INTRODUCTION
India has a vast population of more than 1210 million according to census of India 2011 (currently in excess of 126 million) with an estimated 470 million children and adolescents (under the age of 20 years age). There is an annual birth cohort of over 27 million. The current picture of child health and survival is mixed. Child mortality has reduced from 115 per 1000 live births in 1990 to 59 per 1000 live births in 2010 and 52 per 1000 in 2012.1 The infant mortality rate has declined from 88/1000 in 1990 to 41/1000 in 2012 and neonatal mortality rate was 29/1000 live births in 2012.2 An estimated 44% children under the age of 5 years were underweight and 48% were stunted. The low-birth weight incidence is estimated to be about 28%. Across the life stages, the coverage for 15 key indicators of continuum of care was not reassuring. It was between 26.5-76.2%.3 The coverage of pneumonia cases with antibiotics in children was only 13%.2
On the positive side is a reduction in national poverty to 22% (Rural 25.7% and urban 13.7%). The literacy rates have increased to 74%. However, the literacy rates in females are much lower (65.5 %) than males (82%) [Census 2011]. In the context of child health development, high female literacy and empowerment of women is crucial since she is the main caregiver in early life when the child is fully dependent on her. The access to drinking water is 93%. The access to tap water is only 43.5% (urban 70.6% and rural households 30.8%), but the access to sanitation is a dismal 36% [Census 2011].
Although a lot of progress has taken place, India will most likely miss the MDG 4 and 5 targets of 2015. No doubt India faces numerous challenges in the years and decades ahead. These challenges have to be converted into opportunities. As a part of the unfinished agenda, in the journey beyond 2015, India has to not only catch up with MDG 4 and 5, but also identify and implement the agenda for improved health, development and wellness for all children and adolescents. This would help accelerate national development, and enable families and communities to realize fully the benefits of the national developmental process.
There is no doubt that India has made remarkable economic progress during the last two decades but its health care system continues to trail behind as compared to other emerging economies in the world. The key issues that have policy implications are the lack of affordability and access to health system and poor equity in a scenario of double burden of disease and ill health.
In the pursuit of universal health care (UHC), the country will have to complete the unfinished agenda which needs to address very high out of pocket expenditures (exceeding about 80%), insufficiency in staff deployment, poor quality of human resources as well as uneven distribution (overwhelming deployment in the private sector). The human resources leave a lot to be desired in terms of skills sets and motivation of health care providers at different levels of health care. These challenges need to meet the expanding needs for building up robust public health system and clinical care as well as equitable social development.
Investments in child health and development should be seen as basic building blocks for increasing the national capital-economic, social, human and ecological. India is leading the other countries in the world in terms of its huge demographic capital and rapid economic growth. The average age of an Indian is expected to be 29 years by 2020. For the next couple of decades; India will continue to maintain this demographic advantage. Therefore, India should leverage its demographic dividend by nurturing a healthy and productive population for accelerating economic development.
In the vision for next 20-25 years heavy investments are needed to maximize the gains of this demographic capital to lay the foundation for India as a lead country in the world through quantum improvements in child health and development. In this context, the maximum input will be needed through the efforts by parents (prominently mothers), families and communities. They have to be encouraged and supported fully for this endeavor.
There is no doubt that there is enough advocacy by technical experts and managers to continue to make heavy investments in continuing to increase the techno- managerial capacity. However, not enough attention has been paid towards making quantum improvements in evidence-based social behavioral area and innovations in addressing the social behavioral determinants of health to close the ever widening equity gap.
HISTORY OF PEDIATRICS IN INDIA
Pediatrics as a discipline in health has come a long way since its inception more than 80 years (1927) ago in India. Dr KC Chaudhuri visited Vienna in 1928 and was greatly impressed by the organization of child welfare activities. Since then, it has been a long journey for the discipline chequered by numerous challenges and opportunities. Between 1940 and 1950, there were only a handful of Pediatricians in the country who were carrying on their shoulders the onerous task of promoting the cause of child health in the country.4
The Indian Academy of Pediatrics (IAP) was started by 169 senior Pediatricians (through a merger of the existing organizations) in the country more than 50 years back. Since then the membership has grown to more than 23,000, with super specialties as well as regional, state and local chapters.5 The members of the Academy have taken up the leadership role and IAP participates in national and state policy and strategy dialogue, undertakes accreditation, organizes CMEs and capacity development and contributes to the process of strengthening child health in the country in an ongoing manner. The academy has many publications to its credit and its official monthly journal is respected and widely read in India and in other countries.
In the first 2-3 decades, it was an arduous struggle for doctors and different categories of health care providers who were interested in child health. During this time, pediatricians were considered as upstarts who regarded children as mini adults for making a diagnosis and providing treatment by adjusting the doses of medicines crudely. There were hardly any questions asked on pediatrics and child health during examination for MBBS and MD degrees. It was not a separate subject in the medical examinations for undergraduates. Now MD and Diplomas are awarded and postgraduation in super specialties is constantly on the rise. There is an immediate need for promotion of Social and Community Pediatrics as a discipline. At the same time, family health, social obstetrics, nutrition, child development need to be nurtured for improvements in child health, child survival and child development.
The mortality rates and status of undernutrition were shocking in the 1970s and 1980s. When the IAP was 5started, the infant mortality rate was about 144/1000 live births. The landscape has changed dramatically during the last 50 years. The expansion of pediatrics has no doubt been unprecedented, but it has not kept pace with the numerous challenges that are emerging. The unfinished work for pediatricians and child health workers continues to grow at a very rapid pace. Consequently, the dream for a happy, healthy and productive India remains to be realized.
The discipline of pediatrics merges seamlessly with Public Health and Family practice. Pediatricians and child health workers cannot do it all by themselves. The only option to achieve success for practitioners of pediatrics and child health is to partner with all the relevant stakeholders and most importantly with families and communities in an equitable manner, establish sustainable networking and focus on the social determinants of health to obtain optimization of health, wellness and development in the country.
Pediatricians and child health workers in India continue to be overwhelmed with the task of dealing with sick children and their management. Their current training prepares them to do clinical management of the sick children predominantly and the professional rewards are also linked to the efforts that are made in clinical work. Not only pediatricians, the child health workers at all levels across the spectrum have to do the same though to a lesser extent since they are predominantly tasked with public health functions for which the monetary gains are modest. Because of the shortage of human resources and unfavorable distribution even the task of diagnosis and treatment of illnesses in children in relegated to unqualified practitioners in rural areas, urban slums and remote inaccessible areas.
For child health care to be successful, it is extremely important to work with parents and families since it is parents who spend most of the time with their children and they are responsible for providing basic child care including day-to-day child health care. Child health cannot succeed unless there is an in-depth understanding of the family interactions between the child with its parents and family members and of the social determinants of health. Since child is mostly dependent on the parents and family, it is important for the family (especially the mother or the main caregiver) to be healthy and empowered to provide care that would help to strengthen child care during health and disease. Child health workers and pediatricians are not trained to address these challenges and cannot do it all by themselves. They must partner with all those who are engaged in child care on a sustainable basis. Beyond this partnership, they have to partner with all those who are engaged in providing social support services. Prominent examples are: women and child welfare, education, nutrition, water and sanitation workers and those responsible for providing social support and rehabilitation. Pediatricians are so overwhelmed with clinical care that issues relating to and understanding of the social determinants of health, effective communication with parents and families, child advocacy, gender bias, needs of adolescents occupy the back seat in day-to-day work of the pediatricians and child health workers. With the availability of increasing evidence base, the scope of Social Pediatrics is enlarging at an unprecedented pace.
