Introduction
Child health plays an essential role in shaping the future of a community. For this reason, governments worldwide have made child health care a priority. Studying the trends of utilization and benefits of child health care schemes is therefore, imperative to assess its impact on the community.
Aim
This study was undertaken to assess the knowledge, utilization and benefits of a child health care scheme Bal Sanjeevani Program (BSP) in a Government District Hospital.
Materials and Methods
Hundred children belonging to Below Poverty Line (BPL) families, between 0 to 6 years of age admitted for tertiary care were divided equally into cases and controls. The children who availed the BSP were enlisted as the case, whereas those who did not avail the benefits of the BSP were enrolled as the control. The study was conducted in March and April 2016. A semi-structured questionnaire was used for data collection, after approval of the Institutional Ethics Committee. Data analysis was done using SPSS 16.0. Descriptive statistics as well as the Chi-square test were used for analysis.
Results
Of the respondents, 61(61%) had heard of the BSP, of which 11(22%) chose not to register for the scheme. Of those not availing the scheme, 39(78%) stated lack of awareness as the main reason for non-utilization. The mean expenditure of those not utilizing the scheme was 12.87 times more than that of the mean expenditure of those utilizing the scheme.
Conclusion
This program significantly alleviates the financial burden on families with children admitted in tertiary care centers. Increasing the awareness regarding the BSP and identifying eligible children at the Primary Health Care (PHC) level would enhance optimum utilization of this scheme.
Introduction
Children are vital to the nation’s present and future. However, communities vary considerably in the resources that they make available to meet health care needs of children. This is reflected in the ways in which communities address their collective commitment to child health [1].
India is home to one-fifth of the maternal deaths and one-quarter of the child deaths reported in the world [2].
Health outcomes have shown considerable improvement over time. However, they are still patterned along dimensions such as gender, caste, wealth, education, and geography. The economic development of the state contributes considerably in determining the trends of under-five mortality [3-5].
The primary goal of public policies is to redress any inequities in health, enabling health systems to achieve equity, alongside efficiency, in the distribution of health in a population [6-8].
Article 45 of the Indian constitution states that: “The state shall endeavour to provide early childhood care and education for all children, until they complete the age of 6 years” [9].
In keeping with this, the government launched The Integrated Child Development Services (ICDS) scheme, which is the largest program for promotion of maternal and child health and nutrition in India. A major component of this scheme is The Bal Sanjeevani Program (BSP) [10].
The BSP was conceived and implemented by the Government of Karnataka under the child development program since the year 2011. Under this scheme, children aged between 0 and 6 years belonging to BPL families and suffering from illness and malnutrition requiring Tertiary Care treatment are entitled for free treatment in selected hospitals (33 hospitals) in the state, up to a maximum of Rs.35,000 ($516) and Rs.50,000 ($738) for the treatment of the neonate. Children admitted for the following illnesses can avail treatment: severe pneumonia, encephalitis-meningitis, complicated malaria, anaemia, diabetes, renal problems- urinary bladder/kidney problems, tertiary care treatment of neonatal baby, liver problems, neurological disorders, secondary malnutrition, complicated diarrhoea, surgery of neonatal baby, treatment of snake bite and poisoning. Identification of the children eligible to avail this scheme is the responsibility of the health worker (anganwadi worker), Child Development Project Officer (CDPO) or the medical officer in the PHC center [11].
Understanding the trend of utilization and non-utilization of this scheme as well as ascertaining the advantages this scheme has to offer to the beneficiaries, would help promote the utilization of this scheme, thereby increasing the quality of paediatric child care and alleviating the financial burden on families with children admitted in tertiary care hospitals.
This study was done to assess the knowledge of the BSP amongest the parents of children admitted to a Government District Hospital, to determine the factors affecting the utilization of this program, as well as to assess the advantages of this program on the beneficiaries.
