RMNCH+A … a continuum of care approach Conference on Healthy Gujarat “Agenda for Action” Dr. Manisha Malhotra, Deputy Commissioner Ministry of Health and Family Welfare Government of India

The Evolution…Reproductive and Child Health Programme in India Evolved from RCH Phase I (1997- 2005) to RCH Phase –II (2005-2012) Lies at the heart of NRHM … the means for major health system strengthening for improving RCH outcomes. RCH II … a comprehensive sector wide flagship programme, under the umbrella of the NRHM, to deliver the targets for improved MNCH outcomes. Aims to reduce social and geographical disparities in access to, and utilisation of quality reproductive and child health services. A range of proven, evidence based strategies adopted in core areas of MH, CH, and FP to achieve the desired reductions in key RCH II/ NRHM goals of MMR, IMR and TFR.

RCH II: Key Principles RCH II (2005-12) envisages A ‘bottom up’ planning approach that gives flexibility to the states to evolve programmes based on their contextual needs. Moving away from ‘One Size Fits All’ design – states allowed to plan according to their requirements. Ensuring a more explicit ‘Pro-Poor’ focus Evolving a shared vision and a common programme i.e. ‘Sector wide approach’

Wide inter and intrastate disparities ! WHERE ARE WE NOW… Wide inter and intrastate disparities ! INDICATOR BASELINE MDG 2015 AS ON DATE IMR 58 (SRS 2004) 27 42 (SRS 2012) NMR 37 - 31 (SRS 2011) MMR 301 (SRS 01-03) 108 212 (SRS 07-09) TFR 2.9 -- 2.4 NOTES 4 Indicator 1951 1971 1981 1991 1999 Current Birth rate 40.8 36.9 33.9 29.5 26.0 23.8 (SRS 2005)  IMR 148 129 110 80 70  58 (SRS 2005) MMR    407 301 SRS 98-99 (SRS 01-03) TFR 6 5.2 4.5 3.6 3.2 2.9 SRS 2000 4

RMNCH+A … A New Strategic Approach (Reproductive, Maternal, Newborn ,Child and Adolescent Health) The Premise- Maternal and Child health cannot be improved in isolation Adolescent Health and Family Planning have an important bearing on the outcomes The Approach- Comprehensive … ‘ life cycle approach’ for improving MNCH outcomes under NRHM. Concept of ‘continuum of care’ Plus denotes.. A Special focus on Adolescents … linking community and facility based care

Why RMNCH+A approach? Vertical compartmentalised schemes do not work if goals and targets are to be achieved ! Adolescent mothers: 16% of all mothers are adolescents High risk pregnancy and chances of dying are twice than in women over age 20 Prevalence of Neonatal mortality (54.2/ 1000 LB) is higher among adolescent mothers (NFHS III, 2005-06) High levels of Anaemia: (55.8% of adolescent girls, 58.7% of pregnant women and 63.2 % of lactating women anaemic) Anaemia is a major contributory factor in maternal deaths due to haemorrhage 22% LBW babies and high prevalence of IUGR 34% under 5 child deaths attributed to Malnutrition Spacing of births can reduce 25% of maternal deaths. 30% increase in use of contraception can halve the infant deaths . The mean BMI for adolescent girls (15-19 years) is 19, a little above the lower normal (range of 18.5-24.9). For boys of the same age group it is lower than normal at 18.3. Almost half of adolescents (both girls and boys) fall below the normal range varying from totally thin to severely thin. Almost. According to NFHS-3 more than half of women, more so in the rural areas, were anaemic in every age group. The prevalence of anaemia is higher for those aged 15-19 years in both women and men. It was found that there has been no change in the prevalence of anaemia among women aged 15-19 and 20-24 years across NFHS-1 and 2. In fact, as per NFHS-3, anaemia is more widespread among both women and children and has risen almost 5 percent since NFHS-2 in both the groups. Iodized salt was used only in approximately 50% of the households (NFHS-3).

RMNCH+A …a new approach ACROSS LEVELS OF CARE ACROSS LIFESTAGES Health facilities at various levels : PHCs, FRUs, DH Outreach services Family / home and community care Appropriate Referral & Follow up

RMNCH+A approach… key features Convergence & partnerships with other Ministries/ departments, development partners, civil society organisations & other stakeholders Heath Systems strengthening : Infrastructure, Human resources, drugs & commodities, referral transport Five high impact interventions across five key life stages Prioritisation of investments : High Priority Districts, tribal blocks, marginalised populations in underserved areas …also urban slums Integrated monitoring and accountability through good governance, use of data, communitisation & grievance redressal

