const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "National Health Mission (NHM) - India";
pres.author = "Musqan";

// ── COLOUR PALETTE ──────────────────────────────────────────────
const C = {
  navyBg:    "0A2342",   // dominant dark navy
  tealAcc:   "1A9E8F",   // teal accent
  lightTeal: "D6F5F2",   // light teal fill
  amber:     "F5A623",   // highlight / stat boxes
  white:     "FFFFFF",
  offWhite:  "F2F6FB",
  textDark:  "1C2B3A",
  textMid:   "3E5573",
  slate:     "3D5A80",
  green:     "27AE60",
  red:       "E74C3C",
};

// ── HELPERS ──────────────────────────────────────────────────────
function titleSlide(slide) {
  // full-bleed navy background
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:10, h:5.625, fill:{ color: C.navyBg }, line:{ color: C.navyBg } });
  // teal accent bar left
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:0.25, h:5.625, fill:{ color: C.tealAcc }, line:{ color: C.tealAcc } });
  // large title
  slide.addText("National Health Mission", {
    x:0.55, y:0.9, w:8.9, h:1.3, fontSize:46, bold:true, color:C.white, fontFace:"Calibri", align:"left", margin:0
  });
  slide.addText("(NHM) – India", {
    x:0.55, y:2.0, w:8.9, h:0.9, fontSize:36, bold:false, color:C.tealAcc, fontFace:"Calibri", align:"left", margin:0
  });
  slide.addText("A Comprehensive Overview for Medical & Health Students", {
    x:0.55, y:2.9, w:8.9, h:0.5, fontSize:17, italic:true, color:"A8C8E8", fontFace:"Calibri", align:"left", margin:0
  });
  // bottom bar
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  slide.addText("Prepared by: Musqan  |  July 2026", {
    x:0.3, y:5.12, w:9.4, h:0.4, fontSize:12, color:C.white, fontFace:"Calibri", align:"left", margin:0
  });
}

function sectionHeader(slide, sectionTitle, subtitle) {
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  });
  if (subtitle) {
    slide.addText(subtitle, {
      x:0.5, y:3.3, w:9, h:0.6, fontSize:16, color:"A8C8E8", fontFace:"Calibri", align:"center", italic:true, margin:0
    });
  }
}

function contentHeader(slide, title) {
  // top navy bar
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:10, h:0.75, fill:{ color: C.navyBg }, line:{ color: C.navyBg } });
  slide.addText(title, {
    x:0.3, y:0.07, w:9.4, h:0.6, fontSize:22, bold:true, color:C.white, fontFace:"Calibri", margin:0
  });
  // teal underline
  slide.addShape(pres.ShapeType.rect, { x:0, y:0.75, w:10, h:0.045, fill:{ color: C.tealAcc }, line:{ color: C.tealAcc } });
  // off-white bg for body
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}

function statBox(slide, x, y, w, h, value, label, color) {
  slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill:{ color: color||C.tealAcc }, line:{ color: color||C.tealAcc }, shadow:{type:"outer",blur:4,offset:2,angle:45,color:"888888",opacity:0.3} });
  slide.addText(value, { x:x+0.05, y:y+0.1, w:w-0.1, h:h*0.52, fontSize:22, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
  slide.addText(label, { x:x+0.05, y:y+h*0.52, w:w-0.1, h:h*0.46, fontSize:10, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
}

function bullet(text) {
  return { text, options:{ bullet:{ type:"bullet" }, breakLine:true, fontSize:14, color:C.textDark, fontFace:"Calibri" } };
}

function footerRef(slide, ref) {
  slide.addShape(pres.ShapeType.rect, { x:0, y:5.3, w:10, h:0.325, fill:{ color: C.navyBg }, line:{ color: C.navyBg } });
  slide.addText(ref, { x:0.2, y:5.32, w:9.6, h:0.28, fontSize:9, color:"A8C8E8", fontFace:"Calibri", italic:true, margin:0 });
}

// ════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleSlide(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 2 — AGENDA
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Presentation Outline");
  const items = [
    "1. Introduction & Background",
    "2. Vision, Mission & Objectives",
    "3. Structure & Governance",
    "4. Sub-Missions: NRHM & NUHM",
    "5. Key Programmatic Components",
    "6. ASHA – Backbone of the Community",
    "7. Maternal & Child Health (RMNCH+A)",
    "8. Communicable Disease Control",
    "9. Non-Communicable Diseases (NCDs)",
    "10. Health Infrastructure Strengthening",
    "11. Key Achievements & Statistics",
    "12. Challenges & Way Forward",
    "13. Budget & Funding",
    "14. Conclusion",
    "15. References",
  ];
  const col1 = items.slice(0, 8);
  const col2 = items.slice(8);
  slide_bullet_col(s, col1, 0.3, 0.95, 4.6);
  slide_bullet_col(s, col2, 5.1, 0.95, 4.6);
  footerRef(s, "Source: Ministry of Health & Family Welfare, GoI | nhm.gov.in");
}
function slide_bullet_col(slide, items, x, y, w) {
  const rows = items.map((t, i) => ({ text: t, options:{ breakLine: i < items.length-1, fontSize:14, color: C.textDark, fontFace:"Calibri" } }));
  slide.addText(rows, { x, y, w, h:4.5, valign:"top", margin:0.12 });
}

// ════════════════════════════════════════════════════════════════
// SLIDE 3 — INTRODUCTION & BACKGROUND
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Introduction & Background");
  // timeline boxes
  const timeline = [
    { year:"2005", event:"NRHM launched\n(12 April)\nFocus: Rural Health", color: C.slate },
    { year:"2013", event:"NUHM added\nNHM umbrella\ncreated (May 2013)", color: C.tealAcc },
    { year:"2017", event:"NHM extended\n(2017–2020)\nExpanded scope", color: C.amber },
    { year:"2021–26", event:"NHM extended\nagain; COVID\nresponse integrated", color: C.green },
  ];
  timeline.forEach((t, i) => {
    const x = 0.3 + i * 2.35;
    s.addShape(pres.ShapeType.rect, { x, y:0.95, w:2.1, h:1.05, fill:{ color: t.color }, line:{ color: t.color }, rounding:0.08 });
    s.addText(t.year, { x, y:0.97, w:2.1, h:0.42, fontSize:19, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(t.event, { x, y:1.35, w:2.1, h:0.62, fontSize:10.5, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
  });
  // connecting arrows
  for (let i=0; i<3; i++) {
    s.addShape(pres.ShapeType.rightArrow, { x: 2.3 + i*2.35, y:1.35, w:0.35, h:0.35, fill:{ color: C.textMid }, line:{ color: C.textMid } });
  }
  // body bullets
  s.addText([
    bullet("Launched to address critical gaps in rural public health infrastructure"),
    bullet("India had high MMR, IMR and poor disease control at its inception"),
    bullet("Provides flexible frameworks — States prepare annual Programme Implementation Plans (PIPs)"),
    bullet("Focus groups: Empowered Action Group (EAG) states, NE states, J&K, Himachal Pradesh"),
    bullet("Largest public health programme of the Government of India"),
    bullet("Currently active under the Ministry of Health & Family Welfare (MoHFW)"),
  ], { x:0.3, y:2.15, w:9.4, h:3.0, valign:"top", margin:0.1 });
  footerRef(s, "Source: MoHFW, Government of India | NRHM launched 12 April 2005 | nhm.gov.in");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 4 — VISION, MISSION & OBJECTIVES
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Vision, Mission & Key Objectives");
  // Vision box
  s.addShape(pres.ShapeType.rect, { x:0.3, y:0.9, w:9.4, h:0.78, fill:{ color: C.tealAcc }, line:{ color: C.tealAcc }, rounding:0.08 });
  s.addText([
    { text:"Vision: ", options:{ bold:true, fontSize:14, color:C.white } },
    { text:"Universal access to equitable, affordable & quality healthcare services that are accountable and responsive to people's needs.", options:{ fontSize:14, color:C.white } }
  ], { x:0.35, y:0.93, w:9.3, h:0.7, margin:0 });
  // Objectives
  const objs = [
    { icon:"🎯", text:"Reduce MMR to <100/lakh live births & IMR to <25/1000 live births" },
    { icon:"💉", text:"Achieve Universal Immunisation for all children" },
    { icon:"🏥", text:"Strengthen sub-centres, PHCs, CHCs & District Hospitals" },
    { icon:"👶", text:"Prevent & control communicable and non-communicable diseases" },
    { icon:"💊", text:"Ensure free essential drugs & diagnostics at public facilities" },
    { icon:"👩‍⚕️", text:"Enhance human resources — doctors, nurses, ANMs, ASHAs" },
    { icon:"📊", text:"Decentralised planning through State PIPs & District Health Missions" },
  ];
  const rows = objs.map((o, i) => ({
    text: `${o.icon}  ${o.text}`,
    options:{ breakLine: i < objs.length-1, fontSize:13, color:C.textDark, fontFace:"Calibri" }
  }));
  s.addText(rows, { x:0.3, y:1.78, w:9.4, h:3.65, valign:"top", margin:0.1 });
  footerRef(s, "Source: NHM Framework for Implementation, MoHFW GoI | nhm.gov.in");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 5 — STRUCTURE & GOVERNANCE
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Organisational Structure & Governance");
  // hierarchy boxes
  const levels = [
    { label:"National Mission Steering Group\n(Chaired by Union Health Minister)", color:C.navyBg, y:0.9, w:4.5 },
    { label:"Empowered Programme Committee\n(Mission Director, MoHFW)", color:C.slate, y:1.85, w:4.5 },
    { label:"State Health Mission\n(Chaired by Chief Minister)", color:C.tealAcc, y:2.8, w:4.5 },
    { label:"District Health Mission\n(Chaired by District Collector)", color:C.amber, y:3.75, w:4.5 },
  ];
  levels.forEach(l => {
    s.addShape(pres.ShapeType.rect, { x:0.4, y:l.y, w:l.w, h:0.78, fill:{ color: l.color }, line:{ color: l.color }, rounding:0.07 });
    s.addText(l.label, { x:0.4, y:l.y+0.05, w:l.w, h:0.68, fontSize:12, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    // arrow
    if (l.y < 3.75) {
      s.addShape(pres.ShapeType.downArrow, { x:1.9, y:l.y+0.78, w:0.5, h:0.3, fill:{ color:C.textMid }, line:{ color:C.textMid } });
    }
  });
  // right side text
  s.addText("Key Principles of Governance", {
    x:5.4, y:0.88, w:4.2, h:0.45, fontSize:15, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0
  });
  const principles = [
    "✔ Decentralised planning & implementation",
    "✔ Community participation & accountability",
    "✔ Flexible funding (untied grants)",
    "✔ Programme Implementation Plans (PIPs)",
    "✔ Village Health Sanitation & Nutrition\n    Committees (VHSNCs)",
    "✔ Rogi Kalyan Samiti (RKS) at facilities",
    "✔ Health Management Information System\n    (HMIS) for data-driven decisions",
  ];
  const rows = principles.map((p, i) => ({
    text: p,
    options:{ breakLine: i < principles.length-1, fontSize:12.5, color:C.textDark, fontFace:"Calibri" }
  }));
  s.addText(rows, { x:5.4, y:1.36, w:4.2, h:3.9, valign:"top", margin:0.08 });
  footerRef(s, "Source: NHM Implementation Framework, MoHFW GoI");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 6 — NRHM vs NUHM
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Sub-Missions: NRHM & NUHM");
  // divider
  s.addShape(pres.ShapeType.rect, { x:4.9, y:0.85, w:0.08, h:4.65, fill:{ color:C.tealAcc }, line:{ color:C.tealAcc } });
  // NRHM header
  s.addShape(pres.ShapeType.rect, { x:0.3, y:0.88, w:4.45, h:0.58, fill:{ color:C.navyBg }, line:{ color:C.navyBg }, rounding:0.07 });
  s.addText("National Rural Health Mission", { x:0.3, y:0.9, w:4.45, h:0.52, fontSize:15, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
  // NUHM header
  s.addShape(pres.ShapeType.rect, { x:5.1, y:0.88, w:4.55, h:0.58, fill:{ color:C.tealAcc }, line:{ color:C.tealAcc }, rounding:0.07 });
  s.addText("National Urban Health Mission", { x:5.1, y:0.9, w:4.55, h:0.52, fontSize:15, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });

