Vikas Samvad InfoPack series – 39
Neo-natal Health in Madhya Pradesh (Part - One)
Status after 10th Five Year Plan

Introduction

Neonatal survival is a very sensitive indicator of population growth and socio-economic development of the society. Neonatal Mortality refers to a death of a live-born baby within the first 28 days of life & Neonatal Mortality Rate (NMR) the number of deaths of neonates per thousand live births [www.wikipedia.org/neonatal].

Review of the 10th Plan (Period 2002-07) shows that neo-natal deaths still represent the largest percentage of overall and preventable child mortality. Only India accounts for 1.2 million or nearly 30% of global neonatal mortality [Estimates based on the projected population of India by the Technical Group on Population Projection, RGI, India, 2008 and Vital Rates from SRS], as various reports show. Rate of neo-natal deaths have been declined from 60 per 1000 live birth between 1978-82 to 39 per 1000 between 2005-06 [National Family Health Survey (NFHS III), 2005 – 06, India: Volume I, International Institute for Population Sciences, Mumbai, September 2007]. But still it is very high & if India has to attain its MDG of halving infant mortality, the rate of neo-natal mortality decline will have to accelerate significantly.

Worldwide 37 per cent of under-five deaths are attributed to neonatal causes (within the first 4 weeks of life). In India, this figure is around 50 per cent, which means that the proportion of U5 deaths by neonatal causes is disproportionately high in this country [PFC 2007 & SRS - See presentation slides 5 and 6].
 
Neonatal survival is closely linked with maternal health, IMR, CMR, MMR & TFR. Ensuring good maternal health is one of the basic component of neonatal survival. According to WHO “A maternal death is defined as the death of a woman while pregnancy or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes." The infant mortality rate (IMR) [www.wikipedia.org/infant mortality] is the number of deaths of children less than 1 year old per thousand live births. The child mortality rate (CMR) is the number of deaths of children less than 5 year old per thousand live births. The maternal mortality rate (MMR) is the number of maternal deaths due to childbearing per 100,000 live births. Total fertility rate (TFR) is the mean number of children a woman is expected to bear during her child-bearing years. It is also independent of the age-sex structure of the population.

The worst affected states are U.P, M.P, Chhattisgarh, Jharkhand, Orissa, Assam & Andhra Pradesh. While the national average of child dying within the 28 days of life is 39/1000, the NMR of U.P. is 47.6, Chhattisgarh 51.1, Jharkhand 48.6, Orissa 45.4, and Assam 45.5, for AP it is 40.3 & for MP it is 44.9 [National Family Health Survey (NFHS III), 2005 – 06, India: Volume I, International Institute for Population Sciences, Mumbai, September 2007]. In this larger context, we are trying to put information, data and situation in an analytical framework, so that a clear picture could emerge and this issue moves form margin to center in the policy sector.

1. Rights Framework and Neonates

Children constitute principle assets of any country.  Children’s development is very important for the overall development of society and the best way to develop national human resources is to take care of children. India has the largest child population in the world. Child comprise 40% of the country’s population There have been many initiatives from different quarters like the civil society, national governments and international organizations towards recognizing the rights of neonatal & infants. The Convention on the Rights of the Child (CRC) lays down the principles of non discrimination in the best interest of the child along with the common standards for the various rights of children. It takes into account the different cultural, social, economic and political realities in which children live. A number of policy initiatives & constitutional provisions have been taken for this purpose.

Constitution of India

a. Fundamental Rights

• Article 14 provides equality before law. “The State shall not deny to any person equality before the law or the equal protection of the laws within the territory of India.”
• Article 15 provides that “The State shall not discriminate against any citizen on grounds only of religion, race, caste, sex, place of birth or any of them.”
• Article 15(3) provides that, “nothing in this article shall prevent the State for making any special provision for women and children”.
• Article 21 ensures the protection of life and personal liberty. No person shall be deprived of his life or personal liberty except according to procedure established by law.

b. Directive Principals to the State Policy

• Article 45 envisages that the State shall endeavor to provide early childhood care and education for all children until they complete the age of six years.
• Article 47 provides that it is the duty of the State to raise the level of nutrition and the standard of living and to improve public health (Directive Principals to the State Policy)

National Policy Framework

The National Policy for Children spells-out in clear terms the Constitutional provisions "It shall be the policy of the State to provide adequate services to children, both before and after birth and through the period of growth, to ensure their full physical, mental and social development. The State shall progressively increase the scope of such services so that, within a reasonable time, all children in the country enjoy optimum conditions for their balanced growth".

