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RMNCH+A strategy: Reproductive, Maternal, neonatal, child and Adolescent Health

Reproductive, Maternal, neonatal, child and Adolescent Health strategy launched by MoHFW, GoI.

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RMNCH+A strategy: Reproductive, Maternal, neonatal, child and Adolescent Health

  1. 1. RMNCH+A strategy Dr. Gaurav Kamboj Junior Resident
  2. 2. “Women are not dying because of a disease we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” Mamoud Fathalla President of the International Federation of Gynecology and Obstetrics (FIGO), XV World Congress, Copenhagen 1997
  3. 3. Framework • Historical background • Goals • Challenges of Reproductive and Child Health- II • Situation of Reproductive, Maternal and Child Health in India • Causes for Maternal and Child Deaths in India • Rationale of RMNCH+A strategies • Strategic RMNCH+A Interventions across life-stages • Health System Strengthening for RMNCH+A Services • Monitoring, information and evaluation
  4. 4. Historical background Milestones of Family Welfare Programme 1951-56 National Family Planning Programme adopted by Govt. of India 1961-66 - Deptt. of Family Planning created in Ministry of Health - Lippes loop introduced, Massive effort to promote IUCD - Expansion of service facilities, spread of small family norm 1974-79 - Campaign for male sterilization - Renaming ‘Family Planning’ to ‘Family Welfare’ 1983 National Health Policy 1985 Universal Immunization Programme 1985-90 Inclusion of various programmes under MCH 1992-97 Child survival and Safe Motherhood Programme (CSSM) 1997-02 Reproductive and Child Health-I (CSSM + RTI/STI components) 2000 National Population Policy 2002 National Health Policy 2005 RCH II and NRHM (2005-2012) 2013-17 NRHM extended (NRHM + NUHM = NHM)
  5. 5. GOALS Health outcome goals established in the 12th Five Year Plan • Reduction of Infant Mortality Rate (IMR) to 25 per 1,000 live births and U5MR to 33 per 1000 live births by 2017 • Reduction in Maternal Mortality Ratio (MMR) to 100 per 100,000 live births by 2017 • Reduction in Total Fertility Rate(TFR) to 2.1 by 2017 Millennium Development Goals 27
  6. 6. Coverage targets for key RMNCH+A interventions for 2017 • Increase facilities equipped for perinatal care (designated as ‘delivery points’) by 100% • Increase proportion of all births in government and accredited private institutions at annual rate of 5.6 % from the baseline of 61% (SRS 2010) • Increase proportion of pregnant women receiving antenatal care at annual rate of 6% from the baseline of 53% (CES 2009) GOALS
  7. 7. Coverage targets for key RMNCH+A interventions for 2017 • Increase proportion of mothers and newborns receiving postnatal care at annual rate of 7.5% from the baseline of 45% (CES 2009) • Increase proportion of deliveries conducted by SBAs at annual rate of 2% from the baseline of 76% (CES 2009) • Increase exclusive breast feeding rates at annual rate of 9.6% from the baseline of 36% (CES 2009) GOALS
  8. 8. Coverage targets for key RMNCH+A interventions for 2017 • Reduce prevalence of under-five children who are underweight at annual rate of 5.5% from the baseline of 45% (NFHS 3) • Increase coverage of three doses of DPT at annual rate of 3.5% from the baseline of 71.5% (CES 2009) • Increase ORS use in under-five children with diarrhoea at annual rate of 7.2% from the baseline of 43% (CES 2009) GOALS
  9. 9. Coverage targets for key RMNCH+A interventions for 2017 • Reduce unmet need for family planning methods at annual rate of 8.8% from the baseline of 21% (DLHS 3) • Increase met need for modern family planning methods among eligible couples at annual rate of 4.5% from the baseline of 47% (DLHS 3) • Reduce anaemia in adolescent girls and boys (15–19 years) at annual rate of 6% from the baseline of 56% and 30%, respectively (NFHS 3) GOALS
  10. 10. Coverage targets for key RMNCH+A interventions for 2017 • Decrease the proportion of total fertility contributed by adolescents (15–19 years) at annual rate of 3.8% per year from the baseline of 16% (NFHS 3) • Raise child sex ratio in the 0–6 years age group at annual rate of 0.6% per year from the baseline of 914 (Census 2011) GOALS
  11. 11. Current challenges of RCH II Programme • Three components of maternal, child and reproductive health have actually been vertically operated in RCH. • ‘Adolescent health’ was the weakest pillar of our RCH program which is now one of the key strategies of RMNCH+A. • Some Districts are yet to use HMIS data to chart their progress against the target effectively. • Timely and transparent payments for JSY are not properly implemented • Inadequate implementation of Strategy for fixed day static services for family planning.
