Review of RCH, RMNCH+A including other maternal health programmes.pptx

This presentation contains in brief about RCH, RMNCH+A and Various maternal health programmes of India.

1. Review of rch , RMNCH+A including other maternal health programmes Harimu Bargayary PG Resident, Community Medicine 1

2. contents 2 EVOLUTION OF THE PROGRAMME REPRODUCTIVE AND CHILD HEALTH (RCH) PROGRAMME REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH (RMNCH+A) PROGRAMME CURRENT STATUS AND TRENDS OF RELATED HEALTH INDICATORS MATERNAL HEALTH PROGRAMMES SUMMARY REFERENCES

3. Major evolution of the programme Year Program launched 1951 (1 st Five-year plan) Family Planning Programme 1977 (5 th Five-year plan) Family Welfare Programme (renamed) 1992 (8 th Five-year plan) Child Survival and Safe Motherhood (renamed) 1997 (9 th Five-year plan) Reproductive and Chid Health Programme – Phase 1 2000 National Population Policy 2005 National Rural Health Mission (NRHM) 2005 (10 th Five-year plan) Reproductive and Chid Health Programme – Phase II 2013 National Health Mission (National Urban Health Mission + NRHM) 2013 Reproductive, Maternal, Newborn , Child and Adolescent Health (RMNCH+A) 3

4. REPRODUCTIVE & CHILD HEALTH (RCH) 4

5. introduction Reproductive and Child Health (RCH) programme is a comprehensive sector wide flagship programme , under the umbrella of the Government of India's ( GoI ) National Health Mission (NHM) , to deliver the RCH targets for reduction of maternal and infant mortality and total fertility rates. The foundation of this program was laid in the International Conference on Population and Development (ICPD) held at Cairo in 1994. 5

6. COMPONENTS OF RCH 1 6 L aunched throughout the country on 15 th October, 1997 . RCH PHASE 1

7. It integrated all ongoing programs on MCH and focused on child survival and safe motherhood, along with implementation of - target free approach, training IEC activities, RTI or STI clinics, facilities for safe abortions, enhanced community participation and adolescent health and reproductive hygiene. 7 Contd …

8. The program focused on the districts on the basis of crude birth rate and female literacy rate . All districts are divided into 3 categories : Category A having 58 districts , Category B having 184 districts and Category C having 265 districts . All the districts were covered in a phased manner over a period of 3 years. 8 Contd …

9. RCH 1 major interventions Essential obstetric care Emergency obstetric care including strengthening of FRUs 24 hour delivery services at PHC / CHCs Medical termination of pregnancy (MTP) Control of RTI and STD Immunization Essential newborn care Control of diarrhoeal diseases and acute respiratory infections of infants Prevention and control of anaemia and vitamin A deficiency in children Training of Dais with the objective of making deliveries safe 9

10. 10 Launched in 1 st April 2005 . Objective: To reduce maternal and child morbidity and mortality with emphasis on rural healthcare .

11. New initiatives under rch ii Training of MBBS doctors in Life saving anaesthetic skills for emergency obstetric care . Setting up of Blood storage centres at FRUs according to Government of India guidelines. 11

12. Essential components of the rch II program. 12

13. Differences between older and newer approach Old Approach (Family Planning) New Approach (Reproductive and Child Health) Population- Centered People- Centered Over-emphasis on sterilization Informed Choice of contraceptives Quantitative targets Qualitative targets Family Planning in a separate basket FP merged with Health: One package for Health, MCH & FP Focus on 30(+) women with 3 or 4 children Focus on new operation, in particular, adolescents (15-25 years) Insensitive to gender issues Focus on gender issues and concern for gender equity and elimination of discrimination against women No linkage with basic needs of the poor Priority for fulfilling the Minimum Needs Programme No consultation with people at the grassroot level Decentralised programme run through panchayats & nagar-palikas Family Welfare Department- the sole custodian of population matters Abolish the Department and establish a Population and Social Development Communion and Fund 13

14. RCH Phase II - Improvements over RCH Phase I Lessons learnt from RCH I Corrective Measures in RCH II Limited involvement and ownership by states States will prepare plans linked to clear outcomes after assessing their own priorities, allowing a needs-based state-specific plan to be developed. Slow pace of implementation Bottlenecks to fund flows to be removed by simplifying processes. Low utilization of public health facilities Addressed through pre-service and in-service training, with a particular focus on provider attitudes and making services more users friendly Infrastructure to be completed within the project time frame Simplified processes of managing and construction of infrastructure. Limited management capacity Lateral infusion of skilled personnel to improve the management capacity structure at the national, state and district levels, with clearly defined functional responsibilities and roles. 14

