The Millennium Development Goals Linkages with Child Health The Challenge in India

The Millennium Development Goals
Linkages with Child Health
The Challenge in India
Dr. KANUPRIYA CHATURVEDI
Dr .S.K CHATURVEDI
Millennium Development Goals
• In the United Nations Millennium Summit in 2000, 147
countries adopted MDGs
– Eradicate extreme poverty and hunger by half relative
to 1990
– Achieve universal primary education
– Promote gender equality and empower women
– Ensure environmental sustainability
– Reduce child mortality by two thirds relative to 1990
– Improve maternal health, including reducing maternal
mortality by three quarters relative to 1990
– Prevent the spread of HIV/ AIDS, malaria and other
diseases
– Develop a global partnership for development
The Global Challenge
• Nearly half the MDGs relate to health & nutrition
• The targets cover a large share of the burden of
disease & deaths among poor people
–
–
–
–
–
Child mortality:
Maternal deaths:
AIDS:
TB:
Malaria
10.4 million/y
0.5 million/y
2.9 million/y
1.6 million/y
1.1 million/y
• Illness, death, malnutrition impede economic
growth & contribute to income poverty
Goal 4: reduce child mortality
• Goal 4: reduce child mortality
• Reduce by two thirds, between 1990 and 2015, the
under-five mortality rate.
• Close to 11 million children die every year before
reaching the age of five, or 20 per minute,30,000 per
day. Nearly 4 million of these die in the first 28 days of
life.
• Most of the deaths are due to a handful of causes
(pneumonia, diarrhoea, measles, malaria, and neonatal
causes).
• Malnutrition is associated with 54% of the deaths.
• 99% of the deaths are in low and middle-income
countries, mostly in sub-Saharan Africa and South Asia.
• Measles deaths world-wide dropped by nearly 40%
between 1999 and 2003, with the largest reduction in
Africa.
What Are Children Dying From in the World?
2002
ARI
18%
Other
25%
Deaths
associated with
malnutrition
Diarrhoea
15%
54%
Malaria
10%
Perinatal
23%
HIV
4%
Measles
5%
Sources: Cause-specific mortality: EIP/CAH/WHO; Malnutrition:
Pelletier DL, et al. AMJ Public Health 1993; 83:1130-3.
Countries with most under-5 deaths,
2000
INDIA
NIGERIA
CHINA
PA KISTA N
ETHIOPIA
CONGO, DEM . REP.
A FGHA NISTA N
B A NGLA DESH
TA NZA NIA
INDONESIA
A NGOLA
NIGER
M OZA M B IQUE
M Y A NM A R
UGA NDA
B RA ZIL
KENY A
M A LI
0
500
1000
1500
2000
2500
3000
Goal 5: Improve maternal health
• Every year, at least 529,000 women die in
pregnancy or childbirth. 99% of these occur in
the developing world.
• For every woman who dies in childbirth, around
20 more suffer injury, infection or disease touching approximately 10 million women each
year.
• Complications resulting from unsafe abortions
account for 13% of all maternal deaths.
Avoidable maternal deaths each year
Maternal Mortality Ratios for Low andMiddle Income Countries, 2000
Number of Countries by level of MMR
Very high (500+)
High (200-500)
MediumMMR(50-200)
Low MMR(<50)
0
10
20
30
40
Number of countries
AFR
SAR
EAP
MNA
LCR
ECA
50
Goal 6: Combat HIV/AIDS, malaria and
other diseases
• Every day, 8000 people die of AIDS-related conditions or some 3
million deaths per year. Only 400 000 of the five to six million people
in the advanced stage of the disease had access to the antiretroviral therapy in developing countries at the end of 2003.
• There are 8.8 million new cases of tuberculosis (TB) a year. There
are 5500 deaths a day, or million deaths worldwide each year from
TB. Some 80% of this morbidity and mortality from TB falls on 22
high-burden countries.
• There are almost 300 million cases of acute cases of malaria each
year. More than a million cases of malaria are fatal each year. Some
90% of the burden falls on tropical Africa, where malaria is a major
cause of mortality and morbidity in children under five years of age.
Challenges in India
MDG4- Reduce child mortality
– Infant and Young Child
mortality
remains
unacceptably high.
– About 2.4 million deaths
occur annually in under-5
year-old children in India.