  const nrhmBullets = [
    "Launched: 12 April 2005",
    "Focus: Rural population (< 50,000)",
    "Priority: EAG states, NE states, J&K",
    "Strengthens sub-centres, PHCs, CHCs, DHs",
    "ASHA deployment in rural villages",
    "Janani Suraksha Yojana (JSY)",
    "Village Health Nutrition Days (VHNDs)",
    "Mobile Medical Units for remote areas",
    "Integrated Disease Surveillance",
  ];
  const nuhmBullets = [
    "Launched: May 2013",
    "Focus: Urban poor, slum dwellers, migrants",
    "Urban Primary Health Centres (UPHCs)",
    "Urban Community Health Centres (UCHCs)",
    "ASHA & link workers for urban areas",
    "Target: Cities with ≥ 50,000 population",
    "Outreach services in slums",
    "Nutrition & sanitation initiatives",
    "Addresses urban health inequity",
  ];
  const makeRows = arr => arr.map((t, i) => ({
    text:`• ${t}`, options:{ breakLine: i < arr.length-1, fontSize:12.5, color:C.textDark, fontFace:"Calibri" }
  }));
  s.addText(makeRows(nrhmBullets), { x:0.3, y:1.53, w:4.45, h:3.9, valign:"top", margin:0.08 });
  s.addText(makeRows(nuhmBullets), { x:5.1, y:1.53, w:4.55, h:3.9, valign:"top", margin:0.08 });
  footerRef(s, "Source: MoHFW NHM documents; nhm.gov.in | NRHM 2005, NUHM 2013");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 7 — KEY PROGRAMMATIC COMPONENTS
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Key Programmatic Components of NHM");
  const comps = [
    { color:C.navyBg,  title:"RMNCH+A",              desc:"Reproductive, Maternal, Newborn,\nChild & Adolescent Health" },
    { color:C.tealAcc, title:"Communicable\nDiseases", desc:"TB, Malaria, HIV/AIDS, Leprosy,\nKala-azar, Dengue, Filariasis" },
    { color:C.amber,   title:"Non-Communicable\nDiseases",desc:"NCD programmes for Cardiovascular,\nCancer, Diabetes, Stroke, Mental Health" },
    { color:C.slate,   title:"Health System\nStrengthening",desc:"Infrastructure, HR, HRD,\nQuality (NQAS), Drugs & Diagnostics" },
    { color:C.green,   title:"Immunisation",          desc:"Universal Immunisation Programme;\n97.98% MR coverage achieved" },
    { color:"8E44AD",  title:"Health Financing",      desc:"Rogi Kalyan Samiti, JSSK,\nPMJAY integration, free drugs" },
  ];
  comps.forEach((c, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.25 + col * 3.2;
    const y = 0.92 + row * 2.1;
    s.addShape(pres.ShapeType.rect, { x, y, w:3.0, h:1.85, fill:{ color:c.color }, line:{ color:c.color }, rounding:0.1 });
    s.addText(c.title, { x, y:y+0.12, w:3.0, h:0.7, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(c.desc, { x, y:y+0.78, w:3.0, h:0.95, fontSize:11, color:C.white, fontFace:"Calibri", align:"center", margin:0.05 });
  });
  footerRef(s, "Source: NHM Programme Components, MoHFW GoI | nhm.gov.in");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 8 — ASHA
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "ASHA – Backbone of Community Health");
  // ASHA full form box
  s.addShape(pres.ShapeType.rect, { x:0.3, y:0.88, w:9.4, h:0.65, fill:{ color:C.tealAcc }, line:{ color:C.tealAcc }, rounding:0.07 });
  s.addText("ASHA = Accredited Social Health Activist", {
    x:0.3, y:0.91, w:9.4, h:0.55, fontSize:17, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0
  });
  // Left column — selection & training
  s.addText("Selection Criteria", { x:0.3, y:1.65, w:4.5, h:0.38, fontSize:14, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
  const sel = [
    "• Female resident of the village (aged 25–45)",
    "• 8th grade education minimum (10th preferred)",
    "• Married / widowed / divorced",
    "• Chosen by the village community (Gram Sabha)",
    "• One ASHA per 1,000 population",
  ];
  s.addText(sel.map((t,i)=>({ text:t, options:{ breakLine:i<sel.length-1, fontSize:12.5, color:C.textDark, fontFace:"Calibri" } })), { x:0.3, y:2.0, w:4.5, h:1.7, valign:"top", margin:0.08 });
  s.addText("Key Roles & Responsibilities", { x:0.3, y:3.75, w:4.5, h:0.38, fontSize:14, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
  const roles = [
    "• Health education & behaviour change communication",
    "• Antenatal & postnatal home visits",
    "• Facilitate institutional deliveries (JSY)",
    "• Immunisation mobilisation",
    "• DOTS for TB, DEWS for disease surveillance",
  ];
  s.addText(roles.map((t,i)=>({ text:t, options:{ breakLine:i<roles.length-1, fontSize:12.5, color:C.textDark, fontFace:"Calibri" } })), { x:0.3, y:4.1, w:4.5, h:1.4, valign:"top", margin:0.08 });
  // Right column — stat boxes
  statBox(s, 5.2, 1.05, 2.1, 1.1, "10+ Lakh", "ASHAs deployed\nacross India", C.navyBg);
  statBox(s, 7.5, 1.05, 2.1, 1.1, "24 modules", "ASHA training\ncurriculum", C.tealAcc);
  statBox(s, 5.2, 2.35, 2.1, 1.1, "Performance\nIncentives", "Results-based\npay model", C.amber);
  statBox(s, 7.5, 2.35, 2.1, 1.1, "Drug Kit\n(ASHA Kit)", "14 essential\nitemsallocated", C.slate);
  s.addText("Impact of ASHA Programme", { x:5.2, y:3.6, w:4.4, h:0.38, fontSize:14, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
  const imp = [
    "• Increased institutional deliveries",
    "• Improved immunisation uptake",
    "• Early detection of high-risk pregnancies",
    "• Bridge between community & health system",
  ];
  s.addText(imp.map((t,i)=>({ text:t, options:{ breakLine:i<imp.length-1, fontSize:12.5, color:C.textDark, fontFace:"Calibri" } })), { x:5.2, y:3.95, w:4.4, h:1.3, valign:"top", margin:0.08 });
  footerRef(s, "Source: ASHA Programme, MoHFW GoI | nhm.gov.in/asha");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 9 — RMNCH+A
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "RMNCH+A – Maternal, Child & Adolescent Health");
  const programs = [
    { name:"Janani Suraksha Yojana (JSY)", desc:"Cash incentive scheme promoting institutional delivery; >1 crore beneficiaries/year" },
    { name:"Janani Shishu Suraksha\nKaryakram (JSSK)", desc:"Free and cashless delivery, C-section, transport & diagnostics at public facilities" },
    { name:"Pradhan Mantri Surakshit\nMatritva Abhiyan (PMSMA)", desc:"Free antenatal check-up on the 9th of every month by specialists" },
    { name:"Rashtriya Bal Swasthya\nKaryakram (RBSK)", desc:"Child health screening & early intervention for 30 conditions from birth to 18 years" },
    { name:"Mission Indradhanush", desc:"Accelerated Immunisation targeting districts with <90% coverage" },
    { name:"WIFS – Weekly Iron & Folic\nAcid Supplementation", desc:"Weekly IFA tablets for adolescent girls aged 10–19 years to tackle anaemia" },
  ];
  programs.forEach((p, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.25 + col * 4.85;
    const y = 0.92 + row * 1.55;
    s.addShape(pres.ShapeType.rect, { x, y, w:4.6, h:1.4, fill:{ color:C.lightTeal }, line:{ color:C.tealAcc, pt:1.5 }, rounding:0.08 });
    s.addText(p.name, { x:x+0.12, y:y+0.1, w:4.36, h:0.45, fontSize:12.5, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
    s.addText(p.desc, { x:x+0.12, y:y+0.5, w:4.36, h:0.82, fontSize:11.5, color:C.textMid, fontFace:"Calibri", margin:0 });
  });
  footerRef(s, "Source: RMNCH+A Strategy, MoHFW GoI | nhm.gov.in/rmncha");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 10 — COMMUNICABLE DISEASE CONTROL
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Communicable Disease Control Programmes");
  const diseases = [
    { name:"TB (NTEP)", stat:"Incidence ↓ from 237 → 195\nper 1L pop (2015–2023)", color:C.red },
    { name:"Malaria (NVBDCP)", stat:"Malaria deaths reduced\n13.28% in 2021 vs 2020", color:C.amber },
    { name:"HIV/AIDS (NACP)", stat:"3rd largest ART programme\nin the world", color:"8E44AD" },
    { name:"Leprosy (NLEP)", stat:"Elimination achieved\n(<1/10,000 pop)", color:C.green },
    { name:"Kala-azar", stat:"Elimination targets\nmet in most blocks", color:C.tealAcc },
    { name:"Measles-Rubella", stat:"97.98% campaign\ncoverage achieved", color:C.navyBg },
  ];
  diseases.forEach((d, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.25 + col * 3.18;
    const y = 0.92 + row * 2.2;
    s.addShape(pres.ShapeType.rect, { x, y, w:3.0, h:1.9, fill:{ color: d.color }, line:{ color: d.color }, rounding:0.1, shadow:{type:"outer",blur:4,offset:2,angle:45,color:"888888",opacity:0.2} });
    s.addText(d.name, { x, y:y+0.12, w:3.0, h:0.55, fontSize:14.5, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(d.stat, { x, y:y+0.65, w:3.0, h:1.1, fontSize:12, color:C.white, fontFace:"Calibri", align:"center", margin:0.05 });
  });
  footerRef(s, "Source: MoHFW Annual Reports 2023-24 | NTEP, NVBDCP, NACP, NLEP data | nhm.gov.in");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 11 — NCDs
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Non-Communicable Disease (NCD) Programmes");
  // top info bar
  s.addShape(pres.ShapeType.rect, { x:0.3, y:0.88, w:9.4, h:0.62, fill:{ color:C.amber }, line:{ color:C.amber }, rounding:0.07 });
  s.addText("NCD burden accounts for ~63% of all deaths in India — NHM integrates comprehensive NCD control under NPCDCS, NP-NCD & NMHP", {
    x:0.35, y:0.91, w:9.3, h:0.55, fontSize:12.5, color:C.textDark, fontFace:"Calibri", align:"center", margin:0
  });
  const ncds = [
    { name:"NPCDCS", full:"National Programme for Prevention & Control of Cancer, Diabetes, CVD & Stroke", color:C.navyBg },
    { name:"NMHP", full:"National Mental Health Programme — District Mental Health Programme (DMHP)", color:C.slate },
    { name:"NPCB", full:"National Programme for Control of Blindness & Visual Impairment", color:C.tealAcc },
    { name:"NDCP", full:"National Deafness Control Programme — hearing screening & cochlear implants", color:C.green },
    { name:"NPPCF", full:"National Programme for Palliative Care & Pain Management", color: C.amber },
    { name:"NCD Screening", full:"Population-based screening for common NCDs at Ayushman Arogya Mandirs (AAMs)", color: "E74C3C" },
  ];
  ncds.forEach((n, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.3 + col * 4.85;
    const y = 1.62 + row * 1.25;
    s.addShape(pres.ShapeType.rect, { x, y, w:4.6, h:1.1, fill:{ color:n.color }, line:{ color:n.color }, rounding:0.08 });
    s.addText(n.name, { x:x+0.12, y:y+0.06, w:4.36, h:0.38, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", margin:0 });
    s.addText(n.full, { x:x+0.12, y:y+0.44, w:4.36, h:0.58, fontSize:11, color:C.white, fontFace:"Calibri", margin:0 });
  });
  footerRef(s, "Source: NHM NCD Division, MoHFW GoI | nhm.gov.in/ncd");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 12 — HEALTH INFRASTRUCTURE
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Health Infrastructure Strengthening");
  // facility pyramid (text-based)
  s.addText("Healthcare Facility Hierarchy", { x:0.3, y:0.9, w:5.0, h:0.4, fontSize:14, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
  const pyramid = [
    { label:"District Hospital (DH)",       n:"747",    color:C.navyBg, w:4.6, x:0.4 },
    { label:"Community Health Centre (CHC)",n:"6,064",  color:C.slate,  w:4.6, x:0.4 },
    { label:"Primary Health Centre (PHC)",  n:"30,913", color:C.tealAcc,w:4.6, x:0.4 },
    { label:"Sub-Centre (SC)",              n:"1,72,148", color:C.green, w:4.6, x:0.4 },
  ];
  pyramid.forEach((p, i) => {
    s.addShape(pres.ShapeType.rect, { x:p.x, y:1.4 + i*0.92, w:p.w, h:0.78, fill:{ color:p.color }, line:{ color:p.color }, rounding:0.06 });
    s.addText(`${p.label}`, { x:p.x+0.1, y:1.42 + i*0.92, w:3.5, h:0.72, fontSize:12.5, bold:true, color:C.white, fontFace:"Calibri", valign:"middle", margin:0 });
    s.addText(p.n, { x:p.x+3.5, y:1.42 + i*0.92, w:0.95, h:0.72, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"right", valign:"middle", margin:0 });
  });
  // right column stats
  const infra = [
    { label:"24×7 PHCs", val:"12,348", color:C.amber },
    { label:"First Referral Units (FRUs)", val:"3,133", color:C.slate },
    { label:"Mobile Medical Units", val:"1,424", color:C.tealAcc },
    { label:"NQAS Certified Facilities", val:"7,998", color:C.green },
    { label:"Ayushman Arogya Mandirs", val:"1,72,148", color:C.navyBg },
  ];
  infra.forEach((item, i) => {
    s.addShape(pres.ShapeType.rect, { x:5.4, y:0.9 + i*0.93, w:4.25, h:0.78, fill:{ color:item.color }, line:{ color:item.color }, rounding:0.07 });
    s.addText(item.label, { x:5.5, y:0.93 + i*0.93, w:2.7, h:0.72, fontSize:12, color:C.white, fontFace:"Calibri", valign:"middle", margin:0 });
    s.addText(item.val, { x:8.2, y:0.93 + i*0.93, w:1.35, h:0.72, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"right", valign:"middle", margin:0 });
  });
  footerRef(s, "Source: MoHFW Annual Report 2023-24 | Rural Health Statistics 2023-24");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 13 — KEY ACHIEVEMENTS
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Key Achievements & Health Impact Statistics");
  // stat boxes row 1
  const stats1 = [
    { val:"MMR\n130→97", sub:"per 1L live births\n2014-16 → 2018-20", color:C.navyBg },
    { val:"IMR\n39→28", sub:"per 1,000 live births\n2014 → 2020", color:C.tealAcc },
    { val:"U5MR\n45→32", sub:"per 1,000 live births\n2014 → 2020", color:C.amber },
    { val:"TFR\n2.3→2.0", sub:"National Family\nHealth Survey NFHS-5", color:C.slate },
  ];
  stats1.forEach((st, i) => {
    const x = 0.3 + i * 2.35;
    s.addShape(pres.ShapeType.rect, { x, y:0.9, w:2.15, h:1.35, fill:{ color:st.color }, line:{ color:st.color }, rounding:0.09, shadow:{type:"outer",blur:5,offset:3,angle:45,color:"555555",opacity:0.3} });
    s.addText(st.val, { x:x+0.05, y:0.93, w:2.05, h:0.65, fontSize:18, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(st.sub, { x:x+0.05, y:1.53, w:2.05, h:0.65, fontSize:10, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
  });
  // row 2 bullets
  const ach = [
    "💊  Over 220 crore COVID-19 vaccine doses administered (Jan 2021 – Mar 2024)",
    "👩‍⚕️  5.23 lakh additional healthcare workers engaged in FY 2023-24 alone",
    "🏥  7,998 public health facilities NQAS certified; 4,200+ nationally certified",
    "🚑  108 & 102 Ambulance services operational across states",
    "🩺  PM-Dialysis Programme benefited 4.53 lakh patients in FY 2023-24",
    "🦟  Kala-azar elimination targets met in nearly all endemic blocks",
    "🔬  TB incidence declined from 237 to 195 per lakh pop (2015–2023)",
    "👶  Measles-Rubella campaign achieved 97.98% coverage",
  ];
  const rows = ach.map((t,i) => ({ text:t, options:{ breakLine:i<ach.length-1, fontSize:12.5, color:C.textDark, fontFace:"Calibri" } }));
  s.addText(rows, { x:0.3, y:2.38, w:9.4, h:3.0, valign:"top", margin:0.1 });
  footerRef(s, "Source: PMO Press Release Jan 2025 | MoHFW Annual Report 2023-24 | pmindia.gov.in");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 14 — CHALLENGES & WAY FORWARD
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Challenges & Way Forward");
  // divider
  s.addShape(pres.ShapeType.rect, { x:4.9, y:0.85, w:0.08, h:4.65, fill:{ color:C.amber }, line:{ color:C.amber } });
  // Challenges header
  s.addText("⚠  Key Challenges", { x:0.3, y:0.9, w:4.45, h:0.45, fontSize:15, bold:true, color:C.red, fontFace:"Calibri", margin:0 });
  const chal = [
    "Human resource shortages especially specialists in rural areas",
    "Uneven quality of care across states",
    "Performance-based pay for ASHAs — motivation & burnout",
    "Ambulance response time non-compliance in several states",
    "Fund utilisation delays — state to district level",
    "Urban-rural health inequity persists",
    "Rising NCD burden vs. primarily communicable disease-oriented system",
    "Weak data quality & HMIS reporting from peripheral facilities",
  ];
  s.addText(chal.map((t,i)=>({ text:`• ${t}`, options:{ breakLine:i<chal.length-1, fontSize:12, color:C.textDark, fontFace:"Calibri" } })), { x:0.3, y:1.42, w:4.45, h:4.0, valign:"top", margin:0.08 });
  // Way Forward header
  s.addText("✅  Way Forward", { x:5.1, y:0.9, w:4.55, h:0.45, fontSize:15, bold:true, color:C.green, fontFace:"Calibri", margin:0 });
  const wf = [
    "Scale up Ayushman Arogya Mandirs for comprehensive primary care",
    "Formalise ASHA pay structure — fixed salaries + incentives",
    "Strengthen digital health (ABHA ID, U-WIN, CoWIN) under NHM",
    "Integrate NCD screening as mandatory at all health facilities",
    "Improve GPS-based ambulance tracking & accountability",
    "Expand medical colleges & specialist training in EAG states",
    "Real-time HMIS dashboards for transparent monitoring",
    "Climate-resilient health systems (NPCCCHH integration)",
  ];
  s.addText(wf.map((t,i)=>({ text:`• ${t}`, options:{ breakLine:i<wf.length-1, fontSize:12, color:C.textDark, fontFace:"Calibri" } })), { x:5.1, y:1.42, w:4.55, h:4.0, valign:"top", margin:0.08 });
  footerRef(s, "Source: CAG Report 2022 | Accountability Initiative NHM Analysis 2020 | PubAdmin Institute Review");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 15 — BUDGET & FUNDING
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Budget, Funding & Financial Architecture");
  // top info bar
  s.addShape(pres.ShapeType.rect, { x:0.3, y:0.88, w:9.4, h:0.6, fill:{ color:C.navyBg }, line:{ color:C.navyBg }, rounding:0.07 });
  s.addText("NHM is funded jointly by Centre & States — 60:40 ratio (Centre:State) | NE & Hilly States 90:10", {
    x:0.35, y:0.91, w:9.3, h:0.52, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0
  });
  // budget bars (visual)
  const budgets = [
    { year:"2020-21", amt:37130, col:C.slate },
    { year:"2021-22", amt:37000, col:C.tealAcc },
    { year:"2022-23", amt:28974, col:C.amber },
    { year:"2023-24", amt:29085, col:C.navyBg },
  ];
  const maxAmt = 37130;
  const barMaxW = 5.5;
  s.addText("Budget Allocation (₹ Crore)", { x:0.3, y:1.6, w:6.5, h:0.4, fontSize:13.5, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
  budgets.forEach((b, i) => {
    const y = 2.1 + i * 0.75;
    const w = (b.amt / maxAmt) * barMaxW;
    s.addText(b.year, { x:0.3, y:y+0.05, w:1.1, h:0.55, fontSize:12, color:C.textDark, fontFace:"Calibri", margin:0 });
    s.addShape(pres.ShapeType.rect, { x:1.5, y, w, h:0.62, fill:{ color:b.col }, line:{ color:b.col }, rounding:0.05 });
    s.addText(`₹ ${(b.amt/100).toFixed(0)}Cr`, { x:1.5 + w + 0.08, y:y+0.1, w:1.5, h:0.45, fontSize:12, bold:true, color:C.textDark, fontFace:"Calibri", margin:0 });
  });
  // right side key mechanisms
  s.addText("Funding Mechanisms", { x:6.5, y:1.58, w:3.1, h:0.4, fontSize:13.5, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
  const fm = [
    "• Programme Implementation Plans (PIP)",
    "• Flexible Pool (Communicable / RCH / NCD)",
    "• Untied grants to sub-centres & PHCs",
    "• Rogi Kalyan Samiti (hospital funds)",
    "• 8th Finance Commission transfers",
    "• State NHM Society as implementing body",
  ];
  s.addText(fm.map((t,i)=>({ text:t, options:{ breakLine:i<fm.length-1, fontSize:12, color:C.textDark, fontFace:"Calibri" } })), { x:6.5, y:2.05, w:3.1, h:3.4, valign:"top", margin:0.08 });
  footerRef(s, "Source: Union Budget 2023-24 | Invest India Blog Jan 2024 | MoHFW Expenditure Reports");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 16 — AYUSHMAN AROGYA MANDIR (AAM)
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Ayushman Arogya Mandir (AAM) – New Vision for Primary Care");
  s.addShape(pres.ShapeType.rect, { x:0.3, y:0.9, w:9.4, h:0.6, fill:{ color:C.tealAcc }, line:{ color:C.tealAcc }, rounding:0.07 });
  s.addText("Renamed from 'Health & Wellness Centres' (HWCs) under Ayushman Bharat | Goal: Comprehensive Primary Health Care for all", {
    x:0.35, y:0.92, w:9.3, h:0.54, fontSize:12.5, color:C.white, fontFace:"Calibri", align:"center", margin:0
  });
  const services = [
    "Maternal & Child Health Services", "Neonatal & Infant Health",
    "Child Health & Immunisation", "Family Planning & Contraceptive Services",
    "Adolescent Health Services", "Communicable Disease Management",
    "Non-Communicable Disease Screening", "Management of Common Ophthalmic/ENT",
    "Basic Oral Health Care", "Mental Health & NCD Screening",
    "Emergency / First-Aid Services", "Geriatric & Palliative Care",
  ];
  s.addText("12 Comprehensive Primary Health Care Services", {
    x:0.3, y:1.6, w:9.4, h:0.38, fontSize:14, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0
  });
  services.forEach((sv, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.3 + col * 3.22;
    const y = 2.05 + row * 0.75;
    s.addShape(pres.ShapeType.rect, { x, y, w:3.1, h:0.62, fill:{ color:C.lightTeal }, line:{ color:C.tealAcc, pt:1 }, rounding:0.07 });
    s.addText(`✔  ${sv}`, { x:x+0.1, y:y+0.08, w:2.9, h:0.48, fontSize:11, color:C.textDark, fontFace:"Calibri", valign:"middle", margin:0 });
  });
  statBox(s, 0.3, 5.0, 2.3, 0.5, "1,72,148", "AAMs operational (Mar 2024)", C.navyBg);
  statBox(s, 2.75, 5.0, 2.3, 0.5, "1,34,650", "Offering all 12 services", C.tealAcc);
  statBox(s, 5.2, 5.0, 2.3, 0.5, "CHO Posted", "Community Health Officers", C.amber);
  footerRef(s, "Source: PIB Press Release Jan 2025 | MoHFW Ayushman Bharat AAM data 2024");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 17 — HUMAN RESOURCES
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Human Resource for Health (HRH) under NHM");
  const hrs = [
    { role:"GDMOs (General Duty Medical Officers)", color:C.navyBg },
    { role:"Specialists (Surgeon, Obs & Gynae, Physician, Paediatrician)", color:C.slate },
    { role:"Staff Nurses", color:C.tealAcc },
    { role:"ANMs (Auxiliary Nurse Midwives)", color:C.green },
    { role:"Community Health Officers (CHOs)", color:C.amber },
    { role:"AYUSH Doctors", color:"8E44AD" },
    { role:"Allied & Healthcare Professionals (AHPs)", color:C.red },
    { role:"Public Health Managers", color:"E67E22" },
  ];
  hrs.forEach((h, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.3 + col * 4.85;
    const y = 0.9 + row * 0.97;
    s.addShape(pres.ShapeType.rect, { x, y, w:0.35, h:0.78, fill:{ color:h.color }, line:{ color:h.color } });
    s.addShape(pres.ShapeType.rect, { x:x+0.35, y, w:4.3, h:0.78, fill:{ color:C.offWhite }, line:{ color:"CCCCCC", pt:0.5 } });
    s.addText(h.role, { x:x+0.5, y:y+0.1, w:4.0, h:0.58, fontSize:13, color:C.textDark, fontFace:"Calibri", valign:"middle", margin:0 });
  });
  // summary boxes
  statBox(s, 0.3, 4.97, 2.9, 0.52, "2.69 Lakh", "Added FY 2021-22", C.navyBg);
  statBox(s, 3.4, 4.97, 2.9, 0.52, "4.21 Lakh", "Added FY 2022-23", C.tealAcc);
  statBox(s, 6.5, 4.97, 3.1, 0.52, "5.23 Lakh", "Added FY 2023-24", C.amber);
  footerRef(s, "Source: PMO Press Release Jan 2025 | MoHFW HRH Reports | nhm.gov.in/hrh");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 18 — DIGITAL HEALTH & INNOVATIONS
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "Digital Health Initiatives under NHM");
  const digital = [
    { name:"ABHA ID", icon:"🪪", desc:"Ayushman Bharat Health Account — unique digital health ID for every Indian citizen" },
    { name:"U-WIN", icon:"💉", desc:"Universal Immunisation Tracking — real-time tracking of vaccination events (piloted 2023)" },
    { name:"e-Sanjeevani", icon:"🖥️", desc:"National telemedicine platform — free OPD consultations; 20+ crore consultations completed" },
    { name:"HMIS & MCTS", icon:"📊", desc:"Health Management & Mother-Child Tracking System for monitoring service delivery" },
    { name:"RCH Portal", icon:"👶", desc:"Reproductive & Child Health portal — tracks pregnant women, newborns, immunisation" },
    { name:"MMU Portal", icon:"🚌", desc:"Mobile Medical Unit Portal (2023) — tracks health delivery to remote tribal groups" },
  ];
  digital.forEach((d, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.25 + col * 4.85;
    const y = 0.9 + row * 1.48;
    s.addShape(pres.ShapeType.rect, { x, y, w:4.6, h:1.3, fill:{ color: row===0?C.navyBg: row===1?C.tealAcc:C.slate }, line:{ color: row===0?C.navyBg: row===1?C.tealAcc:C.slate }, rounding:0.09 });
    s.addText(`${d.icon} ${d.name}`, { x:x+0.12, y:y+0.1, w:4.36, h:0.42, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", margin:0 });
    s.addText(d.desc, { x:x+0.12, y:y+0.5, w:4.36, h:0.72, fontSize:11.5, color:C.white, fontFace:"Calibri", margin:0 });
  });
  footerRef(s, "Source: NHA Digital Health Mission | MoHFW 2023-24 | ABDM nhp.gov.in");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 19 — CONCLUSION
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:10, h:5.625, fill:{ color:C.navyBg }, line:{ color:C.navyBg } });
  s.addShape(pres.ShapeType.rect, { x:0, y:1.1, w:10, h:0.06, fill:{ color:C.tealAcc }, line:{ color:C.tealAcc } });
  s.addShape(pres.ShapeType.rect, { x:0, y:4.45, w:10, h:0.06, fill:{ color:C.tealAcc }, line:{ color:C.tealAcc } });
  s.addText("Conclusion", { x:0.5, y:0.2, w:9, h:0.8, fontSize:34, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
  const points = [
    "NHM is India's largest and most ambitious public health programme, significantly transforming health outcomes since 2005.",
    "Through NRHM & NUHM, it addresses the distinct health challenges of both rural and urban populations under one mission.",
    "Key pillars — ASHA workers, RMNCH+A, disease control, infrastructure strengthening & digital health — have collectively reduced MMR, IMR and U5MR.",
    "India is on track to meet SDG health targets for maternal and child mortality well ahead of 2030.",
    "Sustained investment, addressing human resource gaps, and deeper digital integration will shape the next decade of NHM.",
  ];
  const rows = points.map((p, i) => ({
    text:`${["①","②","③","④","⑤"][i]}  ${p}`,
    options:{ breakLine: i < points.length-1, fontSize:13, color:C.white, fontFace:"Calibri", paraSpaceAfter:6 }
  }));
  s.addText(rows, { x:0.6, y:1.28, w:8.8, h:3.1, valign:"top", margin:0.15 });
  s.addText("Presented by: Musqan  |  Source: MoHFW GoI, nhm.gov.in  |  July 2026", {
    x:0.3, y:4.55, w:9.4, h:0.45, fontSize:11, color:C.tealAcc, fontFace:"Calibri", align:"center", italic:true, margin:0
  });
}

