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: 10.4 million/y
– Maternal deaths: 0.5 million/y
– AIDS: 2.9 million/y
– TB: 1.6 million/y
– Malaria 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.
 W ha t Are Children Dying From in the W orld?
2002
ARI
Other 18%
25%

Deaths
associated with Diarrhoea
malnutrition 15%

54%
Perinatal Malaria
23% 10%
HIV Meas les
4% 5%
Sources: C ause-specific m ortality: EIP/C AH /W H O; M alnutrition:
Pelletier D L, et al. AM J Public H ealth 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 50
Number of countries

AFR SAR EAP MNA LCR ECA

 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 anti-
retroviral 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 160

mortality remains
unacceptably high. 140
– About 2.4 million deaths 120
occur annually in under-5 100
year-old children in India.
Seven out of every 10 of 80
these are due to 60
diarrhea, pneumonia, 40
measles, or malnutrition
and often a combination 20
of these conditions. 0
– In India abut 30% of 1990 2003 2015
children born with LBW.
1990 2003 2015
 100
120
140

0
20
40
60
80
1980
1981
1982

Rural
1983
1984
1985

Total
1986
1987
1988

Urban
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Goal 4. Reduce child mortality: Infant Mortality Rate

2004
 Trend of U5MR and IMR in India

160
140
120
100
80
60
40
20
0
90

92

95

97

99

02
19

19

19

19

19

20
U5MR IMR
 Contribution of the 21 larger states to national infant deaths, 2000
96 97
100 93
89
83
90
76
80
Cumulative contribution (%)

67
70
57
60
50 43
Cumulative share in total number of infant deaths nationally
40
Share in total number of infant deaths nationally
30 25
20
9 9 8
10 6 5 5 5 4 4 3 3 3 2 2 2 1 0 0 0 0
0

Jammu & Kashmir

Assam
Karnataka
Maharashtra

Tamil Nadu

Haryana

Kerala
West Bengal

Uttaranchal
Bihar

Rajasthan

Orissa

Gujarat

Delhi

Himachal Pradesh
Punjab
Uttar Pradesh

Jharkhand
Madhya Pradesh

Chhatisgarh
Andhra Pradesh
 Causes of U5 deaths-1985 & 1998
Rural India
40 34.8
29.5
30 25 24.5 26.2

20 17.3
12.3
8.8
10 5.4 5 4.6
1.5 1.0 1.1
0
Diarrhoea Fever NNT Anaemia Pneumonia Prematurity Others

1985 1998
 MDG5- Improve maternal health

 130000 deaths an 600

year
 Equivalent to
maternal Deaths in a 500
year in India
 Every day in the year
 Every six minute in 400
India
 For every Maternal 300
Death 20 mothers
start leading a
life in the morbid 200
conditions.
 Every here 1- 1.25
100
lakh children get MDS
(Maternal Deprivation
Syndrome) 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 3.7 3.86 3.97
3.5
3
2 1.75
1
0 0.2
0
1981 1990 1994 1998 1999 2000 2001 2002 2005
 People living with HIV

5.6
5.2

3.6

1.8
1.2

Kenya Zimbabwe Nigeria India South Africa

 Combat malaria and other diseases
4
• Target: Halt by 3.5
3
2015 and begin 2.5
reversal of 2
1.5
incidence of 1
malaria and 0.5
0
other major
diseases
90

92

94

96

98

00

02
19

19

19

19

19

20

20
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 Proportion of all deaths (%)

• Oral rehydration therapy 15

• Antibiotics for sepsis 6
• Antibiotics for pneumonia 6
• Antimalarials 5
• Zinc 4
• Newborn resuscitation 4
• Antibiotics for dysentery 3
• Vitamin A <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 efficacy-
family 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 under-
privileged 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)