  12. 12. Situation of Reproductive, Maternal and Child Health in India • Maternal mortality ratio (MMR) declined from 254 (SRS 2005) to 178 (SRS 2013) • MMR in Haryana – 146 (SRS 2013) • IMR is 42 per 1,000 live births (SRS 2013) • NMR is 29 per 1,000 live births (SRS 2012) • U5MR is 52 per 1,000 live births (SRS 2012) • TFR is 2.4 (SRS 2012) (TFR for Haryana- 2.3) • JSY initiative resulted in a phenomenal increase in the rate of institutional deliveries in India from 47% (DLHS-3, 2007-08) to 73% (CES 2009). 398 327 301 254 212 178 0 50 100 150 200 250 300 350 400 450 1997-1998 1999-2001 2001-2003 2004-2006 2007-2009 2010-12 INDIA INDIA
  13. 13. Causes OF Maternal Death in India Haemorrhage 38% Sepsis 11%Abortion 8% Obstructed labour 5% Hypertensive disorder 5% others 33% Source: Causes of maternal deaths in India, SRS 2001-03
  14. 14. Causes for under 5 child death in India 2010 pnuemonia 8% preterm 19% asphyxia 10% sepsis 8% others 2%congenital 5% diarrhoea 1% diarrhoea 11% measles 3% meningitis 2% injuries 4% others 12% pnuemonia 15% Source: WHO/CHERG 2010 Neonatal deaths: 52%
  15. 15. Causes for Maternal and Child Deaths in India THE THREE DELAYS (1) The delay in deciding to seek care (2) The delay in reaching the appropriate health facility (3) The delay in receiving quality care once inside an institution Useful to design programmes to address these delays.
  16. 16. Rationale of RMNCH+A strategies • It is important to recognize that reproductive, maternal and child health cannot be addressed in isolation • To provide an understanding of comprehensive approach to improve child survival and safe motherhood
  17. 17. Why ‘Plus’ in RMNCH+A? 1. Inclusion of adolescence as a distinct ‘life stage’ in the overall strategy. 2. Linking of maternal and child health to reproductive health and other components like family planning, adolescent health, HIV, and PC&PNDT. 3. Linking of community and facility-based care as well as referrals between various levels of health care system to create a continuous care pathway.
  18. 18. Strategic RMNCH+A Interventions Across Life Stages There are two dimensions to healthcare: (1) stages of the life cycle (2) places where the care is provided ‘Continuum of Care’ Adolescence/ pre pregnancies Pregnancy Birth Newborn/ post natal Childhood
  19. 19. Adolescent Health Priority interventions 1. Adolescent nutrition; IFA supplementation 2. Facility-based adolescent reproductive and sexual health services (Adolescent health clinics) 3. Information and counseling on adolescent sexual reproductive health and other health issues 4. Menstrual hygiene 5. Preventive health checkups
  20. 20. Adolescent Nutrition • Nutrition education sessions to be held at community level- quarterly Adolescent Health Days (to coincide with Kishori Diwas in SABLA districts) • Screening for low BMI followed by counseling at adolescent health clinics. • National Iron + Initiative: Proposes to include new age groups • Adolescents, both in and out of school • Women in reproductive age group
  21. 21. • Weekly iron and folic acid supplementation scheme: It aims to cover adolescents enrolled in class VI–XII of government, government aided and municipal schools as well as ‘out of school’ girls (10-19) ‘Iron ki nili goli’ Mondays will be 'Iron' days: Azad
  22. 22. IFA supplementation programme and service delivery
  23. 23. Adolescent Friendly Health Clinics • Sub-centre level- by ANM • PHC - Adolescent Information and Counseling Centre will be made functional by MO and ANM on weekly basis. • CHC, DH/SDH and Medical College- Adolescent Health Clinics will provide services on a daily basis by RMNCH+A counsellors • Appropriate referrals for HIV testing and RTI/STI management to ICTCs • Provision of contraceptives
  24. 24. Information & counseling on Health Issues • School will serve as platform to educate and counsel adolescents on behavior risk modification. • Under Child Health Screening & Early Intervention Services, screening for diabetes & other NCDs is proposed. • Peer educators • In order to reduce adolescent pregnancy, focused messaging to individuals, families and communities (including men) will be reinforced. Life-skills-based Adolescence Education Programme
  25. 25. Menstrual Hygiene Scheme • Promotes better health and hygiene among adolescent girls (10-19 years) in rural areas • Sanitary napkins are provided under NRHM’s brand ‘Free days’. These napkins are sold to adolescent girls by ASHAs. Rs. 6/pack
  26. 26. Preventive health checkups and screening School Health Programme • Bi-annual health screening for students (6–18 years) enrolled in government and government-aided schools for disease, deficiency and disability. • Dedicated mobile health teams at block level.  2 Medical Officers (MBBS / Dental / AYUSH qualified)  2 paramedics (one ANM and any one of the following Pharmacist/Ophthalmic Assistant/Dental assistant) • Those need of secondary and tertiary care will be entitled to free treatment.