// ════════════════════════════════════════════════════════════════
// SLIDE 20 — REFERENCES
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentHeader(s, "References");
  const refs = [
    "1. Ministry of Health & Family Welfare (MoHFW), Government of India. National Health Mission – Framework for Implementation. New Delhi: MoHFW; 2013. Available at: nhm.gov.in",
    "2. PMO India. Cabinet approves Achievements under National Health Mission (2021-24). Press Release, 22 Jan 2025. Available at: pmindia.gov.in",
    "3. Press Information Bureau (PIB), Government of India. NHM Achieves Multiple Milestones in 2023-24. PIB Release, Jan 2025.",
    "4. Invest India. National Health Mission: Healthcare for All. Blog, 25 Jan 2024. investindia.gov.in",
    "5. Accountability Initiative. National Health Mission – Pre-Budget Brief. Shah S, Kapur A, Andasu A (2020). accountabilityindia.in",
    "6. PubAdmin Institute. Comprehensive Overview of the National Health Mission: Initiatives & Impact (2024). pubadmin.institute",
    "7. MoHFW. Rural Health Statistics 2023-24. New Delhi: Government of India, 2024.",
    "8. National Family Health Survey (NFHS-5). 2019-21. International Institute for Population Sciences (IIPS), Mumbai.",
    "9. WHO. World Health Statistics 2023. Geneva: World Health Organization, 2023.",
    "10. MoHFW. NHM HMIS Dashboard. hmis.nhp.gov.in (accessed July 2026).",
  ];
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// ════════════════════════════════════════════════════════════════
// WRITE FILE
// ════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/nhm-ppt/NHM_Musqan.pptx" })
  .then(() => console.log("SUCCESS: NHM_Musqan.pptx written"))
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const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "MusQan – Child Friendly Services Initiative";
pres.author = "Musqan";

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// ════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
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  // big child icon area (colour block)
  s.addShape(pres.ShapeType.rect, { x:6.8, y:0, w:3.2, h:5.625, fill:{color:"0D3160"}, line:{color:"0D3160"} });
  s.addText("👧🏽", { x:7.2, y:1.3, w:2.2, h:2.2, fontSize:96, align:"center", margin:0 });
  s.addText("MusQan", { x:0.5, y:0.6, w:6.1, h:1.2, fontSize:54, bold:true, color:C.teal, fontFace:"Calibri", align:"left", margin:0 });
  s.addText("Ensuring Child-Friendly Services\nin Public Health Facilities", {
    x:0.5, y:1.72, w:6.1, h:1.1, fontSize:20, color:C.white, fontFace:"Calibri", align:"left", margin:0
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  s.addText([
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    { text:" | Government of India | 2021", options:{fontSize:13, color:"A8C8E8"} }
  ], { x:0.5, y:3.1, w:5.8, h:0.4, margin:0 });
  s.addText("Age Group: 0 – 12 Years  |  Under: National Health Mission (NHM)", {
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  s.addText("Prepared by: Musqan  |  July 2026  |  For: Medical & Health Students", {
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}

// ════════════════════════════════════════════════════════════════
// SLIDE 2 — AGENDA
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Presentation Outline", "What we will cover in this presentation");
  const items = [
    ["1.","Background & Context — India's Child Health Burden"],
    ["2.","What is MusQan? — Full Form, Launch & Overview"],
    ["3.","Vision, Goal & Objectives"],
    ["4.","Seven Dimensions of Quality Care"],
    ["5.","Target Beneficiaries & Age Group"],
    ["6.","Key Focus Areas — Child-Friendly Services"],
    ["7.","Targeted Facility Types"],
    ["8.","Operational Framework — Rapid Improvement (RI) Cycles"],
    ["9.","MusQan Certification Process"],
    ["10.","Norms for Certification & Incentivisation"],
    ["11.","Key Performance Indicators (KPIs)"],
    ["12.","Relationship with NQAS & NHM"],
    ["13.","Progress & Implementation Status"],
    ["14.","Challenges & Way Forward"],
    ["15.","References"],
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  });
  footRef(s, "Source: MusQan Guidelines, MoHFW GoI 2021 | qps.nhsrcindia.org/musqan");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 3 — BACKGROUND & CONTEXT
// ════════════════════════════════════════════════════════════════
{
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  topBar(s, "Background & Context — India's Child Health Journey");
  // stat boxes top
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    { v:"44", sub:"NMR per 1,000 live births\n(Year 2000)", col:C.red },
    { v:"23", sub:"NMR per 1,000 live births\n(SRS 2018) — 48% ↓", col:C.green },
    { v:"96", sub:"U5MR per 1,000\nlive births (2000)", col:C.red },
    { v:"36", sub:"U5MR per 1,000\nlive births (2018)", col:C.green },
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    bul("Massive scale-up of community and facility-based care improved newborn & child survival"),
    bul("However, with increasing utilisation of health services, poor Quality of Care (QoC) became a major roadblock"),
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    bul("Child-unfriendly settings deterred families from using public health facilities"),
    bul("Need for a dedicated Quality Improvement (QI) framework specifically for the paediatric age group (0–12 yrs)"),
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  footRef(s, "Source: MusQan Guidelines MoHFW 2021 | SRS 2018 | qps.nhsrcindia.org | PIB Dec 2022");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 4 — WHAT IS MUSQAN
// ════════════════════════════════════════════════════════════════
{
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  topBar(s, "What is MusQan? — Overview & Full Form");
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    { text:"Q", options:{fontSize:26, bold:true, color:C.amber} },
    { text:"an  →  ", options:{fontSize:26, bold:true, color:C.white} },
    { text:"Mus", options:{fontSize:20, bold:true, color:C.teal} },
    { text:"kurahat  ", options:{fontSize:20, color:C.white} },
    { text:"Q", options:{fontSize:20, bold:true, color:C.amber} },
    { text:"uality  ", options:{fontSize:20, color:C.white} },
    { text:"an", options:{fontSize:20, bold:true, color:C.teal} },
    { text:"d  Sust", options:{fontSize:20, color:C.white} },
    { text:"ain", options:{fontSize:20, bold:true, color:C.teal} },
    { text:"ability  (symbolic — 'Smile')", options:{fontSize:16, italic:true, color:"A8C8E8"} },
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    { icon:"🏥", label:"Under", val:"NHM / NQAS", color:C.navyBg },
    { icon:"👶", label:"Age Group", val:"0–12 Years", color:C.amber },
    { icon:"🏛️", label:"Nodal Body", val:"MoHFW + NHSRC", color:C.purple },
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    '"MusQan is designed to ensure provision of quality child-friendly services from birth to children up to 12 years of age. It aims to reduce preventable newborn and child morbidity and mortality. It encompasses all pivotal aspects of child growth and development — physical, mental and social — and intends to achieve an explicit improvement in the quality of childcare services in public facilities of India."',
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  footRef(s, "Source: NHSRC — qps.nhsrcindia.org/musqan | MoHFW MusQan Guidelines 2021");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 5 — VISION, GOAL & OBJECTIVES
// ════════════════════════════════════════════════════════════════
{
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  topBar(s, "Vision, Goal & Objectives of MusQan");

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    { text:"Every child in India receives quality, safe, and child-friendly healthcare in public health facilities — from birth to 12 years.", options:{fontSize:14, color:C.white} }
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    { text:"Ensure provision of quality child-friendly services in public health facilities to REDUCE PREVENTABLE NEWBORN AND CHILD MORBIDITY AND MORTALITY.", options:{fontSize:14, color:C.textDark} }
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  const objs = [
    { n:"01", t:"Make child-friendly services ACCESSIBLE and AVAILABLE to patients and parents" },
    { n:"02", t:"Provide a CHILD-FRIENDLY ENVIRONMENT in public health facilities" },
    { n:"03", t:"Promote, protect and SUPPORT BREASTFEEDING at all facility levels" },
    { n:"04", t:"Provide RESPECTFUL and DIGNIFIED care to mothers, parents and attendants" },
    { n:"05", t:"Strengthen CLINICAL PROTOCOLS and STAFF COMPETENCIES for child health" },
    { n:"06", t:"Address gaps in SNCUs, NBSUs, Postnatal wards, Paediatric OPD and NRCs" },
  ];
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    s.addText(o.n, { x, y:y+0.05, w:0.42, h:0.46, fontSize:12, bold:true, color:C.teal, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(o.t, { x:x+0.5, y:y+0.05, w:4.2, h:0.48, fontSize:12, color:C.textDark, fontFace:"Calibri", valign:"middle", margin:0 });
  });
  footRef(s, "Source: MusQan Guidelines 2021, MoHFW GoI | NHSRC | PIB Press Release Dec 2022");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 6 — 7 DIMENSIONS OF QUALITY
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Seven Dimensions of Quality Care under MusQan", "Within the NQAS framework");

  const dims = [
    { n:"1", label:"TIMELY", desc:"Services provided without harmful delays", color:C.teal },
    { n:"2", label:"EFFECTIVE", desc:"Evidence-based interventions for best outcomes", color:C.green },
    { n:"3", label:"EFFICIENT", desc:"Optimal use of resources, avoiding waste", color:C.navyBg },
    { n:"4", label:"SAFE", desc:"Minimise risks and harm to children & caregivers", color:C.red },
    { n:"5", label:"PERSON-CENTRED", desc:"Responsive to individual child & family preferences", color:C.amber },
    { n:"6", label:"EQUITABLE", desc:"Same quality care regardless of gender, region or background", color:C.purple },
    { n:"7", label:"INTEGRATED", desc:"Coordinated care across all facility levels & teams", color:C.skyBlue },
  ];
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    const col = i%4; const row = Math.floor(i/4);
    const x = 0.25+col*2.38; const y = 0.97+row*2.05;
    const isLast = i===6;
    const finalX = isLast ? 3.56 : x;
    s.addShape(pres.ShapeType.rect, { x:finalX, y, w:2.15, h:1.78, fill:{color:d.color}, line:{color:d.color}, rounding:0.1,
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    s.addText(d.n, { x:finalX, y:y+0.1, w:2.15, h:0.5, fontSize:26, bold:true, color:"FFFFFF44", fontFace:"Calibri", align:"center", margin:0 });
    s.addText(d.label, { x:finalX, y:y+0.6, w:2.15, h:0.48, fontSize:13.5, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(d.desc, { x:finalX+0.1, y:y+1.07, w:1.95, h:0.62, fontSize:10.5, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
  });
  footRef(s, "Source: MusQan Framework, MoHFW 2021 | Adapted from WHO Quality of Care dimensions");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 7 — TARGET BENEFICIARIES
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Target Beneficiaries & Age Group");

  // central age group banner
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  s.addText("PRIMARY TARGET: Children aged 0 – 12 Years  (Newborn → Early Childhood → Middle Childhood)", {
    x:0.4, y:1.03, w:9.2, h:0.68, fontSize:16, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0
  });

  // age band boxes
  const bands = [
    { label:"Newborn\n(0–28 days)", facilities:"SNCU, NBSU\nLabour Room", color:C.red },
    { label:"Infant\n(1–12 months)", facilities:"Postnatal Ward\nPaediatric OPD", color:C.amber },
    { label:"Under-5\n(1–5 years)", facilities:"Paediatric OPD\nNRC (Nutrition)", color:C.green },
    { label:"Child\n(6–12 years)", facilities:"Paediatric OPD\nOPD & IPD", color:C.navyBg },
  ];
  bands.forEach((b,i)=>{
    const x = 0.28+i*2.37;
    s.addShape(pres.ShapeType.rect, { x, y:1.98, w:2.15, h:1.4, fill:{color:b.color}, line:{color:b.color}, rounding:0.09 });
    s.addText(b.label, { x, y:2.02, w:2.15, h:0.62, fontSize:14, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(b.facilities, { x, y:2.62, w:2.15, h:0.65, fontSize:11, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
  });