POLICY PORTFOLIO
The policy strategy portfolio in India has progressively evolved since its beginning with the National Family Planning program in 1951. India was the first country to have launched the National Family Planning Program in the world. Immunization program was started in 1976.6 The Family Planning Program was changed to Family Welfare in 1977 to broaden the scope of the program and reduce the stigma that was attached to the program. This was then followed by the Control of Diarrheal Disease Program in 1978, Universal Immunization program in 1985, and a National ARI Control Program in 1990.
In the late 1980s, these vertical programs were consolidated into GOBI (Growth monitoring, ORT, Breast feeding and Immunization) strategy promoted by UNICEF. This started an era of integration and consolidation which lead to the launch of the Child Survival and Safe Motherhood (CSSM) strategy in 1998, which then evolved into Reproductive and Child Health I (RCH I) and RCH II programs followed by National Rural Health Mission (NRHM) in 2005. The national rural health mission now includes urban population also and is called National Health Mission (NHM).
The above strategies have evolved into numerous projects and programs. Some examples are Integrated Management of Childhood Illness (IMCI). To this has been added newborn health (IMNCI), adolescent health and family planning. For the child, there is the program on Rasthriya Bal Suraksha Karyakram (RBSK),7 and for adolescents Rashtriya Kishore Swasthya Karyakram (RKSK). The details of IMNCI and RKSK are given in other chapters in this book. All of these have now been consolidated into Reproductive Maternal Neonatal Child Health plus Adolescent health (RMNCH plus A strategy).8 The latest strategy has numerous subcomponents to cover each life stage. India is also committed to implement Universal Health Coverage (UHC).
Vertical and integrated approaches have been implemented in India during the last 5 decades. While 6the vertical approaches are effective, they are resource intensive and tend to derail the long-term benefits of integrated approaches. Some examples of successful vertical program are the National Program of Immunization, National TB and National AIDS Control programs. The policy debate on vertical and integrated programs will continue and the implementation of these programs would also continue. A balanced approach is needed, so that the health system can cope with these vertical and integrated programs and the families and communities can benefit from them optimally.
In the agenda beyond 2015, there is a need for stock taking. The future planning should be based on evidence and also requires consolidation following the implementation experience. Waiting in the wings are additional components of early child development (ECD) and pre-conception and peri-conception care for health, wellness and development in children during the critical period of rapid brain development. The care for early childhood development is written as another chapter in this book. The pre-conception and peri-conception care is covered under the chapter on life cycle approach in this book.
HUMAN RESOURCE FOR HEALTH
In the context of human resources for health, India's landscape is quite complicated. India provides a picture of contrasts. There were 918,303 registered doctors with medical qualifications from medical colleges in conformity with the norms of Medical Council of India. There were 686,319 Ayush doctors who were registered (56.5% Ayurvedic, 34.8% Homeopaths, 7.4% Unani and others included Sidha and Naturopaths). The total number of nurses and midwives were 1,562,186 and Lady Health Visitors were 44,498.9
In the public health system, the Government of India had 29,562 medical doctors (allopath) in PHCs and there were 5,805 specialist doctors posted in the PHC. There are no pediatricians posted in PHCs. In the CHCs, the recommendation is to post one pediatrician and one obstetrician and gynecologist in addition to specialist in medicine and surgery. The shortage of pediatricians was 43% and of the obstetrician was 40.7%.10 Even the norms of providing a pediatrician for an average population of 120,000-180,000 have not been met. Clearly there is an imbalance in the deployment of pediatricians in the rural areas of the country. Consequently, there is a serious constraint in provision of quality clinical and public health care to rural children by professionally trained workforce.
There are four types of private practitioners in India11 who diagnose and treat illnesses in children and provide some preventive care.
- Nonregistered medical practitioners (Quacks): There are no precise estimates of the nonregistered medical practitioners, but they abound in the rural and urban slum areas of the country. Estimates exceed at least 1 million (gross underestimate). These practitioners cater to the needs of the people who are living on the margins of the society. They charge for the medicines dispensed and they keep their profit margin but normally do not charge for consultation. Their practices are irrational and often harmful. They prescribe a lot of medicines and in a large proportion of the cases, these practitioners are not aware of the drug dosages and schedules as well as drug side effects. These practitioners do not have any legal standing. Despite the lack of legal approval, they are flourishing since they are accessible and socially acceptable. The expenses incurred are out of pocket from the clients.
- Registered medical practitioners (RMPs) include practitioners who are registered but most of them have not been educated through a full prescribed curriculum. They manage to get registered after a variable period of apprenticeship with another practitioner. It also includes practitioners of Indian system of medicine-Ayurveda, Homeopathy, Unani, Sidha and Naturopathy. Amongst these, the number of registered medical practitioners from Indian system of medicine is 686,319 and estimates for other RMPs are not available. According to the Supreme Court of India, these practitioners are not allowed to prescribe medicines that are beyond the scope of the system that they are trained in. However, it is common knowledge that they prescribe and dispense medicines from modern system of medicines quite freely.
- Solo practitioners or small nursing homes abound in periurban and urban areas. These institutions provide some inpatient care also. This is generally done by single doctor with the assistance of other staff in the facility.
- Private hospitals, mostly located in the urban and periurban areas of the country where people have a large capacity to pay for the services rendered. The last couple of decades have seen large corporate who provide health care to well to do people. They also attract patients from outside the county as a part of growing medical tourism in the country.
The shortfalls in the services accessible to people living in the rural areas are summarized in Table 1.
Bulk of the preventive and public health services in India are provided by the Government sector. The preventive and public health services are provided predominantly by female workers and volunteers in the rural areas of the country. In contrast, large proportion of curative services and clinical services to women and children are provided by males in the urban areas.
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This may be a major constraint in care seeking in many parts of the country since care seeking by the clients is often influenced by the sex of the provider. It is estimated that some 80% of the expenses on medical diagnosis and treatment are out of pocket, about 5% are covered by the employer and about 10% by insurance.12
There are serious imbalances in human resources in the distribution across the different states of the county, a lower than recommended doctor nurses ratio, with a serious mismatch in the deployment in public health and in the rural areas of the country.
