Reproductive and Child Health in India This lecture has been prepared with a view to share the experience of running a project within the Family Planning Program in India - no need to elaborate that India is the only other population billionaire, the experience from where can provide lessons to many other Governments in shaping and reshaping their Population Management Programs. RCH Program in India was launched as a Post-ICPD phenomena. It coincided with the ninth five-year development plan of the country. Although the project is completing its life in March 20003 but now it is being designated as RCH-I as the country is preparing itself to enter in the second phase of the RCH Project from the next fiscal year. Shiv Chandra Mathur Professor of Preventive and Social Medicine and Director, State Institute of Health and Family Welfare, Rajasthan, Jaipur, India. 11/15/2018 Shiv Chandra Mathur

Description of RCH Project in India RCH is a five year project launched within the framework of fifty year old nationwide National Family Planning Program in India. It’s a new approach of managing Population Growth by eliciting more community participation and empowering people to take care of their reproductive health. It’s a project to improve the quality of reproductive health services delivered from public facilities. It entails the creation of more peripheral facilities on one hand and rejuvenating the existing facilities by providing major inputs like trained manpower and requisite equipment's on the other. This project of Government of India has a major funding support from World Bank. The other agencies supporting the Project include UNFPA, Unicef , European Commission, DFID and SIDA. The first census (1951) in post-independence era revealed India’s Population to be 330 million which by 1991 reached to 840 million and more than one billion by 2001. India is the second largest population of the world. In approximately 2.5 percent of landmass, 15 percent of the world's population inhabits in India. After signing the MOU at ICPD, Cairo in 1994, Government of India has made critical changes in its managerial approach towards population control. This lecture documents the success and failure in managing the paradigm shift in India’s Family Planning Program. 11/15/2018 Shiv Chandra Mathur

Goal of RCH Project in India In a large, diverse federal set-up, people may acquire the ability to regulate their fertility, women are able to go through pregnancy and childbirth safely, the outcome of pregnancy is successful in terms of maternal and infant survival and well being and couples are able to have sexual relations free of fear of pregnancy and of contracting disease. 11/15/2018 Shiv Chandra Mathur

High-level timing goals Post - Alma-Ata, Government of India in its National Health Policy, envisaged Health for All by 2000. Mid-decade evaluation of NHP revealed the need to re-strategize to achieve certain reproductive health indicators. Post-ICPD phenomena gave a boost to this change. Development Program in India are being implemented on a five-year plan model and it was thought of that the goals envisaged in the new RCH approach may coincide with ninth five-year plan of the country. 11/15/2018 Shiv Chandra Mathur

Objectives of RCH Project in India Introduce a new system of service delivery through decentralized planning and broadening the menu of services delivered under the banner of Family Planning Program in India. Maneuvering the health care services in a way that it may induce a desired change in specific community health indicators like IMR, TFR, MMR, CBR, effective CPR, Immunization Coverage and delivery by trained hands. 11/15/2018 Shiv Chandra Mathur

Relationship to other projects Transition from Expanded Program of Immunization - Universal Immunization Program - Child Survival and Safe Motherhood on one hand and striking balance between related projects like Reproductive/Sexual Tract Infection prevention in HIV/AIDS Control Program on the other hand. Attempts to institutionalize the project based activities in the long term National Family Planning Program in India. Setting up a public sector - private sector partnership in delivery of health care services by eliciting NGO support. 11/15/2018 Shiv Chandra Mathur

Components of RCH Project in India Essential Obstetric Care Emergency Obstetric Care Essential New Born Care Medical Termination of Pregnancy Contraceptives Delivery RTI/STI Care Empowering Adolescents Strengthening Immunization 11/15/2018 Shiv Chandra Mathur

Project Intervention Based on the status of crude birth rate and female literacy status more than 500 districts of the country were divided in three categories. Weaker districts were given additional inputs like more trained manpower at the periphery and facilities for referral transport. 11/15/2018 Shiv Chandra Mathur

Logistics Peripheral facilities were stratified in three categories: Each subcenter managed by an Auxiliary Nurse Midwife catering to the population of 3000-5000 persons was equipped with Kit A(prophylactics), Kit B (Essential Drugs) and Kit C (bare minimum equipment). Each Primary Health Center managed by a Medical Officer catering to a population of 25000 to 30000 persons was equipped with Kit D with a wider set of equipment Community Health Centers managed by specialists catering to a population of approximately 250 000 were equipped with Kit E and F (standard surgical set); Kit G (IUD Insertion kit); Kit H to L (normal and abnormal delivery Kits); kit M ( for anesthesia); kit N (for neonatal resuscitation); kit O (Laboratory Tests); and kit P ( for Blood Transfusion) 11/15/2018 Shiv Chandra Mathur