  // secondary beneficiaries
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    { icon:"👩", label:"Mothers / Parents / Attendants", desc:"Respectful, dignified care; support for breastfeeding" },
    { icon:"👨‍⚕️", label:"Healthcare Workers", desc:"Capacity building, competency enhancement" },
    { icon:"🏥", label:"Public Health Facilities", desc:"Institutional improvement & NQAS certification" },
  ];
  secs.forEach((sec,i)=>{
    const x = 0.3+i*3.2;
    s.addShape(pres.ShapeType.rect, { x, y:4.0, w:3.0, h:1.1, fill:{color:C.lightTeal}, line:{color:C.teal, pt:1.5}, rounding:0.08 });
    s.addText(`${sec.icon}  ${sec.label}`, { x:x+0.1, y:4.04, w:2.8, h:0.4, fontSize:13, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
    s.addText(sec.desc, { x:x+0.1, y:4.42, w:2.8, h:0.58, fontSize:11.5, color:C.textMid, fontFace:"Calibri", margin:0 });
  });
  footRef(s, "Source: MusQan Guidelines 2021, MoHFW GoI | PIB Lok Sabha Reply Dec 2022");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 8 — KEY FOCUS AREAS
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Key Focus Areas — Child-Friendly Services");

  const areas = [
    { icon:"🤱", title:"Breastfeeding Support", desc:"Promote, protect and support breastfeeding at all facility levels; Baby-Friendly Hospital standards" },
    { icon:"🧼", title:"Infection Prevention & Control", desc:"Hand hygiene, clean delivery practices, SNCU infection protocols, equipment sterilisation" },
    { icon:"🩺", title:"Clinical Care Quality", desc:"Evidence-based clinical protocols for sick newborns, children; emergency triage (ETAT)" },
    { icon:"💊", title:"Nutrition & Feeding", desc:"NRC (Nutritional Rehabilitation Centre) protocols; management of SAM/MAM in children" },
    { icon:"😊", title:"Child-Friendly Environment", desc:"Colour-coded wards, play areas, reduced separation anxiety, family-centred care principles" },
    { icon:"📋", title:"Respectful & Dignified Care", desc:"No denial of services; respectful communication with parents; privacy and confidentiality" },
    { icon:"📊", title:"Data & Monitoring", desc:"Key Performance Indicators (KPIs) tracking; HMIS integration; facility-level dashboards" },
    { icon:"🎓", title:"Capacity Building", desc:"Staff training on child health protocols; competency assessments; supportive supervision" },
  ];
  areas.forEach((a,i)=>{
    const col=i%2; const row=Math.floor(i/2);
    const x=0.28+col*4.85; const y=0.97+row*1.13;
    s.addShape(pres.ShapeType.rect, { x, y, w:4.6, h:1.0, fill:{color:C.offWhite}, line:{color:C.teal, pt:1.2}, rounding:0.08 });
    s.addText(a.icon, { x:x+0.1, y:y+0.12, w:0.6, h:0.72, fontSize:22, margin:0 });
    s.addText(a.title, { x:x+0.72, y:y+0.06, w:3.75, h:0.36, fontSize:13, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
    s.addText(a.desc, { x:x+0.72, y:y+0.4, w:3.75, h:0.52, fontSize:11, color:C.textMid, fontFace:"Calibri", margin:0 });
  });
  footRef(s, "Source: MusQan Guidelines 2021 | NHSRC India | MoHFW Child Health Division");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 9 — TARGETED FACILITY TYPES
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Targeted Facility Types & Units");

  const facilities = [
    { abbr:"SNCU", full:"Special Newborn Care Unit", desc:"Intensive care for sick & small newborns; central unit of MusQan at tertiary/DH level", color:C.red },
    { abbr:"NBSU", full:"Newborn Stabilisation Unit", desc:"Stabilisation of newborns at CHC level before referral; warmth, oxygen, IV fluids", color:C.amber },
    { abbr:"NBCare", full:"Newborn Care Corner", desc:"Immediate newborn care at delivery point — resuscitation, warmth, breastfeeding initiation", color:C.green },
    { abbr:"PNW", full:"Postnatal Ward", desc:"Care for mother-newborn dyad after delivery; breastfeeding, kangaroo mother care", color:C.teal },
    { abbr:"Paed OPD", full:"Paediatric OPD", desc:"Outpatient care for children 0–12 years; common illnesses, immunisation, growth monitoring", color:C.navyBg },
    { abbr:"NRC", full:"Nutritional Rehabilitation Centre", desc:"Management of Severe Acute Malnutrition (SAM) in children; facility-based therapeutic feeding", color:C.purple },
  ];
  facilities.forEach((f,i)=>{
    const col=i%3; const row=Math.floor(i/3);
    const x=0.28+col*3.18; const y=0.97+row*2.12;
    s.addShape(pres.ShapeType.rect, { x, y, w:3.0, h:1.95, fill:{color:f.color}, line:{color:f.color}, rounding:0.1,
      shadow:{type:"outer",blur:4,offset:2,angle:45,color:"777777",opacity:0.25} });
    s.addText(f.abbr, { x, y:y+0.1, w:3.0, h:0.55, fontSize:20, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(f.full, { x:x+0.1, y:y+0.62, w:2.8, h:0.36, fontSize:11.5, bold:true, color:"FFFFFFCC", fontFace:"Calibri", align:"center", margin:0 });
    s.addText(f.desc, { x:x+0.1, y:y+0.97, w:2.8, h:0.9, fontSize:10.5, color:C.white, fontFace:"Calibri", align:"center", margin:0.04 });
  });
  footRef(s, "Source: MusQan Guidelines 2021 | NHSRC | NHM Child Health — sncu.nhp.gov.in");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 10 — OPERATIONAL FRAMEWORK / RI CYCLES
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Operational Framework — Rapid Improvement (RI) Cycles");

  // intro box
  s.addShape(pres.ShapeType.rect, { x:0.3, y:0.97, w:9.4, h:0.62, fill:{color:C.lightTeal}, line:{color:C.teal, pt:1.5}, rounding:0.07 });
  s.addText("MusQan follows a systematic, multi-pronged approach. State & District teams support facilities to undertake a series of Rapid Improvement (RI) cycles to close quality gaps in the shortest possible time.",
    { x:0.4, y:1.01, w:9.2, h:0.55, fontSize:12.5, color:C.textMid, fontFace:"Calibri", italic:true, margin:0 });

  // PDSA cycle (text-based representation)
  const steps = [
    { n:"STEP 1", title:"ASSESS — Gap Analysis", desc:"Baseline assessment against MusQan standards using standardised tools. Identify gaps in SNCUs, NBSUs, PNW, Paed OPD, NRC.", color:C.navyBg },
    { n:"STEP 2", title:"PLAN — Rapid Improvement Plan", desc:"State & District teams formulate a time-bound Rapid Improvement (RI) plan targeting specific gaps. Monthly milestones set.", color:C.teal },
    { n:"STEP 3", title:"DO — Implementation", desc:"Implement quality improvement activities: training, infrastructure, protocols, IEC material. Community Health Officers involved.", color:C.green },
    { n:"STEP 4", title:"STUDY — Monitor & Measure", desc:"Track KPIs regularly. Monthly data review at state & district level. Identify barriers and enablers.", color:C.amber },
    { n:"STEP 5", title:"ACT — Course Correct & Certify", desc:"Sustained improvement leads to Internal then External Assessment. Certification awarded on meeting thresholds.", color:C.purple },
  ];
  steps.forEach((st,i)=>{
    const y = 1.72+i*0.72;
    s.addShape(pres.ShapeType.rect, { x:0.3, y, w:0.9, h:0.62, fill:{color:st.color}, line:{color:st.color}, rounding:0.06 });
    s.addText(st.n, { x:0.3, y:y+0.06, w:0.9, h:0.52, fontSize:11, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addShape(pres.ShapeType.rect, { x:1.28, y:y+0.04, w:8.4, h:0.58, fill:{color:C.offWhite}, line:{color:st.color, pt:1} });
    s.addText(`${st.title}:  `, { x:1.38, y:y+0.08, w:2.3, h:0.45, fontSize:12.5, bold:true, color:st.color, fontFace:"Calibri", margin:0 });
    s.addText(st.desc, { x:3.5, y:y+0.08, w:6.1, h:0.45, fontSize:11.5, color:C.textDark, fontFace:"Calibri", margin:0 });
  });
  footRef(s, "Source: MusQan Guidelines 2021, MoHFW GoI | NHSRC Technical Support | qps.nhsrcindia.org");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 11 — CERTIFICATION PROCESS
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "MusQan Certification Process");

  const stages = [
    { n:"Stage 1", title:"Internal Assessment", desc:"Facility team conducts self-assessment using MusQan tools. Score calculated against standards. Report submitted to district.", color:C.navyBg, icon:"📋" },
    { n:"Stage 2", title:"State-level Verification", desc:"State team verifies internal assessment findings. Provides mentoring support. Gap closure plan reviewed and validated.", color:C.teal, icon:"✅" },
    { n:"Stage 3", title:"External Assessment", desc:"Independent external assessors (NHSRC empanelled) conduct objective evaluation at the facility. Final score assigned.", color:C.amber, icon:"🔍" },
    { n:"Stage 4", title:"Certification & Award", desc:"Facilities meeting threshold score receive MusQan Certification. Incentive released to the facility.", color:C.green, icon:"🏆" },
  ];
  stages.forEach((st,i)=>{
    const x=0.28+i*2.37;
    s.addShape(pres.ShapeType.rect, { x, y:0.97, w:2.15, h:3.65, fill:{color:st.color}, line:{color:st.color}, rounding:0.1,
      shadow:{type:"outer",blur:6,offset:3,angle:45,color:"666666",opacity:0.25} });
    s.addText(st.icon, { x, y:1.05, w:2.15, h:0.65, fontSize:32, align:"center", margin:0 });
    s.addText(st.n, { x, y:1.68, w:2.15, h:0.35, fontSize:11.5, color:"FFFFFFAA", fontFace:"Calibri", align:"center", margin:0 });
    s.addText(st.title, { x:x+0.1, y:1.98, w:1.95, h:0.52, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(st.desc, { x:x+0.1, y:2.5, w:1.95, h:1.05, fontSize:11, color:C.white, fontFace:"Calibri", align:"center", margin:0.05 });
  });
  // arrows between stages
  for (let i=0;i<3;i++) {
    s.addShape(pres.ShapeType.rightArrow, { x:2.35+i*2.37, y:2.4, w:0.42, h:0.38, fill:{color:"AAAAAA"}, line:{color:"AAAAAA"} });
  }
  // Key documents
  s.addText("Key MusQan Documents:", { x:0.3, y:4.75, w:3.5, h:0.35, fontSize:13, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
  const docs = [
    "📖 MusQan Guidelines", "🛠 MusQan Assessment Tools",
    "📑 List of Documents for External Assessment", "📊 MusQan KPI Tracking Sheets",
  ];
  const docR = docs.map((d,i)=>({ text:d, options:{ breakLine:i<docs.length-1, fontSize:12, color:C.textDark, fontFace:"Calibri" } }));
  s.addText(docR, { x:0.3, y:5.1, w:4.5, h:0.5, valign:"top", margin:0 });
  s.addText("All documents available at: qps.nhsrcindia.org/musqan", {
    x:5.0, y:4.78, w:4.7, h:0.35, fontSize:11.5, color:C.teal, fontFace:"Calibri", italic:true, margin:0
  });
  footRef(s, "Source: MusQan Certification Process, NHSRC | MoHFW GoI 2021 | qps.nhsrcindia.org/musqan");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 12 — NORMS FOR CERTIFICATION & INCENTIVISATION
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Norms for Certification & Incentivisation");

  // header note
  s.addShape(pres.ShapeType.rect, { x:0.3, y:0.97, w:9.4, h:0.6, fill:{color:C.lightAmb}, line:{color:C.amber, pt:1.5}, rounding:0.08 });
  s.addText("💡 Incentives under MusQan are linked to certification level achieved. Facilities are scored and categorised into Bronze, Silver or Gold levels based on external assessment score.",
    { x:0.4, y:1.01, w:9.2, h:0.52, fontSize:12.5, color:C.textMid, fontFace:"Calibri", margin:0 });

  // Certification tiers
  const tiers = [
    { level:"BRONZE", score:"≥ 50%", incentive:"Entry-level certification; supportive supervision intensified; gap closure plan mandatory", color:"CD7F32", icon:"🥉" },
    { level:"SILVER", score:"≥ 70%", incentive:"Silver certified facilities receive financial incentive for sustained quality improvement activities", color:"A8A8A8", icon:"🥈" },
    { level:"GOLD", score:"≥ 90%", incentive:"Highest certification; recognised as model child-friendly facility; higher incentive amount", color:"D4AF37", icon:"🥇" },
  ];
  tiers.forEach((t,i)=>{
    const x=0.28+i*3.18;
    s.addShape(pres.ShapeType.rect, { x, y:1.72, w:3.0, h:2.65, fill:{color:t.color}, line:{color:t.color}, rounding:0.1,
      shadow:{type:"outer",blur:6,offset:3,angle:45,color:"666666",opacity:0.25} });
    s.addText(t.icon, { x, y:1.78, w:3.0, h:0.7, fontSize:36, align:"center", margin:0 });
    s.addText(t.level, { x, y:2.45, w:3.0, h:0.48, fontSize:18, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(`Score: ${t.score}`, { x:x+0.15, y:2.9, w:2.7, h:0.38, fontSize:13.5, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(t.incentive, { x:x+0.1, y:3.28, w:2.8, h:1.0, fontSize:11, color:C.white, fontFace:"Calibri", align:"center", margin:0.05 });
  });

  // bottom note
  s.addText("Assessment Tools:", { x:0.3, y:4.55, w:9.4, h:0.35, fontSize:13, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
  const notes = [
    { text:"✔  Separate assessment tools available for DH/SDH, CHC facilities", options:{breakLine:true, fontSize:12.5, color:C.textDark, fontFace:"Calibri"} },
    { text:"✔  Facilities may also address critical issues based on local need during RI cycles", options:{fontSize:12.5, color:C.textDark, fontFace:"Calibri"} },
  ];
  s.addText(notes, { x:0.3, y:4.92, w:9.4, h:0.5, valign:"top", margin:0 });
  footRef(s, "Source: MusQan Guidelines 2021 — Chapter 3.6 Certification Protocol | MoHFW GoI");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 13 — KEY PERFORMANCE INDICATORS
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Key Performance Indicators (KPIs) under MusQan");

  s.addShape(pres.ShapeType.rect, { x:0.3, y:0.97, w:9.4, h:0.55, fill:{color:C.navyBg}, line:{color:C.navyBg}, rounding:0.07 });
  s.addText("KPIs are tracked for each facility unit — SNCU, NBSU, Postnatal Ward, Paediatric OPD & NRC — against defined benchmarks", {
    x:0.4, y:1.01, w:9.2, h:0.47, fontSize:12.5, bold:false, color:C.white, fontFace:"Calibri", align:"center", margin:0
  });

  const kpis = [
    { unit:"SNCU", kpis:["Survival rate of admitted newborns", "Rate of nosocomial infections", "Exclusive breastfeeding at discharge", "Coverage of KMC (Kangaroo Mother Care)"] },
    { unit:"NBSU", kpis:["Rate of outborn admissions stabilised", "Hypothermia rate on admission", "Time to first feed", "Referral completion rate"] },
    { unit:"Postnatal Ward", kpis:["Exclusive breastfeeding initiation within 1 hr", "Skin-to-skin contact rate", "Newborn danger sign counselling", "Postpartum haemorrhage prevention"] },
    { unit:"Paediatric OPD", kpis:["Triage completion rate", "IMNCI protocol adherence", "Immunisation coverage at OPD", "Wait time for children"] },
    { unit:"NRC", kpis:["SAM admission rate", "Default rate from NRC", "Weight gain during stay (>8g/kg/day)", "Caregiver counselling coverage"] },
  ];
  kpis.forEach((k,i)=>{
    const col=i%3; const row=Math.floor(i/3);
    const isLast = (i===3||i===4);
    const x = isLast ? 0.28+(i-3)*4.85 : 0.28+col*3.18;
    const w = isLast ? 4.6 : 3.0;
    const y = 1.65+row*1.88;
    s.addShape(pres.ShapeType.rect, { x, y, w, h:1.72, fill:{color:C.offWhite}, line:{color:C.teal, pt:1.2}, rounding:0.08 });
    s.addShape(pres.ShapeType.rect, { x, y, w, h:0.42, fill:{color:C.teal}, line:{color:C.teal}, rounding:0.08 });
    s.addText(k.unit, { x:x+0.1, y:y+0.04, w:w-0.2, h:0.36, fontSize:13, bold:true, color:C.white, fontFace:"Calibri", margin:0 });
    const rows = k.kpis.map((kp,j)=>({ text:`• ${kp}`, options:{ breakLine:j<k.kpis.length-1, fontSize:11, color:C.textDark, fontFace:"Calibri" } }));
    s.addText(rows, { x:x+0.1, y:y+0.47, w:w-0.2, h:1.18, valign:"top", margin:0 });
  });
  footRef(s, "Source: MusQan Guidelines Annexure A — List of KPIs | MoHFW GoI 2021");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 14 — MUSQAN & NQAS / NHM RELATIONSHIP
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "MusQan Within the NQAS & NHM Framework");

  // outer NHM box
  s.addShape(pres.ShapeType.rect, { x:0.25, y:0.95, w:9.5, h:4.22, fill:{color:C.offWhite}, line:{color:C.navyBg, pt:2}, rounding:0.1 });
  s.addText("National Health Mission (NHM)", { x:0.3, y:1.0, w:4.0, h:0.42, fontSize:13.5, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });

  // NQAS box
  s.addShape(pres.ShapeType.rect, { x:0.5, y:1.5, w:9.0, h:3.5, fill:{color:"EAF4FB"}, line:{color:C.skyBlue, pt:1.5}, rounding:0.08 });
  s.addText("National Quality Assurance Standards (NQAS)", { x:0.6, y:1.58, w:5.0, h:0.38, fontSize:13, bold:true, color:C.skyBlue, fontFace:"Calibri", margin:0 });

  // sister QI programmes
  const siblings = [
    { name:"LaQshya", target:"Labour Room & Maternity OT Quality", color:C.purple },
    { name:"MusQan", target:"Child-Friendly Services\n(0–12 years)", color:C.teal },
    { name:"KAYAKALP", target:"Cleanliness & Hygiene in\nPublic Health Facilities", color:C.green },
    { name:"SUMAN", target:"Surakshit Matritva\nAashwasan (Maternal care)", color:C.amber },
  ];
  siblings.forEach((sib,i)=>{
    const x=0.65+i*2.28;
    s.addShape(pres.ShapeType.rect, { x, y:2.08, w:2.1, h:1.7, fill:{color:sib.color}, line:{color:sib.color}, rounding:0.08,
      shadow:{type:"outer",blur:4,offset:2,angle:45,color:"888888",opacity:0.2} });
    s.addText(sib.name, { x, y:2.14, w:2.1, h:0.52, fontSize:15, bold:true, color:C.white, fontFace:"Calibri", align:"center", margin:0 });
    s.addText(sib.target, { x:x+0.08, y:2.64, w:1.94, h:1.0, fontSize:10.5, color:C.white, fontFace:"Calibri", align:"center", margin:0.04 });
  });

  s.addText("↑ All are Quality Improvement Initiatives under NQAS within NHM — MusQan is specifically for the paediatric (0–12 yr) domain", {
    x:0.6, y:3.88, w:8.8, h:0.42, fontSize:11.5, italic:true, color:C.textMid, fontFace:"Calibri", align:"center", margin:0
  });

  // note
  s.addText("Note: MusQan ≠ JSSK (which covers free services for pregnant women & infants up to 1 year)", {
    x:0.3, y:4.35, w:9.4, h:0.38, fontSize:12, bold:true, color:C.red, fontFace:"Calibri", margin:0
  });
  footRef(s, "Source: NHM NQAS Framework | MoHFW Quality Division | qps.nhsrcindia.org");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 15 — PROGRESS & IMPLEMENTATION STATUS
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Progress & Implementation Status");