To deal with the above mentioned issues, concerns and imbalances, the Central Government proposes to train and deploy rural health workers through an abridged version of the traditional medical degree with its focus on prevention, health promotion and rehabilitation. The serious shortage of health workforce in the rural areas has been mitigated to some extent by deploying practitioners of Indian system of medicine (Ayush). NRHM has added village-based Accredited Social Health Activists (ASHAs) and more than 900,000 have been deployed since the inception of the NHM in 2005.13
Production of health workers of different cadres has increased no doubt but it falls far short of the needs. There is an imbalance in distribution across private and public sector with the public sector facing serious shortages and large number of positions that continue to remain vacant. There is an urgent need for adoption of sustained and innovative action to address the crisis relating to shortage and quality of health work force in the country.14
Meeting the Immediate and Emerging Needs to Fill Human Resource Gaps
Community health worker and health volunteers programs have been in place for a number of years in India, through government health programs and a number of non-governmental initiatives. These health workers and health volunteers have worked as an interface between the families (especially in underserved populations) and the formal health system. Some community health workers have been made responsible for providing basic health care and render core public health functions like immunization promotion, home-based postnatal care, treatment of diarrhea, growth monitoring, breastfeeding promotion, child spacing, health promotion, etc. The contribution of these workers can be enhanced substantially by ongoing support from skilled health workforce backed up by a well- financed primary health care system.
At present, the capacity of community health workers is low and they are inadequately compensated for the work that they are expected to perform. Capacity development of community development workers can be undertaken to ensure their improved performance rapidly. This can be achieved through investments in critical areas that are most promising. Health services can be optimally utilized to overcome the current barriers by undertaking the following measures:
- Diagnosis of high-risk conditions is now possible by use of simple tests and kits. Examples include assessment of weight or mid upper arm circumference, use of maternal child protection (MCP) cards, pregnancy test, rapid diagnostic kit for malaria, hemoglobin estimation, etc. by community health workers.
- Supportive supervision although critical is not done adequately in the program setting. There are logistics and high cost issues that constrain supervision. The supervision to be successful should be supportive and ongoing. This is now possible with the addition of mobile and smart phones to the portfolio of the supervisors and community health workers to capture real time information, monitor progress and add supportive supervision and guidance to them, so that they are able to strengthen the interface with the family in an ongoing manner. Mobile phones can also be used for problem solving and improving behavior of the families in the context of child care.
- Minimum quality of basic health care can be ensured through the provision of and replenishment of kits and simple treatment protocols to the community health workers. This can also increase the acceptance of the workers in the community as credible care providers since they can strengthen the services delivered at the point of care and make timely referrals. Free referral transport for women in labor has been started, but this should be expanded to cover sick children and sick mothers also.
- Persuasive evidence indicates that short-term intensive training on selected competencies can be rapidly scaled up to tackle the constraint of the time 8lag between recruitment and deployment. Through an ongoing process in which skills building is backed up by practice of the skills learnt, it is possible to upgrade the performance of the community health workers rapidly. This helps to improve their practices and sustain them. This approach would contribute to a progressive improvement of quality of services delivered to very large population in the country.
There is a big gap between the human resource and the needs for optimizing the delivery of quality health services to match the demands. Pediatricians especially those who wish to contribute to the discipline of social pediatrics or are inclined towards public health should take the lead through innovations and expanding their horizons. A scheme has been proposed by the Indian Academy of Pediatrics in which each branch of IAP should adopt a village for provision of comprehensive health care.5 It would be a huge contribution if each pediatrician takes on the responsibility of making contributions for a clearly defined geographical area through provision of support to the local public health system. The access to expert pediatric care can be enhanced through the application of this strategy.
Application of Mobile Technology
New windows have opened up to engage the millions of families through the effective use of the constantly expanding mobile technology and internet connectivity. At present, private sector makes extensive use of the technology while only a start has been made in the health discipline.
UNFINISHED AGENDA OF 2015 (MDG)
The MDG 4 and 5 (2015) are not likely to be achieved by India, even though progress towards reaching the goals has been impressive. The causes of child mortality in age group 0-5 years in India according to Child Health Epidemiology Reference Group (CHERG) are neonatal causes (52%), pneumonia (15%), diarrhea (11%), measles (3%) and injuries (4%).15 Undernutrition continues to be an underlying or contributory cause of death in more than 50% of the cases.
Regarding the high neonatal death rate in the country, India Neonatal Action Plan has been prepared. This has been discussed in details in a chapter in this book. The still birth rate is very high, it is estimated to be 25-60/1000.16 Therefore, it will be important to focus on perinatal mortality and not just on neonatal mortality. This should be on the radar of the pediatricians and for achieving progress in the reduction of preventable still births active partnerships would be required with the obstetricians and midwives. At the same time, one trained person should be available at the time of child birth to ensure the provision of resuscitation for better management of perinatal birth asphyxia if required.
Progress has been made in the prevention and treatment of acute diarrhea in children, but the rate of reduction of deaths due to acute diarrhea has to be enhanced. The coverage with WHO ORS and zinc combined with preventive measures need to enhanced with a focus on equity.
Prevention and management of pneumonia in children continues to be neglected in India. Pneumonia continues to be a leading cause of death among children below 5 year age. Amongst the causes of death, pneumonia is the most common cause of death in India after the age of 1 month. The annual number of deaths due to pneumonia is estimated to be around 400,000 per year.15 The incidence of pneumonia is about 0.3 per child per year.17 The main bacteria that cause pneumonia are Streptococcus pneumoniae and H. influenzae b, but viruses or mixed infections are mainly responsible for childhood pneumonia. Despite the availability of evidence for control of pneumonia by prevention, and timely and appropriate treatment, it continues to be a major public health problem in the country. Key interventions to reduce morbidity and mortality from pneumonia are early recognition, appropriate treatment, timely referral and provision of vaccines and use of other preventive measures.
Under the program of community case management of pneumonia, WHO has recommended that trained supplied and supervised community health workers recognize and treat children with pneumonia. WHO has recently revised pneumonia treatment guidelines to recommend that chest indrawing pneumonia can also be treated on an outpatient basis by trained health workers based on studies from different rural sites.18,19 There are several potential benefits of treatment of pneumonia (except for very severe cases) by CHWs in the community. These include (a) rationalize the need for referral and hospitalization, (b) contain the costs of treatment, food, transport and loss of family wages, (c) reduce the pressure on overburdened hospitals and health centers, (d) decrease the risk of complications from hospital acquired infections, and (e) increase equity by improved coverage for poor families and those who live in inaccessible areas. The problem of pneumonia in the young infants is also very important and it would be worthwhile to consider the use of oral antibiotics for the treatment of fast breathing pneumonia in the community. Early evidence is available that the fast breathing pneumonia in the young infant can be treated by community health workers in settings where referral compliance is low.20 This would require the strengthening of home-based postnatal care (HBPNC).
Since most cases of pneumonia in children occur in the community and access to treatment is low, community-based management could be a highly effective management strategy. However, it is not yet implemented in India due to numerous policy and programmatic barriers and low demand from the community. The major policy bottleneck for the last 30 years has been to authorize the community health workers (CHWs) to prescribe first line oral antibiotics for the treatment of pneumonia in children. The successful management of childhood pneumonia includes rapid and accurate detection of pneumonia, triaging, appropriate treatment (including referral) and management of comorbid conditions. CHWs can recognize fast breathing, chest indrawing and danger signs of pneumonia but this is not happening because they are not well trained, supervised or supplied with timers (to count the breathing rates) widely. Current WHO guidelines recommend CHWs treat fast breathing pneumonia with oral amoxicillin in 2-59 months old children and refer those with chest in drawing pneumonia or danger signs. However, despite this recommendation, strategic interventions in the context of CHWs are also not yet optimized.
