REPRODUCTIVE AND CHILD HEALTH PROGRAM(RCH) Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Lesson Objectives To Learn about the various components of RCH program To know about the goals. objectives target groups, service components and RCH program To know about the services/activities under the program To know about the new initiatives in the program Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Components The RCH program incorporated the earlier existing programs i.e. National Family Welfare Program and Child Survival and Survival & Safe Motherhood Program ( CSSM) and added two more components one relating to sexually transmitted disease and the other relating to reproductive tract infections. The program was formally launched on 15 October 1997. Dr. KANUPRIYA CHATURVEDI

Components: FAMILY PLANNING CLIENT CHILD SURVIVAL APPROACH AND SAFE Adolescent Health Care and Family Life Education CLIENT APPROACH TO HEALTH CARE CHILD SURVIVAL AND SAFE MOTHERHOOD PREVENTION/ MANAGEMENTOF RTI/STD/AIDS Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI RCH PROGRAM Family Planning Improved method mix Private sector inclusion Address quality Collaborate with NACO in condom distribution Maternal Health Quality ANC Institutional Deliveries Skilled Birth Attendance EmObstetric care Home based post-partum & NBC Quality safe abortion services RTI/STI Child Health) Intensify existing services : Immunization, NBC Micronutrient Supply CDD ARI IMNCI. Adolescent health Anemia Awareness about RH issues Dr. KANUPRIYA CHATURVEDI

RCH Program (cross cutting Issues) Human Resources Anesthetists Obstetricians Lady doctors Contractual ANMs Staff Nurses in 24 Hrs PHCs Counselor IEC Branding Involving Professional Agencies Media Inter-personal Communication Celebrity involvement MIS Output based Monitoring Triangulation of Data CES/DHS ISC Awareness about RH issues Anemia Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI The Paradigm Shift Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Program Objectives Promotion of MCH to ensure safe mother hood and child survival Reduction of maternal and child morbidity and mortality Attainment of population stabilization Dr. KANUPRIYA CHATURVEDI

Highlights of the program Integration of all programs related fertility regulation, maternal and child health and reproductive health. Services are client oriented, demand driven through decentralized participatory process and target free approach Up-gradation of facilities : creation of First referral units Provision of specialist services for STD and RTI Provision of out reach services for vulnerable groups Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Categories: Differential approach Based on CBR and female literacy rate, Category A:58 districts Category B:184 districts Category C:265 districts All the districts covered in a phased manner over a period of 3yrs Dr. KANUPRIYA CHATURVEDI

Service Package: for mothers Essential obstetric care Early registration Minimum 3 ANC Safe delivery 3 PNC Referral More relevant for Assam, Bihar,Rajasthan, Orissa,UP, MP Dr. KANUPRIYA CHATURVEDI

Emergency obstetric care Strengthen FRUs Supply of kits and skilled manpower TBA (Traditional Birth Attendants) Dai training NGOs involved: More local specific 24-hr Delivery services at PHCs/CHCs: Promote institutional deliveries Additional honorariumto staff Safe deliveries Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Contd. Deliveries by trained personnel in safe and hygienic surroundings are encouraged Institutional deliveries are encouraged for women having complications. In case of complication referrals are made to First Referral Units for Management of obstetric emergencies. Three postnatal checkups are given to mothers after the delivery. Spacing of at least three years between children are encouraged.   Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI For children Essential newborn care like keeping the baby warm, checking the baby’s weight and giving the baby mother’s first milk are encouraged. Babies that are premature or have low birth weight are provided special care. Babies with any complications refereed to the health center. Exclusive breast-feeding are encouraged for the first three months. Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Contd. Immunization are administered to every child meticulously to prevent death and disabilities. Vitamin A Prophylaxis ORT. Acute respiratory infection in children treated by cotrimoxazole tablets. Treatment of Anemia Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI For Eligible Couples Promoting use of contraceptive methods among eligible couples is important to prevent unwanted pregnancies. Couples should be able to choose from various contraceptive methods including condoms,oral pills, IUDs,male and female sterilization Safe services for medical termination of pregnancies should be encouraged for women desiring abortions   Other New Services Treatment of RTI/STI is given. Promotion activities for adolescents health. Dr. KANUPRIYA CHATURVEDI

Drug and equipment kits: Mid-wifery kit & drug kit Kit-E – Laparotomy set Kit-F - Mini– Laparotomy set Kit-G – IUD insertion set Kit-H – Vasectomy set Kit- I – Normal delivery set Kit- J – Vacuum extraction set Kit- k – Embryotomy set Kit- L – Uterine evacuation set Kit-M – Equipment for anesthesia Kit-N- Neonatal resuscitation set Kit-O- Equipment and reagent for blood test Kit-P – Donor blood transfusion set Dr. KANUPRIYA CHATURVEDI