Materials and Methods
This was a frequency matched case control study conducted in Regional Advanced Paediatric Care Centre (RAPCC), Mangaluru, Karnataka, India. The hospital is a government nodal referral centre for neonatal and paediatric care covering a population of nearly 1.23 crores (12 million). The study was conducted for two months between March 2016 and April 2016. The study population consisted of BPL parents, whose children had been admitted for treatment of illnesses that were covered under the BSP. The sample size was calculated to be 100 children taking 95% confidence level. Ratio of case and control was taken as 1:1, i.e., 50 cases and 50 controls. After obtaining clearance from the Institutional Ethics Committee, the study participants were divided into two groups- cases and controls. Convenience sampling was used to select the participants for the study. The study was done by dividing the study population into two groups, the case and control groups. The children between zero to six years of age who were eligible to avail the benefits of the BSP and who had availed the BSP was enlisted as the case; whereas, the equal number of children of same age group and socioeconomic status as that of the case, who were eligible to utilize the scheme, but had not availed the benefits of the BSP were enrolled as the controls. Children above six years of age, those belonging to non BPL families, those who were admitted for illnesses not covered by the BSP and those who did not consent to participate in the study were excluded from the study. Matching was done with regard to the socioeconomic status and age. A semi-structured questionnaire was used for data collection. The questionnaire was divided into three sections. The first section dealt with the demographic details of the participant, the second part had questions to assess the knowledge and utilization of the scheme and the third part had questions to gauge the advantages or benefits of the scheme. The questionnaire was filled by the investigator, based on the information given by the parents, after interviewing them regarding the scheme. The willing participants were required to consent to participate in the study. The information provided by all the participants was kept confidential and was only used for research purposes.
Statistical Analysis
The data obtained was analysed by SPSS software version 16.0 using descriptive statistics. Statistical significance was assessed by Chi-square test wherein p<0.05 was considered to be statistically significant.
Results
Out of the total number of cases, 34 (68%) of them were infants and the rest 16 (32%) were between one to six years of age. The association between the age of the participants and their utilization of the BSP was found to be statistically significant. Males constituted 24 (48%) of the cases and 29 (58%) of the controls. Females constituted 26 (52%) of the cases and 21 (42%) of the controls. Majority of the cases 44 (88%) as well as controls 45 (90%) were Hindus. Most of the cases 32 (64%) resided in rural areas whereas 27 (54%) of the controls resided in urban areas. Most of the cases 35 (70%) as well as controls 34(68%) belonged to nuclear families. Majority of the cases 37 (74%) as well as controls 44 (88%) belonged to low socioeconomic status according to BG Prasad Scale [12].
Mean per capita income of the cases and control groups were Rs.2429 ($36.32) and Rs.1929 ($28.84) respectively. Majority of the cases i.e., 26 (52%) lived 50 to 100 km away from the tertiary care center [Table/Fig-1].
Socioeconomic profile of the study participants.
| Determinants | Controls% (No.)n=50 | Cases% (No.)n=50 | Total% (No.)n=100 | p-value |
|---|
| Age |
| < 1 year | 68% (34) | 26% (13) | 47% (47) | <0.001 |
| 1 to 3 years | 16% (8) | 8% (4) | 12% (12) |
| >3 years | 16% (8) | 66% (33) | 41% (26) |
| Sex |
| Male | 48% (24) | 58% (29) | 53% (53) | 0.321 |