The Government of India has also adopted the National Charter for Children, which emphasizes Government of India’s commitment to children’s rights to survival, health and nutrition, standard of living, play and leisure, early childhood care, education, protection of the girl child, empowering adolescents, equality, life and liberty, name and nationality, freedom of expression, freedom of association and peaceful assembly, the right to a family and the right to be protected from economic exploitation and all forms of abuse The National Charter for Children was notified in the Gazette of India on 9 th February, 2004.

This plan commits itself to ensure all rights to all children up to the age of 18 years. The Government shall ensure all measures and an enabling environment for survival, growth, development and protection of all children, so that each child can realize his or her inherent potential and grow up to be a healthy and productive citizen. It aims to reduce Neonatal Mortality Rate to below 18 per 1000 live births by 2010.

Convention on Child Rights (CRC): CRC acknowledges that every child has certain basic rights which fall into four broad categories:

a. Subsistence rights: including the rights to food, shelter and health care.

i. Article 6: Children have the right to live. Governments should ensure that children survive and develop healthily.
ii. Article 24.1: States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.

b. Development rights: which allow children to reach their fullest potential 

i. Article 18.3: States Parties shall take all appropriate measures to ensure that children of working parents have the right to benefit from child care services and facilities for which they are eligible.
ii. Article 27.1: States Parties recognize the right of every child to a standard of living adequate for child's physical, mental, spiritual, moral and social development.  

c. Protection rights: such as the right to life and protection from abuse, neglect and exploitation

i.    Article 3.1. In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.
ii.    Article 4: Governments have a responsibility to take all available measures to make sure children’s rights are respected, protected and fulfilled. When countries ratify the Convention, they agree to review their laws relating to children.

d. Participation rights: This allows children to play an active role in community and political life.

In spite of having large number of policy initiatives & constitutional provision for the safeguards & protection of children’s in India, the rate of neo-natal & infant mortality in Madhya Pradesh represents a havoc situation.

Challenges for Survival of Neonates

The small and lean figure clothed in a torn Ghagra (traditional dress of the Sahariya women), was spotted near the Choolha (hearth) along with her 1-hour-old child. She was constantly applying heat on her stomach with the help of a cloth made hot from the burning fire.  Outside the mud hut, the temperature was above 44 degree Celsius. Her head was covered with a Chunari (traditional cloth used by women to cover their face and head) beneath which, one could see tired sunken eyes, which looked exhausted and drained. Beads of perspiration ran over her face, where fear   and pain were written large. On the other side of the hearth lay a rusted sickle stained with blood. Guddi, this 26-year-old Sahariya tribal woman, had just gone through one of the most horrendous situations of her life. She had given birth to a baby boy just about an hour ago, with the help of a few neighboring women who had used the sickle to separate the child from the mother by cutting the placenta with it.  When asked whether she had breastfed her child on the initial milk, which is very nutritious for the child, the hollow look on her face gave way to anger and helplessness as she asked “How do you expect me to feed my child when I have not eaten for three days?”

The birth of a child signifies the beginning of a lot of positive dreams in the lives of parents. But in the case of Guddi’s child she does not even have the right to weave dreams about her child because, the women in Patalgarh village are forbidden from it…

The survival of neo-natal is still a big challenge in rural & tribal regions like Patalgarh Village of Madhya Pradesh. Patalgarh is a small village of the Karahal block of Sheopur district, situated at the distance of 70 kms from the district headquarters and 65 kms from the block headquarters. Patalgarh is dominated by Sahariya tribe, one of the three primitive tribes of Madhya Pradesh. These adivasis who were dependent on forest for survival for generations had limited needs. Their traditional means of earning a livelihood was one of agriculture, gathering forest products and hunting. To access the services available at the block or district headquarter one has to travel through the thick forest and bumpy, muddy roads. Ignored by the society, inhuman behavior of system and deprived of their basic needs they are a community that has been subjected to a lot of social, economic and political discrimination.