  27. 27. Pregnancy and Childbirth Priority interventions: 1. Delivery of ANC package & tracking of high- risk preg. 2. Skilled obstetric care 3. Immediate essential newborn care & resuscitation 4. Emergency obstetric and new born care 5. Postpartum care for mother and newborn 6. Postpartum IUCD and sterilization 7. Implementation of PC&PNDT Act
  28. 28. Preventive use of folic acid in peri- conception period • Enables to enter pregnancy in optimal health. • Prevention of neural tube defects and other congenital anomalies. • Peri-conception phase ( 3 months before & 3 months after conception) • 1 pre-pregnancy visit for couples planning pregnancy A new scheme for delaying first birth after marriage and ensuring spacing between first and second child was launched in May 2012 and has provision for incentivizing ASHAs for their efforts.
  29. 29. Delivery of ANC package and tracking of High-risk Pregnancies • Pregnancy Testing Kits ‘Nishchay’ available at all sub- centres and through ASHAs. • Universal access to full antenatal package both at community outreach and facility level. • Mother and Child Tracking system (MCTS) enables service providers to follow up women and programme managers to monitor service delivery • Universal confidential HIV screening (PPTCT Program).
  30. 30. Skilled Obstetric care and Essential Newborn care and Resuscitation • Delivery points • Prioritized for allocation of resources • Branded and positioned as quality RMNCH+A 24 X 7 centres • Janani Suraksha Yojana (JSY)- • Reach the unreached pregnant women who still deliver at home • 48 hours stay at the health facility • Postpartum family planning methods (PPIUCD) & counselling on exclusive breast feeding • Direct cash payments through AADHAR enabled payment system
  31. 31. • Janani Shishu Suraksha Karyakram (JSSK) • Reduce out-of-pocket expenses. • Free assured transport (ambulance service) • Newborn Care Corners • Established at delivery points • Providers are trained in basic newborn care and resuscitation through Navjaat Shishu Suraksha Karyakram (NSSK). Skilled Obstetric care and Essential Newborn care and Resuscitation
  32. 32. Emergency Obstetric & Newborn Care • MCH Wing- A comprehensive package of maternal, newborn and reproductive (family planning) services.
  33. 33. Adolescent Health Clinic SNCU
  34. 34. Multi skilling of Doctors • Life Saving Anaesthetic Skills (LSAS)- 8 week training programme of MBBS doctors • Obstetric Management Skills including Caesarean section (CEmOC) – 16 week training of MBBS doctors • Basic Emergency Obstetric Care (BEmOC) - 10 days training for Medical Officers • Skilled Birth Attendants(SBA) - 3 week training for ANMs/Staff Nurses.
  35. 35. Postpartum care for mother and baby • 48 hours of stay at health facility for institutional delivery • At least 3 postnatal visits to mother and 6 postnatal visits to newborn are to be made within six weeks of delivery • If Home delivery: 1st visit within 24 hours of birth
  36. 36. Postpartum IUCD insertion and sterilization • Post-partum IUCD (PPIUCD) insertion at district and sub-district hospital level • Training of M.O.s in ‘Minilap’ for provision of Post-Partum Sterilisation in high case load facilities • RMNCH counselor will ensure healthy timing and spacing between pregnancies and will counsel on breast feeding and other childcare practices.
  37. 37. Implementation of PC&PNDT Act • Improve sex ratio at birth by regulating pre- conception and pre-natal diagnostic techniques misused for sex selection • Key action: • Dedicated PC&PNDT cells at state/district level • Strengthening of human resources & infrastructure at all levels • Building community opinion against sex selective abortion and foeticide
  38. 38. Newborn and Child care Priority interventions 1. Home-based newborn care and prompt referral 2. Facility-based care of the sick newborn 3. Integrated management of common childhood illnesses (diarrhoea, pneumonia and malaria) 4. Child nutrition & essential micronutrients supplementation 5. Immunisation 6. Early detection and management of defects at birth, deficiencies, diseases and disability in children (0–18 years)
  39. 39. Home-based newborn care and prompt referral • Home-based newborn care scheme (2011) provides immediate postnatal care and essential newborn care to all newborns up to the age of 42 days. • Special care to pre terms and newborns by ASHAs. • ASHA are also trained in identification of illnesses, appropriate care and referral through home visits.