| Female | 52% (26) | 42% (21) | 47% (47) |
| Religion |
| Hindu | 88% (44) | 90% (45) | 89% (89) | 0.801 |
| Muslim | 12% (6) | 6% (3) | 9% (9) |
| Christian | 0% (0) | 4% (2) | 2% (2) |
| Area of residence |
| Urban | 36% (18) | 54% (27) | 45% (45) | 0.567 |
| Rural | 64% (32) | 46% (23) | 55% (55) |
| Type of family |
| Nuclear | 70% (35) | 68% (34) | 69% (69) | 0.829 |
| Joint | 30% (15) | 32% (16) | 31% (31) |
| Socioeconomic Status (BG Prasad Scale) |
| High | 0% (0) | 2% (1) | 1% (1) | 0.057 |
| Middle | 6% (3) | 2% (1) | 4% (4) |
| Low | 94% (47) | 96% (48) | 95% (95) |
| Percapita income |
| ≤ $15 (Rs1000) | 16% (8) | 24% (17) | 25 %(25) | |
| $15 to $45 (Rs.1000 to Rs. 3000) | 62% (31) | 60% (30) | 61% (61) |
| $45 to $75 Rs. 3000 to Rs. 5000 | 18% (9) | 2% (1) | 10% (10) |
| >$75 (Rs. 5000) | 4% (2) | 4% (2) | 4% (4) |
| Mean income | $36.32(Rs. 2429) | $28.84(Rs. 1929) | $32.58(Rs. 2179) |
| Distance of home from the hospital |
| <10 km | 0% (0) | 8% (4) | 4% (4) | 0.062 |
| 10 to 20 km | 8% (4) | 10% (5) | 9% (9) |
| 20 to 50 km | 6% (3) | 18% (9) | 12% (12) |
| 50 to 100 km | 52% (26) | 26% (13) | 39% (39) |
| >100 km | 34% (17) | 38% (19) | 36% (36) |
Cases predominantly showed a trend of suffering from neonatal problems 17 (34%), surgical problems 8 (16%), neurological problems 8 (16%), and pneumonia 7 (14%). Controls however showed a trend of suffering from miscellaneous diseases 18 (36%), surgical problems 7 (14%), and anaemia 7 (14%). Cases were mostly referred from Taluk Hospitals 19 (38%) or had not been referred 15 (30%) whereas most of the controls were referred from Taluk Hospitals 29 (58%) or Private Hospitals 11 (22%). The association between the place of reference of the participants and their utilization of the BSP was found to be statistically significant with a p-value <0.05, which was 0.003. The cure rate of the cases was found to be 30 (60%), while 12 (24%) have ongoing treatment, 5 (10%) were referred elsewhere and 3 (6%) had passed away. The association between the outcome of treatment of the participants and their utilization of the BSP was found to be statistically significant with a p-value <0.05, which was 0.021. Out of the total sample size of 100, 61 (61%) had heard of the BSP, including 50 (100%) of the cases and 11 (22%) of the controls. The main source of information regarding the scheme for those who were aware of the scheme (total 61 patients, comprising 50 patients belonged to the cases group and 11 belonged to the controls) were hospital doctors for both cases 47 (94%) and control 8 (72.72%). Other sources included PHC or Anganwadi workers {3 (6%) cases and 2 (18.18%) of controls} and friends or family {1 (9%) controls}. Most of the cases i.e., 44 (88%) and all the controls i.e., 11 (100%), who were aware about the scheme, were unaware about the age groups of children that could have availed benefits of the scheme, the monetary benefits received and the number of children who availed the scheme [Table/Fig-2].
Knowledge regarding the BSP.
| Determinants | Controls % (No.)N= 50 | Cases % (No.)N= 50 | p-value |
|---|
| Diseases |
| Pneumonia | 14% (7) | 8% (4) | |
| Meningitis and Encephalitis | 4% (2) | 0% (0) |
| Complicated Malaria | 0% (0) | 0% (0) |
| Anaemia | 2% (1) | 14% (7) |
| Diabetes | 0% (0) | 0% (0) |
| Renal Problems | 0% (0) | 4% (2) |
| Neonatal Problems | 34% (17) | 6% (3) |
| Liver Disorder | 0% (0) | 2% (1) |
| Neurological Disorder | 16% (8) | 6% (3) |
| Malnutrition | 0% (0) | 0% (0) |
| Diarrhea | 0% (0) | 6% (3) |
| Surgery | 16% (8) | 14% (7) |
| Snakebite | 0% (0) | 0% (0) |
| Poisoning | 0% (0) | 0% (0) |
| Others | 12% (6) | 36% (18) |
| Referred from |
| PHC* | 6% (3) | 12% (6) | 0.003 |
| CHC** | 12% (6) | 0% (0) |
| Taluk Hospital | 38% (19) | 58% (29) |
| Private Hospital | 14% (7) | 22% (11) |
| Not Referred | 30% (15) | 8% (4) |
| Outcome of treatment |
| Ongoing | 24% (12) | 46% (23) | 0.021 |