5 X 5 matrix for High Impact RMNCH+A Interventions When Implemented with High Coverage and High Quality Reproductive Health Maternal Health Newborn Health Child Health Adolescent Health Focus on spacing methods, particularly PPIUCD at high case load facilities Focus on interval IUCD at all facilities including subcentres on fixed days Home delivery of Contraceptives (HDC) and Ensuring Spacing at Birth (ESB) through ASHAs Ensuring access to Pregnancy Testing Kits (PTK-"Nischay Kits") and strengthening comprehensive abortion care services. Maintaining quality sterilization services. Use MCTS to ensure early registration of pregnancy and full ANC Detect high risk pregnancies and line list including severely anemic mothers and ensure appropriate management. Equip Delivery points with highly trained HR and ensure equitable access to EmOC services through FRUs; Add MCH wings as per need Review maternal, infant and child deaths for corrective actions Identify villages with low institutional delivery & distribute Misoprostol to select women during pregnancy; incentivize ANMs for domiciliary deliveries Early initiation and exclusive breastfeeding Home based newborn care through ASHA Essential Newborn Care and resuscitation services at all delivery points Special Newborn Care Units with highly trained human resource and other infra structure Community level use of Gentamycin by ANM Complementary feeding, IFA supplementation and focus on nutrition Diarrhoea management at community level using ORS and Zinc Management of pneumonia Full immunization coverage Rashtriya Bal Swasthya Karyakram (RBSK): screening of children for 4Ds’ (birth defects, development delays, deficiencies and disease) and its management Address teenage pregnancy and increase contraceptive prevalence in adolescents Introduce Community based services through peer educators Strengthen ARSH clinics Roll out National Iron Plus Initiative including weekly IFA supplementation Promote Menstrual Hygiene Health Systems Strengthening Case load based deployment of HR at all levels Ambulances, drugs, diagnostics, reproductive health commodities Health Education, Demand Promotion & Behavior change communication Supportive supervision and use of data for monitoring and review, including scorecards based on HMIS Public grievances redressal mechanism; client satisfaction and patient safety through all round quality assurance Cross cutting Interventions Bring down out of pocket expenses by ensuring JSSK, RBSK and other free entitlements ANMs & Nurses to provide specialized and quality care to pregnant women and children Address social determinants of health through convergence Focus on un-served and underserved villages, urban slums and blocks Introduce difficult area and performance based incentives

Matrix for High Impact RMNCH+A Interventions List of Minimum Essential Commodities Reproductive Health Maternal Health Newborn Health Child Health Adolescent Health Tubal Rings IUCD 380-A, IUCD 375 Oral Contraceptive Pills (OCPs) / (Mala-N ) Condoms Emergency Contraceptive Pills(ECP) -(Levonorgestrel 1.5mg) Pregnancy Testing Kits (PTKs) - Nischay Injection Oxytocin Tablet Misoprostol Injection Magnesium Sulphate Tablet Mifepristone (Only at facilities conducting Safe Abortion Services) Injection Vitamin K Mucous extractor Vaccines - BCG, Oral Polio Vaccine (OPV), Hep B   Oral Rehydration Salt (ORS) Zinc Sulphate Dispersible Tablets Syrup Salbutamol & Salbutamol nebulising solution Vaccines - DPT, Measles JE (19 States), Pentavalent vaccine (in 8 States) Syrup Vitamin A Tablet Albendazole Tablet Dicyclomine Sanitary Napkin Cross cutting Commodities as per level of facility Iron & Folic Acid (IFA) Tablet, IFA small tablet, IFA syrup Syrup /tablets : Paracetamol, Trimethoprim & Sulphamethoxazole, Chloroquin and Inj. Dexamethasone Antibiotics : Cap /Inj. Ampicillin, Metronidazole, Amoxycillin; Inj. Gentamicin, Inj. Ceftriaxone; Clinical /Digital Thermometer; Weighing machine; BP apparatus; Stop Watch; Cold box; Vaccine carrier; Oxygen; Bag & mask Testing for Haemoglobin, urine and blood sugar

New initiatives National Iron + Initiative to prevent and control anaemia - Includes Weekly Iron Folic Acid Supplementation for 13 crore adolescents Emphasis on spacing Door step delivery of contraceptives by >8.8 lakh ASHAs Post partum IUCD /FPS to reach > 1.66 crore women accessing public health facilities Provision of information on Sexual and Reproductive Health, Mental Health, Nutrition, Injuries and Violence, Substance misuse and NCDS. Scaling up of facility based services

New initiatives contd.. About 16000 health facilities with case loads above laid down benchmarks identified as “Delivery Points” Improving Infrastructure for quality MCH care: 468 Maternal and Child Health Wings with 28000 additional beds New focus on 24 crore adolescents: Reaching out to them in their own spaces besides facility based care Strengthening pre-service and in-service training of ANMs and nurses Moving Beyond Numbers towards quality of care: Quality Assurance Guidelines, skills labs etc.