Training/Manpower Development Awareness Generation Training for people’s representatives and professionals from other development sectors. Integrated Skill Training for health professionals in the field like Auxiliary Nurse Midwives, Lady Health Visitors, Sector Supervisors and Medical Officers working at Primary Heath Centers. Specialized Skill Training for specialist performing contraception operations and Medical Termination of Pregnancies and for nurses conducting IUD insertions. Communication Training for extension and publicity staff. Management Training for technocrats managing the program at district and state level. 11/15/2018 Shiv Chandra Mathur

IEC Procedures Extensive use of following communication methods in persuading people to cultivate rational reproductive health practices: Television-spots; films; interactive panel and live phone-in discussions. Radio-talks; panel discussions and counseling sessions. Field Publicity through Songs and Drama. Putting Hoarding and Banner at critical points in the city/village Use of Print Media by putting features and ads in newspapers and magazines Putting Posters in Public Facilities and distributing hand-outs and pamphlets lucidly illustrating the subject. 11/15/2018 Shiv Chandra Mathur

Community Need Assessment Health Management Information System is being introduced where demographic and reproductive health information of every family is updated periodically through contact drive survey to elicit the hidden demand for obstetric-child health services on one hand and unmet demand for contraception on the other. Such a procedure strengthens the management through de-centralized planning which in spirit fulfills the guidelines of ICPD Cairo. 11/15/2018 Shiv Chandra Mathur

Monitoring - Performance Indicators Following indicators were used to assess the implementation progress of the RCH Project at the central level: Decentralized Planning: District Action Plan on fiscal year basis were to be prepared and implemented by district level Managers. Health Facilities identified and developed as First Referral Units for Emergency Obstetric Care. Increase in the percentage of women receiving complete antenatal care, institutional delivery and postnatal care. Increase in the number of Health Facilities providing Medical Termination of Pregnancy/Sterilization Services. Coverage of Full Immunization of Children 11/15/2018 Shiv Chandra Mathur

Monitoring - Performance Indicators (2) Increase in the Percentage of children seeking care for common disorders like ARI and Diarrhea. Increase in the current contraceptive prevalence and reduction in the unmet demand of contraception. Completion of In-service orientation/skill-impartation training. 11/15/2018 Shiv Chandra Mathur

Evaluation - Impact Indicators Maternal Mortality Rate. Total Fertility Rate. Institutional Delivery. Reduction in the prevalence of RTI/STI. Infant Mortality Rate. Underfive Mortality Rate. Effective Couple Protection Rate. 11/15/2018 Shiv Chandra Mathur

Observations in implementing RCH Project in India (1) Implementing RCH Project from April1998 to March 2003 in a country like India has provided following experience: Inadequacy of decentralization form Center to the Districts in management of finance, procurement and related issues. Weak Management capacity especially in Monitoring and Evaluation, Budgeting, Communication and Extension and delivery of Quality services. Weakness of Program Management at District level by District Managers who are frequently not oriented to Public Health. Ad hocism in human resource utilization and resource gap in reaching national norms in medical manpower. Poor vision for sustaining the activities in the post-project phase. 11/15/2018 Shiv Chandra Mathur

Observations in implementing RCH Project in India (2) Weakness of outreach services in holding the subjects for completing the cycle of reproductive health care. Lack of one unified concept/system and one unified nomenclature. Multiplicity of Funding Agencies. Lack of an effective referral back-up. RCH and AIDS being implemented in two distinct compartments with some of the activities being unduly duplicated. Low level of commitment to RCH at state levels Disillusionment of the (Globalization/Privatization!) middle level Managers seeing Bank Loans getting priority over the grants given by UN and Bilateral agencies in development projects with RCH as a distinct example! 11/15/2018 Shiv Chandra Mathur

Future of RCH in India ICPD Cairo has disseminated very strong signals throughout the world and Government of India very enthusiastically initiated the paradigm shift by launching a nationwide RCH Project for five years at the turn of second millenium. It has a huge input in the shape of soft loan from World Bank and grants from agencies varying from UNFPA and Unicef to SIDA and DFID. Implementing the project for five years, a consensus has evolved to carry on the for yet another five years with mid-course improvement. Thus the project implemented so far is designated as RCH-1 and the one yet to be launched as RCH-2. Since India is a federal country where Health is a state subject. Most of the States have recently came up with their Population Policies embracing the subject of Reproductive Health. Eventually they have a new mould to put in RCH Project to effect a desired change. It is also hoped that involving NGOs and Private sector to a larger extent will strike balance with changing times of Globalization and new systems of health care delivery throughout the world. 11/15/2018 Shiv Chandra Mathur