15. Lessons learnt from RCH I Corrective Measures in RCH II Need to incorporate the system of smooth flow of funds Financial management systems will be built into the program management structure. Implemented as a project ; there was a need to incorporate well-defined outcome indicators Visualized as a long-term program , oriented towards achieving ambitious, but realistic health outcomes and improvements “One size fits all” design Differential approach may be extended to the district level depending upon the performance of districts Need to move away from “stand alone” public health approach Adopted a program approach, bringing in key elements of sector management and reform and strengthening of systems Focused almost exclusively on the supply side Necessarily includes supply side strategies, complemented by an integrated and robust strategy to stimulate demand for services. Centrally designed with little consultation Designed after wider consultation. 15 Contd …

16. REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH (RMNCH+A) For Healthy Mother and Child 16

17. INTRODUCTION Following the GoI’s “Call to Action (CAT) Summit” in February, 2013 , the MoFHW launched RMNCH+A to influence the key interventions for reducing maternal and child morbidity and mortality .  17

18. What’s new ? B uilt upon the continuum of care concept . H olistic in design, encompassing all interventions aimed at reproductive , maternal , newborn , child , and adolescent health under a broad umbrella . F ocuses on the strategic lifecycle approach . It promotes links between various interventions across thematic areas to enhance coverage throughout the lifecycle. 18

19. 19 RMNCH + A

20. 20

21. CONTINUUM OF CARE 21

22. National Health Outcome Goals established in the 12 th Five Year Plan relevant to rmnch+a • Reduction of Infant Mortality Rate (IMR) to 25 per 1,000 live births by 2017 • Reduction in Maternal Mortality Ratio (MMR) to 100 per 100,000 live births by 2017 • Reduction in Total Fertility Rate(TFR) to 2.1 by 2017 22

23. 5 X 5 matrix for high-impact RMNCH+A interventions To be implemented with High Coverage and High Quality Reproductive Health Maternal Health Newborn Health Child Health Adolescent Health Health Systems Strenthening Cross Cutting Interventions 23

24. RMNCAH+N strategy covers Reproductive, Maternal, Newborn, Child and Adolescent Health and the “plus” within it focuses on Nutrition , as well as important linkages between these services and other components like family planning, adolescent health, HIV, gender, and preconception and prenatal diagnostic techniques. It also focuses on linkages between community-based services and facility-based services and ensures referrals, and counter-referrals between various levels of health care system to create a continuous care pathway. 24 YEAR 2021

25. 25

26. Under RMNCAH+N, reproductive health and nutrition interventions are cross cutting across all life stages . The reproductive health forms the primary pillar of RMNCAH+N. RMNCAH+N aims at ensuring healthy reproductive practices , encouraging contraceptive use while having an effective integration of the maternal, child, adolescent health and family planning . 26

27. 27

28. Priority interventions in various stages of life stages Adolescent Pregnancy and Childbirth Newborn and Childcare Reproductive Years Adolescent nutrition; IFA supplementation Facility-based adolescent reproductive and sexual health services(ARSH) (Adolescent health clinics) Information and counselling on adolescent sexual reproductive health and other health issues Menstrual hygiene Preventive health checkups Delivery of antenatal care package and tracking of high-risk pregnancies Skilled obstetric care Immediate essential newborn care and resuscitation Emergency obstetric and new born care Postpartum care for mother and newborn Postpartum IUCD and sterilization Implementation of PC&PNDT Act Home-based newborn care and prompt referral Facility-based care of the sick newborn Integrated management of common childhood illnesses (diarrhea, pneumonia and malaria) Child nutrition and essential micronutrients supplementation Immunization Early detection and management of defects at birth, deficiencies, diseases and disability in children (0–18 years) Community-based promotion and delivery of contraceptives Promotion of spacing methods (interval IUCD) Sterilisation services (vasectomies and tubectomies) Comprehensive abortion care (includes MTP Act) Prevention and management of sexually transmitted and reproductive infections (STI/RTI) 28

29. Current Status of key RMNCAH+n /RCH Indicators Indicator Current status (SRS 2020) National Health Policy targets SDG 2030 Target INDIA UTTAR PRADESH Maternal Mortality Ratio (per lakh live births) 97 167 100 by 2020 < 70 Neonatal Mortality Rate (%) 20 28 16 by 2025 < 12 Infant Mortality Rate (%) 28 38 28 by 2019 - Under 5 Mortality Rate (%) 32 43 23 by 2025 < 25 Total Fertility Rate 2.0 2.4(NFHS-5) Replacement level fertility - 29

