Monitoring & Evaluation Key Findings of District Level Household Survey – III (2008) Concurrent Evaluation of NRHM Health Management Information System (HMIS)

Trends in Vital Rates 1971 - 2007

Evidence of NRHM at Work ...

Several States/UTs have improved during 2007

District Level Household Survey-3 Preliminary Results Ministry of Health and Family Welfare (DLHS-3 nodal agency: IIPS, Mumbai)

Background DLHS III survey preliminary results for 15 states (AP, BIH, CHT, GOA, JRK, KAR, KER, MP, ORS, PON, RAJ, SIK, TN, UP, WB) results from DLHS II & III have been compared Analysis includes the following: Marriage-main findings; Fertility / infertility; Maternal Health; Child Health; Family Planning; General (VHSC, ANMs living at AC quarters)

Marriage Mean Age at Marriage Boys Girls % of girls marrying before reaching 18 years of age

Mean age at marriage for boys-years

Mean age at marriage for girls-years

Percentage of girls married below age 18 10

Marriage – main findings Mean age at marriage for both boys and girls has increased between the two rounds of DLHS. The difference in mean age of marriage (both boys and girls) between states reporting lowest and highest was in the range of 8 years

Marriage –main points Rajasthan is the only state where mean age at marriage for boys and girls is lower than the legal age at marriage Bihar is the other state where female mean age at marriage is lower than legal age. Bihar reported the lowest (17.6 years) mean age while it was the highest in Goa (25.1 years) In case of males, Goa reported the highest (29.6 yrs) while Rajasthan (20.7 yrs) reported the lowest % of females marrying before reaching 18 years of age had come down in high-focus states yet it has a long way to go to attain the stage reached by Kerala and Goa.

Fertility Births to women during age 15-19 out of total births, DLHS-3 Women with two children wanting no more Mean children ever born to women aged 40-44 years Infertility among women 15-44 years

Births to women during age 15-19 out of total births, DLHS-3 (%) 14

Women with two children wanting no more children 15

Mean children ever born to women aged 40-44 years. 16

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Fertility/infertility-main points Out of total births, many states like AP, Bih, Jrk, Cht, Kar, UP, WB have higher % of births to women aged 15-19 years Large no. of women (44% or higher) do not want any child after two children Mean number of children ever born to women aged 40-44 have declined in most states. Infertility is as high as 14% in some states (Goa, Kar, WB)

Maternal Health Any antenatal care Complete antenatal care package of services Institutional births Mothers who received JSY financial assistance

% mothers who availed any ANC service

% mothers who availed complete package of ANC services

% mothers who availed any ANC and complete package of ANC services (DLHS-3)

Antenatal Care Services Proportion of women availing any ANC and complete package of ANC services has increased The difference between availing any ANC and complete package was substantial in high-focus states Follow-up ANC care services for ensuring complete coverage are required in all states

Institutional Deliveries

% increase/decrease in institutional deliveries

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Institutional Deliveries Institutional deliveries have increased in most of the states in the country High-focus states have shown tremendous growth in institutional deliveries barring Sikkim, Jharkhand and Chattisgarh Maximum increases in institutional deliveries have been witnessed in states of Orissa, Bihar, Rajasthan and MP

Institutional Deliveries Using a cut-off of 40% of institutional births, the states were classified by DLHS results. Eight out of 15 states in DLHS II had reported more than 40% of institutional births while it had increased to 11 states in DLHS III High-focus states of MP, Orissa, Rajasthan and Bihar have shown good progress and the former three states have joined the other 8 states. In states like Bih, Cht, Goa, Jrk, UP, the JSY assistance received is received by a lower percentage of women

Child Health Coverage in Child Immunization Other Child Health Indicators

Coverage in Child Immunization

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Coverage in Child Immunization Full immunization coverage has improved across the states in the country Quantum of change or increase has been good in high- focus states Jharkhand, Rajasthan and Bihar have shown very positive results while MP, UP and Chattisgarh have lagged behind Proportion of children who received no vaccination has declined

Family Planning Modern CPR Method-wise CPR Unmet Need for Family Planning Limiting Need Spacing Need

Trends in Modern Contraceptive Prevalence-Overall

Family Planning Increase in CPR has been marginal in most of the states barring Rajasthan Increase in spacing use has been witnessed in only six out of the 15 states. States such as UP, Jharkhand, MP, Bihar, Chattisgarh, Karnataka, TN, Kerala and Pondicherry have depicted decline in spacing method use

Unmet Need for Family Planning-Total

Unmet Need for Family Planning-Limiting

Unmet Need for Family Planning-Spacing

Unmet Need for Family Planning Pace of increase in CPR is a concern and there is still substantial unmet need for limiting and spacing The unmet need for family planning varies considerably across the states and is particularly high in high focus states Ranges from a minimum of 8.7% in AP to 37% in Bihar One in four to three women in high-focus states had unmet need for family planning Limiting and spacing needs were the highest in Bihar, UP and Jharkhand Unmet need for limiting has increased in several states. This is a poor reflection of availability of services and service provisions especially when majority of clients depend on public health services in high focus states

CPR and Unmet Need for Family Planning -DLHS III

CPR and Unmet Need for Family Planning States with low CPR have higher levels of unmet need and the converse is true. Unmet need for family planning is higher than CPR in states of UP, Bihar and Jharkhand The line graph from the intersection point on wards (refer previous slide) clearly depicts that family planning programme has not gained the needed momentum in these states On prioritization, states of UP, Bihar and Jharkhand will have to gear up with necessary service provisions to tap the potential demand and convert latent need into real need

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Program implications Campaigns around increasing female age at marriage should be undertaken especially in high-focus states Maternal health indicators have progressed reasonably well. ANC and institutional deliveries have increased. Yet follow-up ANC services and promotion of JSY should be continued On the child health front, immunization coverage has improved substantially. Sustaining and further improvements through VHNDs should be aimed at Community perceptions related to behavioural practices on initiation and exclusive breastfeeding, use of ORS and timely treatment for ARI needs reinforcement in the form of IPC and BCC.

Program implications The pace of overall contraceptive change in high-focus states seems to be an area of concern. High-focus states have high unmet need for both limiting and spacing methods Unmet need has to be addressed systematically through appropriate service provisions, sterilization camps, IPC and BCC strategies Re-strategizing and re-focusing on family planning programme should be taken up on priority, as improvement in family planning will significant result in positive changes in maternal and child health indicators. Infertility treatment services also required Obstetric fistula treatment services

Program implications Centrality of addressing family planning within the RCH framework should be the focus specifically in high-focus states VHSC formation needs to be geared up Why ANMs are staying at the SC quarter when it is available

Over to Concurrent Evaluation of NRHM …