005). Childhood Illnesses The major causes of child deaths in India are given in 3 Compared to India, Sub-Saharan Africa has only 16 % children born underweight (Gragnolati, et al, 2005) Table 4. It can be seen that diarrhoea and acute respiratory infections (ARI) are the most serious childhood illnesses leading to U5 deaths. Several interventions are available to save the children from dying, for example, use of Oral Rehyderation Solution (ORS) for diarrhoea. However, the management of diarrhoea through ORS is not satisfactory in India. The knowledge of ORS in mothers has increased from 43 per cent in NFHS I ( ) to 75 per cent by NFHS-III ( ). However, the use of ORS has remained the same at 26.8 per cent in NFHS-II ( ) and 26 per cent by NFHS-III ( ). Table 4: Causes of Child Deaths in India in Causes Less than 1-5 Years 1 Year (%) (%) Perinatal conditions Respiratory infections Diarrhoeal diseases Other infections and parasitic diseases Unintentional injuries Malaria Symptoms, signs and ill-defined conditions Nutritional deficiencies Congenital anomalies Fever of unknown origin Digestive diseases 1.7 Others Total 100% 100% Source: Registrar General of India, Govt of India. Summary report on Cause of Death: Due to poor health service management and access, only about 2/3rd of the children suffering from acute respiratory infections, fever, and diarrhoea have received treatment at a facility or have been taken to a provider (NFHS-III). In many cases, children brought for medical consultation are found suffering from more than one ailment, making both diagnosis and treatment difficult. To address this issue, WHO and UNICEF have jointly developed generic guidelines for the treatment of childhood problems called Integrated Management of Childhood Illnesses (IMCI) (WHO, 2003). The Government of India has constituted a group of technical experts in pediatrics and neonatology and representatives from the Ministries of Health, and Women and Child Development to address the training needs for the management VIKALPA VOLUME 35 NO 2 APRIL - JUNE

6 of childhood illnesses in India, with a special focus on neonatal care. With the help of experts, it has adapted the international IMCI guidelines to develop an Indian version, known as the Integrated Management of Neonatal and Childhood Illness (IMNCI) (MoHFW, 2009), a skill-based training programme. The training is based on a participatory approach combining classroom sessions with hands-on clinical sessions in both facility and community settings. (Exhibit 5 displays the components of IMNCI trainings). Under IMNCI, all infants under two months are to be periodically assessed at home and sick children older than two months are to be assessed for common illnesses, nutritional and immunization status, feeding and other problems. The IMNCI involves the use of only a limited number of essential drugs in order to promote their rational use. The mother is given clear instructions on how to give oral drugs and to treat the child at home when hospital admission is either not required or is not possible. She is also directed to return for follow-up visits as per the IMNCI protocol. In India, IMNCI is a component of the World Bank-supported Reproductive and Child Health (RCH) II programme. It is being implemented through a joint effort of UNICEF, National Rural Health Mission (NRHM), Government of India, and other child survival partners. IMNCI was first piloted in six districts, starting in 2002 (Ingle and Malhotra, 2007). It is being rolled out nationally but the process seems to be very slow (NRHM, 2009). Overall it is seen that the child health situation in India is far from being satisfactory on many dimensions such as immunization, malnutrition, mortality, etc. Even though basic epidemiological data is known and effective interventions are available, the Indian health system is not able to deliver them to a large majority of children with effectiveness. It reflects the lack of management capacity at national, state, and district levels. MANAGERIAL CHALLENGES In India, neonatal deaths account for 50 per cent of the 5,000 U5 deaths every day one of the highest in the world. One of the key managerial challenges in India has been to implement various public health programmes for child health. While many programmes have been started early, their coverage remains low due to implementation failures. For example, India launched the Universal Immunization Programme in 1985, but the status of full immunization in India reached only 43.5 per cent by India started the Integrated Child Development Scheme (ICDS) in 1975 to provide supplementary nutrition to children and nutrition education to mothers, but 50 per cent of our children are still malnourished; nearly double that of Sub-Saharan Africa where such programmes do not exist!! The WHO/ UNICEF training programme on Integrated Management of Neonatal and Childhood Illnesses, known as IMNCI, started in India a few years ago, but the progress is slow and may take some time to make an impact on child mortality. It is really disturbing to know that much poorer countries like Nepal and Bangladesh are on track for achieving child mortality reduction target of MDG, while India will not achieve this goal even by Community-based initiatives can extend the delivery of interventions in remote areas where health services are either non-existent or non-functioning. India has not launched any major community-based demand generation initiative till very recently. In the last four years, community volunteers called ASHA s were appointed under NRHM. But such activities are not sustainable in the long run without strong political commitment and managerial leadership to support them. For example, in 1970, the Union Health Minister, Mr Raj Narayan, promoted a programme for Village Health Workers (VHW) to generate demand and provide primary healthcare at the village level. Unfortunately, with the change in government, this initiative lost political priority and was discontinued. Hence the long-term aim should be to strengthen the national health system in India, which requires substantial augmentation of management capacity and accountability. While the management of maternal health programmes requires medical interventions to bring down Maternal Mortality Ratio (MMR), the management of child health programmes requires medical attention mainly to reduce Neonatal Mortality (NMR). Reduction in IMR and U5MR can be achieved mostly through non-medical interventions at community level, mentioned in Exhibit 1. If these proven interventions can be implemented successfully, it would be possible to save several thousand child deaths. Successful implementation of simple interventions for child health requires substantial managerial capacity. Our study shows that the Government is unwilling to invest in expanding the managerial ca- 14 WHY SHOULD 5000 CHILDREN DIE IN INDIA EVERY DAY?