30. trend in Maternal Mortality Ratio (MMR) 30

31. Number of states which have achieved Sustainable Development Goal (SDG) for Maternal Mortality Ratio (MMR) target has risen from: 31 Kerala (19) < Maharashtra (33) < Andhra Pradesh (45) < Telangana (43) < Tamil Nadu (54) < Jharkhand (56) < Gujarat (57) < Karnataka (69)

32. trend in neonatal Mortality Rate ( nMR ) 32 Six (6) States/ UT have attained SDG target of NMR ( < 12 by 2030): Kerala (4), Delhi (9), Tamil Nadu (9), Maharashtra (11), Jammu & Kashmir (12) and Punjab (12).

33. Trend in infant Mortality Rate ( iMR ) 33 At the National level, IMR is reported to be 28 and varies from 31 in rural areas to 19 in urban areas respectively. At the national level, mortality for female infants is at par with male infants.

34. trend in under 5 Mortality Rate (u5MR) 34 U5MR for Female is higher (33) than male (31). However there has been a decline of 4 points in male U5MR and 3 points in female U5MR during the corresponding period. Highest decline of U5MR is observed in the State of Uttar Pradesh (5 points) and Karnataka (5 points). Eleven (11) States/UT have already attained SDGs target of U5MR.

35. trend in total fertility Rate ( tfR ) TFR varies from 2.2 in rural areas to 1.6 in urban areas. States with Replacement level Fertility above 2.1: Bihar, Meghalaya, Uttar Pradesh, Jharkhand and Manipur. 35

36. Other Key RMNCAH+N Indicators (At national level) Indicators NFHS-5 NFHS-4 Reproductive Health Health worker ever talked to female non-users about family planning 23.9% 17.7% mCPR 56.5% 47.8% Male Sterilization 0.3% 0.3% Unmet Need 9.4% 12.9 % Maternal Health Mothers who had an ANC in the 1 st trimester 70.0% 58.6% Maternal Health PW are anaemic 52.2% 50.4% Consumption of IFA among PW (min. 100days) 44.1% 30.3% 4 ANC 58.1% 51.2% Registered pregnancies and received MCP card 95.9% 89.3% Mothers who received postnatal care from a doctor/nurse/LHV/ANM/midwife/other health personnel within 2 days of delivery 78.0% 62.4% 36

37. Indicators NFHS-5 NFHS-4 Newborn & Child Health Institutional delivery 88.6% 78.9% Newborn & Child Health Early Initiation of Breast Feeding (EIBF) 41.8% 41.6% Exclusively Breastfed 63.7% 54.9% Immunization level 76.4% 62.0% Prevalence of diarrhoea 7.3% 9.2% children are stunted 35.5% 38.4% Children are anaemic 67.1% 58.6% Adolescent Health Teenage Marriage (female) 23.3% 26.8% Teenage Pregnancy 6.8% 7.9% Adolescent are anaemic (female) 59.1% 54.1% Adolescent are anaemic (male) 31.1% 29.2% using hygienic methods of protection during menstrual period 77.3% 57.6% 37 Contd …

38. Other Key RMNCAH+N Indicators (At uttar pradesh ) Indicators NFHS-5 NFHS-4 Reproductive Health Health worker ever talked to female non-users about family planning 25.1 % 12.8% mCPR 44.5% 31.7% Male Sterilization 0.1% 0.1% Unmet Need 12.9% 18.1% Maternal Health Mothers who had an ANC in the 1 st trimester 62.5% 45.9% Maternal Health PW are anaemic 45.9% 51.0% Consumption of IFA among PW (min. 100days) 22.3% 12.9% 4 ANC 42.4% 26.4% Registered pregnancies and received MCP card 95.7% 79.8% Mothers who received postnatal care from a doctor/nurse/LHV/ANM/midwife/other health personnel within 2 days of delivery 72.0% 54.0% 38

39. Indicators NFHS-5 NFHS-4 Newborn & Child Health Institutional delivery 83.4% 67.8% Newborn & Child Health Early Initiation of Breast Feeding (EIBF) 23.9% 25.2% Exclusively Breastfed 59.7% 41.6% Immunization level 69.6% 51.1% Prevalence of diarrhoea 5.6% 15.0% children are stunted 39.7% 46.3% Children are anaemic 66.4% 63.2% Adolescent Health Teenage Marriage (female) 15.8% 21.1% Teenage Pregnancy 2.9% 3.8% Adolescent are anaemic (female) 52.9% 53.7% Adolescent are anaemic (male) 28.2% 31.5% using hygienic methods of protection during menstrual period 72.6% 47.1% 39 Contd …

