Partha’s Fundamentals of Pediatrics Swati Y Bhave, A Parthasarathy, MKC Nair, Anupama S Borker
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Importance of Pediatrics and Essential Pediatric Care in Developing CountriesCHAPTER 1

Yeshwant Krishna Amdekar
 
 
INTRODUCTION
 
Why Pediatric Care?
Children are considered “national wealth” and hence pediatric care has its implication on the ultimate progress of the nation. The health of a newborn is directly related to maternal health and subsequently the health of an infant in particular depends upon the nutritional care taken by the mother. Thus, the most vulnerable segment of our population is the mother and the child and hence maternal and child health together assumes importance. In fact, infant mortality, under-5 mortality, maternal mortality, nutritional status of children and immunization coverage are some of the health indicators of the well-being of the nation. What is most encouraging is the fact that simple interventions can make a difference, only if the majority practices them.
 
What is Pediatric Care?
Ideal pediatric care starts from a girl child in the community. If a girl child remains healthy through childhood and is subsequently well cared for during pregnancy, it lays down a strong foundation of health for the newborn. Minimum care during pregnancy includes periodic antenatal check-up, folic acid supplementation from the time of conception, adequate nutrition, tetanus toxoid administration and the treatment of diseases, if any. Good birthweight ensures good start to life of a newborn. Institutional delivery or at least birth attended by trained health personnel is most important to prevent neonatal morbidity and mortality.
Breast-feeding must be initiated within first half an hour of birth. This is possible for all types of deliveries including cesarean section. Exclusive breast-feeding up to first 5–6 months followed by complementary feeds out of “family pot” takes care of adequate nutrition of an infant. Ideally, most infants need supplements of iron and vitamin D in late infancy and low birthweight infants may need multivitamin and multimineral supplements early in infancy. Beyond infancy and toddler age, parents must ensure good lifestyle in term of healthy food intake and adequate physical exercise. Vaccinations as per standard guidelines prevent serious diseases and help maintain normal health. A healthy child turns into a healthy adult and achieves expected lifespan without suffering from lifestyle diseases. This is the way “national health” can make a nation progress.
 
How to Deliver Pediatric Care? Maternal and Child Health Services in India
Safe motherhood policies and childhood survival programs are critically important in a country in which infant and child mortality and maternal mortality is high. Realizing this, concrete steps were taken during first and second five-year plan (1951–1956 and 1956–1961). Integration of family planning and maternal and child health and nutrition services took place in fifth five-year plan as minimum need program in 1974–1979. Primary objective was to provide basic health to pregnant and lactating women and pre-school children. Since then promotion of health of mothers and children has been one of the most important aspect of family welfare program in India and has been further strengthened by child survival and safe motherhood program of Ministry of Health in 1992. The Expanded Program of Immunization was launched in 1978, which was upgraded to Universal Immunization Program in 1985. In the same year, oral rehydration therapy (ORT) was propagated to prevent diarrhea morbidity and mortality. Under maternal and child health program, the ministry has undertaken different schemes such as oral rehydration therapy, development of regional institutes of maternal and child health in states where infant mortality is high, universal immunization program and maternal and child health supplemental program within post-partum program. Reproductive and Child Health Program (RCH 1) was started in 1997 and further modified to RCH 2 in 2005.
All these programs are available free for the community. The Government of India has encouraged public-private partnership to disseminate all such programs in the community. Thus every physician and health personnel can contribute to child welfare.2
 
PRESENT SCENARIO OF MATERNAL AND CHILD HEALTH IN INDIA
The National Family Health Survey (NFHS) 2005–2006 results have improved as compared to previous two surveys, but are still far away from the desired level. Fifty percent mothers have had three antenatal visits through their pregnancy. Folic acid supplements were taken only by 22% of mothers. Forty percent births took place in institutions and trained personnel conducted another 10% births. Thirty-five percent mothers availed postnatal care. Breast-feeding was initiated within first half an hour in 23% of neonates and 46% infants were exclusively breast-fed during first 5 months. Complementary feeds were started in 55% of infants between 6 and 9 months. Bacillus Calmette Guerin (BCG) and oral polio vaccine (OPV) coverage was 78% but DPT3 only 55% and measles vaccine coverage was 58%. Vitamin A prophylaxis was used only in 25% children. From amongst children suffering from diarrhea, 60% visited health facility but only 25% of these received ORS. From amongst children suffering from acute respiratory infection, 70% of them visited health facility but only 20% of these children received proper antibiotics. It is unfortunate that the community has not availed of free health services and thus there is a gap between health services provided by the government and the services utilized by the community. Obviously the fault lies in inadequate health education of the community. This has resulted in poor health of children. Forty-five percent of children less than 3 years of age were stunted, 40% underweight and 25% wasted. Prevalence of anemia in 6–36 months of age group was as high as 80%. One of every three malnourished children in the world is from India and 50% deaths in children are attributable to malnutrition.
 