Hypoxemia in children with pneumonia is a major complication responsible for high mortality.21 It is estimated that median prevalence of hypoxemia is 13% in cases of severe pneumonia.22 Hypoxemia is oxygen saturation of less than 90% in low altitude and it may not be possible to detect hypoxemia by clinical signs alone. Detection of hypoxemia by the use of pulse oximetry can be very useful in rationalization of treatment with oxygen in the facility.
Time has now come for Pediatricians to advocate for community case management of pneumonia in children as an added program to the existing portfolio of Reproductive, Maternal, Newborn and Child Health (RMNCH) plus A to rapidly achieve the target of mortality reduction.
Prevention Lowers Health-care Costs
The issues relating to costs of health care and cost of prevention should be at the center stage of policy. This field in opening up rapidly and evidence base is required for rational decision making. The principle is to have the maximum returns for the investments made. The implications of quantum strengthening of public health in child care is to reduce the health care costs, increase equity, reduce costs on investigation and treatment of medical conditions.
Besides an overall saving on the costs incurred evidence is required to strengthen advocacy for public health and prevention since it contributes to productivity, reduces absenteeism of parents from work, and reduction of family disruptions caused by illnesses.
CHILD HEALTH AGENDA BEYOND 2015
There are two major groups of stakeholders that shape the nation's future (1) family and community (2) providers and the Government. There is an urgent need for development of a balanced approach to understand the role of these two groups of main stakeholders and other key stakeholders from within and outside of health department to redefine vision, policies, strategies, roles and responsibilities on the basis of sound understanding of the dynamics that determines the survival, health development and quality of life. A consensus is needed to be built up to articulate the document on vision and policy on child health and survival, in India.
While upto date, a lot of progress has taken place to focus on improved child survival, time has now come to carve out vision, mission and balanced strategies to set the agenda for India beyond 2015. Based on the current scenario in India, all the concerned stakeholders should place on the agenda evolution of a policy and strategy for the country which may consider the following outline framework. National and state governments, various academic bodies and other decision making partners should be engaged in this process. An outline is suggested for consideration of all those who are engaged with upgrading child health care in India.
Proposed Vision and Goals
During the next 25 years, all concerned stakeholders should work together to improve the health and quality of life for all children and adolescents (upto the age of 20 years) from the current focus on sickness and disease. The aim is to improve health, development and wellness. The goal is to increase the number of children and adolescents in India who are healthy, well-nourished and are able to achieve their full developmental potential.
Component 1: Family and Community are Healthy and Secure
Recognize the potential and the crucial role of families and communities in child health, child care and development. Focus on prevention and encourage adoption of healthier behavior. Create, sustain, and recognize the central role of families and communities to promote health and wellness through a focus on prevention. A healthy and safe community environment can help families to incorporate them in their day-to-day life according to affordability. This depends on many factors, e.g. food, water, and access 10to basic health care, as well as family behavior based on personal, family and community experiences of the past.
Component 2: Strengthen Preventive and Clinical Services at All Levels
Ensure that health care and community prevention efforts are available, accessible and integrated. These should be mutually reinforcing to produce impact. The availability of these services at all levels of health care delivery and use of evidence-based clinical and community preventive services are central to improving and enhancing physical and mental health of children. Through decades of practice and research, certain clinical preventive services have proven to be both effective and cost-saving. These evidence-based practices have been recommended by WHO and key family and community behaviors have been identified for improved child survival and healthy child development.23 The barriers commonly encountered in access have to be addressed. The aim should be that clinical services are supported and reinforced by community prevention efforts that have the potential to reach the largest numbers of people.
Component 3: Improve Health and Empower the Care-givers (Mothers and Fathers)
Mothers, fathers and families make the day-to-day decision about practices, though these can be influenced by the providers especially those who work at the interface of the family and the health system. These practices can become actionable if the families have access to services and knowledge. Sustained efforts are required across the different life stages to enable a sustainable behavior change. In this context, since the mother is main care-giver and father supports her in child care, priority should be given to the empowerment of the mother. The behavior and actions that influence child health and development depend to a large extent on the health of the mother. Therefore the efforts to enhance child health, wellness and development would largely depend on the mother's health (including her mental health and empowerment). There is a section in this article that addresses the issues relating to women's empowerment.
Component 4: Increase Equity in Coverage and Quality
The failure to achieve the MDG targets and coverage are due to large disparities in access and affordability. There are interstate, interdistrict, rural, urban, social and economic, gender, age and caste differences, There is no doubt that this problem requires resource intensive interventions, but it would not be possible to realize the goals and targets unless the equity in coverage combined good quality services is achieved in an incremental manner and the gaps are reduced. The aim is to eliminate disparities, by tackling quality and coverage issues. Innovations in equity are required and the policy should ensure that these innovations benefit the coverage and quality of services. The issues relating to equity are addressed in another section of this article.
Family and Community Practices that Promote Child Survival, Growth and Development23
The family and community practices included in this section cover the children under five years of age. Similar evidence is required for other life stages that would contribute substantially to child and adolescent health and development. A wealth of literature is building up to cover the age group 10-19 years (adolescence). This should be simplified and demystified for adoption by families and communities in their day-to-day life. However, greater focus is required on the age group of 5-9 years. The importance of care during this age should be realized and the efforts should be integrated with school health and mid-day meal program.
Practice 1: Enhance the Coverage of Immunizations for Further Decline of Child Mortality and Morbidity Related to Vaccine Preventable Diseases
The families should be guided and supported to complete the full schedule of immunizations (BCG, DTP, OPV, Measles and new vaccines) recommended in the national schedule for immunizations especially before the first birthday. This can be achieved through promotion by the local health workers and activists (ASHAs), as well as further strengthening of outreach immunization sessions, national immunization days and social mobilization. Additional efforts through national immunization days or week with a focus on covering the unreached should be continued. The safety of vaccination should be increased for greater acceptance and every opportunity should be fully utilized. The topic of immunization is covered in other chapters in this book.
Practice 2: Breastfeed All Infants Exclusively for Six Months After Birth
Breastfeeding is associated with reduced child mortality/morbidity and improved child development including the development of the brain. It is important to ensure early initiation of breastfeeding after child birth and then make use of all contacts with the families to support exclusive breastfeeding by all women for the first 6 months age. For success in exclusive breastfeeding, a beginning should be made by initiating breastfeeding within one hour of birth. This should be accomplished by changes in hospital policies/actions, counseling/education from peers or 11health workers, mass media and community education. Ensuring exclusive breastfeeding is a critically important practice but the current coverage continues to leave a lot of scope for improvement. There is a chapter on breastfeeding in this book.
Practice 3: Starting At 6 Months Age, Feed the Child Adequate Quantities of Freshly Prepared Locally Available, Energy Rich and Nutrient Rich Complementary Foods and Continue Breastfeeding Up to 2 Years Age and Beyond
To achieve this, there is a need for developing a partnership between the health care providers and the family. The existing mechanism of daily attendance at Anganwadi center should be strengthened and barriers should be removed to ensure improved feeding. Involvement of mothers should be enhanced through combining feeding with play and communication activities in children 0-3 years age. This is not commonly done at present. This practice is the key to prevention of undernutrition and when feeding is combined with play and communication, it can lay the foundation for healthy child development. Mothers often find it challenging to feed adequate quantities of foods initially (from 6 upto 12 months age). Consequently, the children slip into undernutrition. Mothers should also be told that they can continue with breastfeeding up to 2 years and beyond, but after the age of 6 months it is no longer a complete food.