  // big stat boxes
  const stats = [
    { v:"2021", sub:"Year of Launch\n(MoHFW GoI)", col:C.navyBg },
    { v:"All States", sub:"Implementation scope\nunder NHM PIPs", col:C.teal },
    { v:"SNCU/NBSU\nPNW/OPD/NRC", sub:"5 unit types\ncovered", col:C.amber },
    { v:"Bronze/Silver\n/Gold", sub:"3-tier\ncertification", col:C.green },
  ];
  stats.forEach((st,i)=>{
    statBox(s, 0.28+i*2.37, 0.97, 2.15, 1.32, st.v, st.sub, st.col);
  });

  s.addText("Implementation Milestones & Status:", { x:0.3, y:2.45, w:9.4, h:0.38, fontSize:14, bold:true, color:C.navyBg, fontFace:"Calibri", margin:0 });
  const miles = [
    bul("MusQan Guidelines published by MoHFW in 2021 (ISBN: 978-93-82655-27-5)"),
    bul("NHSRC designated as Technical Support Institute for MusQan implementation"),
    bul("State-level trainings initiated under NHM quality improvement streams"),
    bul("External assessors empanelled by NHSRC for objective certification assessments"),
    bul("MusQan Certification Status tracked and updated regularly on NHSRC portal"),
    bul("Integrated with existing SNCU tracking portals and NHM HMIS"),
    bul("MusQan tools and assessment checklists made publicly available for download"),
    bul("Over 7,998 public health facilities already under NQAS; MusQan extends this to paediatric domain"),
    bulLast("PIB reported MusQan status in Lok Sabha (Dec 2022) — high-case-load CHCs & DHs prioritised"),
  ];
  s.addText(miles, { x:0.3, y:2.87, w:9.4, h:2.35, valign:"top", margin:0.06 });
  footRef(s, "Source: PIB Press Release Dec 2022 | NHSRC qps.nhsrcindia.org/musqan-certification-status | MoHFW 2021");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 16 — CHALLENGES & WAY FORWARD
// ════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  topBar(s, "Challenges & Way Forward");
  // divider
  s.addShape(pres.ShapeType.rect, { x:4.92, y:0.88, w:0.08, h:4.35, fill:{color:C.amber}, line:{color:C.amber} });

  s.addText("⚠ Challenges", { x:0.3, y:0.92, w:4.45, h:0.42, fontSize:15, bold:true, color:C.red, fontFace:"Calibri", margin:0 });
  const chal = [
    "Varied infrastructure & readiness across states and districts",
    "Shortage of trained paediatric nurses & neonatologists in rural facilities",
    "Inconsistent SNCU & NBSU functionality in EAG states",
    "Data quality — under-reporting of KPIs to HMIS",
    "Delayed release of incentive funds to facilities",
    "Staff motivation & high turnover at peripheral levels",
    "Limited community awareness about child-friendly rights at hospitals",
    "COVID-19 disrupted training & assessment activities (2020–21)",
  ];
  s.addText(chal.map((t,i)=>({ text:`• ${t}`, options:{ breakLine:i<chal.length-1, fontSize:12, color:C.textDark, fontFace:"Calibri" } })),
    { x:0.3, y:1.42, w:4.45, h:3.75, valign:"top", margin:0.07 });

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  const wf = [
    "Scale-up MusQan to all District & Sub-District Hospitals nationwide",
    "Integrate MusQan scores into NHM performance dashboards",
    "Strengthen SNCU-to-NBSU continuum of care linkages",
    "Dedicate CHO (Community Health Officer) role in child health QI",
    "Link MusQan certification to performance-based NHM incentives",
    "Expand digital real-time KPI tracking across all units",
    "Family-centred care training for all paediatric ward staff",
    "Build state capacity for independent external assessment pools",
  ];
  s.addText(wf.map((t,i)=>({ text:`• ${t}`, options:{ breakLine:i<wf.length-1, fontSize:12, color:C.textDark, fontFace:"Calibri" } })),
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  footRef(s, "Source: Accountability Initiative NHM Reports | PIB Dec 2022 | NHSRC Review | MoHFW Annual Reports");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 17 — CONCLUSION
// ════════════════════════════════════════════════════════════════
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    "It operates within the NQAS framework under NHM and addresses the 5 critical units: SNCU, NBSU, Postnatal Ward, Paediatric OPD, and NRC.",
    "Its goal is simple but profound: reduce preventable newborn and child morbidity and mortality through quality, respectful and accessible care.",
    "The 3-tier certification system (Bronze → Silver → Gold) incentivises continuous quality improvement at facility level.",
    "As India strives to meet SDG Goal 3 targets, MusQan is a vital pillar ensuring that every child's first healthcare experience is safe, humane and effective.",
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// ════════════════════════════════════════════════════════════════
// SLIDE 18 — REFERENCES
// ════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  topBar(s, "References");
  const refs = [
    "1. Ministry of Health & Family Welfare, Government of India. MusQan – Ensuring Child Friendly Services in Public Health Facilities. New Delhi: MoHFW; 2021. ISBN: 978-93-82655-27-5.",
    "2. National Health Systems Resource Centre (NHSRC). MusQan Programme Page. Available at: qps.nhsrcindia.org/musqan (Accessed July 2026).",
    "3. Press Information Bureau (PIB), Government of India. Measures taken to Improve Women and Child Health Facilities. Lok Sabha Written Reply, 16 Dec 2022. pib.gov.in/PRID=1884185.",
    "4. Ministry of Health & Family Welfare. National Quality Assurance Standards (NQAS) Framework. New Delhi: MoHFW GoI.",
    "5. Ministry of Health & Family Welfare. LaQshya, KAYAKALP, SUMAN — Sister QI Programmes under NQAS. nhm.gov.in.",
    "6. Sample Registration System (SRS). Neonatal & Under-5 Mortality Rate Data 2018. Office of the Registrar General of India.",
    "7. National Family Health Survey (NFHS-5). 2019–21. International Institute for Population Sciences (IIPS), Mumbai.",
    "8. PMO India. Cabinet approves Achievements under NHM 2021–24. Press Release, 22 Jan 2025. pmindia.gov.in.",
    "9. Sleepy Classes IAS. Unlocking the Secrets of the Muskan Initiative. sleepyclasses.com/musqan-initiative-hcs-pyq-2.",
    "10. WHO. Standards for Improving Quality of Maternal and Newborn Care in Health Facilities. Geneva: WHO; 2016.",
  ];
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  footRef(s, "All data sourced from official Government of India publications, NHSRC and peer-reviewed sources.");
}

// ════════════════════════════════════════════════════════════════
// WRITE FILE
// ════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/nhm-ppt/MusQan_Musqan.pptx" })
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from docx import Document
from docx.shared import Pt, Inches, RGBColor, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.style import WD_STYLE_TYPE
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import datetime

doc = Document()

# ── PAGE MARGINS ─────────────────────────────────────────────────
section = doc.sections[0]
section.top_margin    = Inches(1.2)
section.bottom_margin = Inches(1.2)
section.left_margin   = Inches(1.25)
section.right_margin  = Inches(1.0)

# ── FONT HELPERS ─────────────────────────────────────────────────
def set_font(run, size, bold=False, italic=False, color=None):
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    run.bold = bold
    run.italic = italic
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def heading1(text):
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    return p

def heading2(text):
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    p.paragraph_format.space_after  = Pt(3)
    return p

def body(text, indent=False):
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    p.paragraph_format.line_spacing = Pt(18)
    return p

def bullet(text, level=0):
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    return p

def mixed(parts):
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def add_table_2col(headers, rows):
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    table.style = 'Table Grid'
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                run.font.name = "Times New Roman"
        hdr_cells[i].paragraphs[0].alignment = WD_ALIGN_PARAGRAPH.CENTER
    for ri, row_data in enumerate(rows):
        cells = table.rows[ri+1].cells
        for ci, val in enumerate(row_data):
            cells[ci].text = val
            for para in cells[ci].paragraphs:
                for run in para.runs:
                    run.font.size = Pt(10)
                    run.font.name = "Times New Roman"
    doc.add_paragraph()

def pagebreak():
    doc.add_page_break()

def divider():
    p = doc.add_paragraph()
    run = p.add_run("─" * 100)
    run.font.size = Pt(8)
    run.font.color.rgb = RGBColor(180, 180, 180)
    p.paragraph_format.space_before = Pt(2)
    p.paragraph_format.space_after  = Pt(2)

# ════════════════════════════════════════════════════════════════
#  TITLE PAGE
# ════════════════════════════════════════════════════════════════
p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run("\n\n\nPROTEIN-ENERGY MALNUTRITION (PEM)")
set_font(run, 22, bold=True, color=(0, 51, 102))
p.paragraph_format.space_after = Pt(6)

p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run("Detailed Aspects, Pathophysiology, Clinical Signs & Symptoms with Justification,\nManagement, and Preventive & Social Medicine Approach")
set_font(run, 14, italic=True, color=(50, 80, 100))
p.paragraph_format.space_after = Pt(24)

divider()

p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run("A COMPREHENSIVE ACADEMIC THESIS")
set_font(run, 13, bold=True, color=(100, 0, 0))

p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run("Prepared by: Musqan")
set_font(run, 12)

p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run(f"Date: {datetime.date.today().strftime('%B %Y')}")
set_font(run, 11, italic=True)

divider()

p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run("References: Robbins & Kumar Basic Pathology (10e) | Park's Textbook of Preventive & Social Medicine |\nLippincott's Biochemistry (8e) | Robbins, Cotran & Kumar Pathologic Basis of Disease |\nDermatology 2-Volume Set (5e) | Sleisenger & Fordtran's GI & Liver Disease | WHO Guidelines")
set_font(run, 10, italic=True, color=(80, 80, 80))

pagebreak()

# ════════════════════════════════════════════════════════════════
#  TABLE OF CONTENTS (manual)
# ════════════════════════════════════════════════════════════════
heading1("TABLE OF CONTENTS")
toc = [
    ("1.", "Introduction and Background", "3"),
    ("2.", "Definition and Classification", "4"),
    ("3.", "Epidemiology and Global Burden", "5"),
    ("4.", "Aetiology and Risk Factors", "6"),
    ("5.", "Pathophysiology", "7"),
    ("6.", "Clinical Manifestations — Signs and Symptoms with Justification", "9"),
    ("6.1", "Marasmus — Detailed Signs and Justification", "9"),
    ("6.2", "Kwashiorkor — Detailed Signs and Justification", "11"),
    ("6.3", "Marasmic-Kwashiorkor (Mixed Form)", "14"),
    ("6.4", "Comparative Summary Table", "14"),
    ("7.", "Investigations and Diagnosis", "15"),
    ("8.", "Clinical Management", "16"),
    ("8.1", "WHO Three-Stage Approach", "16"),
    ("8.2", "Stage 1: Stabilisation Phase", "16"),
    ("8.3", "Stage 2: Rehabilitation Phase", "18"),
    ("8.4", "Stage 3: Follow-up and Community Reintegration", "19"),
    ("8.5", "Refeeding Syndrome — Mechanism and Prevention", "19"),
    ("9.", "Preventive and Social Medicine Approach", "20"),
    ("9.1", "Primordial Prevention", "20"),
    ("9.2", "Primary Prevention", "21"),
    ("9.3", "Secondary Prevention", "22"),
    ("9.4", "Tertiary Prevention / Rehabilitation", "23"),
    ("9.5", "National Programmes in India", "23"),
    ("9.6", "Social Determinants of PEM", "24"),
    ("10.", "Prognosis and Complications", "25"),
    ("11.", "Conclusion", "26"),
    ("12.", "References", "27"),
]
for num, title, pg in toc:
    p = doc.add_paragraph()
    p.paragraph_format.tab_stops.add_tab_stop(Inches(5.5))
    run1 = p.add_run(f"{num}  {title}")
    set_font(run1, 11)
    run2 = p.add_run(f"\t{pg}")
    set_font(run2, 11)
    p.paragraph_format.space_after = Pt(2)

pagebreak()

# ════════════════════════════════════════════════════════════════
#  CHAPTER 1 — INTRODUCTION
# ════════════════════════════════════════════════════════════════
heading1("1. INTRODUCTION AND BACKGROUND")

body("Protein-Energy Malnutrition (PEM), now increasingly referred to as Severe Acute Malnutrition (SAM) in contemporary literature, represents one of the most pervasive and devastating public health challenges confronting the developing world. It is a spectrum of nutritional disorders arising from an inadequate dietary intake of both protein and calories, relative to the metabolic requirements of the body. PEM manifests across a broad clinical continuum — from mild forms characterised by subtle growth faltering, to life-threatening syndromes such as marasmus and kwashiorkor.")

body("Although global progress in reducing child undernutrition has been made, the pace remains uneven and insufficient. Between 2012 and 2024, low-income countries actually experienced a 13.7% increase in the number of stunted children under five years, underscoring that economic growth alone has not translated into nutritional security. Worldwide, approximately 50 million children are affected by severe acute malnutrition, and malnutrition is estimated to be an underlying contributing cause in 45% of all deaths in children under five years of age.")

body("The consequences of PEM extend far beyond physical wasting. Impaired brain development during the first 1,000 days of life — from conception to the second birthday — is now recognised as an irreversible and irreparable consequence of severe malnutrition. Cognitive deficits, reduced educational attainment, lowered economic productivity in adulthood, and intergenerational transmission of poverty are all well-documented sequelae.")

body("In India, PEM constitutes a major public health and nutritional burden. Park's Textbook of Preventive and Social Medicine documents that the prevalence of severe PEM ranges between 5–6% and mild PEM around 40% in children, with PEM estimated to underlie 30% of deaths in children under five. As many as 27% of children in low-income countries have stunted growth (low height-for-age), and 17% have wasting (low weight-for-height).")

body("This thesis provides a detailed and systematically justified account of PEM — its definitions, epidemiology, aetiology, pathophysiology, clinical signs and symptoms (each with mechanistic justification), investigations, clinical management (including the WHO three-stage approach), preventive and social medicine strategies, national programmes, and prognosis.")

pagebreak()

# ════════════════════════════════════════════════════════════════
#  CHAPTER 2 — DEFINITION AND CLASSIFICATION
# ════════════════════════════════════════════════════════════════
heading1("2. DEFINITION AND CLASSIFICATION")

heading2("2.1 Definitions")

body("Protein-Energy Malnutrition (PEM) is defined as a state of undernutrition caused by deficient dietary intake of protein and/or energy, leading to clinical syndromes characterised by impaired growth, muscle wasting, immune dysfunction, and multi-organ dysfunction. The World Health Organization defines severe acute malnutrition (SAM) as a weight-to-height ratio that is 3 standard deviations below the median growth standard, visible severe wasting, or the presence of nutritional oedema.")

heading2("2.2 Classification Systems")

heading3("A. Based on Clinical Presentation")
add_table_2col(
    ["Type", "Predominant Deficit", "Oedema", "Key Feature"],
    [
        ["Marasmus", "Energy (calories) primarily", "Absent", "Severe wasting and emaciation"],
        ["Kwashiorkor", "Protein primarily", "Present (bilateral pitting)", "Oedema, fatty liver, skin changes"],
        ["Marasmic-Kwashiorkor", "Both protein and energy", "Present", "Features of both syndromes"],
    ]
)

heading3("B. Lippincott's Biochemistry Comparative Table (Weight-Based)")
add_table_2col(
    ["Parameter", "Kwashiorkor", "Marasmus"],
    [
        ["Weight for Age (% expected)", "60–80%", "< 60%"],
        ["Weight for Height", "Normal or decreased", "Markedly decreased"],
        ["Oedema", "Present", "Absent"],
        ["Muscle and Fat Content", "Decreased (masked by oedema)", "Markedly decreased"],
        ["Fatty Liver", "Present", "Absent"],
        ["Serum Albumin", "Markedly decreased", "Normal or mildly decreased"],
        ["Skin/Hair Changes", "Present", "Absent"],
    ]
)

heading3("C. Gomez Classification (Weight-for-Age)")
add_table_2col(
    ["Grade", "Weight-for-Age (% Standard)", "Severity"],
    [
        ["Grade I", "75–90%", "Mild malnutrition"],
        ["Grade II", "60–75%", "Moderate malnutrition"],
        ["Grade III", "< 60%", "Severe malnutrition (with or without oedema)"],
    ]
)

heading3("D. Waterlow Classification (Height-Based)")
body("Waterlow proposed using stunting (height-for-age) to reflect chronic malnutrition and wasting (weight-for-height) to reflect acute malnutrition. This distinction is epidemiologically important: stunting indicates past chronic deprivation while wasting indicates current acute deficit.")

heading3("E. Mid-Upper Arm Circumference (MUAC) Classification")
add_table_2col(
    ["MUAC Value", "Nutritional Status"],
    [
        ["> 13.5 cm", "Satisfactory nutritional status"],
        ["12.5 – 13.5 cm", "Mild to moderate malnutrition"],
        ["< 12.5 cm", "Severe malnutrition"],
    ]
)
body("MUAC is a reliable field tool for assessing muscle mass reduction — one of the earliest adaptive responses to inadequate energy intake. It cannot be used before 12 months of age, but between ages 1 and 5 years it remains relatively constant in well-nourished children, making deviations highly meaningful.")

pagebreak()

# ════════════════════════════════════════════════════════════════
#  CHAPTER 3 — EPIDEMIOLOGY
# ════════════════════════════════════════════════════════════════
heading1("3. EPIDEMIOLOGY AND GLOBAL BURDEN")

body("Malnutrition is not uniformly distributed — it is overwhelmingly concentrated in sub-Saharan Africa, South Asia (particularly India, Bangladesh, Pakistan), Southeast Asia, and parts of Latin America. The convergence of poverty, food insecurity, infection burden, and inadequate healthcare access creates a 'malnutrition trap' in these regions.")

heading2("3.1 Global Statistics")
bullet("Approximately 50 million children worldwide are affected by severe acute malnutrition (Robbins & Kumar, 10e)")
bullet("Malnutrition underlies approximately 45% of deaths in children under five years of age globally")
bullet("27% of children in low-income countries have stunting (low height-for-age); 17% have wasting")
bullet("Between 2012–2024, low-income countries saw a 13.7% increase in stunted children under 5, while upper-middle-income countries saw a 37.3% reduction")
bullet("In refugee settings (e.g., Syrian refugee camps), 20% of children are severely or moderately malnourished")

heading2("3.2 Indian Epidemiology (Park's PSM)")
bullet("Severe PEM prevalence: 5–6% of children in survey populations")
bullet("Mild PEM: approximately 40% of children")
bullet("PEM is an underlying cause in ~30% of under-five deaths in India")
bullet("Mortality is highest between 12–24 months of age — the weaning period")
bullet("PEM is often associated with other deficiencies: vitamin A, iron, iodine, zinc")

heading2("3.3 Burden and Age Vulnerability")
body("The period of greatest nutritional vulnerability spans from the third trimester of pregnancy through the first two years of life (the 'First 1000 Days'). During this window, brain growth is at its peak, and the immune system is immature. Inadequate nutrition during this critical period has irreversible consequences on neurodevelopment, immune competence, and physical growth trajectory.")

body("The 12–24 month age group is particularly vulnerable because: (1) breast milk alone is no longer nutritionally adequate; (2) complementary feeding is often delayed or nutritionally poor; (3) frequency of infections peaks; and (4) physical activity increases caloric demands. Park's Textbook notes that mortality rates peak during this weaning period.")

pagebreak()

