NEW BORN AND CHILD HEALTHCARE Presented By: Dr. Dr. Ka Kalpi Kalpit lpitt Sharma Sharma Dr. Dr. Amit Amit Chhabra Chha Chhabr bra a Dr. Dr. Adit Ad Aditi itii Mittal Mitt Mittal al Anamika Anamik Anamika a Prasad Prasa Prasad d Apoorvya Apoorvy Apoorvya a Kapoor Kapoo Ka poorr Akanksha Akank Akanksha sha Sharma Sharma
Overview Definition Areas of concern National Health Programmes
RCH IMNCI UIP NSSK State Health Programmes Analysis of Health organizations at different levels Suggestions/Recommendations
Overview Definition Areas of concern National Health Programmes
RCH IMNCI UIP NSSK State Health Programmes Analysis of Health organizations at different levels Suggestions/Recommendations
What do we mean by newborn and child health care care The professional and academic field that focuses on the determinants , mechanisms and systems that promote and maintain the health , safety , well-being and appropriate development of children in community and society in order to enhance the future health and welf elfare are of sub subsequ sequen entt gener enera ation tions. s.
TERMS: Neonatal Period-Birth --> 28 days of life
IMR-
the number of infant deaths per 1000 live births
Neonatal mortality rate-the number of neonatal deaths per 1000 live births.
StateState -wise burden of neonatal deaths Neonatal Mortality burden in major states HP 0.4%
As
Hr
Kr 0.5%
TN Kn WB
As 2.9%
TN 3.8%
Hr 1.8%
Pb 1.3%
Pb
UP
Rest 1.5%
UP 26.1%
Kn 4.1%
WB
Gj4.5% Guj 4.5%
Or
MP
Mh
Or 4.7%
AP
Mh 5.6%
Bi
Rj AP 6.4% Rj 7.2%
Bi 11.8%
MP 13.0%
Estimation based on data from National Human Development Report 2001 7 & SRS 200 1
About half of child deaths occur in the neonatal
period (ICMR Study 2003) Day
When do neonates die die? die ?
Week 1
D1
74.1
1st day
20%
By 3rd day
25%
By 7th day
37%
By 28th day
50%
39.3
D2
U5 Child deaths
7.3
D3
10.2
D4
6.2
D5
5.5
D6
2.8
D7
2.8
Week 2
12.6
Week 3
10
Week 4
3.1
0
10
20
30
40
Percent (%)
50
60
70
80
National goals & MDG context 1990
I fa t Mortality Rat
80
N o atal Mort rat
53
U5M Rat
Curr
55
t
NRHM
MDG
2012
2015
<30
<27
<20
<20
-
<36
2007
37 2005
107
74 2005
Developments related to child health
1978 : EPI 1984 : UIP 1985 : Oral rehydration therapy 1 1990 : UIP and ORT universalized , ARI as a pilot in 26 districts 1992 : CSSM 1997 : RCH 1 2005 : NRHM and RCH 2
NRHM Launched in April 2005. To reduce maternal and infant mortality and To provide universal access to public health services.
Reproductive Child Health (RCH)
Programme To improve the health status of women and children, especially the poor and under served, Government of India during 1997-98 launched the RCH Programme for implementation during the 9th plan period. The second phase of RCH program i.e. RCH II has been commenced from 1st April, 2005 the five year file 2010. The main objective of the program is to bring about a change in mainly three critical health indicators i.e. reducing total fertility rate, infant mortality rate and maternal mortality rate
COMPONENTS OF RCH-II: 1. Population Stabilization 2. Material Health 3. Newborn Care 4. Child Health 5. Adolescent Health 6. RTI/STI treatment and control 7. Urban Health. 8. Tribal Health 9. Other Priority Areas: a. Targeted of services b. Strengthening service delivery c. Infrastructure and maintenance d. Supply of drugs and equipment e. Strengthening of health care providers.
RCH II HBNC NRC Facility based care SNCUs Micronutrient Supplementation Vitamin A and Iron folic acid IMNCI
HBNC-Home based newborn and childhood care
Care of Sick
New born at Home
Based on Gadchiroli Model.