Safe motherhood & neonatal care is still a big dream for the villagers like in Patalgarh village. The village that is situated in the interiors does not have even the basic infrastructural facility. The nearest hospital is situated at a distance of 35 kms. Here maximum of deliveries are still conducted at home by the untrained village women & dais. No proper ante natal care & in case of emergency no system of referral & transport are available. The mothers are not even capable to feed their newborns due to hunger & starvation. It is not only the case of Patalagarh, but is very common situation in rural & backward districts like Sheopur, Sidhi, Chattarpur,Satna,Rewa,Jhabua ,Mandla, Dindori & other.

Indicators for neonatal mortality and infant mortality are more sensitive to the changes that have a bearing on the quality of life, particularly to the health and longevity of people. In preparing neonatal-mortality-reduction strategies it is important for countries to know the magnitude of neonatal mortality in order to assess needs and develop programmes that will reduce avoidable neonatal deaths more quickly.

NFHS II data reveals that Neonatal Mortality Rate (NMR) of M.P. is 54.9% against the national average of 43.4% which indicates that this vulnerable age is exposed to several exogenous and endogenous factors, which influence the health, growth and development of the child. Neonatal mortality statistics was much higher in rural areas with 64.6% in comparison to urban Madhya Pradesh which had NMR of 41.9% [National Family Health Survey (NFHS II), 1998-99, India]. Even the states like U.P. (53.6%), Bihar (46.5%), Orissa (48.6%) & Assam (44.6%) had comparatively lower neonatal mortality rate then M.P. Literacy has a great impact on the neonatal mortalities, which is clearly depicted through the NFHS II data that in urban India NMR is 44.1% among illiterate while it is 57.0% for rural India. While among the literate it is 30.8% & 44.0% in urban & rural areas repectively.And the situation of Madhya Pradesh in respect of literacy rate is not very enthusiastic. The total literacy rate (Census 2001) of M.P. is 63.7% & among the female it is as low as 50.3%.

Again the caste structure has bearing on the neonatal mortalities in India it is 56.2% for SC population & 55.1% [National Family Health Survey (NFHS II), 1998-99, India] for ST population. M.P. has the largest tribal population with 46 different tribal groups. Madhya Pradesh has 9.16 million & 12.23 million ST and SC population. This indicates that the situation of Madhya Pradesh is very crucial with regard to neonatal mortalities as the state has wide SC/ST population & adjoining high rate of illiteracy in rural & urban areas.

Different indicators of NFHS II pinpoints on the deliberate situation of the state regarding neonatal deaths demanding immediate attention. Neonatal deaths comprise approximately 64% of infant deaths. But in spite of that no specific policy measures & programme were taken during the tenth plan period (2002-2007) for neonatal care in M.P.

The Madhya Pradesh state had started many initiatives during the 10th five year plan to take care of the poor health indicators focusing specially on the maternal & child health. But these initiatives are far satisfactory to reduce infant mortality to 30 per thousand live births by 2010. Madhya Pradesh is among the six worst affected states in the country. While taking into account the health indices e.g. Total Fertility Rate (TFR), Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR) and Birth Rate, the State is considered as one of the BIMARU state.

Though the state claims committed to provide health care facilities to the poorest of the poor in the state but health infrastructure & service are much below the actual requirement. State has established 12 new district hospitals during the 10th plan period. At present the State has 48 district hospitals, 8843 Sub Centres requiring 1614 more sub centers, 1153 Primary Health Centre & having need of 1614 more PHC and 266 CHC & 140 [www.health.mp.gov.in (Health Institutions in Madhya Pradesh, as on August' 2007)] more are required to cater the health needs of the community & to cut down its MMR, IMR & thereby NMR.

improvement is agonizingly slow. Availability of trained staff and doctors is still a great challenge.

