|DR. J. K. SEHGAL MEMORIAL ORATION
|Year : 2010 | Volume
| Issue : 2 | Page : 75-80
Strategic issues in child health
Associate Professor, Department of Community Medicine, IMS, Banaras Hindu University, Uttar Pradesh, India
|Date of Web Publication||27-Nov-2010|
C P Mishra
Department of Community Medicine, IMS, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mishra C P. Strategic issues in child health. Indian J Public Health 2010;54:75-80
The world has witnessed a significant improvement in child health. However, even today children below than 5 years of age face multiple obstacles, including birth injuries, infectious diseases, malnutrition, and home environment that lacks intellectual stimulation, and environment with polluted water and air. Several issues which pertain to the child health are discussed here.
| Child mortality|| |
Impressive gains have been made in reducing child mortality globally. Child deaths are halved from 20 million in 1960 to well under 10 million in 2009. But progress in mortality reduction is uneven geographically, with the child mortality rate increasing or remaining constant in at least 26 countries. The greatest numbers of "under 5" child deaths in the world are found in Sierra Leone, Angola, and Afghanistan, where between 257 and 270 children die for every 1000 live births.  In India, a wide variation occurs in child mortality in different regions of the country with the overall mortality rate being 74 per 1000 live births. The present neonatal mortality (39/1000 live births) has remained stationary in the last one decade. According to SRS (2008), the infant mortality rate (IMR) in the country has been 53 per 1000 live births and the IMRs for male and female children were 52/1000 and 55/1000 live births, respectively. Urban-rural differences do exist with the IMR being 36/1000 live births in the urban and 58/1000 in the rural area. 
| Childhood morbidity|| |
In India, common morbidities among children under 3 years of age are fever, acute respiratory infections, diarrhea, and malnutrition. Unfortunately malnutrition is rarely perceived as a morbid event by families, communities, and health system. The prevalence of underweight declined from 52% (NFHS-1) to 47% (NFHS-2) but this decline was only 1% from NFHS-2 to NFHS-3. Reduction in stunting was to the extent of 8% from NFHS-2 (46%) to NFHS-3 (38%).  However, there was an increase in the proportion of children who were wasted (16-19%). Besides the deficiency of macronutrients, there is enough evidence to substantiate a high magnitude of micronutrient deficiency disorders in India. Apart from the major macro- and micronutrients, there exist more than 300 nutrients, which are vital for the body. Recent evidence suggests that even mild vitamin A deficiency (VAD) probably increases morbidity and mortality in children emphasizing the public health importance of this disorder. According to NNMB (2003), the prevalence of severe forms of VAD such as corneal ulcers/softening of cornea (keratomalacia) has in general become rare. Bitot's spots were present in varying magnitudes in different parts of the country. The prevalence was higher than the WHO cut-off level of 0.5% indicating the public health significance of the problem of VAD. 
The prevalence of anemia is very high among young children. As much as 72.9% of the children up to the age of 3 in urban areas and 81.2% in rural areas are anemic. Also the overall prevalence has increased from 74.2% (1998-1999) to 79.2% (2005-2006).  Nagaland has the lowest (44.3%) and Bihar has the highest prevalence. In children (<2 years), iron deficiency anemia causes permanent neurologic damage resulting in suboptimal scholastic skills leading many of them to below average class or premature dropping out of the schools. It also triggers increased morbidity from infectious diseases. 
Iodine deficiency disorders (IDD) have been recognized as a public health problem in India since 1920s. The most devastating outcomes are increase in perinatal mortality, mental retardation, and reproductive failure and in severely endemic areas cretinism may affect up to 5-15% of the population.  Psychological problems (namely, anxiety, frustration, depression) in adolescents are increasing day by day and pose serious challenges to the families and call for vibrant and operational adolescent friendly health services.
The relevance of limiting micronutrients is given below:
The deficiency of zinc is emerging as an important public health problem. Zinc is an important nutrient for a child's growth, resistance to severe infection, and survival.
A meta-analysis of eight mortality trials indicates that improving the vitamin A status of children aged 6 months to 5 years reduced mortality rates by about 23% in a population with at least low prevalence of clinical signs of vitamin A deficiency. 
Childhood and adolescent disabilities are emerging as a serious public health threat. In one of the studies (Mishra et al. unpublished data), it was found that out of 594, 543, and 607 subjects belonging to age groups <5, 5-9, and 10-19 years, respectively, 1.8%, 10.3%, and 11.9%, respectively, had disability as per the WHO classification. There existed a significant association between the age and disability status of subjects (χ2 = 47.017, df = 2, P<0.001). The spectrum of disability included behavior disability (1.4%), communicable disability (5.7%), personal care disability (1.5%), locomotor disability (2.8%), body disposition disability (3.2%), dexterity disability (1.9%), and situational disability (2.3%).
| Key concerns|| |
- Childhood problems have been identified through special surveys and research pursuits. Benefits of health and related services can be obtained only and only if these conditions are identified by the service providers and systems are fully operational to deal with these problems.