Target for Achievement by 2015—How Far have We Reached?
United Nations had set goals for the countries in the world in the year 2000–UN millennium goals—to be achieved by the year 2015 and India has been a signatory to it.
Goals related to social indices such as reduction in poverty, increase in enrolment at primary school without drop-outs, safe drinking water, gender parity and health indices, some of them are related to maternal and child health. The twelfth five-year plan will be unfolded in April 2012 and will seek achievement of these goals.
Maternal mortality rate is expected to be reduced by three-fourth from 437 per 100,000 of live births in 1991 to 109 by 2015. At present pace, we may, at best, achieve up to 139, falling short by 30 points. Infant mortality rate (IMR) is at present 47 per 1,000 of which 67% is contributed by neonatal mortality. Target for IMR by 2015 is 26.67 per 1,000 and it is likely that we may miss it by 12 points. Present under-5 mortality rate stands at 64 per 1,000 live births and we have to reduce it to 42 per 1,000. We may be short by 12 points.
Measles vaccine coverage in first year is expected to be 100% by 2015 while at present it is 70%. We are unlikely to meet the target. Hundred percent births are to be attended by trained personnel by 2015. At present, only 50% births are being attended by trained personnel and we will miss the target by almost 30 points. It is also expected that we halt increasing prevalence of malaria and tuberculosis and also reverse the trend by 2015.
 
RESPONSIBILITY OF MEDICAL PERSONNEL
It is very clear that maternal and child health influences the well-being of the society. Normal growth and development through childhood ensures normal adult life. Seeds of many adult diseases are sown in early childhood. Hence, it is important for undergraduate medical students to get sensitized to issues related to maternal and child health.
Education and empowerment of mother is the hallmark of successful child health management and every physician must strive hard to facilitate the same. Proper communication is the key to success. Advice regarding nutrition, hygiene and immunization sets the foundation of good health in children. Growth monitoring helps to identify early deviation if any that can be corrected in time. Diarrhea is a “nutritional disease” and hence it is preventable by ensuring good nutrition. Use of oral rehydration therapy and zinc supplement reduces morbidity and mortality due to diarrhea. Early diagnosis of pneumonia is clinically possible with attention to tachypnea, chest retraction and grunting and timely institution of antibiotic would save such a child. Similarly, diseases such as malaria or tuberculosis must be suspected on the basis of standard guidelines and appropriately treated. Rational antibiotic therapy is the most vital step to prevent drug resistance.
In summary, pediatric care is directly related to health of the nation and is most important in a developing country like India. Simple cost-effective measures are available, that if implemented universally to all children would help us to achieve expected health targets by 2015. Every physician is expected to deliver holistic care that demands commitment, concern and compassion besides knowledge. Undergraduate medical student must acquire knowledge related to child care and develop into a good physician that would contribute to the welfare of the nation.3
 
1.1 NATIONAL RURAL HEALTH MISSION
Govindaraj M, Sanjay KS
 
INTRODUCTION
Recognizing the importance of health in the process of economic and social development and to improve quality of life of citizens, Government of India launched National Rural Health Mission (NRHM) on 5th April, 2005 for period of 7 years (2005–2012). By making necessary architectural change in basic, rural healthcare system mission adopts synergistic approach by relating health to determinants of good health viz. nutrition, sanitation, hygiene and safe drinking water. It also brings Local Health Tradition and Indian System of Medicine (AYUSH) to main stream of healthcare. Mission seeks to provide effective services throughout the country with special focus on 18 states which have weak public health indicators viz. Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh.
 