# ════════════════════════════════════════════════════════════════
#  CHAPTER 4 — AETIOLOGY
# ════════════════════════════════════════════════════════════════
heading1("4. AETIOLOGY AND RISK FACTORS")

heading2("4.1 Primary Causes (Dietary Inadequacy)")
body("Primary PEM arises from an insufficient intake of dietary protein and/or calories — without an underlying organic disease. It is the predominant form in developing countries.")
bullet("Early and abrupt cessation of breastfeeding")
bullet("Inadequate or nutritionally poor complementary foods (e.g., thin cereal gruels, watery porridges)")
bullet("Food insecurity and poverty — inability to afford nutritionally adequate diets")
bullet("Large family size — insufficient food distributed over many children")
bullet("Ignorance of appropriate child feeding practices")
bullet("Cultural taboos restricting protein-rich foods for children")
bullet("Agricultural failures, drought, famine, conflict")

heading2("4.2 Secondary Causes (Disease-Related)")
body("Secondary PEM occurs when an underlying condition impairs intake, absorption, or increases requirements.")
bullet("Infections: gastrointestinal infections (diarrhoea causing malabsorption and anorexia), measles, tuberculosis, HIV/AIDS — all increase catabolism and reduce appetite")
bullet("Malabsorption syndromes: coeliac disease, tropical sprue, inflammatory bowel disease")
bullet("Chronic illnesses: chronic kidney disease (protein losses), chronic liver disease, congenital heart disease")
bullet("Cancer and cachexia: pro-inflammatory cytokines (TNF-α, IL-1, IL-6) suppress appetite and drive catabolism")
bullet("Prematurity and low birth weight — increased requirements with poor reserves")
bullet("Surgical conditions: short bowel syndrome, post-operative catabolism")
bullet("Endocrine disorders: hyperthyroidism (increased metabolic demands)")

heading2("4.3 Social and Environmental Risk Factors")
body("PEM does not occur in isolation; it is deeply rooted in social determinants:")
bullet("Poverty and income inequality — the most fundamental determinant")
bullet("Maternal malnutrition and low birth weight — intergenerational cycle")
bullet("Low maternal education — inversely correlated with child nutritional status")
bullet("Poor sanitation and unsafe water — perpetuate infection-malnutrition cycle")
bullet("Inadequate health services — lack of growth monitoring and nutrition counselling")
bullet("Gender inequality — girls may receive less food in some cultures")
bullet("Political instability and conflict — disrupt food systems and health services")

pagebreak()

# ════════════════════════════════════════════════════════════════
#  CHAPTER 5 — PATHOPHYSIOLOGY
# ════════════════════════════════════════════════════════════════
heading1("5. PATHOPHYSIOLOGY")

heading2("5.1 Body Compartment Framework")
body("From a functional standpoint, the human body maintains two distinct protein compartments that are regulated differently in response to nutritional deprivation (Robbins & Kumar Basic Pathology, 10e):")
bullet("Somatic compartment: skeletal muscle proteins — catabolised preferentially in marasmus")
bullet("Visceral compartment: proteins in visceral organs, primarily the liver (albumin, transport proteins) — depleted more severely in kwashiorkor")
body("This differential depletion forms the mechanistic foundation for understanding why marasmus and kwashiorkor produce such different clinical pictures despite both being forms of PEM.")

heading2("5.2 Metabolic Adaptations in Marasmus (Energy-Deficient State)")
body("Marasmus develops when total caloric deprivation is the dominant deficit. The body enters a state of prolonged starvation and implements a series of adaptive metabolic responses:")

heading3("Phase 1: Glycogen Depletion (Hours)")
body("Hepatic glycogen stores are depleted within 12–24 hours of fasting. Blood glucose falls, triggering a fall in insulin and a rise in glucagon — the key hormonal switch initiating catabolism.")

heading3("Phase 2: Lipolysis (Days to Weeks)")
body("Adipose tissue is mobilised via hormone-sensitive lipase activated by catecholamines and cortisol. Free fatty acids are released into circulation, providing fuel for muscle and other tissues. Ketone bodies (acetoacetate, β-hydroxybutyrate) are generated in the liver from acetyl-CoA and serve as an alternative fuel for the brain, reducing its dependence on glucose. Leptin production falls, which may stimulate the hypothalamic-pituitary-adrenal (HPA) axis to increase cortisol, further driving lipolysis.")

heading3("Phase 3: Protein Catabolism (Sustained Starvation)")
body("When fat stores are exhausted, skeletal muscle protein is catabolised for gluconeogenesis. This generates a negative nitrogen balance. The somatic protein compartment is severely depleted. Because caloric restriction also suppresses insulin levels, lipolysis and proteolysis both continue. Critically, the visceral protein compartment (albumin) is relatively preserved through multiple adaptive mechanisms — hence serum albumin levels are normal or only slightly reduced in pure marasmus.")

heading3("Hormonal Profile in Marasmus")
body("Cortisol: elevated — drives lipolysis, gluconeogenesis, and muscle catabolism. Insulin: low — permitting lipolysis and gluconeogenesis. IGF-1: decreased — growth arrest. T3: decreased — reduced metabolic rate (adaptive). Growth hormone: elevated but IGF-1 is low (growth hormone resistance).")

heading2("5.3 Pathophysiology of Kwashiorkor (Protein-Deficient State)")
body("Kwashiorkor represents a paradoxical state where energy intake from carbohydrates may be relatively adequate, but protein intake is profoundly deficient. The classic example is a child weaned early onto a starchy, carbohydrate-rich diet (e.g., plantains, cassava, maize porridge).")

heading3("Role of Insulin in Kwashiorkor")
body("Adequate carbohydrate intake maintains insulin levels. Insulin suppresses lipolysis and proteolysis (including somatic muscle catabolism). However, insulin does not prevent the reduction in hepatic protein synthesis caused by amino acid deficiency. This is why subcutaneous fat and muscle mass are relatively spared in kwashiorkor (partly masked by oedema) — Lippincott's Biochemistry describes kwashiorkor as 'nonadapted malnutrition' because of this failure to adapt proteolysis in the face of amino acid depletion.")

heading3("Hypoalbuminaemia and Oedema")
body("The liver requires adequate amino acids (especially essential amino acids: leucine, isoleucine, valine, lysine, threonine) to synthesise proteins. In kwashiorkor, the visceral protein compartment is severely depleted. Serum albumin falls markedly (often below 2.5 g/dL, sometimes < 1.5 g/dL). Albumin is the principal determinant of plasma oncotic pressure. When oncotic pressure falls, the Starling forces are disrupted: hydrostatic pressure exceeds oncotic pressure at the capillary level, and fluid moves into the interstitium, causing oedema.")

heading3("Fatty Liver")
body("Hepatic fat accumulation in kwashiorkor results from impaired synthesis of the apolipoprotein component of VLDL (Very Low Density Lipoprotein). Adequate amounts of apolipoprotein B-100 are required to package triglycerides into VLDL particles for export from the liver. Amino acid deficiency impairs apolipoprotein synthesis → VLDL export is blocked → triglycerides accumulate in hepatocytes → fatty liver (hepatic steatosis). This is morphologically evident as macrovesicular steatosis. Unlike alcoholic hepatitis, cirrhosis is rare in kwashiorkor.")

heading3("Free Radical Hypothesis")
body("An important additional mechanism postulated for kwashiorkor involves oxidative stress. Aflatoxin exposure, infections, and micronutrient deficiencies (especially selenium, zinc, vitamin E, and vitamin C) impair antioxidant defences. Free radical-mediated membrane damage may contribute to the skin lesions, intestinal mucosal damage, and hepatocellular injury seen in kwashiorkor. This theory, known as the 'free radical hypothesis of kwashiorkor,' may explain why some children develop kwashiorkor on seemingly adequate caloric diets.")

heading2("5.4 Gut Microbiome and PEM")
body("Recent studies (cited in Robbins & Kumar Basic Pathology, 10e) demonstrate substantial differences between the gut microbiome of children with SAM and that of properly nourished children. Critically, alterations in the gut microbiome appear to play a causative role — not merely a consequential one — in the pathogenesis of SAM. Dysbiosis may impair nutrient absorption, worsen intestinal inflammation, and perpetuate the infection-malnutrition cycle.")

heading2("5.5 Immune Dysfunction")
body("PEM profoundly impairs immunity, particularly T cell-mediated (cellular) immunity. The thymus and lymphoid organs undergo significant atrophy, particularly in kwashiorkor. Functional consequences include:")
bullet("Reduced lymphocyte count and impaired T cell proliferative responses")
bullet("Decreased secretory IgA — impaired mucosal immunity")
bullet("Reduced complement function — impaired opsonisation")
bullet("Impaired phagocytic activity of neutrophils and macrophages")
bullet("Blunted fever response (hypothermia may mask infection)")
body("This immune compromise results in increased susceptibility to infections (particularly respiratory infections, measles, tuberculosis, and gastrointestinal infections), and these infections in turn worsen malnutrition — creating a vicious cycle.")

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# ════════════════════════════════════════════════════════════════
#  CHAPTER 6 — SIGNS AND SYMPTOMS WITH JUSTIFICATION
# ════════════════════════════════════════════════════════════════
heading1("6. CLINICAL MANIFESTATIONS — SIGNS AND SYMPTOMS WITH JUSTIFICATION")

body("The following section systematically details every cardinal and associated sign of PEM with a mechanistic justification for each. Understanding the 'why' behind each sign transforms clinical observation from rote memorisation into applied pathophysiology.")

heading2("6.1 Marasmus — Detailed Signs and Justification")

heading3("(A) Severe Wasting and Emaciation")
mixed([
    ("Sign: ", True, False),
    ("Generalised loss of muscle mass and subcutaneous fat. Extremities are emaciated; the skin hangs in loose folds ('baggy pants' sign). Ribs are visibly prominent.", False, False)
])
mixed([
    ("Justification: ", True, False),
    ("Sustained caloric deficit leads to exhaustion of glycogen stores, then lipolysis of adipose tissue, and finally proteolysis of somatic muscle proteins for gluconeogenesis. Both the somatic protein and fat compartments are severely depleted. The relative preservation of the visceral compartment (albumin synthesis) compared to somatic proteins is why serum albumin remains near normal in marasmus. (Robbins & Kumar Basic Pathology, 10e)", False, True)
])

heading3("(B) 'Old Man' or 'Monkey Face' Appearance")
mixed([("Sign: ", True, False), ("The face appears wizened and aged, with buccal (temporal) fat pad wasting, sunken eyes, and prominent skull. The head appears disproportionately large relative to the emaciated body.", False, False)])
mixed([("Justification: ", True, False), ("Buccal fat pads (Bichat's fat pads) are among the last adipose deposits to be mobilised in normal starvation; their loss in marasmus indicates extreme, prolonged fat depletion. Temporal muscle wasting further accentuates the sunken appearance. The brain and skull continue to grow normally (nervous system is relatively protected from early depletion), creating the appearance of a large head on an emaciated body.", False, True)])

heading3("(C) Growth Retardation and Weight Loss")
mixed([("Sign: ", True, False), ("Arrested linear growth (stunting) and severe weight loss. Weight-for-age is < 60% of expected. Height-for-age is reduced (stunting). Mid-upper arm circumference < 12.5 cm.", False, False)])
mixed([("Justification: ", True, False), ("Growth requires adequate protein for cell proliferation and structural proteins, and adequate energy for anabolic processes. In marasmus, IGF-1 falls markedly due to growth hormone resistance induced by low insulin and amino acid deficiency. Reduced IGF-1 impairs long bone growth (epiphyseal plate activity is suppressed). Chronic deficiency produces stunting (irreversible if prolonged); acute deficiency causes wasting (potentially reversible).", False, True)])

heading3("(D) Muscle Wasting")
mixed([("Sign: ", True, False), ("Loss of bulk in temporal, deltoid, quadriceps, and gluteal muscles. Reduced handgrip strength. The child is weak and hypotonic.", False, False)])
mixed([("Justification: ", True, False), ("Elevated cortisol and glucagon levels drive muscle protein catabolism via the ubiquitin-proteasome pathway and lysosomal autophagy. Amino acids from skeletal muscle are released into circulation and used by the liver for gluconeogenesis (alanine-glucose cycle) to maintain blood glucose. Insulin-like growth factor-1 (IGF-1) deficiency removes the principal anabolic stimulus for muscle synthesis.", False, True)])

heading3("(E) Skin Changes in Marasmus")
mixed([("Sign: ", True, False), ("Dry, wrinkled skin with loss of turgor. Skin hangs in folds. No frank dermatosis (unlike kwashiorkor). Reduced skin turgor on pinch test.", False, False)])
mixed([("Justification: ", True, False), ("Loss of subcutaneous fat removes the structural support beneath the dermis, causing skin to hang in folds. Dehydration reduces skin turgor. Absence of the characteristic 'flaky paint' dermatosis of kwashiorkor is because insulin levels are low in marasmus, preventing the metabolic alterations that drive skin desquamation in kwashiorkor.", False, True)])

heading3("(F) Hair Changes in Marasmus")
mixed([("Sign: ", True, False), ("Sparse, thin, dry hair. Hair may be easily plucked (Flag sign may be absent or mild).", False, False)])
mixed([("Justification: ", True, False), ("Hair follicle cells are among the most rapidly dividing cells in the body and are highly sensitive to nutritional deprivation. Protein deficiency reduces keratin synthesis, producing thin, brittle hair. Reduced thyroid hormone (T3) from adaptive hypothyroidism contributes to hair loss and dryness.", False, True)])

heading3("(G) Irritability and Apathy")
mixed([("Sign: ", True, False), ("Alternating periods of irritability (when disturbed) and apathy (at rest). Reduced social interaction.", False, False)])
mixed([("Justification: ", True, False), ("Hypoglycaemia impairs cerebral glucose supply, causing neuroglycopenic symptoms including irritability. Reduced neurotransmitter synthesis (serotonin, dopamine) due to amino acid deficiency (tryptophan, tyrosine) contributes to behavioural changes. Weakness and fatigue limit responsiveness.", False, True)])

heading3("(H) Anaemia")
mixed([("Sign: ", True, False), ("Pallor of conjunctivae, palms, and mucous membranes. Usually microcytic-hypochromic (iron deficiency). Mixed picture possible (concurrent folate deficiency may produce macrocytosis).", False, False)])
mixed([("Justification: ", True, False), ("Bone marrow in both marasmus and kwashiorkor shows hypoplasia with reduced red cell precursors. Iron deficiency results from inadequate dietary iron (staple diets poor in haem iron). Concurrent folate deficiency may produce a mixed microcytic-macrocytic picture. Reduced EPO responsiveness due to chronic inflammation compounds anaemia. (Robbins & Kumar Basic Pathology, 10e)", False, True)])

heading3("(I) Hypothermia")
mixed([("Sign: ", True, False), ("Subnormal body temperature (< 36.5°C). Cold extremities.", False, False)])
mixed([("Justification: ", True, False), ("Reduced subcutaneous fat insulation leads to increased heat loss. Adaptive reduction in thyroid hormone (T3) decreases basal metabolic rate and heat production — a critical energy-conserving adaptation. Simultaneously, this hypothyroidism can mask underlying infection (blunted febrile response), making fever an unreliable sign in malnourished children.", False, True)])

heading3("(J) Bradycardia and Hypotension")
mixed([("Sign: ", True, False), ("Reduced pulse rate (bradycardia) and low blood pressure.", False, False)])
mixed([("Justification: ", True, False), ("Reduced metabolic demands and adaptive down-regulation of the sympathetic nervous system reduce cardiac output. Depletion of myocardial protein affects cardiac muscle mass and contractility. Reduced circulating volume (dehydration) contributes to hypotension.", False, True)])

heading3("(K) Immune Deficiency and Susceptibility to Infections")
mixed([("Sign: ", True, False), ("Recurrent and severe infections — respiratory, gastrointestinal, measles, tuberculosis. Infections often atypical and severe.", False, False)])
mixed([("Justification: ", True, False), ("T cell-mediated immunity is predominantly impaired. Thymic atrophy reduces T lymphocyte production and maturation. Reduced complement synthesis (visceral proteins) impairs opsonisation. Secretory IgA is reduced, compromising mucosal defences. The blunted fever response means that life-threatening infections may be afebrile, delaying recognition and treatment.", False, True)])

heading2("6.2 Kwashiorkor — Detailed Signs and Justification")

heading3("(A) Bilateral Pitting Oedema")
mixed([("Sign: ", True, False), ("Oedema is the cardinal and defining feature of kwashiorkor. It begins peripherally (dorsum of feet, ankles, legs) and can extend to become generalised (anasarca). It is bilateral and pitting. Facial puffiness ('moon face') is characteristic.", False, False)])
mixed([("Justification: ", True, False), ("Serum albumin falls markedly (visceral protein compartment is severely depleted due to inadequate amino acid supply for hepatic synthesis). Albumin provides 60–80% of plasma oncotic pressure. When albumin falls below approximately 2.5 g/dL, plasma oncotic pressure is insufficient to counteract capillary hydrostatic pressure. Starling forces become disrupted: net filtration exceeds reabsorption → fluid moves into the interstitium → oedema. Weight may appear near-normal (60–80% of expected) because the fluid gain masks underlying tissue loss — this 'masked wasting' is a critical diagnostic trap. (Lippincott's Biochemistry, 8e; Robbins & Kumar Basic Pathology, 10e)", False, True)])

heading3("(B) Hepatomegaly and Fatty Liver")
mixed([("Sign: ", True, False), ("Enlarged, palpable, and firm liver. Not tender in most cases. Jaundice is rare. Liver biopsy or ultrasound reveals macrovesicular steatosis.", False, False)])
mixed([("Justification: ", True, False), ("The liver requires apolipoprotein B-100 (apoB-100) to assemble VLDL particles for exporting triglycerides. ApoB-100 synthesis is severely impaired by amino acid deficiency. Without adequate apoB-100, triglycerides accumulate within hepatocytes (macrovesicular steatosis). Concurrently, increased mobilisation of peripheral fat (despite insulin levels being relatively maintained) delivers increased free fatty acids to the liver. The combination of excess fat delivery and impaired export drives progressive hepatic steatosis. Cirrhosis is rare because the steatosis is functional rather than necro-inflammatory.", False, True)])