- Low birth weight leads to greater neonatal and infant mortality, impaired physical and mental performance, and cause of adult disease in later life. Their detection and management pose several challenges.
- 5 to 10% of newborns require some resuscitation and 1% cases require resuscitation. This calls for staff and support services in position.
- The prevention of hypothermia and sepsis and the management of initial feeding problems in general and in the event of diseases (i.e., HIV) require special efforts.
- At a macrolevel, organizations of triage and emergency treatment are still in a conceptual stage.
- The involvement of private sectors in curative care should be the entry point for preventive and promotive services.
- Growth monitoring is on a low profile.
| Critical period in a child's life|| |
The most critical phase in a child's life is the intrauterine life. Here maximum growth velocity occurs and in a span of 9 months, from a single zygote a nearly 3-kg baby is born. During this phase and for subsequent 2 years, brain development takes place. Growth velocity estimates in terms of height and weight, done in a study using the mixed longitudinal design, identified 06-24 months as the critical period in the growth of a child.  The emotional bonding provided by breast feeding and tender loving care (TLC) rendered to a child in the early part of life have a tremendous influence on the psychosocial development of the child.
| Service provisions|| |
Neither Integrated Management of Neonatal and Childhood Illness (IMNCI) in major states of India nor Comprehensive Child Survival Programme (CCSP) in Uttar Pradesh has moved beyond capacity building of ASHAs and ANMs. Assessment classification and treatment of childhood and neonatal illness are not operationalized and referral mechanisms are yet to be established. It has made no perceptible dent in health care behavior and positive community practices for child care. In spite of concentrated efforts to improve RCH services in the NRHM, the achievements in the progress have not been up to the mark. This is amply highlighted by the facts that only 18.8% mothers had full antenatal checkups, institutional delivery was 47%, and 13.3% mothers received financial assistance under JSY. 
As far as child interventions are concerned, the achievements are as follows: 
- Children under 3 years breast fed within 1 h of birth: 40.5%
- Children aged 0-5 years exclusively breast fed: 46.8%
- Children aged 6-35 months breast fed for at least 6 months: 25.5%
- Children aged 6-9 months receiving solid/semisolid food and breast milk: 57.1%
- Children aged 12-23 months fully immunized: 54.0%
- Women aware about danger signs of ARI: 57.4%
- Children with diarrhea in the last 2 weeks who received ORS: 34.2%
- Children with diarrhea in the last 2 weeks who were given treatment: 70.6%
- Children with acute respiratory infection or fever in last 2 weeks who sought advice or treatment: 77.4%.
The high levels of undernutrition and persisting hunger in the region not only calls for an assessment of the situation of food production and consumption but also issues like access to food by the poor. With the objective of ensuring food security to all the people, especially the poor, the public distribution system (PDS) was a major intervention in the country. But the PDS has failed in serving its purpose. Hence, it was redesigned as the targeted public distribution system (TPDS) with effect from June 1997. Under the TPDS, higher rates of subsidies are given to the poor and the poorest among the poor. But various studies have identified major deficiencies of the TPDS such as high exclusion and inclusion errors, poor viability of fair price shops (FPS), failure in fulfilling price stabilization objectives, and leakages. The TPDS in its current form as an antipoverty program, clearly, is not doing very well. Thus there is a need to restructure and reform the TPDS. The GOI has taken measures to check the diversion of food grains and strengthen the TPDS. Global positioning system and radio-frequency identification devices are effective measures to curb the diversion and leakages. To eliminate the problem of bogus ration card, provision of food credit cards or computerization of operations has been made. Even more, further innovations are needed to strengthen the TPDS.  It is, therefore, impending upon the region to increase the productivity and production of food grains at a rate faster than the growth of the population in the future. The second challenge would be the provision of food at reasonable and cheap prices to the population so that real incomes are not depleted by unusually high market prices of food grains. Given the existing demand and supply condition, this requires a better management of food grain stocks and an effective use of the PDS.