Pilot in UP, Bihar, Orissa, Rajasthan and MP
Iron
and folic acid supplementation
Objectives
Screening of children for anaemia wherever required and appropriate treatment of those found anaemic Reducing prevalence of anaemia by 25% and moderate and severe anemia by 50% in children
Strategy Infants:
Exclusive breast feeding for six months, and introduction of green leafy vegetables in the seventh month
Preschool children : advocacy with regard to dietary diversification
Vitamin
A supplementation strategy
Objectives
Decrease prevalence of Vitamin A deficiency form the current 0.7% to 0.3% Strategy Infancy: to encourage colostrums feeding 1,00,000 IU dose of Vitamin A is being given at nine months Childhood: Vitamin A dose of 2,00,000I.U at 18,24,30 and 36 months of age
Integrated Management of Neonatal and Childhood illness (IMNCI) The Indian version of IMCI funded by WHOUNICEF. Component of newborn and child health strategy in RCH Phase II. IMNCI for children Management of Acute Respiratory Illnesses Management of Diarrhoea and Dehydration Management of malnutrition and growth monitoring of under fives
IMNCI country
adaptation and implementation so far
Training for IMNCI
IMNCI
status
India
Rajasthan
Number of districts where IMNCI is implemented
156
33
Total number of people trained on IMNCI (30,nov,2009)
124636
16672
Immunization
Delivering effective and safe vaccines Aim is to reduce mortality and morbidity due to VDPs. India has one of the lowest immunization (RI) rates in the world.
routine
only 43.5% of children age 12-23 months were fully vaccinated
5% had received no vaccinati ons at all
Annual birth
cohort of 24 million surviving infants
over 12.5 million underimmunized children each year
under 5 year mortality rate of 74/1000
EPI
UPI
CSSM
was launched in India in 1978 to control other VPDs. diphtheria, pertussis, tetanus, poliomyelitis, typhoid and childhood tuberculosis
It
gained momentum in 1985 Measles vaccine was included in the programme and typhoid vaccine was discontinued
UIP was merged in child survival and safe motherhood program (CSSM) in 1992-93
The Cold-chain system was strengthened Training programmes were launched extensively throughout the country. Intensified polio eradication activities were started in 1995-96
Since 1997 immunization activities are an important component of Reproductive and Child Health (RCH) program. From April 2005, immunization is an important component of RCH II under the National Rural Health Mission (NRHM).
IMMUNIZATION PROGRAM IN RAJASTHAN Deptt. Of Medical & Health services is organizing MCHN days on Monday and Thursday. On this day, the ANM, Aanganwadi workers, trained Midwife are taking parts. Microplans of all districts are prepared after training of workers/ officers jointly to organize the MCHN days. Alternate vaccine delivery system is implemented so that vaccines reaches each Aanganwadi/sub centre as per microplan. To monitor MCHN days effectively - a core group is framed at Distt. Level, Panchyat samiti level, PHC level etc. - special monitoring drive is being organized with the help of Deptt.of Women and child Welfare
RECOMMENDED IMMUNIZATION SCHEDULE FOLLOWED IN INDIA
SINo
Age
Disease
Vaccination
1
AT BIRTH
HEPATITIS B
HEP B VACCINE -I
2
AT BIRTH
POLIO
ORAL PV 0 DOSE
3
BIRTH TO 6 WK
TUBERCULOSIS
BCG
4
4 -6 WEEKS
HEPATITIS B
HEP B VACCINE -II
Remarks
DIPHTHERIA
5
6 WEEKS
PERTUSIS TETANUS POLIO
DPT-I OPV -I
DIPHTHERIA
6
10
WK
PERTUSIS TETANUS POLIO HEPATITIS B
DPT-II
*DELHI GOVT
OPV-II
RECOMMENDA
HEP B VACCINE III*
TION
DIPHTHERIA 7
14
WEEKS
TETANUS POLIO
8
24 WEEKS
9
9 -12MTHS
DPT-III
PERTUSIS
OPV- III
HEP B VACCINE IV*
HEPATITIS B
HEP B VACCINE III*
POLIO
OPV-IV
MEASLES
MEASLES
*DELHI GOVT RECOMMENDATION
*IAP RECOMMENDATION
MUMPS 10
15-18 MTHS
MEASELES
MMR*
RUBELLA DIPHTHERIA 11
18 MTHS
PERTUSIS
DPT BOOSTER I
TETANUS
OPV V
POLIO 12
24 MTHS
TYPHOID
TYPHOID*
DIPHTHERIA 13
4-5 YR
PERTUSIS TETANUS
DPT
BOOSTER II OPV -VI
*RECOMMENDED
BY DELHI GOVT & IAP ONLY *IAP RECOMMENDATION
Navjat shishu suraksha karyakram (NSSK) Launched on 15th september,2009 Focuses on:
Prevention of hypothermia Prevention of infection Early initiation of breast feeding Basic newborn resuscitation
Objectives of NSSK One trained person at institutional facility, where deliveries take place NSSK will train healthcare providers at the district hospitals, CHCs and PHCs
RAJASTHAN GOVT. Concerned Deptt Deptt:: Deptt Deptt.. Of Women & Child Development Draft XIth FiveFive-Year Plan document prepared by the Govt. of Rajasthan
Basic theme and focus: women and children children.. The main thrust ofthe XI plan To ensure survival, protection and development of Children IMR MMR Malnutrition among children in the 00 -3 years age group Sex ratio Countering Anemia (among women in the 1515 -49 years age group) Minimizing drop out rate in elementary education.