NRHM—The Vision
It aims to undertake necessary change in health system to enable it to effectively handle increased allocations as promised under National Common Minimum Program and promote its policies.
It has as its key component creation of cadre of accredited social health activist (ASHA) in each village implementing village health plan prepared by health and sanitation committee of the Panchayath, strengthening of rural hospital accountable to community through Indian Public Health Standard (IPHS).
It will also integrate multiple vertical health and family welfare programs like Reproductive and Child Health (RCH) Monitoring Software; vector-borne disease control program against malaria, filaria, kala-azar, dengue fever/DHF and Japanese encephalitis; National Leprosy Eradication Program; Revised National Tuberculosis Control Program (RNTCP); Control Program for Blindness; Iodine Deficiency Program; and Integrated Disease Surveillance Project.
It seeks to revitalize local health tradition and mainstream AYUSH into the public health system. It seeks decentralization of programs for district health management, and improving health of rural people especially poor women and children, equitable, affordable accountable and effective primary healthcare.
 
Goals
NRHM program aims at:
  • Reduction in infant mortality rate (IMR) and maternal mortality ratio (MMR).
  • Universal access to public health services such as women and child health, water, sanitation and hygiene, immunization and nutrition.
  • Prevention and control of communicable and noncommunicable diseases, including locally endemic diseases.
  • Access to integrated comprehensive primary healthcare.
  • Population stabilization, gender and demographic balance.
  • Revitalize local health tradition and mainstream AYUSH.
  • Production of healthy lifestyles.
 
Strategies
 
Core Strategies
  • Train and enhance capacity of Panchayath Raj Institutions (PRIs) to own, control and manage public health services.
  • Promote access to improved healthcare at household level through the female health activist (ASHA).
  • Health plan for each village through Village Health Committee of the Panchayath.
  • Strengthening subcenter so as to enable local planning and action with more multipurpose workers.
  • Strengthening existing PHCs and CHCs, and provision of 30–50 bedded CHC per lakh population for improved and curative care (Indian Public Health Standards defining personnel, equipment and management standards).
  • Preparation and implementation of an intersectoral district health plan prepared by the District Health Mission, including drinking water, sanitation and hygiene, and nutrition.
  • Integrating vertical health and family welfare programs at National, State, Block, and District levels.
  • Technical support to national, state and district health missions, for public health management.
  • Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision.
  • Formulation of transparent policies for deployment and career development of human resources for health.
  • Developing capacities for preventive healthcare at all levels for promoting healthy lifestyles, reduction in consumption of tobacco and alcohol, etc.
  • Promoting non-profit sector, particularly in underserved areas.
 
Supplementary Strategies
  • Regulation of private sector including the informal rural practitioners to ensure availability of quality service to citizens at reasonable cost.
  • Promotion of public private partnerships for achieving goals.
  • Mainstreaming AYUSH–revitalizing local health traditions.
  • Reorienting medical education to support rural health issues.
 
PLAN OF ACTION
Mission plans to implement its strategies effectively through various components are depicted in Flow chart 1.1.14.
zoom view
Flow chart 1.1.1: Proposed NRHM infrastructure
 
Accredited Social Health Activists (ASHA)
Accredited social health activist (ASHA) is a female health activist, volunteer chosen by and accountable to village Panchayath, to act as the interface and bridge between the community and public health system. General norm of selection will be one ASHA for 1,000 population. Whereas in tribal, hilly and desert areas norm would be relaxed to one ASHA per habitation. She should be resident of village with education of eighth class at least and age group of 25–45 years, having communication skills and leadership activities. Induction training of ASHA will be 23 days in all, spread over 12 months. Model of training is proposed through training of trainers including contract plus distance learning module, in partnership with NGO, ICD training centers and state health institutions.
 