  40. 40. Facility-based care of Sick Newborns • NBSU: 4-bedded unit providing basic level of sick newborn care, established at CHCs/FRUs • SNCUs at District Hospitals and tertiary care hospitals GOAL One SNCU in • Each district of the country, and • Health facilities with more than 3,000 deliveries per year Free up to 30 days
  41. 41. Child nutrition • Follow up of all LBW babies by ASHA and ANM • National Iron + initiative • Tracking of BMI of Adolescents at the AWC • Deworming combined with Vitamin A supplementation during biannual rounds. Nutritional Rehabilitation Centres (NRCs) Will provide medical and nutritional care for children with severe acute malnutrition (SAM)
  42. 42. Integrated management of Common Childhood Illnesses (pneumonia, diarrhoea and malaria) • Availability of ORS and Zinc ensured at all sub-centres and frontline workers • Timely identification and prompt referral of children with fast breathing and/or lower chest in-drawing. • Prevention and treatment of malaria as per the guidelines in the National Malaria Control Programme. At community- ASHA package First level care- IMNCI Referral level care - F-IMNCI
  43. 43. Immunisation • Second dose of Measles introduced • Pentavalent vaccine, first introduced in two states (Kerala and Tamil Nadu), is now being expanded to six states and will eventually be scaled up to cover the entire country. • Coverage of vaccine beyond first year of life must be emphasised and monitored • Investigation report of every serious AEFI case must be submitted within 15 days of occurrence to district AEFI Committees
  44. 44. To strengthen routine immunization, newer initiatives include Provision for AD Syringes to ensure injection safety Support for AVD from PHC to outreach sessions Mobilization of children to immunization session sites by ASHA MCTS for tracking service delivery by -Generating due lists for ANMs -SMS alerts to beneficiaries -Maintaining records for actual services delivered.
  45. 45. Child Health Screening and Early Intervention Services (Rashtriya Bal Swasthya Karyakram) • Aims to reach 27 crore children annually in the age group of 0-18 years • Mobile health teams at block level • Screening for 30 identified health conditions. • Age group 0–6 years enrolled at AWC at least twice a year • Age group 6-18 years in schools annually • Free management of these children at District Early Interventions Centres Defects Deficiencies Diseases Development delays including disabilities Detect 4 D’s
  46. 46. Through the Reproductive Years Priority interventions 1. Community-based promotion and delivery of contraceptives. 2. Promotion of spacing methods (interval IUCD) 3. Sterilisation services (vasectomies, tubectomies) 4. Comprehensive abortion care (includes MTP Act) 1. Prevention and management of STI/RTIs
  47. 47. Community based doorstep distribution of contraceptives • ASHA charges a nominal amount from beneficiaries to deliver contraceptives at the doorstep, that is, • INR 1 for a pack of 3 condoms • INR 1 for a cycle of OCPs • INR 2 for a pack of emergency contraceptive pills (ECP) • Extended to all districts in the country
  48. 48. Promotion of spacing methods (interval IUCD) • Availability of IUCD CuT380 A (protection for 10 yrs) • Incentivise ASHAs to • Encourage the delay of the first birth in newly married couples • Spacing of three years between the first and second childbirths. • Ensuring IUCD services on: • Fixed days at all sub centres and PHCs • Regular IUCD insertion services at CHC, SDH and DH • RMNCH counsellors at the facilities with high case load
  49. 49. Sterilization services • Promotion of NSV for increasing male participation. • Emphasis on Minilap tubectomy. • Accreditation of private providers & NGOs for service delivery. • Increasing the pool of trained service providers. • Operationalising fixed day centers for sterilization is an essential step in this direction.
  50. 50. Comprehensive abortion care • Manual Vacuum Aspiration (MVA) facilities and medical methods of abortion in 24 X 7 PHCs • The comprehensive MTP services at all DH & SDH with priority given to ‘delivery points’ • Capacity building of MOs • Medical abortion drugs are to be included in the essential drug list: • Mifepristone + Misoprostol for upto 7 weeks • Ethacridine lactate for 12 to 20 weeks
  51. 51. Management of RTIs and STIs • Provided at all CHC, FRU and 24 X 7 PHCs. • Syndromic management at delivery points • Availability of colour-coded kits • RPR testing kits for syphilis and HIV • Service providers should be trained in syndromic management of STI and RTI. • To be made available across entire reproductive age group (including adolescents, youth and adults.)