Practice 4: Ensure that Children Get Adequate Amounts of Micronutrients (Vitamin A, Iron and Zinc through Supplementation
The mothers/families should be educated about giving foods that are rich in iron and vitamin A. Arrangements are needed to ensure easy access of families to iron, vitamin A and zinc supplements as per national recommendations. Health workers should educate mothers and families about foods that are rich in these micronutrients. There are many foods that are rich in these micronutrients. The deficiency of iron, zinc and vitamin A contribute to increased mortality, undernutrition, anemia and poor child development.
Practice 5: Wash Hands After Defecation Before Preparing Meals Before Feeding Children. Ensure that Feces (Especially the Child's Feces), is Disposed Off Safely
This practice needs to be universalized to prevent the transmission of infections. The widespread application of this practice would help control of infections and reduce deaths. This means increased access to plenty of water, soaps and hand sanitizers. The hospitals, health centers and clinics should be the role models. The millions of providers should incorporate this practice in all their day-to-day work. This should be regularly practiced and demonstrated during all contacts with the families and children. Ensuring this practice daily in Anganwadi centers and schools will form lifelong habit. ‘SWACH Bharat’ is now a national program. As a part of this program, clean toilets and their regular use should be aggressively promoted.
Practice 6: In Malarious Areas Protect Children and Mothers by Ensuring that They Sleep Regularly Under Insecticide Treated Bednets
The adoption of this practice would require access to insecticide treated bednets that are affordable. It can be done through social marketing and it would require promotion for widespread adoption. It would require bringing about a behavior change and persistence will be required so that it happens. The widespread adoption of this practice would help children and mothers who are very vulnerable. Besides helping the family using the treated bednets, this would help others in the community if a large proportion of families adopt this practice.
Practice 7: The Mother (Care-givers) should Continue to Feed Sick and Undernourished Children Breast Milk, Foods and Fluids During Illness. They Should Spend More Time with Sick Children and Play and Talk to Them as much as Possible to Encourage Early Recovery from Illness
Children get sick frequently. They are fussy and do not want to eat or drink fluids during illness. The mother (caregiver) should spend more time (as much as possible) with sick children. The caregiver should feed the sick child, foods that are appetising and attractive. If the child does not want to eat a lot at one time, encourage the child to eat small amounts of fluids and foods but more often so that the overall daily intake is not reduced. By adopting this practice, the child would recover early and not lose weight. During recovery, the appetite is increased so more foods and fluids should be given. The parents should not continue with food restrictions following recovery from illness.
Practice 8: Mothers (Care-givers) Should Give Home Treatment for Illnesses as Advised
Most illnesses and problems including undernutrition are treated at home. This may be done without the use of medicines or by use of home measures. Treatment of illnesses at home also comprises of giving medicines that have been prescribed by the doctor or the health worker to make sure that the medicine is given according to the dose prescribed, for the correct duration of time and full course of medicines is completed.
The providers of health care should spend adequate time to explain the home treatment thoroughly and check the understanding of the mother (care-giver), so that the advice is followed correctly. If medicines are prescribed, these should be labeled properly, dispensed in child safe containers and the prescription should be written in a format that mothers who are not educated can also follow the guidance without difficulty. It is also important to make sure that the mother (care-giver) returns for timely follow up or this can be ensured through phone conversation.
The health care providers should realize that most of the treatment of sick children is done at home and compliance is very important to ensure early recovery. Life-threatening illnesses like diarrhea, pneumonia and malaria can be treated at home effectively provided that this is done under competent guidance and support.
Practice 9: Increase the Capacity of the Mothers and Care-givers as Well the Health Workers and Volunteers to Recognize Signs of Illness in Children that Would Require Treatment Outside Home and Provide Guidance about Appropriate Treatment Provider or Facility
Non-care seeking or delayed and inappropriate care seeking contributes to high mortality in common childhood illnesses like diarrhea, pneumonia. Reduction in preventable deaths is possible. This would require education of mothers and families and training of community health volunteers and workers. Poor or delayed care seeking is a constraint that has been identified and this can be overcome through programs like Community IMCI, Home-based Post-natal Care Program, and Care for Early Child Development. Training should be focused on health care providers that are preferred during sickness by the families and communities.
Practice 10: Follow Health Workers Advice about Treatment, Referral and Follow Up and Ensure Treatment During Referral, Especially if it Takes Time for the Sick Child Family to Reach the Referral Facility
Counseling and mass communication are the strategies to be considered. Free referral transport system and accompanied referral are important. Correct choice of referral facility and prior information to the referral facility can help provide timely treatment, save time and also inconvenience. This can now be facilitated through phone contact. Non-adherence to the treatment advice and delay in referral can become serious impediments to early recovery. Adherence to referral advice and treatment is also an important consideration in determining the outcome. Adherence to treatment from the client's perspective needs to be explored for greater success in outcomes. The referral facilities are generally overloaded. Rationalization of referral can mitigate this problem by avoiding the wrong choice of referral facility. To the extent possible, referral from one facility to the other should be avoided, so that patient care is not ignored when the patient is traveling to the referral facility since this can destabilize the condition of the patient.
Practice 11: Promote Mental and Social Development by Responding to a Child's Needs for Care by Talking Playing and Providing a Stimulating Environment
Evidence is strong that multisensorial stimulation when combined with feeding, prevention and early and appropriate response to illness especially in children under the age of 3 years leads to better survival, improved child health, mental and social development. This is especially noticeable in children who are born low-birth weight, children who are undernourished and stunted and those who come from poor and marginalized families.24
This can be achieved by (a) Home-based and parent-focused efforts that aim to improve parenting skills or the parent's ability to perform psychosocial stimulation, (b) Center-based and child-focused that provide psychosocial stimulation directly to the child. Interventions that utilize more than one delivery channel have the maximum impact. It is important to plan socially equitable approach such that families that are socially and economically deprived are targeted.
Practice 12: Ensure that Every Pregnant Woman has Adequate Antenatal Care: This Includes Early Pregnancy Registration and at Least Four Antenatal Visits with an Appropriate Health-care Worker and Receiving the Recommended Doses of Tetanus Toxoid Vaccination
This can be done through community-based antenatal check-ups and provision of care, use of MCP cards, identification and referral of high-risk pregnant women and birth preparedness to ensure skilled birth attendance at the time of delivery. It requires improving access, social mobilization and mass communication campaigns. These interventions are likely to help reduce still births, premature deliveries and early neonatal deaths. The impact on still births and early neonatal deaths is more likely to occur through a greater focus on improving the quality of child birth and postnatal care. There is great concern about high early neonatal morality. This topic has been covered under India Neonatal Action Program (INAP) in this book.