heading3("(C) 'Flaky Paint' or 'Crazy Paving' Dermatosis")
mixed([("Sign: ", True, False), ("Characteristic skin lesions with alternating zones of hyperpigmentation, desquamation, and hypopigmentation — described as 'flaky paint' or 'enamel paint' dermatosis. Most prominent in areas of friction and pressure (perineum, buttocks, inner thighs).", False, False)])
mixed([("Justification: ", True, False), ("The skin changes result from multiple interacting factors: (1) Protein deficiency impairs epidermal cell turnover and keratin synthesis. (2) Micronutrient deficiencies — particularly zinc, niacin (B3), riboflavin (B2), and essential fatty acids — cause specific dermatoses. (3) Oxidative stress from free radical damage causes lipid peroxidation of epidermal membranes. (4) Relative insulin excess (from carbohydrate feeding) may contribute to abnormal keratinisation. Skin biopsy characteristically shows epidermal pallor and dyskeratosis. (Dermatology 2-Volume Set, 5e; DermNet NZ)", False, True)])

heading3("(D) Hair Changes — Depigmentation, Flag Sign, Easy Pluckability")
mixed([("Sign: ", True, False), ("Hair loses its natural colour, becoming reddish, brownish, or blonde (leucotrichia/dyschromia). The 'Flag sign' (Bandera sign) refers to alternating bands of pale (malnourished) and darker (recovery) hair along the shaft, indicating alternating periods of malnutrition and adequate feeding. Hair becomes straight, fine-textured, silky, and easily plucked with minimal pain.", False, False)])
mixed([("Justification: ", True, False), ("Hair pigmentation depends on melanin production by melanocytes, a process requiring the amino acid tyrosine and copper-dependent tyrosinase enzyme. Protein and micronutrient deficiency impairs melanin synthesis → depigmentation. Easy pluckability reflects protein deficiency in the hair matrix and the inner root sheath, which loses its firm attachment to the follicle. The alternating bands (flag sign) record the nutritional history chronologically — each band represents the hair growth rate (~1 cm/month), analogous to growth arrest lines in bone.", False, True)])

heading3("(E) 'Moon Face' (Facies Lunaris)")
mixed([("Sign: ", True, False), ("Round, puffy appearance of the face due to facial oedema and parotid enlargement.", False, False)])
mixed([("Justification: ", True, False), ("Facial oedema results from the same hypoalbuminaemia-driven fluid shift that causes peripheral oedema. Parotid gland enlargement may result from increased salivary secretion stimulated by starchy diets, or from protein-energy imbalances affecting glandular tissue. Unlike in marasmus where buccal fat loss creates a sunken face, the oedematous face of kwashiorkor creates the contrasting 'moon face' appearance.", False, True)])

heading3("(F) Growth Retardation and Stunting")
mixed([("Sign: ", True, False), ("Height-for-age below 2 SD of reference median (stunting). Weight-for-age typically 60–80% of expected.", False, False)])
mixed([("Justification: ", True, False), ("IGF-1 is reduced in kwashiorkor due to amino acid deficiency impairing hepatic IGF-1 synthesis — despite growth hormone levels being elevated (GH resistance). IGF-1 is the principal mediator of linear bone growth at the epiphyseal plate. Without IGF-1, chondrocyte proliferation at the growth plate is arrested. Prolonged kwashiorkor results in irreversible stunting. Weight may appear near-normal due to oedema masking tissue loss.", False, True)])

heading3("(G) Psychomotor Changes — Apathy, Misery, Anorexia")
mixed([("Sign: ", True, False), ("The child with kwashiorkor is typically described as apathetic, miserable, unhappy, and anorexic — contrasting with the alert but irritable child of marasmus. Loss of appetite is a prominent and clinically important feature.", False, False)])
mixed([("Justification: ", True, False), ("Serotonin synthesis requires tryptophan (an essential amino acid severely deficient in kwashiorkor diets). Tryptophan deficiency reduces central serotonin — producing depression, apathy, and reduced emotional responsiveness. Dopaminergic signalling is also impaired. Hepatic dysfunction from fatty liver may produce subclinical hepatic encephalopathy, contributing to mental dullness. Anorexia is partly driven by cytokines (IL-1, TNF-α) from concomitant infections, and partly by central hypothalamic dysregulation.", False, True)])

heading3("(H) Anaemia (More Severe than Marasmus)")
mixed([("Sign: ", True, False), ("More pronounced pallor. Mixed-picture anaemia. Bone marrow shows hypoplasia with reduced red cell precursors.", False, False)])
mixed([("Justification: ", True, False), ("In addition to mechanisms shared with marasmus (iron deficiency, folate deficiency, marrow hypoplasia), kwashiorkor produces more severe visceral protein depletion, reducing transferrin synthesis (transport protein for iron) and ceruloplasmin (copper transport protein needed for iron mobilisation from stores). Additionally, haemolysis may occur due to glutathione deficiency (requires glycine and cysteine synthesis, both impaired).", False, True)])

heading3("(I) Infections and Immune Compromise")
mixed([("Sign: ", True, False), ("Severe, often fatal infections. Thymus and lymph nodes are markedly atrophied (more than in marasmus).", False, False)])
mixed([("Justification: ", True, False), ("Lymphoid atrophy is more severe in kwashiorkor than marasmus. Complement proteins (C3, C4, Factor B) are synthesised in the liver — their synthesis is severely impaired. Zinc deficiency (common in kwashiorkor) critically impairs T-lymphocyte maturation, as zinc is required for thymulin (thymic hormone) activity. Secretory IgA production is impaired, leaving mucosal surfaces vulnerable. The combination of blunted fever, impaired opsonisation, and reduced T-cell function makes infections rapidly fatal.", False, True)])

heading3("(J) Gastrointestinal Changes")
mixed([("Sign: ", True, False), ("Diarrhoea (often chronic), lactose intolerance, abdominal distension.", False, False)])
mixed([("Justification: ", True, False), ("The small bowel in kwashiorkor shows decreased mitotic index in the crypts of the glands, mucosal atrophy, and loss of villi and microvilli (Robbins & Kumar Basic Pathology, 10e). This villous atrophy reduces the absorptive surface area, impairing nutrient absorption and creating a vicious cycle. Disaccharidase deficiency (especially lactase) results from loss of brush border enzymes on the mucosal surface, producing lactose intolerance — clinically important because initial treatment with milk-based formulas may worsen diarrhoea. Oedema of the bowel wall contributes to abdominal distension.", False, True)])

heading2("6.3 Marasmic-Kwashiorkor (Mixed Form)")
body("Marasmic-kwashiorkor occurs when a child with pre-existing marasmus subsequently experiences a relative increase in carbohydrate intake (or a protein-poor diet), triggering the kwashiorkor overlay. Features include the severe wasting and emaciation of marasmus combined with the oedema, skin changes, and fatty liver of kwashiorkor. This is the most severe form of PEM, carrying the highest mortality. The apparently 'adequate' weight from oedema masks profound somatic wasting.")

heading2("6.4 Comparative Summary Table")
add_table_2col(
    ["Clinical Feature", "Marasmus", "Kwashiorkor"],
    [
        ["Weight for age", "< 60%", "60–80% (masked by oedema)"],
        ["Oedema", "Absent", "Present — bilateral pitting"],
        ["Wasting/emaciation", "Severe ('skin and bones')", "Moderate (masked by oedema)"],
        ["Subcutaneous fat", "Markedly depleted", "Relatively spared (masked)"],
        ["Muscle mass", "Severely depleted", "Moderately depleted"],
        ["Serum albumin", "Normal to mildly reduced", "Markedly reduced (< 2.5 g/dL)"],
        ["Fatty liver", "Absent", "Present (macrovesicular steatosis)"],
        ["Skin changes", "Dry, wrinkled, skin folds", "Flaky paint / crazy paving dermatosis"],
        ["Hair changes", "Sparse, thin, dry", "Dyschromia, flag sign, easy pluckability"],
        ["Face", "Wizened / old man face", "Moon face (oedema)"],
        ["Behaviour", "Alert but irritable", "Apathetic, miserable"],
        ["Anorexia", "Usually hungry", "Prominent anorexia"],
        ["Anaemia", "Mild-moderate", "Moderate-severe"],
        ["Immune deficiency", "Present", "More severe"],
        ["GI changes", "Less prominent", "Villous atrophy, lactose intolerance"],
    ]
)

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# ════════════════════════════════════════════════════════════════
#  CHAPTER 7 — INVESTIGATIONS
# ════════════════════════════════════════════════════════════════
heading1("7. INVESTIGATIONS AND DIAGNOSIS")

heading2("7.1 Anthropometric Assessment (Primary)")
bullet("Weight-for-height (WHZ): < -3 SD = severe acute malnutrition")
bullet("Height-for-age (HAZ): < -2 SD = stunting")
bullet("Mid-Upper Arm Circumference (MUAC): < 12.5 cm = SAM in children 6–59 months")
bullet("Weight-for-age (Gomez classification): < 60% = severe malnutrition")
bullet("Skinfold thickness (triceps, subscapular): reduced in fat depletion")

heading2("7.2 Biochemical Investigations")
add_table_2col(
    ["Investigation", "Expected Finding", "Significance"],
    [
        ["Serum albumin", "Markedly low in kwashiorkor (< 2.5 g/dL); near normal in marasmus", "Visceral protein depletion marker"],
        ["Serum transferrin", "Reduced", "Hepatic protein synthesis marker"],
        ["Serum pre-albumin (transthyretin)", "Reduced — earliest sensitive marker", "Short half-life (2 days) — responds quickly to treatment"],
        ["Full blood count", "Normocytic/microcytic anaemia; lymphopenia", "Nutritional anaemia, immune status"],
        ["Serum iron & ferritin", "Low — iron deficiency", "Most common associated micronutrient deficiency"],
        ["Serum zinc, copper, selenium", "Reduced", "Micronutrient deficiencies"],
        ["Liver function tests", "Elevated transaminases, low albumin, elevated ALP in kwashiorkor", "Hepatic steatosis assessment"],
        ["Blood glucose", "Hypoglycaemia (< 3 mmol/L) especially at night", "Risk of fatal hypoglycaemic coma"],
        ["Electrolytes (Na, K, Mg, PO4)", "Hyponatraemia, hypokalaemia, hypomagnesaemia, hypophosphataemia", "Critical in refeeding risk assessment"],
        ["C-reactive protein (CRP)", "Elevated if concurrent infection", "Infection detection — essential before interpreting albumin"],
        ["Urine analysis", "Increased creatinine-height index = muscle depletion", "Somatic muscle mass assessment"],
        ["Thyroid function (T3, T4, TSH)", "Low T3 (adaptive hypothyroidism)", "Metabolic adaptation"],
    ]
)

heading2("7.3 Other Investigations")
bullet("Stool examination: parasites, especially Giardia, Ascaris — perpetuate malabsorption")
bullet("Blood culture and sensitivity: identify occult sepsis (may be afebrile)")
bullet("Chest X-ray: assess for tuberculosis or pneumonia")
bullet("Urinalysis and urine culture: urinary tract infection (common, often silent)")
bullet("Abdominal ultrasound: assess hepatomegaly, ascites, fatty liver")
bullet("Bone age (wrist X-ray): assess degree of growth retardation")
bullet("Skin biopsy: in kwashiorkor with severe dermatosis — shows epidermal pallor")

heading2("7.4 Diagnostic Criteria (Academy of Nutrition and Dietetics / ASPEN)")
body("For adults, the Academy of Nutrition and Dietetics and ASPEN recommend diagnosing PEM when at least 2 of 6 criteria are present: (1) insufficient energy intake; (2) significant weight loss; (3) loss of muscle mass; (4) loss of subcutaneous fat; (5) fluid accumulation unrelated to hypervolaemia; and (6) reduced handgrip strength.")

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# ════════════════════════════════════════════════════════════════
#  CHAPTER 8 — MANAGEMENT
# ════════════════════════════════════════════════════════════════
heading1("8. CLINICAL MANAGEMENT")

heading2("8.1 WHO Three-Stage Approach")
body("The WHO has published a comprehensive three-phase treatment protocol for severe acute malnutrition. The phases must be followed sequentially and the transition must be carefully timed based on the child's clinical response. Rushing through phases, particularly Phase 1, significantly increases mortality — including from refeeding syndrome.")

heading2("8.2 Stage 1 — Stabilisation Phase (Days 1–7)")
body("The goal of the stabilisation phase is to treat life-threatening complications, not to achieve weight gain. Attempting aggressive nutritional rehabilitation at this stage is dangerous.")

heading3("A. Hypoglycaemia Management (First Priority)")
bullet("Screen all malnourished children: blood glucose < 3 mmol/L (54 mg/dL) = hypoglycaemia")
bullet("If conscious and able to feed: give 10% glucose or sucrose solution orally (50 mL bolus)")
bullet("If unconscious or unable to feed: IV 10% dextrose (5 mL/kg) followed by 10% glucose via NGT")
bullet("Prevent recurrence: feed 2-hourly day and night")
bullet("Justification: Hypoglycaemic coma is a leading cause of death in the first 24–48 hours. Glycogen stores are depleted; gluconeogenic capacity is impaired. Regular feeding prevents fatal neuroglycopenia.")

heading3("B. Hypothermia Management")
bullet("Warm the child: skin-to-skin contact (Kangaroo Mother Care), warm blankets, avoid draughts")
bullet("Monitor temperature 2-hourly. Target core temperature > 36.5°C")
bullet("Feed frequently — metabolic activity from feeding generates heat")
bullet("Justification: Reduced subcutaneous fat insulation and adaptive hypothyroidism impair thermoregulation. Hypothermia precipitates cardiac arrhythmias and worsens metabolic acidosis.")

heading3("C. Dehydration and Electrolyte Correction")
bullet("Do NOT use standard ORS (WHO-ORS) — it contains too much sodium and insufficient potassium/magnesium for SAM")
bullet("Use ReSoMal (Rehydration Solution for Malnutrition): lower sodium (45 mmol/L vs 90 mmol/L), higher potassium and magnesium")
bullet("Rate: 5 mL/kg every 30 minutes for 2 hours, then 5–10 mL/kg/hour for next 4–10 hours")
bullet("IV rehydration only for shock with deteriorating consciousness — use with extreme caution (risk of fluid overload and cardiac failure)")
bullet("Justification: Total body sodium is elevated in SAM (intracellular), but serum sodium may be low (dilutional hyponatraemia). Potassium and magnesium are depleted intracellularly. Sodium loading worsens intracellular Na-K imbalance and precipitates cardiac failure. ReSoMal composition is physiologically matched to the metabolic state of SAM.")

heading3("D. Electrolyte Supplementation")
bullet("Potassium: 3–4 mmol/kg/day")
bullet("Magnesium: 0.4–0.6 mmol/kg/day")
bullet("Zinc: 2 mg/kg/day")
bullet("Copper: 0.3 mg/kg/day")
bullet("Note: Do NOT give iron in Phase 1 — free iron worsens oxidative stress and infection")

heading3("E. Infection Treatment")
bullet("All malnourished children should be treated with broad-spectrum antibiotics even if no signs of infection — infection may be clinically occult (afebrile)")
bullet("Cotrimoxazole (if not severely ill) OR Amoxicillin 40 mg/kg/day for 5 days")
bullet("Severe illness or complications: Ampicillin + Gentamicin IV")
bullet("Treat TB if suspected; treat Giardia with metronidazole; treat intestinal helminths")
bullet("Justification: The blunted febrile response due to reduced cytokine production and adaptive hypothyroidism means infection may be entirely afebrile. Untreated occult sepsis rapidly progresses to septicaemia and death. The dictum in SAM management is to treat all children empirically.")

heading3("F. Micronutrient Supplementation (Phase 1)")
bullet("Vitamin A (on Day 1 only): 50,000 IU if < 6 months; 100,000 IU if 6–12 months; 200,000 IU if > 12 months")
bullet("Folic acid: 5 mg Day 1, then 1 mg/day")
bullet("Multivitamin supplement (without iron)")
bullet("Do NOT give iron until Phase 2")

heading3("G. Nutritional Support in Phase 1 — F-75 Formula")
bullet("F-75 (75 kcal/100 mL, 0.9 g protein/100 mL) is the initial therapeutic milk formula")
bullet("Designed to meet basal metabolic requirements without overloading compromised systems")
bullet("Start at 100 mL/kg/day, divided into 8–12 feeds (2–3 hourly)")
bullet("Feed by NGT if unable to take orally")
bullet("Never give F-100 in Phase 1 — its higher energy content can precipitate cardiac failure and refeeding syndrome")

heading2("8.3 Stage 2 — Rehabilitation Phase (Weeks 2–6)")
body("Transition to rehabilitation phase occurs when: appetite returns (key indicator), infections resolve, oedema is reducing, and alertness improves. This is signalled by a positive response to the appetite test (child readily eats Ready-to-Use Therapeutic Food/RUTF).")

heading3("A. Nutritional Rehabilitation")
bullet("Transition from F-75 to F-100 (100 kcal/100 mL, 2.9 g protein/100 mL) or RUTF (Ready-to-Use Therapeutic Food — Plumpy'Nut type, peanut-based)")
bullet("RUTF provides 500 kcal per 92g sachet; target 150–220 kcal/kg/day")
bullet("High-protein diet promotes lean mass restoration (target 4–5 g protein/kg/day)")
bullet("Now introduce IRON supplementation: 3 mg elemental iron/kg/day for 3 months")
bullet("Continue potassium, magnesium, zinc, copper, multivitamins")

heading3("B. Sensory Stimulation and Emotional Support")
bullet("Structured play, sensory stimulation sessions for 15–30 minutes daily")
bullet("Loving, stimulating environment — reduces stress hormones (cortisol) that drive catabolism")
bullet("Psychological recovery parallels nutritional recovery — essential for full rehabilitation")
bullet("Teach mother/caregiver appropriate feeding techniques and food preparation")

heading3("C. Expected Rate of Recovery")
bullet("Weight gain of 10–20 g/kg/day in rehabilitation phase indicates satisfactory recovery")
bullet("Oedema should resolve; skin and hair changes improve")
bullet("Target: weight-for-height ≥ -1 SD before discharge")

heading2("8.4 Stage 3 — Follow-up and Community Reintegration")
bullet("Monthly weight monitoring for 6 months after discharge")
bullet("Continue micronutrient supplementation at home")
bullet("Provide nutritional counselling to caregivers — appropriate weaning foods, feeding frequency, hygiene")
bullet("Link to social protection programs (food supplementation, conditional cash transfers)")
bullet("Immunisations — catch up on missed vaccines once nutritionally stable (immune system recovering)")
bullet("Deworming every 3–6 months")
bullet("Growth chart maintenance — community health worker and ASHA involvement")

heading2("8.5 Refeeding Syndrome — Mechanism and Prevention")
body("Refeeding syndrome is a potentially fatal metabolic complication occurring when nutrition is reintroduced too rapidly after prolonged starvation. It is the principal reason why Phase 1 of SAM management uses the low-energy F-75 formula rather than immediately providing high-calorie nutrition.")