In spite of its existence for the last 35 years, ICDS has a limited coverage and impact. ICDS has to be universalized and the current scheme does not focus on 0-3 year olds. The program needs to be restructured in a mission mode with a mission structure at the central level and a similar structure at the state level. Without prejudicing the interest of the 3-6 year olds, the focus of the entire ICDS has to shift to a much greater extent than before to the 0-3 year olds. A major factor adversely affecting the success of ICDS is leakages which at least in part are due to centralized procurement of ready-to-eat (RTE) foods. Centralized procurement of food has the additional problem of irregular supply of food in the anganwadis, and thrusting food items on beneficiaries irrespective of their taste and preferences. Very often this leads to nonacceptance or rejection of the food distributed. The food distributed has to be hygienically prepared and culturally acceptable. Micronutrients do not work unless the child and mother are consuming sufficient calories through proper quantity of fat, protein, etc. For children between 3 and 6 years of age, food diversification is necessary, that is, addition of egg, milk, fruits, and leafy vegetables to their meal. There is also a need for fortification in the diet of adolescent children especially girls. It is also a matter of concern that only 21% children of age 12-35 months received a vitamin A dose in the last 6 months. Less than 10% coverage is reported in Nagaland (8.7%) and Uttar Pradesh (7.3%). Only states such as Tamil Nadu (37.2%), Goa (37.3%), Tripura (38.0%), Kerala (38.2%), West Bengal (41.2%), and Mizoram (42.2%) have a better coverage, though substantially low. The coverage under the National Nutritional Anaemia Control Programme (NNCP) needs improvement as only 22.3% of pregnant women consumed iron and folic acid for 90 days.  National anemia control program for children has not been operationalized to the desired extent. According to NFHS-3, only 51% (urban 72%, rural 41%) of families are consuming iodized salt. 
As per the poverty line criteria based on the NSSO 61st round survey (Rs. 356 per capita for rural families and Rs. 540 per capita for urban families), 28% of the Indian population is below poverty line (BPL). On the basis of employing a new poverty line ($1.25 per day at 2005 purchasing power parity [PPP]), 41.6% of the Indian population is BPL. The field of child health is further complicated by the emergence of WHO child growth standards. By using this criterion, 15.6% of children (1-3 years) are suffering from severe malnutrition. It is considerably high in comparison to the figure of 4.2% based on IAP classification. Instead of lamenting and denying these statistics, it may be worthwhile to focus on taking urgent steps to bring down these gross income and health disparities among our populace. According to the Global Hunger Index (GHI) computed on the basis of child mortality rates, child malnutrition rates, and proportion of energy-deficient population, India ranked 66th out of 88 countries. 
| Operational efficacy of health systems|| |
India has created a wide network of subcenters, PHCs, and CHCs in rural areas. A larger number of public and private hospitals, nursing homes, and private practitioners exist in urban areas. However, community-based care in urban pockets, as in rural areas, for maternal and child health services is not up to the mark. 
The poor performance of Indian Public Health System is widely acknowledged. Analysts have attributed this failure to a number of factors, which include almost all the components that make a system functional, that is, infrastructure, human resources, logistics, and participation of the community. Because of the mission mode in National Rural Health Mission (NRHM), the execution moved at a fast pace and the professional systemic approach adopted in the mission has shown its impact. However, it has a long way to go and more innovations are required to meet the challenges. The states that have been lagging behind in the pre-NRHM period are still struggling to implement the NRHM in its letter and spirit. There is an acute shortage of all categories of staff in health sectors across the length and breadth of the nation. There are 14,851 subcenters with no ANM, 130,812 subcenters with one ANM, and 25,743 subcenters with two ANMs. There are 31.6% CHCs where specialists are in position.  However, only 25.2% CHCs have obstetricians and gynecologists. 
Enhanced funds through the central government are being utilized through the process of decentralized planning and implementation to ensure the ownership of respective state governments to the reform process. Community-based monitoring and proactive roles of Village Health and Sanitation Committees and Rogi Kalyan Samitis have restored the confidence of the community in the public health system. District action plans and convergence of key health and health-related initiatives are being ensured through the district and state health missions. The proposed financial outlay of Rs. 6207.84 crores for National Urban Health Mission (NUHM) in the 11th plan has big hopes for vulnerable sections in urban slums. 
| Innovations in NRHM|| |
A wide range of innovative approaches are being implemented by states to address identified needs/specific gaps in health services. Two hundred and eighteen innovations are documented by the mission for its stockholders and for cross-learning purposes. Innovations for safe motherhood are Birth Waiting Rooms (Andhra Pradesh), Janani Suraksha Vahini (Karnataka), Janani Express Yojana (MP), Mamta Friendly Hospital Initiatives (New Delhi), Saubhgyawati Scheme (Uttar Pradesh), and Ayushmati and Vande Matram Schemes (West Bengal). Innovations for infant and young child feeding and immunization are Bal Shakti Yojana (Madhya Pradesh), Ankur Project (Maharashtra), Panchamrit Campaign (Rajasthan), and Kano Parbo Na (West Bengal). With NRHM on, a disproportionate increase in quantity without a proportionate increase in manpower and physical facility has led to a compromise in quality. The time spent per patient is limited, and emphasis on interpersonal communication and utilization of health facility visit for health awareness has been negligible. On one side, where JSY has brought pregnant women to institutions for delivery, the recommended 48-h stay in most places could not be ensured. 
| Major issues|| |
- Concentrated efforts should be made to reduce mother's malnutrition and its knock-on effects on child malnutrition.