Goals set for various national /int. policies Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI RCH Program: Phase II RCH Phase II began from 1 April 2005. The components being: Essential obstetrical care Emergency obstetrical care Strengthening referral system Strengthening project management Strengthening infrastructure Capacity building Improving referral system Strengthening MIS Innovative schemes Dr. KANUPRIYA CHATURVEDI

Essential obstetric care Promotion of institutional deliveries 50% of the PHCs and CHCs made operational as 24 hours delivery centers. Skilled attendance at birth Policy descions to permit Health workers to use drugs in emergency situations to reduce maternal mortality Dr. KANUPRIYA CHATURVEDI

Emergency obstetric care Operationalisation of FRUs to provide: 24 hours delivery services Emergency obstetric care New born care and emergency care of the sick child Full range of family planning services Safe abortion services Treatment of RTI and STI Blood storage facility Essential laboratory services Referral ( transport ) services Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI New initiatives Training of PHC doctors in life saving anesthetic skills for emergency obstetric care a FRUs Setting up of blood storage centres at FRUs Janani suraksha yojana Vandemataram scheme Safe abortion services Integrated Management of Childhood illnesses. Dr. KANUPRIYA CHATURVEDI

24 hrs. Functioning of PHCs • It is planned to establish 2000 FRUs in phases in RCH-II 50% PHCs and all CHCs to be operationalised in phases • Availability of Services such as - 24 Hrs. Delivery services - New Born care - Family Planning, Counselling and services - Availability of RTI, STI services - Safe abortion services (MVA etc.) Dr. KANUPRIYA CHATURVEDI

Training in Anaesthesia • Training of MBBS Doctors in Life Saving Anaesthetic Skills for Emergency Obstetric Care. • 18 weeks training course • The First Training Programme Conducted at AIIMS for Chhattisgarh • Training to be conducted in phases and limited to the requirement at FRUs. • Training guidelines giving criteria for certification, selection of trainees & training instt./medical college, minimum procedures etc. finalized Dr. KANUPRIYA CHATURVEDI 26

Training in Obstetric Management • Training of MBBS doctors in obstetric management and skills including C.S. in RCH-II • Training to be conducted in collaboration with FOGSI • Duration of training to be 16 weeks • Expert Group is considering other details Dr. KANUPRIYA CHATURVEDI

Blood Storage Facility Management of obstetric emergencies is sometimes not possible due to non-availability of blood. The Drugs and Cosmetics Act was therefore modified to facilitate establishment of blood storage centres at FRU’s. Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Janani Surkasha Yojna To promote Institutional Deliveries To reduce overall Maternal Mortality Ratio Infant Mortality Rate A safe motherhood intervention, replacing the “NationalMaternity Benefit Scheme”, under NRHM 100 % centrally sponsored Integrates cash assistance with delivery & post-delivery care. Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Vandematram Scheme It is a voluntary scheme wherein any obstetric and gynaec specialist, maternity home can volunteer Enrolled doctors will display ‘vandemataram logo’ at their clinics. Iron and folic acid tablets, oral pills, TT injections, etc will be provided for free distribution. Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Referral Transport Key issues: Roads, transportation, RCH I funds poorly Utilized, Community participation lacking Under Consideration – Place funds with AWW /ANM; [ JSY] – Develop community mechanisms – Provide out source ambulances at PHCs CHCs, and FRUs Easy access to ambulance & assistance from AWW Dr. KANUPRIYA CHATURVEDI 31

Dr. KANUPRIYA CHATURVEDI Role of ASHA • A village level link worker attached to AWW/ANM • Motivator for ANC, PNC, Institutional Delivery, Immunization and Family Planning Services • Provide Escort to beneficiary for above services. • Adolescents Health Counsellor. • Link between beneficiaries and ANMs. Dr. KANUPRIYA CHATURVEDI 32

Dr. KANUPRIYA CHATURVEDI Strategy for addressing Adolescent Reproductive and Sexual Health (ARSH) A two-pronged strategy will be supported: Incorporation of adolescent issues in all the RCH training programs and all RCH materials developed for communication and behaviour change. Dedicated days and dedicated timings for adolescents at PHC’s. Dr. KANUPRIYA CHATURVEDI 33

Infection Management and Environment Plan IMEP which is being extended to health care facilities includes: Treatment and disposal of biomedical wastes Disposal of syringe waste Provision of water sanitation and good hygiene conditions Dr. KANUPRIYA CHATURVEDI

Safe Abortion Practices MEDICAL METHOD Termination of early pregnancy (49days) using 2 drugs - mifeprestone followed by mesoprostol MANUAL VACCUM ASPIRATION Safe and simple technique for termination of pregnancy. Can be used at PHC or comparable facility FOGSI, WHO & state govt. are coordinating the project Dr. KANUPRIYA CHATURVEDI

