1. MID TERM REVIEW OF REPRODUCTIVE AND CHILD HEALTH PROGRAMME – II NGO Consultation 17 December 2008 1

2. Overview of the Presentation 2  RCH II / NRHM Programme Goals  Strategies  Progress of Interventions

3. 3 CURRENT STATUS VIS-A-VIS RCH II/NRHM GOALS RCH II Goal Indicator All India Status (Source of Data) Targets forNo. of states having achieved % of total population (for states having achieved) 10 th Plan (2007) RCH II /NRHM (2012) 10 th Plan targets RCH II /NRHM targets 10 th Plan targets # RCH II /NRHM targets # MMR (per lakh live births) 398 (SRS 1997-98) 301 (SRS 2001-03) <200<1008Nil43.1%Nil IMR (per 1000 live births) 71 (SRS 1997) 55 (SRS 2007) <45<3013531.1%3.7% TFR3.3 (SRS 1997) 2.8 (SRS 2006) 2.32.110544.3%25.0% Note: 1. # Census 2001 2. Current MMR and TFR data pre-dates RCH II, while IMR data is for first year of RCH II. 3. Union territories (except Delhi) have been excluded in the findings

4. RCH II STRATEGIES 4

5. 5 MATERNAL HEALTH STRATEGIES Demand Promotion: Janani Suraksha Yojana. Services: Public sector Early detection of pregnancy through rapid detection kits. Quality ANC, PNC, Institutional and Safe Delivery Skilled Attendance at birth (domiciliary & health facilities). Essential and Emergency Obstetric Care Operationalise facilities- FRUs, CHCs, 24 Hrs PHCs. Multi-skilling of doctors to overcome shortage of critical specialities (training on Life saving Anaesthesia Skills and Emergency Obstetric Care) Strengthen Referral Systems including transport. Management of RTIs & STIs at PHCs & CHCs/FRUs. Safe Abortion Services – PHC/ FRU level Services: Private sector  Accrediting private health institutions under JSY  Fixed package for contracting out services (e.g. Chiranjeevi scheme in Gujarat)  Supporting Private Gynaecologist to establish their nursing homes in Tribal area where Chiranjeevi scheme is not working (in Gujarat)

6. 6 Key Features  Early Registration  Referral Transport (Home to Health Institution)  Promoting Institutional birth  Post delivery visit and reporting  Family Planning and Counseling JANANI SURAKSHA YOJANA (JSY ) Supported by ASHA/ any Link worker Cash Assistance

7. 7 CHILD HEALTH STRATEGIES Integrated Management of Neonatal and Childhood Illnesses Pre-service and In-service training of providers Improving health systems (e.g. facility upgradation, availability of logistics, referral systems) Community and Family level care Home Based Newborn and Child Care/ Facility Based Newborn Care Infant and Young Child Feeding including Improving Early and Exclusive Breastfeeding and Complementary Feeding Nutritional Rehabilitation Centre for Management of Acute Malnutrition Reduction in morbidity and mortality due to Acute Respiratory Infections (ARI) and Diarrhoeal Diseases Supplementation with micronutrients: Vitamin A & iron School Health Program

8. IMMUNISATION INTERVENTIONS 8 Introduction of new vaccines based on disease specific mortality and morbidity indicators – Hepatitis B System Strengthening : Activity based funding to strengthen service delivery Alternate vaccine delivery to ensure reach into villages Alternate Vaccinators to ensure sessions are held ASHA/Link workers used for Social Mobilization to ensure demand creation in community. Strengthening Supportive supervision Half yearly meeting at State with districts to ensure monitoring. Support for POL to assist active supervision Capacity Building: Trainings at all levels for all aspects of immunization service delivery Monitoring and supervision of the programme at service delivery level Demand generation: Social Mobilization

9. FAMILY PLANNING STRATEGIES 9 1.Reduce unmet need for spacing methods 2.Reduce unmet need for terminal methods 3.Increasing male participation 4.Expanding contraceptive choices 5.Ensuring quality care in Family Planning 6.Introducing indemnity insurance 7.Revision of compensation to acceptors of sterilization 8.Social marketing of Family Planning products 9.Strengthening contraceptive logistics 10.Emphasis on promotion of IUD 380 and Emergency Contraception

10. PROGRESS OF RCH II 10

11. 11 INSTITUTIONAL DELIVERIES 11

12. JSY PERFORMANCE Allocation for 2008-09 is Rs. 1281.47 crores 12

13. MATERNAL HEALTH PROGRESS Training of MOs in anaesthesia and EmOC and ANMs/SNs in SBA has gained considerable momentum. Achievements in MH trainings (cumulative): FacilityTargetAchievement* FRU3,3601,652 24-hour PHC14,22511,135 13 Trainings06-0707-0808-09 (upto Sep) Anesthesia (MOs)26398534 EmOC (MOs)40101213 SBA (SN/ ANMs)1800510517922 Achievements in Facility Operationalisation: * – NRHM data, Aug 2008

14. VILLAGE HEALTH AND NUTRITION DAYS KEY COMPONENTS Registration of pregnancy ANC PNC Birth planning Immunization Counselling on nutrition Counselling on family planning Services for sick children 14 Based on data from NRHM

15. PROGRESS: 2005-08 Maternal health Institutional deliveries have increased in most of the states in the country. High focus states have shown tremendous growth. Maximum increases in MP, Orissa, Rajasthan, Assam, and Bihar. Ten fold increase in JSY beneficiaries to 73.29 lakhs in 3 years. Greater transparency in JSY implementation seen during state visits. JSY has led to huge increases in institutional delivery: MP (21.9% points); Rajasthan (12.2% points); Bihar (11% points); Orissa (10.2% points). 15