- Breast feeding in the first hour is the significant input for child health. If Indian mothers enhance early initiation of breastfeeding within 1 h, we can save 250,000 babies from death annually by just this action; this would reduce the overwhelming share of neonatal mortality in our IMR.
- Feeding recommendations by grassroot workers should emphasize on exclusive breast feeding for 6 months and solid food 6 months onward along with breast milk.
- Micronutrient malnutrition continues unabated in the country leading to heavy economic loss.
- Exact mapping of micronutrient deficiencies has not been done for the country.
- Existing programs do not address the problem in a holistic manner. Only nutrient supplementation programs are in existence and that too not covering the entire high-risk group.
- There is inadequate monitoring of micronutrient deficiencies in the country. NFHS undertaken every 6 years covers only anemia levels in women and children under 3 years and projects only a state-level picture. NNMB exists only in few states giving state-level projections for the eight states only.
- Dietary diversification and nutrition education have not been given the required thrust.
- Food fortification has not been studied adequately.
- Nutrition-oriented horticultural interventions to promote the production of fruits and vegetables at household and community level are yet to be taken up.
- Awareness generation on the consequences of micronutrient malnutrition, its prevention, and management is not being addressed adequately.
- Inherent qualities of Road to Health Cards is not internalized by family as well as the health system. The purpose of any growth monitoring system should be to identify the deterioration of a child on a nutritional scale at an early stage and to pinpoint regions for the same and take necessary corrective measures at the earliest.
- ICDS can check the deterioration of a child's nutritional scale; this is a very crucial input because once a child deteriorates, chances of a spontaneous recovery are very rare. 
- Green, white, and blue revolutions have contributed significantly in improving the nutritional health of the population of India. However, it can be optimized by adopting the 3A approach (awareness, access, and affordability) and empowerment of the community in the field of nutrition. The importance of nutritional education can be well appreciated by the statement "if you give a fish to a hungry person, he will eat once or twice but, if you teach him how to fish he will take care of his livelihood and will also teach others."
- Considering the diversities in the country, area-specific feeding recommendations are to be made, tested, and executed for better nutritional outcomes.
- Domestic violence may have adverse pregnancy outcomes.  Conducive and child friendly environment is the key to optimum growth and development and subsequent scholastic performance.
| Receptivity of a child|| |
Receptivity of a child in the family is the major determinant of its survival and development.  Sex-wise differences in child feeding and rearing practices, utilization of child health interventions, and health-seeking behavior during illness will reflect about child receptivity. This can be gauged by prevailing sex selective abortions, sex-specific neonatal and infant mortality, and child mortality rates.
Receptivity of the girl child can be enhanced by providing better opportunities for education, employment, and equity in all spaces of life.
| Family welfare initiatives|| |
Adverse effects of early pregnancy, multiple pregnancy, and pregnancies at short birth intervals are widely acknowledged. Issues pertaining to family planning stabilization are submerged in the ocean of NRHM. Even today, the current use of any family planning method is 47.1% (44.4% in rural and 53.0% in urban).  These are average statistics and there exist wide variations across the country. Empowered action group states have higher fertility. As high fertility and child mortality go hand in hand, concentrated efforts are required to limit the size of the family. Jansankhya Stiratha Kosh with its major strategies such as GIS mapping, website, Prema and Santhushti, and family welfare-linked health insurance schemes have tremendous potential for population stabilization. The universal insurance scheme launched in 2003 has several bottlenecks in effective implementation but it is the critical input for the poor. 
| Conclusion|| |
Urgency in planning and implementation of child health intervention is a very pertinent issue. It calls for micro-planning and micro-financing. There is a need and scope for medical and social audit for child health interventions. Reaching the unreached by adopting the indigenous, scientific, affordable, and acceptable technology through multisectoral linkages and community participation for key issues in child health should be the primary concern of all partners involved in child care. National and international organizations have shown concerns over the rights of children. In order to ensure them, attitudinal changes in the providers of child interventions and care givers at family and community levels are of paramount importance. Legislations, service provision, and empowerment through health and nutrition education are well-recognized public health approaches. Each approach has its merits and demerits. However, demand-driven strategies are better than supply-oriented strategies. Nonetheless, a holistic approach encompassing the three approaches will have a synergistic effect on child survival and development.
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