Behavior Change to Influence the Key Practices of Families and Communities
Behavior change is required that involves adoption of several behaviors and these are different at different life 13stages along the continuum. Behavior change would occur when the main care-giver (mother) is healthy and motivated to practice the positive behaviors that are recommended. For this to occur, she has to be empowered and fully supported by the family, the community and the health care providers. Practice, persistence and perseverance is required on a sustained basis. It requires family and community support for success.
There is no single formula that can be applied and the situation is very different in each community Therefore, adaptations are required and these need to be adjusted from time to time based on the experience of the mother and other caregivers in the family.
A change in behavior is unlikely to occur until the system is supportive and supplies are available to ensure the practice of correct behavior. Examples include availability of ORS and zinc in the treatment of diarrhea, easy access to iron and vitamin A to prevent micronutrient deficiency, soap and water to promote frequent hands washing, availability of first line oral antibiotics for the treatment of pneumonia in the community. Efforts to improve behavior should be complemented fully with increased access to good quality services in an equitable manner.
There are age old practices, some of them are good and need to be reinforced others are neutral and can be continued without harming the child or the mother. There are others that are harmful. These need to be corrected. The health care providers can address them successfully through continuous dialogue and engagement with the mothers and the families. There are numerous problems in implementation. These need to be addressed with patience. There seems to be no magical or quick fix solution to address this problem.
There is a need for consistency at all levels and delivery points, so that the mothers and families can understand and be convinced about the importance of change in behavior. Example of this included exclusive breastfeeding up to 6 months age and continued breastfeeding for up to 2 years and beyond.
A conceptual model for health development and wellness is shown in Figure 1.
The Current Focus in Pediatrics and the Need for a Paradigm Shift
Pediatrics in India has been close to Public Health and it has distinguished itself with contributing to eradication of polio and control of vaccine preventable diseases. Efforts have been made to tackle undernutrition through a focus on partnership with Integrated Child Development Services (ICDS) scheme. The ICDS program has been covered up in another chapter in this book. A large number of partnerships are helping to monitor the ICDS program. They provide consultancy support to the programs in their geographical areas to strengthen efforts towards growth monitoring and care for early child development. Pediatricians work very closely with obstetricians since prenatal care, preconception care and peri-conception care are closely linked to child survival, child health and child development.
However, in pediatrics, the current focus continues to remain on diagnosis and treatment of children and adolescents who are sick. Our doctors and child health workers are trained to do this and this is a priority in the services provided in the Government and private facilities. Most resources in the Government and private sector as well by the families continue to be expended on diagnosis and treatment in the inpatient and outpatient settings. Sometimes the problems relating to iatrogenesis and hospital acquired infections make the situation worse and even life-threatening. This leads to very substantial out of pocket expenses incurred by the family, besides causing family inconvenience and family disruptions. For poor families, this translates into lack of care or catastrophic debts. For children, the follow ups are a big challenge especially for the various problems relating to long-term follow-up care and support. These need to be strengthened.
The problems in referral of sick patients are serious. Referrals are often irrational and delayed. The advice is vague and the referral facility is not preinformed to be in readiness. The patients are not provided prereferral treatment and frequently there is no accompanied referral. The damage can be enormous with catastrophic outcomes.
In contrast to adults, the child is dependant to a very large extent on the mother and the care-givers in the family. The mother's health and positive attitude towards caring of the child is extremely important to influence her day-to-day child care practices. Therefore, the ongoing engagement of the mothers (care-givers) is the key to the success of medical and behavioral interventions. To achieve this engagement, it is important to build the capacity of the family at each contact. If these contacts are frequent (face to face or through phone or electronic communication) the enhancement of capacity can be progressive and when combined with practice, it can lead to improved quality of services provided in health as well as during disease by the mother and the family. By the adoption of this approach, the learning can be sustained and it is ongoing.
Pediatrics offers many unique opportunities for interactions and for bringing about behavior change. The child is brought by the parents and families for vaccination even when the child is well. There are provisions for regular weight monitoring during the early years of life and beyond. There are numerous other opportunities for contact with the clients and families, e.g. antenatal care contacts, daily contact during the attendance at Anaganwadi centers and many more. There are a large number of concerns and problems that the parents and the families of children face as they raise the children through different life stages. A large number of caregivers are keen to get guidance for these concerns and problems. Most of these concerns and problems need discussions and guidance and not medicines.
Some of these problems and concerns when parents and families like to seek advice include, difficulty in breastfeeding, excessive crying, feeding problems, poor growth, spitting of milk or vomiting, increased frequency of stools, constipation, concerns at the time when the child is cutting teeth, fussy child, poor appetite or feeding difficulty, red perianal area, excessive salivation, pica, thumb sucking, delayed speech, aggressive behavior, lying and abusing, sleep problems, difficulties in toilet training and many more.
During each contact with the care-givers, the time spent with the caregivers and the child can be profitably utilized to enhance the capacity of the families and care- givers in upgrading care to enhance child health and development.
There are gaps in addressing many common problems and concerns of children since their management requires spending a lot of time to address these common concerns of the parents by counseling and communication. The component of home care and supportive treatment continues to be weak and will need to be strengthened to improve quality of child care during sickness and more importantly enhance child health, wellness and healthy child development. At the same time, the model will help the mother to improve her own health and wellness (physical and mental).
At present, there is a quickfix expectation from the caregivers and families (Pills or medicines for each problem or illness and to get an instantaneous relief). This leads to prescription of large number of medicines (most of them not necessary). The child health care providers respond to this expectation. Other factors determining the provider behavior are perceived lack of time, business interest of the providers and also insufficient confidence to solve problems and concerns that would not respond to medicines. In contrast, the solution for these problems and concerns are related to day-to-day life of the child and behavior of the care-givers and the child and its development stage. It requires a lot of listening to the parents and families patiently and also counseling for their resolution.
The pediatricians and child health-care providers often find themselves to be incompetent to deal with these common problems and concerns. There is little evidence- based guidance to help the providers and their resolution requires effective counseling as well as spending time to listen to the mother (care-giver). These contacts can serve as excellent entry points to educate the family and also introduce and implement measures that would contribute to child health, child nutrition and child development in 15a positive way. The Pediatricians and child health care providers should be adequately compensated for the time they spend with the families in teaching them and educating them.
We all know that professional time of care-givers is valuable. This is applicable to doctors who practice child health, as well as different categories of health care workers and volunteers. Unless investments are made in training the different cadres and provisions are made for adequate compensation for the professional time spent on counselling and advice, it is unlikely that there would be any change in the current scenario. These costs will have to be borne by the caregivers as out of pocket expenses if the service is provided in the private sector. In the government sector adequate budgetary provisions are needed and it is important to ensure the adequacy of human resources deployed to make it possible.
Besides face to face contact, there is a lot of merit in increasing the use of client retained records (e.g. mother child protection cards) and educational material (e.g. short crisp flyers) to reinforce the key family and community practices. The possession of phone across the country has been increasing progressively during the last 10 years or more and the use of mobile phones can serve as an excellent tool for effective communication between the providers and the caregivers. This can also be used for monitoring the progress and for bringing about an ongoing behaviour change. Social media can also serve as an excellent entry point to bring about the change proposed.