The biggest concern for the State in the health sector is poor health indicators like Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR) & Total Fertility Rate (TFR) which directly or indirectly affects the Neo-natal Mortality Rate (NMR). The neonatal mortality rate of M.P. had declined only up to 44.9 in 2005-06 from 54.9% in 1998-99.

The IMR of the state as per the NFHS-3 is 69.5/1000 but now is 72/1000 [SRS 2007 released in Oct 2008] live birth against the national average of 57/1000 live birth, with a Maternal Mortality Rate (MMR) of 379 per one lakh live births. Situation in the backward district of M.P is worst. The MMR for sidhi 1044, Chatterpur 934, Jhabua 895, Satna 804, Tikamgarh 842, Raisen 757, Shadol 750 & Mandla 724 [Study Report to chart out the burden of Maternal Mortality at the decentralized level by A. Ranjan of Population Resource Center of RCVP Narohana Academy of Administration (Bhopal)] which has direct impact on NMR. Neo-natal deaths cannot be substantially reduced without efforts to reduce maternal mortality & improving maternal health.

One important component of improving maternal health to reduce NMR & IMR is to control the TFR. Fertility has a direct bearing on infant mortality. TFR is also very high in the state. The national average of TFR is 2.68 & for M.P. it is 3.12 & for the rural M.P. it is still 3.34 & long way is to be covered to reach a level of 2.1 by 2011 [National Family Health Survey (NFHS III), 2005 – 06, India: Volume I, International Institute for Population Sciences, Mumbai, September 2007]

As per health bulletin data of Family Welfare & RCH Programme for April to Sep 2008 out of the total delivery of 852837, 189545 (about 22%) are Domiciliary Deliveries in M.P. And these 22% infant born do not receive any neonatology care.

To secure maternal & child health, it is very important to promote safe motherhood by ensuring Ante natal care of all the pregnant women. But in M.P. 20.3 % of women do not receive any antenatal care by the state & only 40.7% women had three or more ANC visit while only 12.4 percentages of women took IFA for at least 90 days. This is the cause of concern & has high risk of neonatal deaths in such cases.

Prevalence of anemia in women in their reproductive age 15-49 years in the state also increases the peril of neonatal deaths. 41% of women in the State are affected by mild anemia & 14.1% by moderate anemia which may lead to maternal & neo-natal mortality [National Family Health Survey (NFHS III), 2005 – 06, India: Volume I, International Institute for Population Sciences, Mumbai, September 2007]. Around 58% of the pregnant women in the country suffer from anemia of different degree.

Even though breast feeding is common in India & state but only 15.9% children are given breastfeed within an hour in M.P.

Low birth weight among the live birth is also high for M.P. In the state 23.4% birth are reported with the birth weight less than 2.5Kg.

If we sit by to analyze the budgetary allocations and its outcome in Madhya Pradesh from 2001 and 2005, one clearly see a sorry state of affair. This period, – being the transitional period between 9th and 10th Five Year Plans, funds to the tune of Re.1685.64 crores were allocated and disbursed to the Department for Women & Child Development.

Child dies due to lack of medical treatment in district hospital Sheopur

Sunita Bai, a Harijan woman of Banikhera village in Sheopur district in State of Madhya Pradesh lost her child immediately after birth. Her husband and other community members say that hospital has inadequate facilities and treatment was not given to the child and the mother after delivery. Both Sunita Bai and her child had developed some complications but were denied adequate medical facilities at the district hospital. She lost her child. Her husband has given a written complaint to the Collector. Media reports challenge the state institutional delivery mantra of the state that state does not have the available infrastructure to save lives of women and children.