7 pacity which is very weak at the state and national levels (Ramani and Mavalankar, 2009). Our observations and interactions with the Health Department indicate that within the various management functions, planning is the weakest component. Planning is generally limited to fixing targets and preparing financial budgets, with very little emphasis on resources required for service delivery such as staff, medicines, and equipment, etc. For example, immunization and other child health intervention targets are decided but there is very little planning of resources except that for vaccines. Monitoring of project activities is very critical for project management to ensure effective and efficient utilization of resources for achieving the desired goals. Performance indicators for monitoring the progress of the projects should be designed and measured regularly. The current HMIS reports generated at the district level (approximately reports are generated every month) do not contain performance indicators; it only has output data. For example, the MIS report contains vaccinewise doses of immunization administered on a given population. It does not monitor performance indicators such as per cent of children fully immunized. Performance monitoring is further compromised due to the old habit of the Health Department staff and managers to exaggerate the services statistics. For example, for many years, immunization services were reported to cover above 90 per cent of the children for each vaccine but repeated surveys showed a much lower coverage. Thus generally monitoring data was used to decorate the performance further rather than finding out the exact situation at the ground level. Uncomfortable data is suppressed or under-played by the government. Monitoring and data for child health are many times not understood by health managers as they come from IAS or state administrative services or are clinical doctors without public health or child health background. There are also frequent transfers of these managers between different programmes and departments to ensure that they do not develop expertise in monitoring any particular programme. In such organizational environment, data are generally used to pressurize service providers and lower level managers to improve performance without understanding the basic bottlenecks of the health delivery system. The available data is not used for planning or decision making (NRHM, 2009). The managers do not see service delivery to mother and child as a continuum of care from pregnancy to child care. Each activity is seen as separate and unconnected and reported as such. Synergies and linkages thus get missed out. For example, neither the workers nor the supervisors connect service delivery performance during pregnancy, childbirth, and U5 period. The health system does not record mortality at each stage nor are there any efforts to measure maternal, neonatal, or infant mortality at the Block or District level so as to assess the outcome or impact of the interventions. The country still depends on SRS, which was developed in the 1960s, for finding out birth and death rates at the state level. India, being a signatory to the MDGs, has the responsibility to achieve a 2/3rd reduction in IMR by 2015 from the base year This amounts to bringing down IMR from 80/1,000 live births in 1990 to 28/1,000 live births by Given that in 2008 our IMR was 53/1,000 live births, we have achieved only 50 per cent reduction in IMR in the last 18 years since 1990, and would achieve an IMR of only 45/1,000 live births by 2015 if we continue at the same rate of reduction (business-asusual)(see Figure 2). Figure 2: Decline in IMR Source: IMR SRS Bulletins; MDG Target for IMR from Our analysis shows that India has achieved an average annual reduction of 1.9 per cent in IMR over the period It should be aiming for an annual average rate of reduction of 6.74 per cent in IMR during the period if MDG target of IMR at 28/1,000 live VIKALPA VOLUME 35 NO 2 APRIL - JUNE