Seven out of every 10 of
these
are
due
to
diarrhea,
pneumonia,
measles, or malnutrition
and often a combination
of these conditions.
– In India abut 30% of
children born with LBW.
160
140
120
100
80
60
40
20
0
1990
2003
1990
2003
2015
2015
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
Total
1987
1986
1985
Rural
1984
1983
1982
20
1981
1980
Goal 4. Reduce child mortality: Infant Mortality Rate
140
120
100
80
60
40
Urban
0
Trend of U5MR and IMR in India
U5MR
20
02
19
99
19
97
19
95
19
92
19
90
160
140
120
100
80
60
40
20
0
IMR
Contribution of the 21 larger states to national infant deaths, 2000
100
83
76
80
67
70
57
60
43
50
Cumulative share in total number of infant deaths nationally
40
5
5
4
4
3
3
3
2
2
2
1
0
0
0
0
Chhatisgarh
Haryana
Punjab
Jammu & Kashmir
Delhi
Uttaranchal
Himachal Pradesh
Kerala
5
Jharkhand
6
Assam
8
Tamil Nadu
10
9
Karnataka
9
Gujarat
20
West Bengal
25
Orissa
30
Share in total number of infant deaths nationally
Maharashtra
Andhra Pradesh
Rajasthan
Bihar
Madhya Pradesh
0
Uttar Pradesh
Cumulative contribution (%)
90
93
89
97
96
Causes of U5 deaths-1985 & 1998
Rural India
40
34.8
30
20
10
26.2
25 24.5
29.5
17.3
12.3
5.4
5
8.8
1.5 1.0
1.1
4.6
0
Diarrhoea
Fever
NNT
Anaemia
Pneumonia
1985 1998
Prematurity
Others
MDG5- Improve maternal health
 130000 deaths an
year
 Equivalent to
maternal Deaths in a
year in
India
 Every day in the year
 Every six minute in
India
 For every Maternal
Death 20 mothers
start
leading a
life in the morbid
conditions.
 Every here 1- 1.25
lakh children get MDS
(Maternal Deprivation
Syndrome)
600
500
400
300
200
100
0
1990
1995
2000
2015
Direct causes of Maternal Deaths
• Haemorrhage (Antepartum & Postpartum).
• Pregnancy Induced Hypertension &
Eclampsia.
• Sepsis & Septicaemia.
• Obstructed Labour & Ruptured Uterus.
• Septic Abortion.
• Other Causes.
MDG6- Combat HIV/AIDS, malaria and
other diseases
• Halt and begin to reverse the spread of
HIV/ AIDS
– Sentinel surveillance – optimal way of
measuring infection among high and low risk
groups
– Number of sentinel sites and their location –
an indicator of adequacy of coverage
Estimated HIV infected people in India
(in millions)
6
5.2
5
4.58
4
3.5
3.7
3.86 3.97
3
2
1.75
1
0.2
0
0
1981 1990 1994 1998 1999 2000 2001 2002 2005
People living with HIV
5.2
5.6
3.6
1.8
1.2
Kenya
Zimbabwe
Nigeria
India
South Africa
Combat malaria and other diseases
20
02
20
00
19
98
19
96
19
94
19
92
19
90
• Target: Halt by
2015 and begin
reversal of
incidence of
malaria and
other major
diseases
4
3.5
3
2.5
2
1.5
1
0.5
0
Malaria cases (in millions)
API
P. falciparum cases (in mil)
Why a special effort now?