| Cured | 60% (30) | 54% (27) |
| Referred | 10% (5) | 0% (0) |
| Death | 6% (3) | 0% (0) |
| Heard of BSP |
| Yes | 100% (50) | 22% (11) | |
| No | 0% (0) | 78% (39) |
| Source of information |
| PHC/Anganwadi worker | 6% (3) | 18.18% (2) | |
| Friends/Family | 0%(0) | 9.09% (1) |
| TV/Radio/Newspaper | 0% (0) | 0% (0) |
| ASHA worker | 0% (0) | 0%(0) |
| Hospital Doctor | 94% (47) | 72.72%(8) |
| Private Doctor | 0% (0) | 0%(0) |
| Age groups that can avail the scheme |
| Aware | 12% (6) | 0% (0) | |
| Unaware | 88% (44) | 100% (11) |
| Monetary benefirs received |
| Aware | 12% (6) | 0% (0) | |
| Unaware | 88% (44) | 100% (11) |
| Number of children that can avail the scheme |
| Aware | 12% (6) | 0% (0) | |
| Unaware | 88% (44) | 100% (11) |
*Primary Health Center (PHC)
**Community Health Center (CHC)
As seen in [Table/Fig-3], out of the 50 controls, 39 (78%) did not avail the scheme due to lack of knowledge, 10 (20%) found the process of availing the scheme too difficult and 1 (2%) claimed that they did not receive cooperation from the authorities. Monetary benefits received from the scheme was the main reason that most of the cases i.e., 49 (98%) chose to avail the scheme and 1 (2%) chose to avail the scheme due to encouragement by PHC workers. Out of the 50 members in the case group, 42 (84%) received all of the benefits of the BSP, i.e. free treatment, monetary benefit and reimbursement of transportation and 8 (16%) received only free treatment because they claimed to not require compensation for loss of wages or transportation.
| Determinants | Controls % (No.) n=50 | Cases % (No.)n=50 |
|---|
| Reason for non utilization |
| Unaware regarding the scheme | Not Applicable | 78% (39) |
| Process of availing was too difficult | Not Applicable | 20% (10) |
| No cooperation from the authorities | Not Applicable | 2% (1) |
| Did not require monetary assistance | Not Applicable | 0% (0) |
| Using another Scheme | Not Applicable | 0% (0) |
| Reason for utilization |
| Monetary benefit | 98% (49) | Not Applicable |
| Encouragement by PHC workers | 2% (1) | Not Applicable |
| Encouragement by ASHA workers | 0% (0) | Not Applicable |
| Encouragement by Doctors | 0% (0) | Not Applicable |
| Benefits received |
| Free treatment | 100% (50) | Not Applicable |
| Free drugs and other facilities | 84% (42) | Not Applicable |
| Monetary benefit | 84% (42) | Not Applicable |
| Reimbursement of transportation | 84% (42) | Not Applicable |
The mean amount of money received from the BSP was Rs.13302 ($198.88). The mean expenditure of the cases was Rs.4264 ($63.75), which was 175% (or 1.75 times) of the mean per capita income [Table/Fig-4]. The mean expenditure of the controls was Rs.54880 ($820), which was 2844.9% (or 28.44 times) of the mean per capita income. The mean of direct costs of the cases was Rs.3164 ($47.31), which was 130% (or 1.30 times) of the mean per capita income. The mean direct costs of the controls was Rs.49494 ($740), which was 2565.78% (or 25.65 times) of the mean per capita income. The mean of indirect costs of the cases was Rs.1100 ($16.45), which was 45.28% (or 45 times) of the mean per capita income. The mean indirect costs of the controls was Rs. 5096 ($76.19), which was 264.17% (or 2.64 times) of the mean per capita income. Majority of the patients in the case group either did not incur any expense i.e., 24 (48%) or used their income or savings i.e., 24 (48%) as funds for treatment. The rest of the cases, 2 (4%) had to liquidate their property to pay for the treatment. Controls also predominantly used their income or savings to fund their treatment i.e., 38 (76%). The rest of the controls had to either resort to liquidation of their property i.e., 8 (16%) or had to borrow money from others i.e., 4 (8%). Out of the 50 cases, 11 (22%) claimed that they could not have had availed treatment for their child if not for the BSP.