Adapted from media report published in Nai Dunia dated January 16, 2007

However, the Department could utilize only a sum of Re.1210.34 crores (71.80%) and the balance amount of Re.475.30 crores (28.20%) remained unutilized [Report of the Comptroller and Auditor General of India – 2005]. If this allocated budget has been utilized fully in optimum way under different welfare schemes, it would have positive impact on the maternal health & would ultimately result in decreased neo-natal deaths to some more extent. 

3. Medical Causes of Neonatal Deaths

Global figures suggest that sepsis, birth asphyxia & preterm child birth are three most important causes of neonatal mortality. Most neonatal deaths occur in pre term & low birth weight babies. There is a far higher risk of death in multiple morbidities co-exist.

Socio-Economic Determinants of Neo-natal Deaths

Various studies reveal that besides medical causes, socio-cultural norms & economic factors are one of the deep rooted determinants of perpetuating neo-natal & infant mortalities. Madhya Pradesh which lies in the heart of the country is very much bounded by the traditional customs & beliefs of the people. One cannot go beyond the religious belief, customs, tradition & social taboos which directly & indirectly affect the maternal & child health & they became more susceptible to infections & death.

Social & cultural factors

Rural & tribal community generally perceived as per the local community norms, values & practices. It is very often presumed that under the effect of their prevailing community norms & values; the rural folk especially the tribal community of Madhya Pradesh have little faith in urban allopathic treatment. They prefer their own traditional ways of treatment & knock the hospital only in very critical & unmanageable situation which many times results in very late detection of disease, morbidity & mortality. Women & infants became more vulnerable in such a situation. The general perception regarding the maternal & child issues which are common in Madhya Pradesh leading to high neonatal mortalities are:

• Pregnancy & child birth is a natural phenomenon & need no special ante-natal care & checkups. The girls are married at a very tender age leading to early child birth at the age below 18years resulting in low birth weight babies, neo-natal & maternal deaths.
• Preference for male child results in large number of children in the family affecting the health of mother & new born.
• Pregnant women are half fed as the foetus needs space for growth.
• Pregnant women should work more as it will help her in having normal & easy delivery.
• New born are not given breastfeeding for the first two three days as the colostrum milk is considered harmful for them, thus resulting in decreased immunization power of newborn. ƒ
• Honey, jaggery & “ghutti” are given to newborn before breast milk.
• For about a month or so after the child birth, the mother is given only specific diet with some herbal medicines & not the complete diet.
• Applying cow dung, oil etc on the navel cord of the newborn is a common practice resulting in infection in neo-natal
• The women or the female members can eat only after the males’ having their food is a traditional custom resulting in high percentage of anemia in women.
• Infanticide of girl child is a common practice.
• Women should follow the decisions by the male members & has no decision making power even on issues concerning to herself & her child.
• Education of the girl is not necessary as she is considered as “Paraya Dhan’. 
  

But why can’t we see the other side of the coin? It is very easy to blame the simple tribal people for not accessing the modern health services. It is not that the poor marginalized rural folk do not want to have a better life style! They too want good health for their family members & special care for their neonates. But the modern medicine system is still far out of their reach. There is need to think & act upon the question why the rural poor do not have faith in the government institutions which are providing free services to them? On one hand the government is not able to provide proper health services and on other hand it is scrapping the traditional and alternative systems in strategic way. The medical practitioners with egoistic behavior & rude attitude could not understand the suffering & pains of poor & marginalized masses. There is no proper linkage & referral system between various health institutions from village level to district level. The system lacks sensitivity, accountability & monitoring on their part. Large number of neonates & pregnant women remains unregistered. Even when these people approach the government institutions, the medical practitioners do not pay any attention to them & instead they even many times demand money from them. Not only this, odd traditional midwives (dais) who could have brought these people closer to modern medicine system have been banned in way from offering their services. Thus no strategic efforts have been made & planed during the five year plans to bring harmonious relation between health institution & rural folk to increase the demand for modern medical services.