heading3("Mechanism")
body("During prolonged starvation, intracellular phosphate, potassium, and magnesium stores are severely depleted, although serum levels may appear normal. When carbohydrates are reintroduced, insulin secretion surges. Insulin drives glucose, phosphate, potassium, and magnesium from the extracellular into the intracellular compartment. This produces:")
bullet("Hypophosphataemia — impairs ATP synthesis, causing cardiac dysfunction, respiratory muscle failure, haemolysis")
bullet("Hypokalaemia — cardiac arrhythmias (QT prolongation, ventricular fibrillation)")
bullet("Hypomagnesaemia — cardiac arrhythmias, seizures, tetany")
bullet("Thiamine deficiency unmasked — glucose loading without thiamine causes Wernicke's encephalopathy")
bullet("Fluid retention — oedema, congestive cardiac failure")

heading3("Prevention")
bullet("Start with F-75 (low energy) in Phase 1; transition to F-100/RUTF only when appetite returns")
bullet("Supplement potassium, magnesium, phosphate before and during refeeding")
bullet("Supplement thiamine BEFORE any glucose administration in prolonged starvation")
bullet("Monitor electrolytes closely during first week of refeeding")
bullet("Avoid IV glucose loading")

pagebreak()

# ════════════════════════════════════════════════════════════════
#  CHAPTER 9 — PREVENTIVE AND SOCIAL MEDICINE
# ════════════════════════════════════════════════════════════════
heading1("9. PREVENTIVE AND SOCIAL MEDICINE APPROACH")

body("PEM is fundamentally a preventable condition. The preventive approach operates at multiple levels of the public health spectrum — from societal structural changes to individual dietary interventions. The following uses the classic framework of primordial, primary, secondary, and tertiary prevention, supplemented by the social determinants of health approach advocated by WHO Commission on Social Determinants of Health (CSDH).")

heading2("9.1 Primordial Prevention — Addressing Root Causes")
body("Primordial prevention targets the social, economic, and environmental conditions that create susceptibility to malnutrition before individual risk factors emerge.")
bullet("Poverty reduction policies: land reform, minimum wage legislation, social protection programmes (conditional cash transfers like MNREGA, PM-KISAN)")
bullet("Gender equity: girls' education reduces future maternal malnutrition and improves infant feeding practices (each additional year of maternal schooling reduces child malnutrition by ~8%)")
bullet("Agricultural policy: crop diversification, promotion of protein-rich crops (legumes, pulses), fortification of staple foods")
bullet("Safe water and sanitation: breaking the infection-malnutrition cycle (WASH — Water, Sanitation, Hygiene programmes)")
bullet("Political stability and food system security: ensuring continuous food access even during shocks")

heading2("9.2 Primary Prevention — FAO/WHO Recommended Strategies (Park's PSM, 8th FAO/WHO Expert Committee)")

heading3("(a) Health Promotion")
body("(Adapted from Park's Textbook of Preventive and Social Medicine, 8th FAO/WHO Expert Committee on Nutrition):")
bullet("1. Measures directed to pregnant and lactating women: nutrition education, distribution of supplements (IFA, calcium, protein-energy supplements for undernourished pregnant women)")
bullet("2. Promotion of exclusive breastfeeding for 6 months: breast milk provides complete nutrition, passive immunity (secretory IgA), and perfect protein quality; protects against infections that precipitate PEM")
bullet("3. Development of low-cost weaning foods: complementary foods should start at 6 months — nutritionally dense, locally available (e.g., fortified cereal-pulse mixes). Child should be fed more frequently at shorter intervals")
bullet("4. Measures to improve family diet: increase household food diversity; promote cultivation of vegetables and legumes in kitchen gardens")
bullet("5. Nutrition education and promotion of correct feeding practices: address myths (e.g., withholding protein foods during illness); counsel on age-appropriate portion sizes and feeding frequency")
bullet("6. Home economics training: food storage, preparation, hygiene practices to reduce waste and contamination")
bullet("7. Family planning and spacing of births: birth spacing of at least 2 years prevents maternal depletion syndrome and allows each child adequate breastfeeding")
bullet("8. Improving family environment: reduce household poverty, overcrowding, and stress — which impair feeding practices")

heading3("(b) Specific Protection")
bullet("Child's diet must contain protein-rich and energy-dense foods: milk, eggs, legumes, fish, poultry — even small amounts daily provide essential amino acids")
bullet("Immunisation against measles, pertussis, diphtheria, tetanus, polio — infections that precipitate PEM by increasing catabolism, anorexia, and nutrient losses")
bullet("Food fortification: iron fortification of rice/flour, iodisation of salt, vitamin A fortification of oil (Dalda fortification in India), zinc fortification")
bullet("Vitamin A supplementation: biannual high-dose supplementation (200,000 IU) for children 6 months–5 years — reduces infection-related mortality, which in turn prevents infection-driven PEM")
bullet("Deworming with albendazole/mebendazole every 6 months — helminth infections impair nutrient absorption and cause iron-deficiency anaemia, worsening PEM")

heading2("9.3 Secondary Prevention — Early Detection and Treatment")

heading3("(a) Periodic Surveillance and Growth Monitoring")
bullet("Maintenance of growth charts by ASHA workers, ANMs at sub-centres — 'Road to Health' chart")
bullet("Monthly weight monitoring at Anganwadi Centres (AWC) under ICDS programme")
bullet("Flag children with weight faltering (no weight gain over 2 months) or crossing downward growth centiles")
bullet("Mid-Upper Arm Circumference (MUAC) tape screening at community level — simple, rapid, reliable")
body("Justification: The first indicator of PEM is under-weight for age. Growth charts allow visual identification of growth faltering at a glance, before severe clinical disease manifests. MUAC < 12.5 cm triggers immediate referral — this measurement is stable between ages 1–5, making deviations highly specific for malnutrition.")

heading3("(b) Early Diagnosis and Treatment of Infections and Diarrhoea")
bullet("ORS for diarrhoea management at household level — prevents the dehydration and nutritional losses that precipitate PEM")
bullet("Zinc supplementation during diarrhoea (20 mg/day for 10–14 days) — reduces duration and severity, and prevents recurrent episodes for 2–3 months")
bullet("Early antibiotic use for respiratory and other bacterial infections")
bullet("IMNCI (Integrated Management of Neonatal and Childhood Illness) protocol at first-level facilities — addresses malnutrition alongside common illnesses")

heading3("(c) Supplementary Feeding Programmes")
bullet("ICDS (Integrated Child Development Services, India): supplementary nutrition for children 6 months–6 years, pregnant women, and lactating mothers through Anganwadi Centres")
bullet("Mid-Day Meal Scheme: hot cooked meals for school children — addresses school-age PEM and improves attendance")
bullet("SABLA (now replaced by POSHAN Abhiyan schemes): nutritional support for adolescent girls")
bullet("NRC (Nutritional Rehabilitation Centres): 182+ NRCs in India under NHM — provide facility-based management of SAM with a 14-day protocol")

heading2("9.4 Tertiary Prevention — Rehabilitation")
bullet("Nutritional rehabilitation services: inpatient (NRC) and outpatient (CMAM — Community-based Management of Acute Malnutrition)")
bullet("Hospital treatment for complicated SAM (infections, severe oedema, impaired consciousness)")
bullet("Follow-up care: monthly visits for 6 months, anthropometric monitoring, psychosocial support")
bullet("Social reintegration: address underlying poverty through linkage to social welfare schemes (PDS, MNREGA)")

heading2("9.5 National Programmes in India — Social Medicine Perspective")

heading3("A. Integrated Child Development Services (ICDS)")
body("ICDS is India's flagship integrated nutrition programme, launched in 1975. It delivers six services through Anganwadi Centres: supplementary nutrition, immunisation, health check-up, referral services, nutrition and health education, and non-formal preschool education. ICDS is the world's largest childhood nutrition programme by reach.")

heading3("B. Pradhan Mantri POSHAN Abhiyan (PM POSHAN / National Nutrition Mission)")
body("Launched 2018, PM POSHAN targets reduction of stunting, wasting, anaemia, and low birth weight through convergence of multiple schemes — integrating ICDS, NHM, Swachh Bharat, and other programmes. It has established a real-time monitoring system (POSHAN Tracker) for growth monitoring and ICDS services.")

heading3("C. Mid-Day Meal Scheme (PM POSHAN for Schools)")
body("Provides hot cooked meals to 120 million school children daily. Addresses school-age malnutrition and incentivises school attendance — addressing both the nutritional and educational deficits caused by PEM.")

heading3("D. National Health Mission (NHM) — NRC Programme")
body("Nutritional Rehabilitation Centres under NHM provide inpatient management for SAM children. A 14-day protocol based on WHO guidelines is followed. ASHAs motivate families to bring severely malnourished children to NRCs and ensure follow-up after discharge.")

heading3("E. Janani Shishu Suraksha Karyakram (JSSK)")
body("Provides free delivery, free treatment of sick newborns, free transport, and free diagnostics at public health facilities — removing financial barriers to maternal and neonatal care, directly addressing the biological precursors of PEM.")

heading3("F. Public Distribution System (PDS)")
body("Subsidised food grains (rice, wheat) distributed to below-poverty-line families — addressing household food insecurity, the most fundamental nutritional determinant.")

heading2("9.6 Social Determinants of PEM")
body("PEM is not merely a medical condition — it is a manifestation of social injustice. The WHO Commission on Social Determinants of Health (CSDH) identifies the following as root causes:")

add_table_2col(
    ["Social Determinant", "Mechanism Linking to PEM"],
    [
        ["Poverty and income inequality", "Inability to access nutritionally adequate diet; food insecurity"],
        ["Maternal education", "Each year of schooling reduces child malnutrition risk by ~8%; improved feeding practices, healthcare use"],
        ["Sanitation and safe water (WASH)", "Prevents infections that precipitate PEM; prevents environmental enteric dysfunction (EED)"],
        ["Agricultural food systems", "Monoculture diets (rice/cassava) lack essential amino acids; crop failure triggers famine"],
        ["Conflict and displacement", "Destroys food systems, displaces populations, disrupts healthcare access"],
        ["Gender inequality", "Girls receive less food; women have less control over household food distribution"],
        ["Climate change", "Increasing drought frequency → crop failure → food insecurity → PEM"],
        ["Health system access", "Lack of growth monitoring, nutrition counselling, and immunisation perpetuates PEM cycle"],
    ]
)

pagebreak()

# ════════════════════════════════════════════════════════════════
#  CHAPTER 10 — PROGNOSIS AND COMPLICATIONS
# ════════════════════════════════════════════════════════════════
heading1("10. PROGNOSIS AND COMPLICATIONS")

heading2("10.1 Acute Complications and Causes of Death")
bullet("Hypoglycaemia — most common early cause of death (especially nocturnal)")
bullet("Hypothermia — exacerbates all metabolic derangements")
bullet("Septicaemia — occult, rapidly fatal in immune-compromised children")
bullet("Severe anaemia — cardiac failure from high-output demands")
bullet("Electrolyte imbalances — cardiac arrhythmias (hypokalaemia, hypophosphataemia)")
bullet("Refeeding syndrome — when treatment is mismanaged")
bullet("Dehydration and shock — severe diarrhoea in the context of fluid imbalance")

heading2("10.2 Long-Term Consequences")
bullet("Permanent growth stunting — irreversible if severe malnutrition during first 2 years")
bullet("Cognitive impairment and intellectual disability — reduced IQ, poor academic performance")
bullet("Impaired myelination of white matter and reduced neuron count — documented on brain imaging and post-mortem studies (Robbins & Kumar Basic Pathology, 10e)")
bullet("Increased risk of NCDs in adult life (Barker hypothesis / Developmental Origins of Health and Disease — DOHaD): foetal programming due to maternal undernutrition increases risk of type 2 diabetes, hypertension, cardiovascular disease")
bullet("Reduced economic productivity — lower earning capacity perpetuates intergenerational poverty")
bullet("Impaired immune memory — reduced response to vaccines; increased susceptibility to infections throughout life")

heading2("10.3 Mortality Rates")
body("Severely wasted children are 9 times more likely to die than well-nourished children (Park's Textbook of PSM). Mortality in appropriately treated SAM in well-resourced NRC settings can be reduced to below 5%. In community settings without access to care, case fatality rates of 30–40% are documented in complicated SAM.")

heading2("10.4 Prognosis with Treatment")
body("With timely institution of the WHO three-stage protocol, dramatic recovery is achievable:")
bullet("Oedema resolves within 1–2 weeks of treatment")
bullet("Appetite returns by end of stabilisation phase (7–10 days)")
bullet("Weight gain of 10–20 g/kg/day in rehabilitation phase")
bullet("Skin and hair changes improve over weeks to months")
bullet("Cognitive recovery is possible if malnutrition occurred after 2 years of age; before 2 years, some deficits may be permanent")
bullet("Recovery of immune function occurs gradually over months")

pagebreak()

# ════════════════════════════════════════════════════════════════
#  CHAPTER 11 — CONCLUSION
# ════════════════════════════════════════════════════════════════
heading1("11. CONCLUSION")

body("Protein-Energy Malnutrition remains one of humanity's most preventable yet persistently devastating public health challenges. As this thesis has detailed, PEM is not a single entity but a spectrum of nutritional disorders — each with a distinct pathophysiological basis, clinical signature, and prognostic implication.")

body("The mechanistic understanding of each sign and symptom is essential for clinicians who must accurately diagnose, distinguish (marasmus from kwashiorkor from their mixed form), and appropriately manage these conditions. The bilateral pitting oedema of kwashiorkor is not cosmetic — it is the clinical imprint of profound visceral protein depletion and hypoalbuminaemia. The emaciated, 'old man' face of marasmus is not simply 'thinness' — it is the consequence of adaptive somatic protein catabolism preserving visceral organ function at the cost of structural tissue. The 'flaky paint' dermatosis reflects the convergence of amino acid deficiency, micronutrient depletion, and oxidative stress on the skin's renewal machinery. Understanding the 'why' transforms clinical observation into rational management.")

body("Management requires discipline in following the WHO three-stage protocol — resisting the temptation to 'feed aggressively' immediately, because refeeding syndrome kills as surely as starvation. The sequencing of F-75 → F-100/RUTF, the empirical antibiotic use despite the absence of fever, the use of ReSoMal instead of standard ORS, the withholding of iron until Phase 2 — each of these counter-intuitive steps has a mechanistic justification grounded in the metabolic pathophysiology of SAM.")

body("The preventive and social medicine perspective is perhaps the most important dimension of this thesis. The most effective 'treatment' for PEM is not a therapeutic formula — it is a girl educated for twelve years, a family with access to clean water and sanitation, a mother who exclusively breastfeeds for six months, an Anganwadi worker who identifies growth faltering early, and a government that ensures food security for its most vulnerable citizens. The 8th FAO/WHO Expert Committee on Nutrition guidelines for PEM prevention — health promotion, specific protection, early detection, and rehabilitation — remain as relevant and actionable today as when they were first articulated.")

body("India has made substantial progress through programmes like ICDS, NHM, POSHAN Abhiyan, and Mid-Day Meals. Yet 40% of Indian children still have mild PEM, and 5–6% have severe PEM. The convergence of political will, community engagement, inter-sectoral action (health, agriculture, education, WASH, social protection), and scientific management guided by evidence-based protocols represents the only path to eliminating this preventable and unjust condition.")

pagebreak()

# ════════════════════════════════════════════════════════════════
#  CHAPTER 12 — REFERENCES
# ════════════════════════════════════════════════════════════════
heading1("12. REFERENCES")

refs = [
    "1. Kumar V, Abbas AK, Aster JC. Robbins & Kumar Basic Pathology. 10th Edition. Philadelphia: Elsevier; 2023. Chapter 7 — Nutritional Diseases (pp. 289–294).",
    "2. Kumar V, Abbas AK, Aster JC, Robbins SL. Robbins, Cotran & Kumar Pathologic Basis of Disease. 10th Edition. Philadelphia: Elsevier; 2023.",
    "3. Park K. Park's Textbook of Preventive and Social Medicine. 25th Edition. Jabalpur: Banarasidas Bhanot; 2023. Chapter on Nutrition (pp. 640–643, 736–737).",
    "4. Harvey RA, Ferrier DR (Eds). Lippincott's Illustrated Reviews: Biochemistry. 8th Edition. Philadelphia: Wolters Kluwer; 2023. Chapter 27 — Protein-Energy Malnutrition (pp. 1026–1030).",
    "5. Griffiths CEM, Barker JNWN, Bleiker T, Chalmers R, Creamer D (Eds). Dermatology: A 2-Volume Set. 5th Edition. Philadelphia: Elsevier; 2022. Chapter on Nutritional Dermatoses.",
    "6. Sleisenger MH, Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th Edition. Philadelphia: Elsevier; 2021.",
    "7. World Health Organization. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers. Geneva: WHO; 1999 (revised guidelines 2013).",
    "8. World Health Organization. WHO Child Growth Standards: Methods and Development. Geneva: WHO; 2006.",
    "9. Cederholm T, Bosaeus I. Malnutrition in Adults. New England Journal of Medicine. 2024; 391(2): 155–165. doi:10.1056/NEJMra2212159.",
    "10. DermNet NZ. Protein-Energy Malnutrition (Kwashiorkor). Available at: dermnetnz.org/topics/protein-energy-malnutrition [Accessed July 2026].",
    "11. Merck Manual (Professional). Protein-Energy Undernutrition. Available at: merckmanuals.com [Accessed July 2026].",
    "12. Golden MH. Specific deficiencies versus growth failure: type I and type II nutrients. SCN News. 1995; (12): 10–14.",
    "13. FAO/WHO. 8th FAO/WHO Expert Committee on Nutrition. Prevention of Protein-Energy Malnutrition in the Community. FAO Nutrition Meetings Report Series.",
    "14. NCBI Bookshelf (StatPearls). Severe Acute Malnutrition: Recognition and Management. Available at: ncbi.nlm.nih.gov/books/NBK559224 [Accessed July 2026].",
    "15. Ministry of Health and Family Welfare, Government of India. Operational Guidelines on Facility-Based Management of Children with Severe Acute Malnutrition. New Delhi: MoHFW; 2011.",
    "16. Bhutta ZA, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet. 2013; 382(9890): 452–477.",
    "17. UNICEF. State of the World's Children 2023: For Every Child, Vaccination. New York: UNICEF; 2023.",
]
for ref in refs:
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    run = p.add_run(ref)
    set_font(run, 10.5)
    p.paragraph_format.space_after = Pt(4)
    p.paragraph_format.line_spacing = Pt(16)

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doc.save(output)
print(f"SUCCESS: Saved to {output}")