Role and Responsibilities
Accredited social health activists will facilitate preparation and implementation of village health plan along with ANM, Anganwadi worker, functionaries of other departments and self help group member under leadership of village health committee of Panchayath.
She will take steps to create awareness and provide information to the community on determinants of health such as nutrition, sanitation, information on existing health services, healthy living and working condition. She will promote construction of household toilets; undertake total sanitation campaign coordinating with village Panchayath.
By coordinating with auxiliary nurse midwifery (ANM), she will counsel women on birth preparedness, importance of safe delivery, breast-feeding, complementary feeding, immunization, contraception, prevention of reproductive tract infection/STD. She will escort pregnant women/sick child to nearest first referral units.
She will be given drug kit containing generic AYUSH and allopathic formulations for common ailments like fever, diarrhea, cough and other things. She will also be DOTS provider under RNTCP. She will act as depot holder for essential drugs like ORS, iron folic acid tablets, oral pills, condoms, chloroquine, AYUSH kits and other drugs. The ANM will act as resource person for ASHA regarding this and conducts weekly/fortnightly meeting.
In co-ordination with Anganwadi worker, ASHA would organize health day once/twice a month promoting pregnancy related issues, immunization, nutrition and creating awareness among eligible couples.
ASHA's performance will be regularly evaluated by following indicators:
  • Percentage of ASHA's attending review meeting after 1 year.
  • Percentage of children with diarrhea who received ORS.
  • Percentage of assisted deliveries and institutional deliveries.
  • Percentage of immunization coverage and percentage of fever cases receiving chloroquine.
 
Impact Indicators
  • Infant mortality rate
  • Child malnutrition rates
  • Number of cases of TB/leprosy detected compared to previous year.
 
Strengthening of Subcenters
Each subcenter will have united fund for local action at 10,000 per annum jointly operated by ANM, village Panchayath health committee; supply of AYUSH allopathic drugs to 5subcenters, along with necessary upgradation of subcenters with additional ANM and equipment. Staff recruitment will also be considered under NRHM.
 
Strengthening of PHCs
  • Strengthening primary health center is undertaken by observing standard treatment guidelines, supply of essential drugs including auto disabled syringes, provision of 24-hour service in at least 50% PHC is by including AYUSH practitioner.
  • Upgradation of all PHCs for 24 hours referral service and provision of second doctor (one male one female) on felt need basis.
 
Strengthening of CHCs
Strengthening community health center (CHC) for first referral care:
  1. Operationalizing 3,222 existing CHC with 30–50 beds as 24-hour first referral units including posting of anesthetist.
    • Promotion of Rogi Kalyan Samiti for hospital management.
    • Develop, display and ensure compliance to citizen's charter at CHC/PHC level.
    • Codification of new Indian public health standards and setting norms for infrastructure.
 
District Health Plan
District becomes core unit for planning, budgeting and implementation, with concept of funneling funds through district. All vertical health and family welfare program merge into one common district health mission at district level and state health mission at state level. Mobile medical unit to improve outreach services and project management unit with data entry operation and human resource assistance are provided.
 
Converging Sanitation and Hygiene under NRHM
Total sanitation campaign (TSC) is implemented through Panchayath Raj Institutions (PRI) under guidance of District Health Mission. Village health and sanitation committee will promote school sanitation program and constructing household toilets with help of ASHA. It also includes construction of rural sanitary marts and women sanitary complex. TSC is presently in 350 districts.
 
National Disease Control Program
Strengthening disease control programs for malaria, TB, kala-azar, filaria, blindness and iodine deficiency and integrated disease surveillance program shall be integrated for effective program delivery. New initiatives against noncommunicable diseases would be launched.
 
Public Private Partnership
Public private partnership (PPP) for public health goals including regulation of private sector is being encouraged. District mission and state mission will be identity need based, thematic areas of partnership.
 
New Health Financing Mechanisms
District health accounting system and an ombudsman is created to monitor district health fund. Community-based health insurance schemes (CBHI) with subsidies from central government is encouraged as part of the mission. DHM can approach private hospitals under PPP for medical services by way of reimbursement on principal of “money follows the patient”.
 
Reorientation of Health Education to Support Rural Areas
Medical and paramedical education facilities are created based on requirement in different parts of the state. Task groups to improve management guidelines are also set up with appropriate suggestions to commission like National Institute of Public Health Management.
 
Technical Support
To be effective mission needs strong technical support. This is provided by Population Research Center (PRC), State Institute of Health and Family Welfare (SIHFW) and various NGO's as resource center. Addition to these, mission has two distinct support mechanisms.
  • Program management support center.
  • Health trust of India.
 