Health care expenses among the study population.
| Determinants | Controls % (N) | Cases % (N) | Total % (N) |
|---|
| Money from BSP |
| ≤ $15 (Rs1000) | 8% (4) | Not Applicable | |
| $15 to $150 (Rs1000-Rs10000) | 38% (19) | Not Applicable | |
| $150 to $300 (Rs10000-Rs20000) | 38% (19) | Not Applicable | |
| $300 to $450 (Rs20000-Rs30000) | 12% (6) | Not Applicable | |
| $450 to $600 (Rs30000-Rs40000) | 2% (1) | Not Applicable | |
| $600 to $750 (Rs40000-Rs50000) | 2% (1) | Not Applicable | |
| Mean | $198.88 | Not Applicable | |
| Expenditure from self |
| </= $15 (Rs. 1000) | 82% (41) | 2% (1) | 42% (42) |
| $15to $75 (Rs1000-Rs5000) | 8% (4) | 30% (15) | 19% (19) |
| $75 to $150 (Rs5000-Rs10000) | 2% (1) | 14% (7) | 8% (8) |
| $150 to $750 (Rs10000-Rs50000) | 4% (2) | 30% (15) | 17% (17) |
| $750 to $1500 (Rs50000-Rs1 lakh) | 4% (2) | 10% (5) | 7% (7) |
| > $1500 (>Rs1lakh) | 0% (0) | 14% (7) | 7% (7) |
| Maximum | $0 | $15 (Rs.1000) | $0 |
| Minimum | $897 (Rs60000) | $5232(Rs350000) | $5232(Rs350000) |
| Mean | $63.75 (Rs4264) | $819.32(Rs54880) | $442.14(Rs29572) |
| Direct costs |
| Minimum Expenditure | $0 | $15 (Rs1000) | $0 |
| Maximum Expenditure | $822 (Rs55000) | $4784 (Rs320000) | $4784(Rs320000) |
| Mean | $47.3 (Rs3164) | $740 (Rs49494) | $393.65(Rs26329) |
| Indirect costs |
| Mimimum Expenditure | $0 | $0 | $0 |
| Maximum Expenditure | $224.2 (Rs15000) | $598 (Rs40000) | $598 (Rs40000) |
| Mean | $16.45 (Rs1100) | $76.19 (Rs5096) | $46.32 (Rs3096) |
| Source of expenditure |
| No expenditure | 48% (24) | 0% (0) | 24% (24) |
| From income or savings | 48% (24) | 76% (38) | 62% (62) |
| From insurance | 0% (0) | 0% (0) | 0% (0) |
| From liquidation of property | 4% (2) | 16% (8) | 10% (10) |
| Borrowing from others | 0% (0) | 8% (4) | 4% (4) |
| Ability to avail treatment without BSP |
| Possible | 78% (39) | Not Applicable | |
| Not possible | 22% (11) | Not Applicable | |
*All conversions from Rupees to Dollars were done according to the rates as on 15 February 2017
Out of the 50 cases, 25 (50%) of the cases were highly satisfied by the encouragement by the PHC worker/doctors to avail this scheme, 37 (74%) were highly satisfied by the attentiveness and treatment provided by the doctor, 22 (44%) were satisfied by the process of availing the scheme, 23 (46%) were satisfied by the waiting time involved before availing the scheme, 20 (40%) were neutral towards the monetary compensation provided for their child’s treatment, 20 (40%) were satisfied by the benefit of availing the scheme for their family and child, 36 (72%) were highly satisfied by the general comfort in the hospital, and 37 (74%) were highly satisfied by their overall stay in hospital [Table/Fig-5].