Economic Factors

Economic factors influence neo-natal & infant mortality in a big way. Child survival depends on the ability of the parents to offer good care. If they are in the BPL category, their capacity for child care is minimal. Also, illiteracy and ignorance of the needs of child care are glaring. The general standard of living and life style of people, the persisting poverty in every household, the feeble capacity of the head of the household to provide food for all the members and women and girl children of the family, and allied environmental and social factors do influence adversely the infant mortality in a community. Due to poor paying capacity & low standard of living, the rural & tribal mass cannot take their infants to neo-natal intensive care units (NICU) in case of emergency as they cannot even bear the transportation cost to bring them to NICU at district/civil hospitals. The numerous economic factors have both direct and indirect impact on the survival of children and on infant mortality. Some of them are as follows:

• Source of livelihood & Household income
• Number of earning members in the family.
• Number of members to be fed in the family.
• Standard of living of the family.
• To which caste do they belong?
• Land holding/farm power
• Economic development of the village.
• Capacity to access health services.
• Basic infrastructure in the village & nearby.

These prevailing socio-economic factors & traditional norms leads to early marriage, early conception, and home based deliveries, anemia in pregnant women & lactating mothers, low birth weight babies, malnutrition among infants, infections which are the major cause of high neo-natal, infant & maternal mortalities in the state. So to curb neonatal deaths priorities should be given to improve the socio-cultural & economic situation in tribal & rural areas.

To cut down neonatal mortalities & to improve the health status of infants & children there is an urgent demand to raise the standard of living of the rural poor by generating new employment opportunities & bring them closer to the mainstream and further expansion of basic infrastructure & economic development.

Every social, economic & political structure has its own system, range & mainstream which lead to growth & development of individual as well as society. In such a system, if particular section or individual is denied or prevented to participate in the mainstream, it is consider a boycott & exclusion of that section or individual. Exclusion is the denial of right of participation in the social, economic, cultural & political life; the denial of control over its resources; denial of opportunities for health care, education, and housing. Exclusion is denial of human dignity; denial of constitutional & human dignity.

Social exclusion is discriminatory practice. Social exclusion and discrimination refer to the process and outcome of keeping social groups outside power centers and resources. It is a multi-dimensional concept. Social exclusion is about more than income poverty. It is a short–hand term for what can happen when people or areas have a combination of linked problems, such as unemployment, discrimination, poor skills, low incomes, poor housing, high crime and family breakdown. These problems are linked and mutually reinforcing.

In the Indian context, dalits/untouchables/lower castes, tribals/adivasis/indigenous peoples, rural and forest-based communities, minorities, the most backward castes, and women and children are the most excluded. Because it is an institutionalized and socially/religiously sanctioned attempt to exclude, segregate or cast out a segment of the population, it is that much more difficult to change.

Women in India are the most excluded and discriminated segment of the population. Patriarchy constrains women in all facets of life. Control of women’s reproductive abilities and sexuality is placed in men’s hands. Patriarchy limits women’s ownership and control of social & economic resources even upon herself. She cannot even decide for herself & for her children. This has deep rooted impact upon the maternal & child health. And if the women is poor & tribal then the problem become multi facet as she faces exclusion both within & outside the group  She does not have access on health services necessary to maintain good reproductive health which ultimately affects the health of newborns & infants.

Exclusion & Tribal life in Madhya Pradesh:

Previously, tribal depends upon collection of forest products & hunting of animals which forms the very basis of their identity & existence. But this balance of tribal life had been totally ruined by the political, social & economic system. In the name of preservation of forest they were again forced to change their food habits & adopt the market trend. The social system considers them as tribal & untouchables & grabs their identity. They are forcibly excluded from their forest life which bounded them to work as laborers & live a miserable life. The forest products & the hunted animals that they used to eat has lot of nutritive values but now by doing labour work they gets only very low income with which they can only eat bread (roti ) or rice & not the balance diet, which has vast impact on their health.

The institutional mechanisms that are responsible for delivery of services do not address the needs of tribal. In tribal regions local government institutions are still not in place. In other areas the Panchayati Raj Institutions are extremely weak.