Ex-President of India, His Excellency APJ Abdul Kalam in his address to Golden Jubilee of Indian Academy of Pediatrics identified six virtues in pediatricians and child health-care providers: (1) generosity, (2) ethics, (3) tolerance, (4) perseverance, (5) concentration, and (6) intelligence. He advised all child health workers (including Pediatricians) to be teachers of the families in addition to being healers.25
Children are the nations' future and it is a well- known African saying that ‘it takes a village to raise a child’. In this context, the family and community role is very important and though it is mentioned in policy and strategy documents, not a lot is happening to strengthen this component of child care and development. Maternal education, her availability with the child, her good health and empowerment as well as support from the family and community are important determinants for optimization of healthy child development and reduction of stunting and improvement in child survival. Community support and access to day care is critical in situations where mother has to go out for work.
Equity as the Way Forward
The differences in child health indicators between different states in India, within each state, between the rich and poor, rural and urban and based on educational status of women are unacceptably wide and are becoming wider. Children from poor families, with low level of literacy, and unsatisfactory living conditions are more likely than their better-off peers have greater health risks, and they have less resistance to disease because of undernutrition and other environmental hazards including poor sanitation. These inequities get exaggerated by reduced access to preventive, promotional and curative care. Even well intentioned services fail to close the gaps since the utilization of services is higher amongst the better off families.
In Table 2 only few categories have been chosen to illustrate the equity problem but similar differentials are seen in other criteria that reflect child health status and coverage with services. The rate of decline in undernutrition (weight for age) was slower in poor as compared to the rich and in rural areas as compared to urban areas. The rates for decline in under five mortality showed a similar pattern.
The disparities based on equity are also highlighted by vaccination coverage though these are less pronounced than other indicators. This can be attributed to very intensive efforts made to bridge the equity gaps in the vaccination program design. Country wide data was reviewed.26 This review comprised of 3 prominent surveys amongst many that were credible (NFHS 3, an ICMR survey done in 1999) and other publications. There is disparity between well performing and poorly performing states and the inequities are exaggerated within the poorly performing states. Girls fare worse than boys (5% lower), lower coverage is seen in infants of women with low literacy, but father's literacy level does not show such a differential.
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The household wealth has a direct relationship with much better coverage amongst the highest quintile as compared to the lowest quintile. Access to health services and other infrastructure, is associated with better vaccination coverage of infants. Although it may be difficult to decide about the different factors (single or in combination), lessons can be drawn to work out strategies that would bridge the equity gaps.
Innovating for Equity
Efforts have been made in the past to bridge the equity gap but successes have not kept pace with the widening gap. Subsidies, cash incentives, social marketing and, the top down trickle approaches have shown variable but largely an unsatisfactory response.
Advances in technology are being made at a very rapid pace in many fields but these advances would not serve much purpose as long as the equity gap keeps widening. To deal with this problem, innovations are required. Innovations for equity should be specifically targeted to reach all children with conscious efforts to reach those who are not being reached at present. They should be designed such that they meet the specific needs of the unreached population groups without any discrimination. These should be suited for local sociocultural context and should be locally adaptable. Failures are bound to occur. Success should be built on solutions to address the failures and there should not be fear of failures. The main agents of change have to be local communities. These interventions should be evidence based with rigorous monitoring for quality of care. To be successful, these should be scalable without being dependant on subsidies.2
Bridging of equity gaps would require: (1) generation of more compelling evidence to advocate equity, (2) Based on evidence, equity should be a priority in the design of child survival, child health and development interventions, strategies and national policy, (3) increasing coverage amongst the poor, socially disadvantaged with interventions that impact mortality and promote health and at the same time maintain the social equilibrium in the community, and (4) combining coverage with quality, so that there is greater acceptance. Quality focus needs to be greater amongst those who are poor and disadvantaged to obtain greater uptake and acceptability of accessible services.27
Continuum of Care and Integrated Care Approach
Essential services for mothers and children during pregnancy, child birth, postpartum period, infancy and childhood continued through adolescence have critical implications on child survival, child health, wellness, development and productivity. The relationship between undernutrition and child survival is well known. There is strong evidence available that the gains in nutritional status and child development are greater when feeding and interventions on early child development through play stimulation and communication are integrated.28 The care for healthy child should comprise of integration of (a) child feeding, (b) play communication and stimulation, (c) prevention of accidents and injuries, and (d) early and appropriate response to illnesses. The adoption of these strategies as continuum of care and integrated care are likely to have even greater dividends in children who are born low-birth weight, those who are undernourished and children from families who are poor, live in remote areas or are disadvantaged.
The Government of India has recommended and is implementing RMNCH plus A strategy.8 Within this policy framework, all the stakeholders should focus on the delivery of integrated care using a continuum of care approach, so that the benefits reach the largest number of families and communities. The efforts are going to succeed only through the up gradation of the current practices and behavior of the families who are the main stakeholders and the beneficiaries.
The concept of continuum of care has an additional and important dimension and that is the linking of the delivery of essential services in a dynamic system that integrates home, family, community, outreach and facility-based care. Amongst the above mentioned delivery channels, it is important to recognize that the gaps in care are most often most prevalent at the levels of the household and community-where day-to-day care and counseling is most required to change family and community practices. Therefore, it is necessary that in this dynamic system, the focus should be on the interface between the system and the family. A multichannel delivery approach is recommended at the interface level to maximize the behavior impact with family care providers and children as the target. A conceptual model for the use of multichannel approach is summarized in Figure 2. Additional opportunities include celebration of national and international days, e.g. Women's day, Mother's day, Father's day, Children's day, International Day of Rural Women Day, Girl Child Day, World Food Day, Swachh Bharat Abhiyan, International Yoga day, etc. in the community.
Mother-child protection (MCP) card has been produced by the Government of India jointly by the National Health Mission and Ministry of Women and Child Welfare after a long debate. It includes WHO growth standards. The card has been introduced to facilitate the process of provision of integrated care to the mother and child under 3 years of age using a continuum of 17care approach.
It brings together various stakeholders and providers at different levels. Since the card is family retained, it serves to empower the mother or the caregivers in the family. It has illustrations and text for guidance to the mother/caregiver about feeding, care, family-based actions and danger signs to alert them on care seeking. Concerted efforts are required by all concerned to develop an ownership of the card and develop a sense of pride and prestige amongst family members for safe upkeep and its continued use. The health care providers should feel accountable and fill the card appropriately.
There are different providers at various levels of health care delivery with different roles and responsibilities. This often leads to fragmentation in the provision of integrated care along the continuum. The policy support (RMNCH plus A), use of tools like MCP card and networking with a focus on interface strengthening will serve to build sustainable partnerships for maternal child and adolescent health in the millennium. It is important to use multiple channels with effective networking amongst the stakeholders at different levels to ensure the provision of continuum of care using an integrated approach.
Networking and Information Exchange through Mobile Phones and Use of Information Technology
Phones are now widely available. In the state of Haryana, all the health care providers at various levels have been provided free Closed User Group (CUG) sims to improve communication. The connectivity is good and through this, networking can be done. Information exchange is rapidly increasing and electronic platforms have been established. These networks will help to enhance the speed of communication and reporting of information. The information system is helping to provide real time on line data. These are beginning to be used for development of capacity through sharing of videos and learning materials. The establishment of networks has the potential to connect the families and communities to bring about the change in a meaningful manner.
