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India’s largest contributor to child mortality gears up to save its children

Prosun Sen

Lalitpur, Uttar Pradesh, India: Sunken eyes, swollen belly, shrivelled skin. Listless, lifeless, weighing barely 4.5 kg, two-year-old Abhilasha had little hope of survival. A few more days and the severely undernourished child would have become yet another unmourned statistic of child mortality in Uttar Pradesh, the largest state of India with an Infant Mortality Rate (IMR) of 73 - but for a timely referral to the newly established Nutrition Rehabilitation Centre (NRC) in her home district, Lalitpur.

The NRC – an infant itself, born on 6th June 2007 – took the dying Abhilasha in its arms and brought her back to life. Within a week, Abhilasha started gaining weight through supervised nutritional supplements and a daily follow-up by a paediatrician and nutritionist.

Extensive nutrition counselling of her mother, with demonstration of nutritious recipes using readily available, low-cost ingredients, saw Abhilasha gain 35 per cent weight in less than a month. Little Abhilasha was back on her feet.

IMNCI encompasses an integrated approach that includes the assessment, classification and management (including referral) of major problems afflicting a sick young infant and children under five years of age, with a sharp focus on newborns at the community level. The assessments include the nutritional and immunization status of all sick infants, and children, and places particular emphasis on home visits for all newborns to teach the mother ways to prevent illnesses through exclusive breastfeeding, keeping the baby warm, and other essential newborn care. During these visits, mothers are also taught to recognize illnesses early and to know when and where to seek timely care.

Within three months of its establishment, the six-bedded NRC, set up with the   support of the United Nations Children’s Fund (UNICEF) at a Community Health Centre (CHC) of Lalitpur District, has treated 70 undernourished children (40 of whom were facing Grade III and IV undernutrition)   through free residential, institutional care. It is worth noting that more than 80 per cent of these children belonged to backward communities, of which 60 per cent comprised girls: a bitter reflection of the impact of social exclusion on child health and nutrition. The NRC pilot’s early results are extremely significant and hold out a ray of hope for a district where 51 per cent of the children are reported to be undernourished.

The NRC is only one of the many successes that the Lalitpur district has seen in the recent past in the arena of child survival.  The NRC itself is an offshoot of a larger child survival revolution that is quietly transforming the lives of an estimated 135,000 under-fives in Lalitpur.

The revolution, better known as Integrated Management of Neonatal and Childhood Illnesses (IMNCI), has been piloted by UNICEF in 25 districts of India. Lalitpur was selected due to its poor child-survival indicators and weak health infrastructure, with the intention of making a visible difference. The results indicate that it has achieved just that.

In 20 months, since the initiation of IMNCI in Lalitpur in October 2005, over 1,000 Community Health Workers, popularly called anganwadi workers (AWWs) and Auxiliary Nurse Midwives (ANMs), have been trained using an intensive eight-day IMNCI module.

Subsequently, equipped with extensive knowledge, basic drugs and a brimming enthusiasm, the trained workers have reached out to 8,248 newborns – roughly 70 per cent of all newborns in the district – within 24 hours of their birth, to assess their condition and counsel the mothers and families on breastfeeding, cord-care, maintaining body warmth, immunization and other essential aspects of neonatal and infant/childcare. 

A total of 32,850 children under five years of age, including 14,481 less than two-month-olds, have been assessed in their homes for feeding problems, undernourishment, diarrhoea and serious infections. Minor problems have been managed at home through counselling and basic drugs, while critical ones have been promptly referred to the nearest health centre for immediate treatment. The timely recognition of illnesses and referral to appropriate health services has contributed to saving many young lives.

In India, the global IMCI strategy has been adapted by experts, including the Indian Academy of Paediatrics and the National Neonatology Forum for the specific requirements of children in India. The group recommended and formulated an adapted version of IMCI, renamed Integrated Management of Neonatal and Childhood Illnesses (IMNCI), placing  more thrust on the neonatal component, which is the most critical period affecting infant mortality in India.

The Lalitpur IMNCI results indicate that the strategy can potentially reduce child mortality, as has been the experience in several other countries. From the skill development of health workers and communities to building and strengthening health systems for neonatal and childcare, IMNCI implementation in Lalitpur has thrown up a successful model.

Recognizing its immense potential, the Department of Health and Family Welfare, Government of Uttar Pradesh, has decided to scale up the intervention, with an added component of maternal health and community mobilization, across the 17 worst-performing districts of the state. The action plan, with an approved budget of $ 6.5 million, aims to bring down the state’s IMR to 40, from the existing 73. If everything goes as planned, achieving MDG 4 (reducing child mortality) by 2015 does not seem to be a distant dream, for the state which presently contributes to the one-fourth of India’s total child mortality.



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