Reduction in IMR to at least 32/1000 by2012 end
At least 90 % of children to receive complete Immunization Quality essential new born care Appr. care & treatment of infants and children suffering from common illness
STA ST ATE CHILD CHILD POL POLICY ICY 200 2008 8 Child policy so as to enable systematic systematic implementation and effective effective monitoring of programmes and policies aimed at children children up to the age of 18 years.
Ensuring food and nutrition security at all levels specially keeping in mind the specific needs of children and adolescent girls. Providing quality education for all children of all categories up to secondary level. Securing for all children legal and social protection from all kinds of abuse, exploitation and neglect with a special focus on girls.
Provide essential healthcare to all children from birth to adulthood, as a right, to reduce mortality and mor bidity due to preventable causes. Strengthen maternal maternal healthcare with special focus on child c hild delivery and feeding practices. S Take care of children affected by HIV and AIDS.
Ensuring facilities of sanitation and safe drinking water. Ensure effectiv effective e teamwork of public and private partners and ensure child participation in matters relating to and decisions affecting affecting their lives.
CHILD HEALTH: APPROACH Strengthening the convergence between the Deptt. ofMedical & Health and Deptt. Of Women & Child Development . Monitoring and Evaluation Cell in the DOHFW for MCH services(in association with DOWCD) Management Information System (MIS) about children Combining the role of Sahyogini(additional worker at Anganw Anganwari ari ) with with ASHA ASHA Yashoda:Facility Yashoda:Facility based base d new-born aides Training of people in IMNCI ( 16,672) (30,nov,2009)
Well baby clinics clini cs at Distt. Hospitals (eg.Dausa (eg.Dausa DH Thurs3-5 Thurs3-5Pm) Pm)
ORS Therapy promotion Acute Respiratory Infections (ARI) awareness. Promoting institutional deliveries for minimizing MaternalMortality MaternalM Mat ernalMort ortality ality (MMR) A system for Maternal Mortality auditing being developed. re-energize -energize energize school health Strengthen and reprogramme Community based monitoring.
ICDS(INTEGRATED CHILD DEVELOPMENT Aanganwadi Centers
SCHEME) E)
Exclusive breastbreast-feeding promotion upto 6months. Promoting Infant and Young Child Feeding(IYCF) practices by encouraging colostrums feeding Complementary feeding promotion of infants aged 6 6--9 month. Provision of Nutritional supplements for < 6 years of age children
Micro Micro--Nutrient deficiency (Vitamin A, iron, folic acid, iodine, zinc) supplementation and fortification. Strengthening the Kishore Kishore Shakti Yojana Yojana for adolescent girls. State level Nutrition Mission under DWCD to coordinating with NRHM NRHM--ICDS ICDS.. Nutrition management and surveillance system. Monthly Maternal Child Health and Nutrition Day (MCHN) organized. Partnership with community and PRIs PRIs. . Malnutrition Treatment Centres (MTCs) in district hospitals/ at all levels.
CHILDREN WITH
SPECIAL NEEDS
Strengthening services and care of such children (in all concerned deptts inclu. inclu. Medical & Health and Education)
Special schools at district level with residential facilities. Close monitoring of interventions (under the Sarva Shiksha Abhiyan). Abhiyan ). Training of social workers, health workers and families for early detection of disability. Provide for counseling of children and their families. Including requirements of such children in all existing schemes for children and frame appropriate schemes for their growth and development. Dissemination of information programs and schemes related to such children
CHILDREN AFFECTED/INFECTED
BY
HIV/AIDS state-wide assessment of children infected and affected Strengthening Prevention of Parent to Child Transmission (PPTCT) services at the district level. Anti Retroviral Treatment (ART) and OI(Opportunistic Infection)treatment services at district hospitals Capacity Building in Health Care workers.