Impact of Exclusion on Health:

The health status of socially excluded communities is also compromised in Madhya Pradesh. Social exclusion and deprivation have a major impact on health. Dalits, tribal, schedule caste, women & children which are among the most excluded communities in the state cannot avail the health services due to various socio-economic reasons. Prevalence of anemia is very high among them. Morbidity and infectious diseases such as malaria, tuberculosis, leprosy, typhoid, and cholera are rampant in areas of Madhya Pradesh. Additionally, malnutrition, birth disorders, and gastrointestinal diseases are common among tribal populations.

In a sense Caste, Culture and Livelihood based exclusion also impact the health indicators and that is why exclusion components should be addressed seriously in policy formation processes.

One of the important reasons for not availing the medical health services by these excluded communities are the insensitive attitude & rude behavior of the medical profession & staff towards them and overwhelming corruption in whole system. When the poor tribal reaches the health institution, they are not given due attention & services. 

The response to exclusion is inclusion. Inclusion is providing equal opportunities of participation and decision making, even by positive discrimination. Attitudinal change will help to address exclusion.

During the tenth five years plan was not only the non availability of services but the more serious & rampant issue was that of social exclusion. The deprived rural & tribal folk in the state was still facing exclusion both from the society as well as from the institutional structures of the government. During the tenth plan though the efforts were made to functionalize the existing institution & expanding their capacities but still they are far behind the reach of the poor tribals. The reason behind is the lack of required efforts on the part of state for social inclusion. No state level program had been implemented with special focus on inclusion of schedule caste & schedule tribes in the mainstream.

The Role of Health Providers to promote Health Development

Looking at the grave situation in the state, the health providers now have to look beyond the health sector and establish supportive linkages with education, health, livelihood, sanitation, communication for comprehensive socio-economic development. They need to aware the people to reduce mortalities. They have to perform a multifaceted role to promote health & to facilitate community participation. The medical practitioners & service providers should be trained for sensible behavior especially when dealing with marginalized section of the society. Incorporation of time to time training for capacity building of health professionals to tackle the rural masses in a more sensible way for service demand generation. It is natural that no sacrifice is expected from the health workers, but could not they be expected to at least fulfill the responsibilities allotted to them. They should be accountable for their attitude & services specially when dealing with vulnerable population. Behaviour change communication should be an integral part of all RCH service delivery systems.

5. Key Strategies required for Neonatal health

• Reduction of neonatal mortality rate requires greater convergent action to influence the wider determinants of health care like female literacy, safe drinking water, sanitation, gender and social empowerment, early child hood development, nutrition, marriage after 18, spacing of children, and behavioral changes etc.
• Bringing positive change & demand generation for the poor marginalized section by bringing attitudinal change on the counter part of the health profession & adding the faith of the rural & tribal folk in the modern health services.
• Establishment of health institution & health infrastructure like no. of PHC, CHC are required to fulfill population norms of 2001 population & upgrading of existing ones with modern technology & expansion of their capacities.
• Neonatal care is not available to most neonates in developing countries because hospitals are inaccessible and costly. Home-based neonatal care, including management of sepsis, is acceptable, feasible, and reduced neonatal and infant mortality by nearly 50% among our malnourished, illiterate, rural study population. This approach could reduce neonatal mortality substantially in developing countries.
• Most neonatal deaths occur at home because of serious difficulties in transporting sick neonates to hospitals, those who arrive are generally seriously ill. So it is strongly recommended to make proper arrangement for transportation of neonates under Janani Express Schemes.
• Strengthening of neonatal intensive care units at the PHC level.
• Planning & implementing special schemes for neonatal care.
• Large number of deliveries are conducted by ANMs and dais (trained and untrained) in rural areas. Hence, training them for timely referral of complicated cases to higher levels could reduce the number of stillbirths.
• Health workers and birth attendants should be trained to encourage mothers to start breast feeding in the first hour after birth and continue exclusive breastfeeding on demand.
• Allocation of segregated budget for neonatal & infant care & optimum & fuller utilization of allocated budget should be ensured.
• Community monitoring & community ownership of health services & social welfare schemes must be promoted.

Seema Jain