Patient satisfaction about BSP.
| S. No | Criteria | Highly Satisfied | Satisfied | Neutral | Dis-satisfied | Highly Dis-satisfied |
|---|
| 1. | Encouragement by the PHC worker/doctors to avail this scheme | 50%(25) | 46%(23) | 4%(2) | 0%(0) | 0%(0) |
| 2. | Attentiveness and treatment provided by the doctor | 74%(37) | 26%(13) | 0%(0) | 0%(0) | 0%(0) |
| 3. | Process of availing the scheme (easy and hassle free) | 42%(21) | 44%(22) | 14%(7) | 0%(0) | 0%(0) |
| 4. | Waiting time involved before availing the scheme | 32%(16) | 46%(23) | 22%(11) | 0%(0) | 0%(0) |
| 5. | Sufficient monetary compensation provided for treatment | 24%(12) | 36%(18) | 40%(20) | 0%(0) | 0%(0) |
| 6. | Benefit of availing the scheme | 36%(18) | 40%(20) | 24%(12) | %(0) | %(0) |
| 8 | General comfort | 72%(36) | 28%(14) | 0%(0) | 0%(0) | 0%(0) |
| 9. | Over all stay in hospital | 74%(37) | 24%(12) | 2%(1) | 0%(0) | 0%(0) |
Discussion
The BSP is a state funded child health care program that aims to alleviate the financial burden on families with children admitted to tertiary care centers for treatment.
Under this scheme, the government funds the treatment of the child, including the cost of drugs and investigations required during the course of the treatment. Also, parents are given monetary compensation for loss of wages and the transportation costs are reimbursed.
It is evident from [Table/Fig-1] that there was significant association (p=0.001) between the age of the child and the utilization of the scheme, with 68% of the beneficiaries less than one year of age. This trend may be because of greater susceptibility in infancy to diseases leading to the requirement of more intensive therapy for the infant’s treatment [13].
No association was found between the utilization of the scheme and the socioeconomic status of the family or the family income. This can be attributed to the fact that the cases and controls both belong to BPL families that fall under similar socioeconomic and financial strata.
Most of the cases were admitted for neonatal problems (34%), surgical problems (16%), neurological problems (16%), and pneumonia (14%). This was similar to the trend noticed in a study done by Singhi S et al., in which gastrointestinal and respiratory diseases (23% each), neurological illnesses (16%), and neonatal problems (15.6%) formed the majority of the cases [14].
Most of the cases have either been referred from a Taluk hospital (38%) or have not been referred (30%). Also, 60% of the cases were completely cured, 12 (24%) have ongoing treatment, 5 (10%) were referred elsewhere and 3 (6%) had passed away.
It was observed that, 61% of the total sample size had heard of the BSP, including 100% (50) of the cases and 22% (11) of the controls. The main source of information regarding the scheme for both cases (94%) and control (72.72%) were the hospital doctors. According to the guidelines of this scheme, the identification of children who were eligible to avail this scheme should be done at the PHC level. The child is then required to be referred to the nearest Tertiary Care Centre [11,12]. As it was evident from the results above, the main source of information regarding the scheme are the doctors working in the tertiary care centre and not the PHC worker. This may be because of the lack of knowledge among the PHC workers regarding the eligibility criteria of the BSP.
It was found that 78% (39) of the controls did not avail the scheme due to lack of knowledge. This may be due to the failure in identification of eligible children and counselling of the parents regarding the scheme, which should have been done at the PHC level.
The mean amount of money received from the BSP was Rs. 13302. The mean expenditure of the cases was Rs.4264, which was 175% (or 1.75 times) of the mean per capita income. The mean expenditure of the controls is Rs.54880, which is 2844.9% (or 28.44 times) of the mean per capita income. Evidently the financial burden on the beneficiaries has been significantly alleviated because of the BSP.
Majority of the cases either did not incur any expense (48%) or used their income or savings (48%) as funds for treatment. This can be attributed to the fact that the beneficiaries of the scheme incurred little or no expenses and hence, could pay for their child’s treatment from their savings.
In present study, 16% of the controls had to resort to liquidation of their property for their child’s treatment and 8% of the controls had to borrow money for treatment. This could be because of the lack of financial assistance received by the parents for their child’s treatment.