ROLE OF STATE GOVERNMENT
State should sign memorandum of understanding indicating their commitment to increase their public health budget preferably by 10% each year and increased devolution to PRI as per 73rd constitution act focusing on performance benchmarks for release of fund. Eighteen states get funding for key components from government of India. Other states should fund intervention like ASHA, program management unit (PMU) and upgradation of SC/PHC/CHC. State health mission is chaired by Chief Minister with secretary and Ministers of Health and Family Welfare to be members of empowered committee. Budget head for NRHM was created earlier under budget expenditure 2006–2007 at national and state levels.
 
TIMELINES (FOR MAJOR COMPONENTS)
  • Merger of multiple societies June 2005
  • Constitution of district/state mission: Provision of additional generic drugs December 2005 at SC/PHC/CHC level
  • Operational program management 2005–2006 units
  • Preparation of village health plans 2006
  • ASHA at village level (with drug kit) 2005–2008
  • Upgrading of rural hospitals 2005–2007
  • Operationalizing district planning 2005–2007
  • Mobile medical unit at district level 2005–08.
 
OUTCOMES
 
National Level
  • Infant mortality rate reduced to 30/1,000 live births
    6
  • Maternal mortality ratio reduced to 100/100,000
  • Total fertility rate reduced to 2.1
  • Malaria mortality reduction rate–50% up to 2010, additional 10% by 2012
  • Kala azar mortality reduction rate: 100% by 2010 and sustaining elimination until 2012
  • Filaria/microfilaria reduction rate: 70% by 2010, 80% by 2012 and elimination by 2015
  • Dengue mortality reduction rate: 50% by 2010 and sustaining at that level until 2012
  • Japanese Encephalitis mortality reduction rate: 50% by 2010 and sustaining at that level until 2012
  • Cataract operation: Increasing to 46 lakhs per year until 2012
  • Leprosy prevalence rate: Reduce from 1.8/10,000 in 2005 to less than 1/10,000 thereafter
  • Tuberculosis DOTS services: Maintain 85% cure rate through entire mission period
  • Upgrading community health centers to Indian public health standards
  • Increase utilization of first referral units from less than 20–75%
  • Engaging 2,50,000 female accredited social health activists (ASHAs) in 10 states.
 
Community Level
  • Availability of trained community level worker at village level, with a drug kit for generic ailments.
  • Health Day at Anganwadi level on a fixed day/month for provision of immunization, ante/postnatal checkups and services related to mother and child healthcare, including nutrition.
  • Availability of generic drugs for common ailments at subcenter and hospital level.
  • Good hospital care through assured availability of doctors, drugs and quality services at PHC/CHC level.
  • Improved access to universal immunization through induction of auto disabled syringes, alternate vaccine delivery and improved mobilization services under the program.
 
MONITORING AND EVALUATION
  • Health MIS to be developed up to CHC level, and web-enabled for citizen scrutiny.
  • Subcenters to report on performance to Panchayaths, hospitals to Rogi Kalyan Samitis and district health mission to zilla parishad.
  • The District Health Mission to monitor compliance to Citizen's Charter at CHC level.
  • Annual district reports on people's health (to be prepared by Govt./NGO collaboration).
  • State and national reports on people's health to be tabled in assemblies, Parliament.
  • External evaluation/social audit through professional bodies/NGOs.
  • Mid-course reviews and appropriate correction.
Baseline survey of households and health facility survey incorporating private health facilities are taken up at district levels. This helps in fixing decentralized monitoring goals and indications. Subcenters should regularly report to the Panchayaths, hospitals to Rogi Kalyan Samiti and District Health Mission to zila parishad. District Health Mission should monitor compliance to citizen charter at CHC level and prepare annual people health report. This is compiled from all districts and states, subsequently tabled in assembly and parliament. In addition external audit, social audit and midcourse reviews are conducted regularly with web enabled citizen scrutiny.
BIBLIOGRAPHY
  1. Government of India (2005) National Rural Health Mission (2005–2012) Mission Document, Ministry of Health and Family Welfare,  New Delhi. 
  1. NRHM: ASHA Guidelines. Ministry of Health and Family Welfare,  New Delhi. 
  1. PARK's Textbook of Preventive and Social Medicine.