40. MATERNAL HEALTH programmes 40

41. 41 JANANI SURAKSHA YOJANA (JSY) Earlier called NATIONAL MATERNITY BENEFIT SCHEME . Launched in 12 th April, 2005 . Objectives: To reduce maternal and neonatal deaths by promoting institutional deliveries and focusing at institutional care among women of BPL families. 100% Centrally sponsored scheme. It integrate cash assistance with delivery and post delivery care . ASHA – effective link between the Government and poor pregnant women.

42. 42 Eligibility for Cash Assistance : LPS States All pregnant women delivering in Government health centres like Sub- centre , PHC/CHC/ FRU / general wards of District and state Hospitals or accredited private institutions HPS States BPL pregnant women, aged 19 years and above LPS & HPS All SC and ST women delivering in a government health centre like Sub- centre , PHC/CHC/ FRU / general ward of District and state Hospitals or accredited private institutions *** While mother will receive her entitled cash, the scheme does not provide for ASHA package for such pregnant women choosing to deliver in an accredited private institution .

43. 43 Category Rural Area Urban Area Mother’s Package ASHA’s Package Mother’s Package ASHA’s Package LPS Rs. 1400/- Rs. 600/- Rs. 1000/- Rs. 200/- HPS Rs. 700/- Rs. 200/- Rs. 600/- Rs. 200/- Scale of Cash Assistance for Institutional Delivery : Limitations of Cash Assistance for Institutional Delivery : In LPS States All births, delivered in a health centre – Government or Accredited Private health institutions. In HPS States Upto 2 live births.

44. 44 Low-performing states (LPS) :- Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa and Jammu and Kashmir. *** The remaining states have been named as High performing States (HPS) .

45. 45 JANANI SHISHU SURAKSHA KARYAKRAM (JSSK) Launched in 1 st June, 2011 . Objective: To eliminate out-of-pocket expenses for institutional delivery of pregnant women and treatment of sick infants . The policy commits to: Free entitlements including cashless delivery and C-sections for pregnant women, and Management of sick neonates upto 30days.

46. 46 Entitlements for Pregnant Women: Free & Zero expense Delivery & Caesarean section Free Drugs & Consumables Free Essential Diagnostics (Blood, Urine tests and USG, etc.) Free Diet during stay in the health institution Normal delivery: upto 3 days C-section : upto 7 days Free Provision of Blood Free Transport from Home to Health Institutions Free Transport between facilities in case of referral Drop Back from Institutions to Home after 48 hours stay Exemption from all kinds of User Charges Entitlements for Pregnant Women: Free & Zero expense Delivery & Caesarean section Free Drugs & Consumables Free Essential Diagnostics (Blood, Urine tests and USG, etc.) Free Provision of Blood Free Transport from Home to Health Institutions Free Transport between facilities in case of referral Drop Back from Institutions to Home after 48 hours stay Exemption from all kinds of User Charges

47. 47 Entitlements for Sick Newborn : Free & Zero expense treatment Free Drugs & Consumables Free Diagnostics Free Provision of Blood Free Transport from Home to Health Institutions Free Transport between facilities in case of referral Drop Back from Institutions to Home Exemption from all kinds of User Charges

48. 48 Average out-of-pocket expenditure per delivery in a public health facility: INDIA: UTTAR PRADESH:

49. 49 PRADHAN MANTRI MATRU VANDANA YOJANA (PMMVY) A maternity benefit program run by the government of  India . Centrally Sponsored DBT scheme. Provides cash incentives for pregnant and lactating mother. previously known as the Indira Gandhi Matritva Sahyog Yojana . originally launched in 2010 and renamed in 2017.