Some Innovative State Initiatives Gujarat Increase access to safe delivery services. It is in partnership with private providers (Chiranjivi Yojana) A Dai Sangathan has been formed by 10 leading NGOs of the state to facilitate interface between the health system and the community Punjab Proposed to pay an incentive of Rs. 500/- to BPL SCs belonging to urban areas Purchase and supply of nutrients like iron, calcium, D-worming tablets for pregnant mothers belonging to SC classes. 40 plus care including screening code for CaCx- in /tn BCC including IEC, counseling, family & community participation. Subsidized Medical Practitioner (SMP) scheme – This scheme is based on success achieved of this scheme in Pune district . Districts will identify remote and hilly areas where medical care is not available . Newly passed out Medical Graduates (Preferably Ayurvedic) will be provided with assistance in the form of honorarium, drugs etc. on a tapering basis for two years so as to settle their private practice. Nurse Practitioners Scheme– Similar to SMP scheme districts will identify villages where nurses can practice Midwifery and other minor ailment treatment on payment basis, they will be provided with honorarium, drugs etc. on a tapering basis for two years so as to settle their private practice. Implementation of Health Insurance scheme on pilot basis. Dr. KANUPRIYA CHATURVEDI 36

Dr. KANUPRIYA CHATURVEDI Contd…. Screening code for Ca Cervix – Tamil Nadu Subsidized Medical Practitioner (SMP) scheme- Assam, Bihar Nurse Practitioners Scheme Laproscopic Training – Maharashtra Implementation of Health Insurance scheme on pilot basis. There is increased trained of Laproscopic Sterilization. Laproscopic Sterilization is on going activity. To train eligible candidates (Gynaecologist & General Surgeon) in Laproscopic sterilization, the following institutes are identified - 1) Sasoon Hospital, Pune 2) YCM Hospital, Pimpari Chinchwad 3) Shri Sali Hospital, Manchar,Dist. Pune 4) Women Hospital - Jalna 5) District Hospital - Alibag 6) Govt. Medical College,Dhule Contribution from Private Sector is there in the form of performance as well as training to Surgeons. The training of Laproscopic Sterilization is to be imparted to team comprising of Gynaecologist / General Surgeon Private Practitioners who are eligible for training and has desired to under go training Family Planning Association of India and Sangamnerkar Dwarika Subsidized Medical Practitioner (SMP) scheme – This scheme is based on success achieved of this scheme in Pune district . Districts will identify remote and hilly areas where medical care is not available . Newly passed out Medical Graduates (Preferably Ayurvedic) will be provided with assistance in the form of honorarium, drugs etc. on a tapering basis for two years so as to settle their private practice. Nurse Practitioners Scheme– Similar to SMP scheme districts will identify villages where nurses can practice Midwifery and other minor ailment treatment on payment basis, they will be provided with honorarium, drugs etc. on a tapering basis for two years so as to settle their private practice. Dr. KANUPRIYA CHATURVEDI 37

Monitoring : Accessibility Indicators No. of eligible couples registered/ANM No. of Antenatal Care sessions held as planned % of sub Centers with no ANM % of sub Centers with working equipment of ANC % ANM/TBA without requisite skill % sub centers with DDKs % of sub centers with infant weighing machine % subcenters with vaccine supplies % sub centers with ORS packets % sub centers with FP supplies Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Quality Indicators Following are the quality indicators used to monitor and evaluate RCH programme through monthly reports: Number of antenatal cases registered Number of pregnant women who had 3 antenatal checkups Number of high risk pregnant women referred Number of pregnant women who had 2 doses of TT Number of pregnant women under prophylaxis and treatment of anaemia Number of deliveries by trained and untrained attendants Number of cases with complications referred to PHC/FRU Number of newborn with birth weight recorded SINCE IT IS A TARGET FREE APPROACH MONTHLY MONITORING IS MANDATOTRY. Dr. KANUPRIYA CHATURVEDI 39

Dr. KANUPRIYA CHATURVEDI Contd.. No. of women given 3 post natal check-ups No. of RTI/STD cases detected, treated and referred No. of children fully immunized No. of adverse reactions reported after immunization No. of cases of ARI and diarrhea under 5yrs No. of cases motivated and followed for contraception. Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI Impact Indicators % DEATHS FROM MATERNAL CAUSES MATERNAL MORTALITY RATIO PREVALENCE OF MATERNAL MORBIDITY % LOW BIRTH WEIGHT NEO-NATAL MORTALITY RATIO PREVALENCE OF POST NATAL MATERNAL MORBIDITY % BABY BREAST FEED WITHIN 6 HRS OF DELIVERY COUPLE PROTECTION RATE PREVALENCE OF TERMINAL METHOD OF STERILIZATION PREVALENCE OF SPACING METHOD % ABORTION RELATED MORBIDITY PREVALENCE OF ADD PREVALENCE OF ARI PREVALENCE OF RTI/STDs Dr. KANUPRIYA CHATURVEDI