• New political and financial commitments
• Renewed focus on building sustainable
health systems and financing
• Successful implementation builds
confidence that scaling up of known
interventions can accelerate progress on MDGs
• Processes and mechanisms emerging to
improve donor harmonization and aid
effectiveness
But rapid gains are possible
through…
•
•
•
•
Practical approaches to achieve the MDGs- key
interventions and policies
Changes in national policies & strategic
directions, capacity building, and financial
support
Stronger health systems
Complementary actions across sectors
(education, water, energy, transport)
Donor mobilization and harmonization
We can learn from success stories…
Evidence based interventions
Estimated U5 Deaths Prevented
With Universal Coverage
Preventive interventions
Proportion of all deaths (%)
• Breastfeeding
13
• Insecticide treated materials
7
• Complementary feeding
6
• Zinc
5
• Clean delivery
4
• Water, sanitation, hygiene
3
• Newborn temperature management
2
• Tetanus toxoid
2
• Vitamin A
2
• Measles vaccine
1
Evidence based interventions
Estimated U5 Deaths Prevented
With Universal Coverage
Treatment interventions
•
•
•
•
•
•
•
•
Oral rehydration therapy
Antibiotics for sepsis
Antibiotics for pneumonia
Antimalarials
Zinc
Newborn resuscitation
Antibiotics for dysentery
Vitamin A
Proportion of all deaths (%)
15
6
6
5
4
4
3
<1
Policies
• For scaling up education with investments in
schools, teachers and supplies
• For scaling up of health with investments in
health staff, doctors, health facilities, medical
and paramedical training – for maternal care,
IMNCI, supplies of drugs/ equipment
• More decentralized planning and community
involvement and public private partnership
• Gender equality and rights for women
• To pursue huge quick wins for health goals
Examples of rapid gains in Health
sector
• Training of large number of village workers to
ensure basic expertise, services and counseling
• Distribution of free ORS, Disposable delivery
kits (DDK), contraceptives, Iron- folic acid
Vitamin A, anti-malarial & insecticide
impregnated bed nets in Malaria endemic areas
• Elimination of user fees for basic health
services financed by increased domestic and
Donor resources.
What does this mean for India
• Develop credible strategies and plans to
reach MDGs as part of PRSP and public
expenditure program
• Improve governance and policy
environment
• Commit domestic resources
• Improve monitoring and evaluation of
results
Examples of rapid gains in Health
sector
• Expanding access to RCH services by focusing on out
reach services, making health facilities functional and
ensuring supplies and logistics
• IEC and Program communication to increase access
to information, motivating for family/community
actions and use of services
• Expansion of use of proven effective drug
combinations for AIDS, TB, Malaria, Diarrhea and
ARI( pneumonia and Asthama)
Approach: Service delivery mode
based planning of interventions
• Scaling interventions with high efficacyfamily and community based interventions
• Making universally accessible- the
outreach services
• Institution based and individual child
centered services like malnutrition
management facilities
Data sources
• IMR and Child mortality
– Sample registration system (SRS): at national and
state level- fairly accurate
– National Family Health Survey) NFHS- fairly accurate
– RCH district rapid household surveys: low precision
• Causes of mortality--RGI:
• Fairly elaborate and reliable
• Delay in sharing collated information
• Recent Involvement of Medical Colleges-Quality
• Disaggregated data for urban and rural
India
Data sources
• MMR
– Direct methods- large sample size required
– Indirect methods
•
•
•
•
Snow ball technique
House- to house survey- better
Sisterhood method
Estimating from sex differentials in mortality at
reproductive ages involving regression techniques
Data sources
• HIV/ AIDS/ Malaria/ TB
– Reports from program implementers
– Under reporting of incidence/ prevalence/
deaths
– Over reporting of cure rates to meet the
targets
Reasons for the shortfall
• Availability– Adequacy of supply- satisfactory
– Periodicity a bottleneck
– Quality of equipment/ drugs- need improvement
• Accessibility–
–
–
–
Difficult to reach areas- neglected
Gender and socioeconomic discrimination
Round the clock services: questionable
Accessibility of govt services in urban areas
Reasons for the shortfall
• Utilization
– Lack of awareness about services
– Irregularity of services
– Quality not always maintained
• Adequate coverage
– Drop outs- a common factor
• Effective coverage
– Skills of workers always not up to the desired level
Costs and benefits
• Existing system takes into account
supplies, staff and minimal on
infrastructures
• Five country assessments and estimates
indicate that annual public investments or
MDGs will be 80US$ per person in 2005-6
scaling up to 124 US$ in 2015
Creation of national / state / district level
processes for scaling up
• Child Survival Partnership: Recommendations
– Ensure effective convergence of all departments, public and
private sector & developing partners,..
– Prioritize the household and community-level interventions
– Face real challenge of reaching high levels of effective
coverage with evidence-based interventions among underprivileged community
– Address operational bottlenecks & management issues
– Work efficiently with community-level private providers.
– Public Private partnership efforts, involvement of NGOs
• Other Initiatives
– Public Private Partnership—in Immunization, Integrated
Management of Childhood illnesses (IMNCI)