Limitation
This study was done in a Tertiary care center in Mangaluru, with a population of 100 children admitted for treatment. Conducting the same study under different settings may not result in the same findings due to differences in the socioeconomic status of the study population as well as the cost of the health care service provided.
Conclusion
The BSP aims to promote a high standard of paediatric and neonatal child care, yet there are a significant number of children who do not utilize this scheme.
Many of the participants (39%) had not heard of the BSP. The main reason for non-utilization was lack of awareness followed by difficulty in availing the scheme. This calls for a need to propagate more information about the benefits of the BSP.
Most of the parents who were utilizing the scheme were unaware regarding the eligibility criteria and the monetary benefits they are to receive under this scheme.
Hence, it is obvious that the BSP significantly alleviates the financial burden on families with children admitted in tertiary care centers. The scheme could be more useful if more awareness was created and eligible children were identified at the PHC level itself instead of at the tertiary care hospital. Awareness regarding government schemes could be propagated through mass media and health care professionals so as to increase the utilization of the scheme by the target population.
*Primary Health Center (PHC)**Community Health Center (CHC)*All conversions from Rupees to Dollars were done according to the rates as on 15 February 2017
[1]. National Research Council (US), Institute of Medicine (US). Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health. Washington (DC; National Academies Press (US). 2004 [Internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92206/ [Accessed on 20/2/2017] [Google Scholar]
[2]. UNICEF. The State of the World’s Children 2009: Maternal and Newborn Health. UNICEF, New York 2009 [Internet]. Available from: https://www.unicef.org/sowc09/report/report.php [Accessed on 20/2/2017] [Google Scholar]
[3]. Joe W, Mishra US, Navaneetham K, Socio-economic inequalities in child health: Recent evidence from India Glob Public Health 2010 5(5):493-508. [Google Scholar]
[4]. Balarajan Y, Villamor E, Nationally representative surveys show recent increases in the prevalence of overweight and obesity among women of reproductive age in Bangladesh, Nepal, and India Journal of Nutrition 2009 139(11):2139-44. [Google Scholar]
[5]. Sen G, Ostlin P, George A, Engendering international health: the challenge of equity 2002 CambridgeMIT Press:281-300. [Google Scholar]
[6]. Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, Challenging inequities in health: from ethics to action New England Journal of Medicine Oxford University Press 2001 45(25):1857-58. [Google Scholar]
[7]. Karlberg I, Getting health reform right: a guide to improving performance and equity International Journal of Integrated Care 2004 4(4):332 [Google Scholar]
[8]. The World Helath organization (WHO). The world health report 2000: Health Systems: Improving Performance. WHO Geneva. 2000;30-40 [Internet]. Available at: http://www.who.int/whr/2000/media_centre/press_release/en/ [Accessed on 20/2/2017] [Google Scholar]
[9]. Integrated Child Development Services (ICDS) website [Internet]. Available at: http://www.icds-wcd.nic.in/cwnew.htm [Accessed on 20/2/2017] [Google Scholar]
[10]. Kapil U, Integrated Child Development Services (ICDS) scheme: a program for holistic development of children in India Indian journal of Paediatrics 2001 69(7):597-601. [Google Scholar]
[11]. Government of Karnataka. Integrated Child Development Scheme Website [Internet]. Available at: http://dwcdkar.gov.in/index.php?option=com_content&view=article&id=62&Itemid=114&lang=en [cited 20/2/2017] [Google Scholar]
[12]. Mangal A, Kumar V, Panesar S, Talwar R, Raut D, Singh S, Updated BG Prasad socioeconomic classification, 2014: A commentary Indian J Public Health 2015 59(1):2-4. [Google Scholar]
[13]. McKhann CF, Kapnick I, Immunity and susceptibility to disease in early infancy The Journal of Paediatrics 1938 13(6):907-18. [Google Scholar]
[14]. Singhi S, Jain V, Gupta G, Paediatric emergencies at a tertiary care hospital in India Journal of Tropical Paediatrics 2003 49(4):207-11. [Google Scholar]