RMNCH+A … a continuum of care approach

Dr. Manisha Malhotra, Deputy CommissionerMinistry of Health and Family Welfare

Government of India

Conference on Healthy Gujarat “Agenda for Action”

The Evolution…Reproductive The Evolution…Reproductive and Child Health Programme in and Child Health Programme in

IndiaIndia

RCH II: Key PrinciplesRCH II: Key Principles

WHERE ARE WE NOW…WHERE ARE WE NOW…

INDICATOR BASELINEMDG2015

AS ON DATE

IMR58

(SRS 2004)27

42 (SRS 2012)

NMR 37 (SRS 2004)

-31

(SRS 2011)

MMR 301(SRS 01-03)

108212

(SRS 07-09)

TFR 2.9(SRS 2004)

--2.4

(SRS 2011) 44

Wide inter and intrastate disparities !

(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 outcomesThe 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

RMNCH+A … A New Strategic Approach RMNCH+A … A New Strategic Approach

Vertical compartmentalised schemes do not work if goals and targets are to be achieved !

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

Why RMNCH+A approach? Why RMNCH+A approach?

7

ACROSS LIFESTAGES ACROSS LEVELS OF CARE

Appropriate Referral & Follow up

RMNCH+A …a new approach RMNCH+A …a new approach

RMNCH+A approach… key features RMNCH+A approach… key features

• 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.

• 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.

Reproductive HealthReproductive Health Maternal HealthMaternal Health Newborn HealthNewborn Health Child HealthChild Health Adolescent HealthAdolescent Health

• 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

• 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

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

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

• 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

• 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

• 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

• 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

• 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

• 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

5 X 5 matrix for High Impact RMNCH+A Interventions

When Implemented with High Coverage and High Quality

•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

•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

Reproductive HealthReproductive Health Maternal HealthMaternal Health Newborn HealthNewborn Health Child HealthChild Health Adolescent HealthAdolescent Health

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

•Injection Vitamin K

•Mucous extractor

•Vaccines - BCG, Oral Polio Vaccine (OPV), Hep B

•Injection Vitamin K

•Mucous extractor

•Vaccines - BCG, Oral Polio Vaccine (OPV), Hep B

• Injection Oxytocin

• Tablet Misoprostol

• Injection Magnesium Sulphate

• Tablet Mifepristone (Only at facilities conducting Safe Abortion Services)

• Injection Oxytocin

• Tablet Misoprostol

• Injection Magnesium Sulphate

• Tablet Mifepristone (Only at facilities conducting Safe Abortion Services)

•Tablet Albendazole

•Tablet Dicyclomine

•Sanitary Napkin

•Tablet Albendazole

•Tablet Dicyclomine

•Sanitary Napkin

Matrix for High Impact RMNCH+A Interventions

List of Minimum Essential Commodities

• 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

• 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

New initiativesNew 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

New initiatives contd..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)

Maternal Health i. % of mothers received at least 3 ANC visitsii. % of Safe Deliveries

Child Health iii. % of Children aged 6 months and above exclusively breastfediv. % of Children 12-23 months fully immunized

Family planning v. % of births of order 3 and abovevi. Contraceptive Prevalence Rate (CPR) – Modern Method

Based on Composite Health Index, bottom 25% districts identified in the state

High Priority Districts .. based on Composite Health IndexHigh Priority Districts .. based on Composite Health Index

15

High Priority Districts .. additional selection criteriaHigh Priority Districts .. additional selection criteria

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

Monitoring progress on RMNCH+A using Score Card Monitoring progress on RMNCH+A using Score Card

1st Trimester registration

3 ANC check-ups

100 IFA intake

Obstetric complications attended

TT2 injections

SBA attending home deliveries

Institutional deliveries

C-Section

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

Score Card: HMIS Indicators across the life cycle Scorecard: HMIS indicators across life cycleScorecard: HMIS indicators across life cycle

Score card & HIGH PRIORITY DISTRICT PERFORMANCE

Anand

Banas Kantha

Patan

Mahesana Sabar Kantha

Gandhinagar

AhmadabadSurendranagar

RajkotJamnagar

Porbandar

Junagadh

Kachchh

Bhavnagar

Rann of Kachchh

Kheda

Panch Mahals

Dohad

Vadodara

NarmadaBharuch

Surat

The DangsNavsari

Valsad

Tapi

Amreli

High performance

Promising

Low

Very low

HPDs

Very Low performing

Ahmedabad

BharuchDahod DahodKachchh KachchhNarmada NarmadaSuratValsad Valsad

Low performing

Banas Kantha Banas KanthaBhavnagarPatanSurendranagarThe Dangs The Dangs Vadodara

Promising

AmreliPanch Mahals Panch Mahals PorbandarRajkotSabar Kantha Sabar Kantha

Good performing

Anand

GandhinagarJamnagarJunagadhKhedaMahesanaNavsari

Good Performing Promising Low Very low performing

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

Five key steps in District Intensification PlanFive key steps in District Intensification Plan

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 aspectsResource mapping exercise in the districtsDevelopment of District Action Plan with special focus on Backward blocksHealth Systems Strengthening and Gap filling : some examples30% Higher financial allocation under NRHM (State PIP)Relaxation of norms for HR, Infrastructure as per guidance from GOIAdditional incentives, difficult area allowance, residential facilitiesAccreditation of private institutions and NGO run facilities/NGOsNeed based capacity building Supply Chain Management

Five key steps for Intensification of efforts in High Priority Districts 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 Thrust on most backward blocks

Five key steps for Intensification of efforts in High Priority Districts… Five key steps for Intensification of efforts in High Priority Districts…

• 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

Harmonization to add value to the National programme and help realise health outcomes

Partners’ support for IntensificationPartners’ support for Intensification

– 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

Structure for monitoring of Intensification efforts in HPDsStructure for monitoring of Intensification efforts in HPDs

– 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

Support Structure at State LevelSupport Structure at State Level

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