16. PROGRESS: 2005-08 Maternal health (contd.) Facility operationalisation: 49% and 46% of FRU and 24x7 PHC targets achieved. Multi skill training of doctors in EmOC and LSAS and “task shifting“ to ANMs and SNs gaining momentum. Referral transport systems, in general have been given emphasis across states; visits to MP and Gujarat indicated wide use of the Janani Express Yojana and EMRI 108 service respectively. Field visits indicate availability of NISHCHAY (Rapid pregnancy testing kit) with peripheral health functionaries. A rapid assessment conducted recently indicates over 82% of ASHAs themselves performed tests. Need to ensure subsequent counselling/ follow up. 16

17. 17 Coverage in Child Immunization 17

18. PROGRESS: 2005-08 Child Health Full immunisation has improved across states; particularly in Assam, Jharkhand, Rajasthan, Bihar, Uttarakhand and Sikkim. Drop outs between BCG and measles, and within doses, have declined. The negative trend seen in full immunisation coverage between CES 2005–2006 has been reversed in DLHS III in Rajasthan, Punjab and Karnataka. Improvements in early initiation of breastfeeding and exclusive breastfeeding. IMNCI implementation has accelerated: 193 districts with 71,355 personnel trained; pre-service IMNCI underway in 62 medical colleges. 18

19. Programmatic interventions in Family Planning 1. Addressing the unmet need in terminal methods Fixed Day Static services Developing Skilled manpower for the same 2. Increasing Male participation through intensive promotion of NSV 3. Promotion of IUDs as a short & long term spacing method 4. Promotion of Emergency Contraceptive Pills 5. Increasing Basket of choices for Contraceptives 19

20. Promotional Interventions in FP Revised COMPENSATION scheme Family planning INSURANCE scheme Ensuring Contraceptive supply Promoting PPP/ Social Marketing Promoting contraception through increased ADVOCACY 20

21. FP Systems: Mechanisms for monitoring for quality Quality Assurance Committees Monitoring all aspects of RCH Technical manuals updated Standards and QA in Sterilization services IUD for MOs and Nursing Personnel Standard Operating Procedures for sterilisation camps Emergency Contraceptive pills Fixed Day Strategy in sterilisation services 21

22. Progress of FP Indicators TFR CPR Contraceptive use reduced from 3.3 to 2.9 (SRS 05) increased to 45.7 % (NFHS 3) increased from 48.2% to 56.3 % (NFHS 3)

23. Indicators Unmet need NFHS 2NFHS 3 Total1613 Permanent87 Spacing86

24. PROGRESS : 2005-08 Behaviour change communication Strong NRHM brand. State-specific BCC strategies have been developed in Chhattisgarh, Jharkhand and Uttar Pradesh, while district specific BCC strategies are underway in MP. Other key state level initiatives include innovative IPC tools in Uttarakhand, BCC kit and training module developed by Chhattisgarh and IPC tools such as flip book for ASHAs in UP, BCC corners at the PHC level in Gujarat, pilot to involve tribal community healers and utilizing Kalyani clubs in Orissa. 24

25. PROGRESS : 2005-08 Monitoring and evaluation Overall, monitoring of the RCH II program has strengthened since its inception. NFHS III 2005/6 released in 2007; DLHS III results released. MoHFW has rationalised the indicator set for the national MIS; a web based system for reporting has been launched. Capacity of the M&E division strengthened. Data Triangulation Cell set up. Several examples of states which have developed better M&E tools: GIS mapping in Gujarat and Orissa; pregnancy cohorts in TN. 25

26. INNOVATIONS Range and spread of innovations is impressive, and over 200 have been identified so far. These cover: Promotion of safe motherhood and institutional deliveries (24) Innovations have been piloted within the NRHM/RCH II parameters of decentralization, flexibility, and results based performance Equity is a central theme in a large number of innovations. Several are state specific but some span several states, or are similar across states (e.g. EMRI, Chiranjeevi-like schemes to promote safe motherhood/ institutional deliveries) Several states have undertaken evaluation of their innovations, while some innovations have been evaluated nationally. 26

27. INNOVATIONS Referral transport (17) Immunisation and IYCF (27) IEC/ BCC (18) ARSH (5) Health insurance (8) Contracting out management of health facilities (14) Social franchising (4) Inceentivising human resources to improve access, performance and range of services (8) Mobile Health clinics (11) Community involvement (28) Programme Monitoring and Management Information Systems (13) Incentives to improve mobility, availability and attendance of staff (22) 27

28. Paradigm shift envisaged under RCH II is well underway RCH II DESIGNPROGRESS Focusing on results Emphasis on outcomes since all states/UTs set targets for IMR, MMR and TFR as well as underlying indicators; and spell out strategies and activities for meeting targets. Flexible financing System of allocating “flexi funds” to states, preparation and appraisal of PIPs established. Encouraging innovative approaches to improve RCH outcomes Over 200 innovations identified across 25 states. 3154 private facilities (equivalent to 12% of total PHCs and CHCs) have been accredited to provide ANC and delivery services. Decentralisation and bottom up planning DHAPs increased from 284 in 2006-07 to 488 in 2007-08. States have increasingly veered towards community ownership, engaging community and PRIs in monitoring of health programs and management of health facilities. Pro poor focus Equity is a central theme in a large number of innovations. 28

29. 29 THANK YOU