RMNCH+A… Prioritising resources for marginalised and underserved populations… “High Priority Districts”

RMNCH+ A Indicators included in composite index (Data Source : DLHS-3) High Priority Districts .. based on Composite Health Index  RMNCH+ A Indicators included in composite index (Data Source : DLHS-3) Maternal Health i. % of mothers received at least 3 ANC visits ii. % of Safe Deliveries  Child Health iii. % of Children aged 6 months and above exclusively breastfed iv. % of Children 12-23 months fully immunized  Family planning v. % of births of order 3 and above vi. Contraceptive Prevalence Rate (CPR) – Modern Method Based on Composite Health Index, bottom 25% districts identified in the state

High Priority Districts .. additional selection criteria Based on Composite Health Index, bottom 25% districts identified in each state LWE /backward/ tribal districts falling in the bottom 50% districts(IAP) 41 Tribal districts out of total 86 tribal districts in India also featured Each state assigned to one Lead Partner agency, UNICEF for Gujarat

Monitoring progress on RMNCH+A using Score Card Score Card is a simple management tool for converting available HMIS information into actionable points and assists in comparative assessment of District and Block performance 16 indicators selected based on life cycle approach ( RMNCH+A) representing various phases Composite Index for each phase to measure the district variation across the state Overall composite index to measure performance of the districts

Scorecard: HMIS indicators across life cycle Score Card: HMIS Indicators across the life cycle Scorecard: HMIS indicators across life cycle Pregnancy care Child birth Postnatal care, newborn & child health Reproductive age group 1st Trimester registration 3 ANC check-ups 100 IFA intake Obstetric complications attended TT2 injections Newborns breastfed within 1 hour Women discharged in < 48 hours Newborns weighing less than 2.5 kg Newborns visited within 24hrs of home delivery 0 - 11 months old receiving Measles vaccine Post-partum sterilization to total female sterilization Male sterilization to total sterilization IUD insertions in public + private accredited institution SBA attending home deliveries Institutional deliveries C-Section

Score card & HIGH PRIORITY DISTRICT PERFORMANCE HPDs Very Low performing Ahmedabad   Bharuch Dahod Kachchh Narmada Surat Valsad Valsad  Low performing Banas Kantha Bhavnagar Patan Surendranagar The Dangs The Dangs  Vadodara Promising Amreli Panch Mahals Panch Mahals  Porbandar Rajkot Sabar Kantha Good performing Anand Gandhinagar Jamnagar Junagadh Kheda Mahesana Navsari Score card & HIGH PRIORITY DISTRICT PERFORMANCE High performance Promising Low Very low

District/Block wise variation (HPDs) (April 2012-March 2013) Composite Index Banas Kantha Dahod Kachchh Narmada Panch Mahals Sabar Kantha The Dangs Valsad Overall Index 0.4714 0.4431 0.4187 0.4395 0.5584 0.5179 0.5126 0.4459 1. Reproductive age group 0.2314 0.1732 0.1343 0.1111 0.4149 0.4305 0.4545 0.0267 2. Pregnancy Care 0.4578 0.3487 0.4076 0.6304 0.4633 0.4746 0.7322 0.49 3. Child Birth 0.2945 0.5142 0.2932 0.2492 0.3154 0.497 0.0355 0.2349 4. Postnatal mother and new born Care 0.7333 0.7617 0.7231 0.6104 0.8567 0.7829 0.7003 0.8313 Good Performing Promising Low Very low performing

Five key steps in District Intensification Plan Rapid Assessment: For gap identification Health Systems Strengthening :Gap filling & Supply Chain Management Improving demand for services Engagement with other Social-Sector departments Concurrent Monitoring & Supportive Supervision

Five key steps for Intensification of efforts in High Priority Districts Rapid Assessment: For gap identification Geographical, epidemiological , socio-cultural, identification of the backward blocks Assessment of Health Facilities and Outreach: Functionality, Utilisation, Equity, Access, Gender aspects Resource mapping exercise in the districts Development of District Action Plan with special focus on Backward blocks Health Systems Strengthening and Gap filling : some examples 30% Higher financial allocation under NRHM (State PIP) Relaxation of norms for HR, Infrastructure as per guidance from GOI Additional incentives, difficult area allowance, residential facilities Accreditation of private institutions and NGO run facilities/NGOs Need based capacity building Supply Chain Management

Thrust on most backward blocks Five key steps for Intensification of efforts in High Priority Districts… Focus on improving demand for services: Behaviour Change Communication Engagement with other Social-Sector departments: Coordinated Planning , supervision and resource sharing Concurrent Monitoring & Supportive Supervision: HMIS based Score Cards quarterly, field data validation through regular monitoring visits to blocks Thrust on most backward blocks

Partners’ support for Intensification Full-Spectrum of RMNCH+A interventions to be addressed Harmonised managerial and technical support extending beyond thematic/organisational expertise Partners to act as catalysts, mentors and handhold SPMUs and DPMUs and field functionaries Differential District Planning based on gap analysis Innovations in service delivery mechanisms Harmonization to add value to the National programme and help realise health outcomes

Structure for monitoring of Intensification efforts in HPDs National RMNCH+A Unit (NRU) anchored in MoHFW, led by JS (RCH) and supported by USAID Consortium of representatives of partner agencies to periodically review the RMNCH+A progress of HPDs NRU to liaise with State Lead Partners, state governments, SPMUs and DPMUs for overall implementation and monitoring of RMNCH+A interventions

Support Structure at State Level State RMNCH+A Unit (SRU) led by State Lead Partner (SLP), consisting of representatives of development partners District Level Monitors (DLM) identified for each HPD from the existing human resource of SLP/Partners State Unified Team (SUT) comprising of experts from development partners and State Government /SPMU