1. Child Heath- status and Initiatives in Gujarat Dr Siddharth Nirupam

2. Presentation outline Current Status of Child Heath Mortality trends Causes of Child Death Child Nutrition Priority intervention (within continuum of care) Programme Thrust- Reaching the Unreached Where are the unreached- mapping and HP areas Why they are not reached- barrier identification and action

3. Trend of Infant Mortality Rate (IMR) in Gujarat Source: SRS Infant Mortality Estimates

4. Causes of under- Five Death

5. Too Thin for AgeToo Thin for Height Normal % [Green] Severe Under Weight % (Red ) Moderate Under Weight % [Yellow ] Moderate Acute Malnutrition (MAM) % Severe Acute Malnutrition (SAM) % 44.6 % Underweight (%) 55.4 % 28.3 % 16.3 % 5.8% 12.9 % 18.7 % Wasting (%) Source:- NFHS- 3 (2005-06) Child Nutrition Status - Gujarat

6. 1. Improving new born care – Home and facility 2. Diarrhea and Pneumonia - Prevention & Management 3. Routine Immunization with equity focus 4. Child Nutrition- IYCF; Malnutrition management Priority Interventions for Child Health

7. Gujarat’s Child Health Programme within Continuum of Care Pregnancy Delivery Newborn Infant Time Period KPSY-1 KPSY-2KPSY-3 3 levels of care- Family care, outreach, Facility VHND – Mamta Abhiyan, e Mamta JSSK, FRU FBNC NSSK IMNCI Plus Adolescent Chiranjeevi Yojana JSY RSBY Bal SakhaExt. BalSak (Trbl Bloks) MA Follow up of LBW & SCNU Discharged EMRI-108 Khilkhilat N U T R I T I O N M I S S I O N

8. Evaluated Achievements of key Interventions across life stages- Gujarat Data source: CES 2009;DLHS 3 Adolescen ce Pre-preg Pregnan cy Delivery Postnatal Neonatal Infancy (%-National Average)

9. Newborn Care Continuum By 34,000 ASHA at home Co-ordination with other departments Home based NB Care Linkages with 108, Free drop back for Mother & Baby (JSSK) Strengthening of inter-facility Transport Emergency Medical Transport Newborn Care Corners NBCC-562 units; Newborn Stabilization Unit NBSU -153 in FRUs/CHCs Sick Newborn Care Units SNCU : 34 units in DH, MC, NGO Availability of skilled HR- Bal sakha Yojana Facility Based Newborn Care

10. Role of Private Sector - (Diarrhoea) ORS Use Rate Curative care & Private Sector CES -2009

11. Undernutrition in Gujarat coverage of 10 proven interventions for its reduction Source: DLHS-3, 2007-08, *NFHS-3 data (2005-06) **data for all India ***Coverage Evaluation Survey, UNICEF,2009 BF: Breastfeeding; CF: Complementary foods; IYCF: Infant and Young Child Feeding; SAM: Severe Acute Malnutrition The Goal  100% %

12. Where are The unreached? Reaching the Unreached for Child Health

13. 41 48 27 Latest SRS reference -2009 by RGI Goal 27 Death rates higher in rural but Urban poor death rates > urban average IMR in ST > State average IInfant Mortality trends- Rural Vs Urban

14. Immunization Status by Wealth Quintile, Gujarat Coverage Evaluation Survey, 2009

15. DLHS-3 Disparity in Infant Feeding by District 3. CF: Timely Introduction 1. BF: Timely Initiation 2. Exclusive BF: 0-6 mo IYCF: Composite Index (1+2+3)

16. Gujarat High Priority Districts (8) HPD and Tribal districts HPD but not Tribal districts

17. Why are they unreached? Reaching the Unreached for Child Health

18. 18 Six Coverage determinants- Tanahashi Model Availability of drugs/supplies Availability of Human Resources Geographical Access Utilization -first contact Effective Coverage -quality Adequate Coverage -continuity

19. Immunization Coverage- where is the gap From Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2) http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_295-303.pdf Availability – critical inputs to health system Adequate coverage- continuity Utilisation – 1rst contact with services Accessibility – physical access to services Effective coverage- quality Target Population Accessibility – to human resources Availability of Vaccines and Supplies (near 100%) Availability of vaccinator (near 100%) Functional Access to Mamta diwas (near 100%) Initial Utilization (BCG coverage ( >95%- DLHRS 11) Continuous (Measles coverage (79%) Fully Immunized (69%) Immunization Program- aim 100% coverage

20. Some Common Bottlenecks in Child Health Programming in India Limited availability of Human Resources Low availability and access to Child Health in some areas- e.g. Urban Low Demand generation in some areas Low skill building- e.g. Facility Newborn care Transport/ communication gaps in difficult areas Inadequate supervision Data Quality

21. Suggested Issues for Child Health Programming Unreached Areas Rural- Drilling down to at least taluka level for local barrier analysis and local solutions Urban Poor- Mapping, infrastructure, service delivery, MIS Child Malnutrition- Experiences from other countries- IYCF communication; SAM management; Micronutrients Gram Sanjivini Samiti - Increasing community participation Emergency Transport- number and type for difficult areas Strengthen Supportive supervision for skills and quality Private sector- Evolving relationship

22. Thanks