Empowering the Women and Families
Empowering of women and families should be an essential and compelling component of the national health strategy and policy in India to close the equity gap for acceleration of national development. This should be the core business of all the stakeholders from the highest in the nation up to the level of the family in the post 2015 agenda. Empowering of women and families is essential to rapidly achieve MDG 4 and 5, improve the health of the mother who is the major care-giver, and most importantly improve the health and development of the children through the life stages. There is a relationship between maternal depression in impoverished families and poor child growth and poor child development. This is partly because depressed mothers interact less with their children and are less responsive.29
The currently low capacity of the caregivers poses a serious challenge to achieve the desired progress and success. The low empowerment and decision making affects timely decision making and action which adversely affects the health of women and of all the family members directly or indirectly. The situation becomes worse in the rural households, in the urban slums, amongst the poor families, in the lower castes and amongst families with low levels of literacy even though they may have some access to numerous health care and welfare schemes.
India has made several ground breaking policy decisions and put into place female Anganwadi workers, female anganwadi helpers, female multipurpose health workers, female supervisors and female accredited social health activists (ASHAs) to overcome the traditional barrier of females having to approach male health workers and volunteers for seeking out for advice on nutrition, development and health care. At present there are more than 13 lacs AWWs, 13 lacs AW helpers more than 9 lacs ASHAs on the ground who are empowered women in their own right and the vast majority of them have influenced their own children and families in addition to serving as community based providers. These workers and volunteers should be seen as role models by the women in the communities they serve. Working with them on a priority basis to enhance their skills and motivation will be a big contribution in women empowerment and this should be considered as an investment for nation building as well as child health, wellness and child development.
Quality and Coverage of Care
Quality and coverage are the next milestone to be achieved in the new paradigm to reduce the gap between the current resource deployment and the outcome indicators, e.g. reduction in mortality, improvement in nutritional status, coverage with key life-saving interventions, reduction in poverty or narrowing of equity gaps in coverage.
In many ways, quality and coverage should be considered together and integrated to the extent possible. Although quality assurance is used almost routinely in the private sector, it is only beginning to become a part of discourse in the health system. One of the major constraints has been that enough resources have not been expended in the process of quality assurance even though a lot of time and money are spent on generating data and prepare a lot of records by providers at all levels of health care. Efforts have been made though these have not progressed except some progress towards accreditation and some research efforts or pilots. Amongst the most important barriers to quality improvement process are the lack of ownership of the work and the lack of accountability to the system. Some of the other barriers include: (1) a presumption that health care is above all the services being rendered and the best is always done to provide care to the sick or save lives. No one would challenge the health care rendered to the patient, (2) often there is no linkage established between quality assessment and quality improvement, (3) resource constraints come in the way of providing quality care and services, (3) there are fears of reprimand for any wrong doing in the mind of those who participate in quality assessments or audits, and (4) there is heavy dependence on the checklists which may be weak interventions if there are intentions to improve quality.
Quality can improve if there is a mindset to improve it or accountability is built in as an integral part of the health system. Quality assurance is an ongoing process and it comprises of external and internal quality assurance. This includes quality assessment and quality improvement that is undertaken as a cycle comprising of (a) Plan, (b) Do, (c) Study and (d) Act. Each cycle leads to identification of gaps, followed by a process of filtration and a resolve by the team to close the gap. The subsequent review and audit has to establish the closure of the loop. All this cannot be achieved without investing in quality improvement process. Each quality assurance cycle should bring about improvements in quality. There is no doubt that external audit is extremely important, but it should be considered to be only supportive of the efforts made by the internal quality assurance processes.
The investments needed in the quality assurance process have to be substantial and sustained. These will prove cost effective since the investments should not be considered only in terms of mortality and disease burden reduction but it should also be assessed as to how much cost saving has occurred and how much productivity has increased.
There is a need to reposition the debate on quality of care with equitable coverage in the post 2015 agenda. For measurements to be meaningful setting benchmarks and standards is an important starting point.
Key Issues to be Considered to Bring about Quality Improvements and Coverage in Child Health Care
- Listen to users of services especially women who are the care-givers: Quality health care must be designed to meet the expectations of the people they serve. In the context of children, the needs and expectations are articulated by the mother and the family members. This would help to increase the demand for services and a greater acceptance of the services in terms of compliance both treatment as well as behavioral. The voices, views and opinions of women and families who are not covered adequately need to be heard even more. This would have to be addressed at all levels and by all the stakeholders at all times. This means spending more time and having greater interactions. This can be achieved formally as well as informally. At the formal level internal and external audits are the way forward in which the strong component should be interactions with the women and the families being served.
- Create a learning environment: The importance of creating a learning environment beyond the academia is a priority. This has to be done especially in settings where the access and use rates of services are low. There is no doubt that there are a lot of lessons to be learnt in the research settings, evidence base and best practices but it is even more important to create a learning environment amongst the program people and the client community to learn what is working and what does not work. The capability of these people (even though poor or illiterate) should not be underestimated even though they are not at a similar professional or academic level as the teachers and the researchers. The learning effort should be undertaken at many different settings and it should be multidisciplinary in the context of continuum of care. If a multichannel strategy has to make progress, then it would be necessary that a learning environment is created at the delivery points in the village and by the active engagement of the community. The new generations of pediatricians and child health workers have to be nurtured in this new environment, so that they can sustain their focus on the woman-centered 19and client centered services. If their experience is shared with decision makers then key decisions can be made based on local learning.
- Getting back to basics: Basics here refer to the social determinants of health, key family behaviors and issues like water, sanitation, access to food, etc. These areas need to be audited and reviewed in the day-to-day work. The lack of attention to basics especially at the family level contributes substantially to the poor health outcomes. Inadequacy of basic infrastructure and supplies like ORS, zinc, first line antibiotics, micronutrient supplements, and vaccines can adversely affect the outcomes and coverage. These must continue to remain a priority of the program at all levels. These basics should be reflected in the records and reports to become an integral part of the accountability platforms during the 21st century.
- Invest in simplification of records and reports: The health information system continues to be a big roadblock in planning, decision making and in the application of midcourse corrections. The programmers as well as researchers continue to depend heavily on data from National and district surveys, SRS and demographic surveys or census data. These are considered to be credible source of information. However, health management information systems have not substantially helped in the planning process.
In the context of records, patient retained records assume great importance since this tool helps them to be empowered about their own health and wellbeing and also proves to be useful in getting continuity of care. It is very difficult to audit the records that are currently available and make any meaningful assessment of the quality of services rendered.
The new generation of the human health workforce should keep abreast of the revolution that is taking place in mobile and electronic technology and work on platforms that reduces and minimizes cumbersome paper work. Electronic communication can help to overcome the barriers of distances and help in making records action oriented and used for problem solving.
At present records are complicated and cumbersome and do not have much usefulness in terms of accountability. One major weakness is that the records are not disaggregated and therefore the equity issues do not come within the radar of managers of program and poor or disadvantaged groups continue to remain marginalized. In equity terms, women and children continue to remain invisible. Records should be such that they reflect the quality of services and are fundamental to the quality improvement process.
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