50. 50 Conditionalities and Installments Conditionalities and Instalments Installments Conditions Amount First installment Early Registration of pregnancy 1,000/- Second installment Received at least one ANC (can be claimed after 6 months of pregnancy) 2,000/- Third installment Child Birth is registered Child has received first cycle of BCG, OPV, DPT and Hepatitis-B or its equivalent / substitute 2,000/- The eligible beneficiaries receive an average of Rs.6000/- including the incentive given under the Janani Suraksha Yojana (JSY). Pregnant women & Lactating Mother receives a cash benefit of Rs.5000/- in 3 installments at the following stages:

51. PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAAn (PMSMA) Launched on 9 th June, 2016 . Aim: To provide fixed day assured, comprehensive, quality antenatal care services, free of cost, universally to all pregnant women on 9 th of every month . G uarantees a minimum package of antenatal care services to women in their 2nd / 3rd trimesters of pregnancy at designated government health facilities . Involves private sector’s health care providers as volunteers to provide specialist care in government facilities. 51

52. 52 Achievements under PMSMA : Since inception - More than 2.88 crore Ante-natal check-ups conducted. More than 23.60 lakh high risk pregnancy cases have been identified across the country. More than 6000 volunteers registered under PMSMA.

53. 53

54. 54

55. Surakshit Matritva Aashwasan (SUMAN) Launched in 10 th October, 2019 . An Initiative for Zero Preventable Maternal and Newborn Deaths . 55

56. Progress so far and way forward: • Standard Operational Guidelines disseminated in 2020-21 • Orientation on SUMAN held from Sept’20-Nov’20 during State MH reviews • IEC collaterals developed and disseminated • SUMAN Identified facilities: • SUMAN notified facilities: 56 CEmONC BEmONC BASIC TOTAL 1109 2619 4140 7868 CEmONC BEmONC BASIC TOTAL 763 1271 3473 5507 Challenges: Many high case load facilities converted into dedicated Covid centres . Non- functionalisation of 104 call- centre across many State/UTs , which is necessary for validation of primary respondents of MDs. Assam, J&K , Kerala, MP, Maharashtra , Karnataka , Punjab (bigger states) yet to notify SUMAN facilities.

57. LA Q SHYA Labour Room Quality Improvement Initiative 57 Launched on 11 th December, 2017 .

58. Target: 2805 LR and 1905 OTs : Government Medical Colleges, District Hospitals, Sub Divisional Hospitals, FRU, High Case Load CHC Front runner states: Maharashtra, Gujarat, Madhya Pradesh and Tamil Nadu Challenges: Zero LaQshya Certification of Medical Colleges in 27 State/UT. High case load district level facilities converted into dedicated Covid health centres . Nil Certification: A&N and Lakshadweep. 58 LaQshya Certification Status

59. Midwifery Services Initiatives in India A Paradigm Shift from Traditional care to Collaborative care 59 Goal : To create a cadre of Nurse Practitioners in Midwifery who are skilled in accordance to competencies prescribed by the International Confederation of Midwives (ICM) and are knowledgeable and capable of providing compassionate women-centered, reproductive, maternal and newborn health care services” Achievement : • As of now 14 National Midwifery Training Institutes have been identified. • Scope of Practice for Midwifery Educators and Nursing Practitioner Midwife has been launched. • Curriculum for Nurse Practitioner Midwife has been published as the gazette notification.

60. Comprehensive abortion care ( cac ) 60 More than 14,500 MOs have been trained in CAC trainings upto June, 2020.

61. 1. CHIRANJEEVI YOJANA - gujarat 2. SAUBHAGYAWATI SCHEME – UttarAKHAND 3. JANANI SAHAYOGI YOJANA – Madhya pradesh 4. AYUSHMATI SCHEME – west bengal 5. MAMTA FRIENDLY HOSPITAL SCHEME – new delhi 6. Janani suvidha yojana - haryana 61 Other Maternal health programmes:

62. SUMMARY The Maternal Health Division under NHM strives to provide quality services to pregnant women and their newborns through various interventions and programmes , building capacity of health personnel and routine health systems strengthening activities. NFHS-5 shows an overall improvement in Sustainable Development Goals indicators in all States/Union Territories (UTs). 62

63. India’s efforts in successfully lowering the MMR ratio provides an optimistic outlook on attaining SDG target of MMR less than 70 much before the stipulated time of 2030. The country has been witnessing a progressive reduction in IMR, U5MR and NMR since 2014 towards achieving the Sustainable Development Goals (SDG) targets by 2030. Although India has achieved replacement level fertility, there is still a significant population in the reproductive age group who must remain at the centre of our intervention efforts. 63 Contd …

64. references 64 Park’s Textbook of PREVENTIVE AND SOCIAL MEDICINE; 26 th edition by K. Park IAPSM’s Textbook of Community Medicine; 2 nd edition by AM Kadri Textbook of Community medicine; 4 th edition by Rajvir Bhalwar https://rch.nhm.gov.in/ https://www.nhp.gov.in/ https://censusindia.gov.in/ https://pib.gov.in/ https://www.google.com/

65. 65