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)