8 births by 2015 is to be achieved. This is indeed a very challenging goal. To realize that, India would require substantial improvement in the effectiveness and efficiency of the child health programmes. CONCLUSION The major causes of deaths of children are well known and effective interventions are also available. India has a reasonably functional primary health care delivery system and new resources are being provided under NRHM. But it needs to develop top-level political commitment and put in more resources as well as ensure efficient management to reduce child mortality. A country cannot become a super power when 5,000 children die needlessly every day. Even the corporate sector, civil society, political parties, and the judiciary should put pressure on the government to ensure that no child dies due to any preventable cause. Exhibit 1: Child Survival Interventions with Sufficient or Limited Evidence of Effect on Reducing Under-5 Mortality Interventions for survival Causes of Death and % of Death by Each Cause of Death Diarr- Pneu- Malaria Measles Neonatal Disorders Others hoea monia Birth Sepsis Pre- Tetanus Others Asphyxia term 22% 21% 9% 1% 10% 8% 8% 2% 5% 14% Preventive Vaccine Vitamin A x x Zinc x Exclusive breast feeding Complementary feeding Clean delivery Water, sanitation, hygiene Insecticide treated material Newborn temp management Antenatal steroids Treatment ORS Antibiotics Vitamin A Zinc Anti-malarial Sufficient evidence, x Limited evidence Source: Jones, et al, Exhibit 2: Early NMR, Late NMR, IMR, CMR and U5MR across the States of India States Year 2004 Year 2005 Year 2006 Year 2007 Early Late IMR CMR U5MR Early Late IMR CMR U5MR Early Late IMR CMR U5MR Early Late IMR CMR U5MR NMR NMR NMR NMR NMR NMR NMR NMR Andhra P Assam Bihar Chhattisgarh Delhi Gujarat Haryana Himachal P J&K Jharkhand x 16 WHY SHOULD 5000 CHILDREN DIE IN INDIA EVERY DAY?

9 Exhibit 2... States Year 2004 Year 2005 Year 2006 Year 2007 Early Late IMR CMR U5MR Early Late IMR CMR U5MR Early Late IMR CMR U5MR Early Late IMR CMR U5MR NMR NMR NMR NMR NMR NMR NMR NMR Karnataka Kerala Madhya P Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar P West Bengal Total (India) Source: SRS, Exhibit 3: Integrated Package of ICDS Services Services Children under 6 Pregnant Women Lactating Women Health Check-ups Health check-ups, Ante-natal Post-natal check-ups Treatment, Referral Treatment of diarrhoea check-ups Deworming, Basic treatment of minor ailments, Referral of severe illnesses Immunization Immunizations BCG,DPT, Polio, TT Measles Health and Infant feeding practices, Infant feeding practices, Nutrition Education Childcare, Childcare, Development, Development, Use of health services, Use of health services, Family planning, Family planning, Sanitation Sanitation Supplemental Hot meal or ready-to-eat snacks Hot meal or ready-to-eat snacks Hot meal or ready-to-eat Nutrition 4 (300 calories and 8-10 gm protein) (500 calories and20-25 gm protein) snacks (500 calories and Double for malnourished children gm protein) Growth Monitoring Monthly weighing (0-3 yrs) Quarterly weighing(3-6 yrs) Weights recorded on growth charts Micronutrient IFA tablets for malnourished children IFA supplementation Supplementation Pre-school Education Early childhood care and pre-school Education(ECE) consisting of early stimulation for under-3 yr olds, and education through the medium of play for 3-6 yr olds Source: Department of Women and Child Development, Adolescent girls under Kishori Shakti Yojana also included. VIKALPA VOLUME 35 NO 2 APRIL - JUNE

10 Exhibit 4: Percentage of Children below 2 SD of Weight-for-Age as given in Three Rounds of NFHS States/UTs NFHS-1* NFHS-2** NFHS-3*** Andhra Pradesh Arunachal Pradesh Assam Bihar Chhattisgarh Goa Gujarat Haryana Himachal Pradesh J & k Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttarakhand West Bengal A and N Islands Chandigarh Delhi D and N Haveli Daman and Diu Lakshadweep Pondicherry India *NFHS 1 provides nutritional status of children below 4 years of age. **NFHS 2 provides nutritional status of children below 3 years of age. ***NFHS 3 provides nutritional status of children below 5 years of age. Sources: Nair, KRG (2000), Economic and Political Weekly, September WHY SHOULD 5000 CHILDREN DIE IN INDIA EVERY DAY?