District Hospital Norms for newborn and child care : Specialist care:
Paediatrician Neonatologist Paediatric surgeon Treatment of acute childhood infections Fully equipped laboratory and diagnostic services Fully equipped blood bank Pharmacy
Paediatric wards Neonatal ICU Nursery Emergency care of newborn and children Immunization sessions Postnatal care Fully equipped operation theatre Incubator/ Warmer Phototherapy Unit Functional ambulance
Ground
reality:
Specialist are present but not in adequate number Infrastructure is adequate Manpower is inadequate No post for neonatologist and paediatric surgeon Laboratories were fully equipped and there were full dignostic
facilities including X-ray , USG , etc No. of beds in paediatric ward were inadequate as per the
patient inflow( 8 beds) Well baby clinic: On every thursday
Free consultation by the paediatrician Free gifts and toys given to children
No Neonatal ICU No incubator/warmer No phototherapy unit No nursery No instruments for emergency care of the newborn Operation theatre is also not fully equipped No facilities for neonatal and child surgeries Provisions for BPL patients were adequate Senior paediatrician post was vacant since 13 th May 2010
Community Health Center Norms for newborn and child care : Specialist care-
Paediatrician Emergency care of sick children Post natal clinics Immunization sessions National health programs
Essential laboratories and diagnostic services Referral services Internal monitoring External monitoring Standard operating procedures Standard treatment protocols RMRS
Ground
reality:
Specialist are present Manpower is adequate X-ray and hematology lab services are available No nursery Incubator/warmer is not operational due to lack of expertise Suction machine is not working Hepatitis B vaccination is not been given No aseptic conditions Due to lack of anaesthetist OT is not operational No provision for admissions of newborn and children No pediatric sphygmomanometer is available No phototherapy unit is available
Primary Health Center Norms for newborn and child care : Treatment of children with
Anaemia Diarrhoea Dehydration Postnatal care Newborn care Immunization programmes Management of low birth weight babies Fixed immunization day
BCG and Measles vaccine should be given regularly Nutrition services School health programmes Collection and reporting of vital statistics Education about health National child health programmes Promotion of safe water supply and basic sanitation Referral services Internal monitoring External monitoring
Ground
reality:
Medical officer was present There is fixed immunization day and immunization schedule is
followed as per government guidelines Physicians visit the schools once in a year Suction machine was not working No equipments in the operation theatre No AYUSH facility No technical expertise and facilities for the management of
low birth weight babies No facilities for HIV testing No facility for proper disposal of hospital waste No ambulance services
Sub Center Norms for newborn and child care : Postnatal care:
Sterlization Immunization Adolescents health School health education programmes Immunization services should be as per government schedule ORS for prevention of diarrhoea and dehydration
Treatment of minor illness like:
Fever Cough Cold Worm Facility for taking peripheral blood smear Field visit and home care National child health programmes Proper maintenance of records and register Transport facility
Ground
reality:
Medicines and vaccines were available and used appropriately MPWs and ANM visit the school twice a month and swasthya
parikshan program once a year Doctor visits the sub centre twice a month Immunization services as per government guidelines ORS is given for the prevention of diarrhoea and dehydration Treatment of minor illness is given Field visit and home care is conducted Health education to adolescents is given by health worker
SUGGESTIONS/RECOMMENDATIONS At Government level:
It should focus on the operational modalities in their action plans. It should fund for addressing inter-state and intradistrict disparities in terms of health infrastructure and indicators .
It should increase contribution to Public Health Budget, increased devolution to Panchayati Raj Institutions and performance benchmarks for release of funds. It should fund interventions like ASHA,Programme Management Unit (PMU), and upgradation of SC/PHC/CHC . It should provide adequate manpower in terms of doctors, paramedics and other administrative staff.
It should provide adequate and the required equipments to the District hospital , CHC,PHC and sub centre. It should provide adequate salaries and perks to the doctors and can even provide some extra money if the doctor is working more than the required time frame. It should develop Health MIS upto CHC level. It should prepare annual district reports on peoples health. State and national reports on peoples health to be tabled in assemblies , parliament. There should be specific protocols on the reporting of sub centres , PHC, CHC, and Disrict hospital. There should be specific protocol to monitor citizens charter.
It should conduct mid course reviews and take appropriate corrective actions It should mainstream AYUSH in public health system. It should change its approach from centralization to decentralization at the district level. It should define time bound goals and report publicly on their progress. Promotion of public private partnerships. Regulation of private sector to ensure availability of quality services to citizens at reasonable cost. Specific protocols should be made to ensure quality. It should appoint MBAs for the improved programme management.
At Panchayati Ra j Institutions level:
A program should be created which can guide and manage all public health institutions in the districts , sub centres , CHCs and PHCs. Regular auditing should be done at the CHC , PHC level A village health plan should be prepared. All health related database should be provided to the panchayats. Funds should be provided at the sub centre and PHC level. Specific protocols for the training of health workers should be developed. Health awareness programmes should be organized regularly.
At NGO level:
External evaluation and social audit should be conducted. Provision of funds. Provision of training and technical support to ASHA and various other organizations. It should conduct school health programmes and various other health awareness programmes. It should help CHC and PHC in conducting programmes which can educate people about basic hygine. It should educate people about institutional deliveries.
At Institutional level:
The medical officer incharge/ Medical Suprintendent should set some protocols for the internal monitoring which incudes: Social audit Medical audit Technical audit Economic audit Disaster preparedness audit
The incharge should set protocols for Standard Operating Procedures. The incharge should monitor citizens charter The incharge should set specific protocols for procuring equipments.
SOME DOs and DONTs