  52. 52. Health Systems Strengthening for RMNCH+A Services Infrastructure a) Facility specific plans to be prepared and implemented as specified under IPHS b) Assess the need for new infrastructure, extension of existing infrastructure on the basis of patient load and location of facility
  53. 53. c) Equip health facilities to support 48 hour stay of mother and newborn. d) Engage private facilities for family planning services, management of sick newborns and children, and pregnancy complications. e) Strengthen referral mechanisms between facilities at various levels and communities. f) Provision for adequate infrastructure for waste management
  54. 54. Human Resources • Creation of regular posts so that contractual appointments can be reduced and sustainable HR structure is developed. • Strengthening sub centres through additional human resources: • Accorded highest priority in this phase • Sub centres of remote and hilly area will have 2 ANMs, 1 MPHW (M), 1 pharmacist and 1AYUSH doctor • Creation of a public health cadre
  55. 55. Policies on drugs, procurement system and logistics management • Availability of free generic drugs for minimizing out of pocket expenses. • Rational prescriptions and use of drugs. • Timely procurement of drugs and consumables. • Placing Essential drug lists (EDL) in the public domain. • Computerized drugs and logistic MIS. • Central Procurement Agency for the efficient purchase of quality medicines for distribution to states and union territory governments.
  56. 56. Quality assurance • Quality assurance at all levels of service delivery • Quality certification/ accreditation of facilities and services  Certification for achievement of IPHS  Comprehensive quality assurance for both infrastructure and service delivery  First certified by District and State Quality Assurance Cells CENTRE • Central Quality Supervisory Committee STATE • State Quality Assurance Committees • Quality Assurance Cell • Full time quality assessors DISTRICT • District Quality Assurance Committees • Quality Circles at the District Hospital level.
  57. 57. I. Supportive supervision of health facilities a. Engaging generalist nurse supervisors at block and district level b. Preparing a clear plan of supervision c. Engaging Medical College faculty for supportive supervision of District Hospitals d. Preparing integrated guidelines and checklists for supportive supervision I. Supportive supervision of frontline workers • Potential supervisors of frontline workers include LHVs, ASHA supervisors, ICDS supervisors and AYUSH doctors
  58. 58. Community participation • Engage Village Health Sanitation and Nutrition Committees and Rogi Kalyan Samiti members • Utilize the Village Health and Nutrition Days as a platform for assured and predictable package of outreach services • Social audit: Centred around activities like: • Maternal death audits via verbal autopsies • Utilization of health facility checklists • Grievances redressal related to RMNCH+A
  59. 59. Monitoring, Information & Evaluation Systems • Civil registration system: Ensure 100% registration of births and deaths. • Web enabled Mother and Child Tracking System (MCTS): • Link MCTS with AADHAR in order to track subsidies to eligible women • Maternal Death Review (MDR): • Facility and Community based • Identify causes of maternal deaths and the gaps in service delivery in order to take corrective action
  60. 60. • Perinatal and Child Death Review: Death reports with cause of death for any child under five should be shared with district health teams on a quarterly basis • Health Management Information System (HMIS) based monitoring and review: Indicator that reflect outcomes such as Full ANC, Institutional Delivery, Sterilization procedure, IUCD insertion, Full Immunization, Child & Maternal Death which is regularly monitored and interpreted. Monitoring, Information & Evaluation Systems
  61. 61. • National & State ‘scorecard’: • Introduced as a tool to increase transparency and track progress against indicators related with intervention coverage. • Refers to two distinct but related management tools: 1.HMIS based dashboard monitoring system 2.Survey based child survival score card. Monitoring, Information & Evaluation Systems
  62. 62. • Review missions: • Annual Joint Review Missions by the RCH Division • Common Review Missions under NRHM • Concurrent evaluation process led by the IIPS • Research studies and evaluations done by international advisory panel Monitoring, Information & Evaluation Systems
  63. 63. References : • A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health(RMNCH+A) in India. Ministry of Health & Family Welfare Government of India February 2013 • Revised operating manual for preparation and monitering of RCH-II & immunization component of NRHM state programme implementation plans (PIPs). Ministry of Health & Family Welfare Government of India. November 2010 • Guidelines for Preparation of Annual Programme Implementation Plan National Rural Health Mission. 2013- 2014