11 Exhibit 5: Types of Training under IMNCI Type of Training Personnel to be Trained Duration Package to be Used Place of Training Clinical Skills Training Medical Officer, Pediatricians, and 8 days Physicians Package Medical College / Staff Nurses District Hospital Health Workers, ANMs, LHVs, 8 days Health Workers District Hospital Mukhya Sevikas, CDPO s and AWWs Package Supervisory Skills Training Medical Officers, Pediatricians, 2days Supervisory Skills Medical College / CDPO s LHVs and Mukhiya Sevikas Package District Hospital REFERENCES Black, E R; Morris, S S and Bryce, J (2003). Where and Why are 10 Million Children Dying Every Year? Lancet, 361 (9376), Bhutta, Z A; Ahmed, T; Black, R E; Cousens, S; Dewey, K; Giugliani, E; Haider, B A;Kirkwood, B; Morris, S S; Sachdev, H P S and Shekar, M (2008). What Works? Interventions for Maternal and Child Undernutrition and Survival, Lancet, 371, Bonu, S; Rani, M and Baker, T (2003). The Impact of National Polio Immunization Campaign on Levels and Equity in Immunization Coverage: Evidence from Rural North India, Social Science & Medicine, 57(10), Bryce, J; Coitinho, D; Darnton-Hill, I; Pelletier, D and Pinstrup- Andersen, P (2008). Maternal and Child Undernutrition; Effective Action at National level, Lancet, published online Jan 17 DOI; /S (07) Gaudin, S and Yazbeck, A S (2006a). Immunization in India : Wealth, Gender, and Regional Inequalities Revisited, Social Science & Medicine, 62(3), Gaudin, S and Yazbeck, A S (2006b). Immunization in India, An Equity Adjusted Assessment, Health, Nutrition, and Population (HNP), NW, Washington, DC: The World Bank, Available on: HEALTHNUTRITIONANDPOPULATION/Resources/ /GaudinYazbeckImmunization inindiafinal.pdf, Accessed on June 10, Gragnolati, M; Shekhar, M; Gupta, M; Bredenkamp, C and Lee, Yi-K Lee (2005). India s Undernourished Children: a Call for Reform and Action, HNP, available at siteresources.worldbank.org/southasiaext/resources/ /indiaundernourished ChildrenFinal.pdf, World Bank, August IIPS (International Institute of Population Sciences) and Macro International (2007). National Family Health Survey (NFHS- 3), : Mumbai. India. Ingle, G K and Malhotra, C (2007). Integrated Management of Neonatal and Childhood Illnesses: An Overview, Indian Journal of Comm unity Medicine, 32(2), Jones, G; Steketee, R W; Black, R E; Bhutta, Z A and Morris, S S (2003). How Many Deaths Can We Prevent This Year? Lancet, 362(9377), MoHFW (Ministry of Health and Family Welfare) (2009). Child Health Programs in India, Government of India. Available on dofw%20website/child%20healthrti.pdf Accessed on June 29, NRHM (2009). Third Common Review Mission Report, National Rural Health Mission, November 2009, pp Rajasthan Patrika (2009). 26 Deaths in 24 Days, September 30. Ramani, K V and Mavalankar, D V (2009). Management Capacity Assessment for National Health Programs: A Study of RCH Program in India, Journal of Health Organization and Management, 23(1), Streefland, P H (1995). Enhancing Coverage and Sustainability of Vaccination Programs: An Explanatory Framework with Special Reference to India, Social Science & Medicine, 41, Victoria, C G; Adair, L; Fall, C; Hallal, P C; Martorell, R; Richter, L and Sachdev, H (2008). Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital, Lancet, 371(9609), , published online January 17.DOI; /S (07) WHO (2003). Student s Handbook IMNCI Integrated Management of Neonatal and Childhood Illnesses, Geneva: WHO; 2003, WHO document WHO/FCH/CAH KV Ramani, a Ph D in Operations Research from Cornell University, USA, is a Professor at the Indian Institute of Management (IIM) Ahmedabad. Dileep Mavalankar, an MD, Dr. PH from the Johns Hopkins Universtiy, USA, is a Professor at IIM Ahmedabad. Sanjay Joshi, an MSW, has a long experience in communications and community health work, and is presently a Research Associate at IIM, Ahmedabad. Imran Malek, a Student of MPH Programme at the SRM University Chennai, is an Intern at IIM, Ahmedabad. Tapasvi Puvar, an MD, MPH from the University of North Carolina, USA, is a Research Associate at IIM, Ahmedabad and now a Regional Child Survival Officer with the Government of Gujarat. Harish Kumar is a Student of MPH at the Tata Institute of Social Sciences (TISS), Mumbai and is currently an intern at IIM, Ahmedabad. VIKALPA VOLUME 35 NO 2 APRIL - JUNE