Presentation on theme: "Reproductive and Child Health Phase II (RCH-II)"— Presentation transcript:
1Reproductive and Child Health Phase II (RCH-II) Dr. Rakesh KumarPG Com. Medicine
2Situation in IndiaHigh Maternal Mortality- 100,000 maternal deaths occurs annuallyHigh Child Mortality -2.1 million deaths annuallyUnmet demand for contraceptionIncreasing concern overAdolescent health,Urban slumsTribal healthRural-urban / Interstate variation
3Milestones in MCH care 1951 –Family Planning Programme India first country to launch1961 – Department Of Family Planning CreatedUniversal Immunization Programme1992 – Child Survival & Safe Motherhood ProgrammeIntegration of family planning , child survial, maternal strategies1997 – RCH Programme Phase-1Target free approachDecentralised planning, Client-centred, quality-oriented, reproductive health approachTill 1977 the major health activity was family planning which was changed into Familywelfare programme with Maternal and Child Health becoming an integral part of familyplanning programme with the vision that reduction in birth rate has a direct relationshipwith reduction in infant and child mortality.
4RCH - II Launched on 1st April 2005 Vision: To bring about outcomes as envisioned in the Millennium Development Goals, the National Population Policy 2000 (NPP 2000), and the National Health Policy 2002Minimizing the regional variations in the areas of RCHPopulation stabilization through an integrated, focused, participatory programmeThe RCH-II, a flagship programme of the Government of India on Reproductive and ChildHealth, was launched in April 2005 under NRHM. This programme has been reoriented and revitalisedto give a pro-outcome and pro-poor focus. It aims at reducing the Maternal Mortality Ratio, theInfant Mortality Rate and Total Fertility Rate
5Neonatal & Child Health Components of RCH-IIRCH-IIMaternal HealthNeonatal & Child HealthFamily PlanningAdolescent HealthControl of RTI & STDs
7Maternal Health Component Essential Obstetric careEmergency obstetric careSafe abortion servicesPrevention & control of RTI /STDs
8“NISHCHAY”- Pregnancy detection kit Services for early detection of pregnancySurveys indicate availability of pregnancy detection kits (NISHCHAY) with peripheral health functionariesASHAs performed over 82 percent of tests themselvesThe Ministry of Health and Family Welfare (MOHFW), GOI, through National Rural Health Mission (NRHM) has introduced rapid home pregnancy test kits (Nishchay). Taking a holistic view of the concept, Nishchay is not a program for the promotion of the pregnancy test kit alone, but is an entry point to RCH and family planning services for women seeking quality and assured RCH and FP services.Key issues addressed by Nishchay are:Low percent of women starting ANC in first trimester due to late pregnancy detectionContraceptive provisioning (IUD/Pill) not started after ruling out pregnancyHigh unsafe abortions due to late detection of pregnancyNishchay pregnancy test kits are made available free of cost to all women in rural areas through the ASHAs, thus reaching out to women, who would otherwise have to travel great distances to confirm a pregnancyHLFPPT undertook a phased Nishchay launch in all the States and UTs of the country. The states have been classified into High, Medium and Low priority groups based on the NFHS-3 data on birthrate and institutional deliveries.The key objectives of the program are:community awareness about Home Based Pregnancy Test Card and RCH servicesincreased utilization of RCH and FP servicesTo achieve these objectives, HLFPPT developed a two tiered training system, wherein Master Trainers were trained at the Block level, who in turn trained the ASHAs – HLFPPT developed the exclusive training kits for the Master Trainers and ASHAs.In phase I, 11 high priority states, namely U.P., Bihar, Jharkhand, Orissa, M.P., Rajasthan, Uttarakhand, Assam, Meghalaya, Nagaland and Chattisgarh were covered – a total of around 5 lakh ASHAs were trained by 856 Master Trainers, supported by 256 NGO partners.The Master Trainers kit comprised of a Flip Chart and Facilitator’s Guide while the ASHAs were given an elaborate training kit comprising of Demo Card, ASHA Booklet, Flex Signboard, Pen, Posters along with the PTC kits.
9Skilled Birth Attendance Skilled Birth AttendantReorienting Medical OfficersPreservice & inservice training for SNs/LHVs/ANMsEnabling EnvironmentOperationalising SCs/ PHCs/CHCs/FRUs for skilled attendance at birth.(Enabling Environment)Policy decisions- ANMs granted permissionto use drugs for managing PPHto use drugs in emergency situations before referralto perform basic procedures at community level in emergency situationsMisoprostol
1024×7 Hours PHCs & CHCs Aim: -To promote institutional deliveries -To provide the round the clock deliveries facility at health centres50% of PHC will be upgraded to provide essential and basic emergency obstetrics careAll upgraded CHC to act as FRU to provide comprehensive obstetric careStatus – Target set for 201052% of targeted PHCs have been strengthened to provide 24-hour services74% of targeted CHC’s have been operationalised as First Referral Units (FRUs)Considerable variation in delivery and quality of servicesOnly 39% of FRUs and 44% of 24/7 PHCs meet all essential criteriaAcross states, number of c-sections per month at FRUs range from 280 to less than 4Number of deliveries per month in 24/7 PHCs varies from 89 to 3BasicEmOCParenteral A/BParent.OxytocicsAnticonvulsantsDigital removal of POCMRPAssisted vaginal deliveryComp.EmOCAll functions of BasicEmOC +Cs sectionsBlood transfusion
11Operationalisation of FRUs All CHCs , Sub district hospital will upgraded and operationalised as FRUsAll FRUs are should provide following services:24 hour delivery services including normal & assisted deliveriesEmergency obstetric care includes surgical intervention –Caesarian SectionNew born careEmergency care of sick childrenFull range of family planning services –LaparoscopicSafe abortion servicesTreatment of RTI /STIBlood storage facilityEssential laboratory servicesReferral transport servicesthe Drugs and Cosmetics Act have been amended and guidelines for these Blood Storage Centers (BSCs), have been prepared and disseminated to the States
12Strengthening referral System Time is an important factor for obstetric emergencies.During RCH I – funds were given to Panchayats for providing assistance to poor people no active involvement of Panchayats.In RCH II : Through involvement of VHNSCReferral transport systems, in general have been given emphasis across states; Madhya Pradesh and Gujarat has widespread availability and use of the Janani Express Yojana.Time is an important factor for obstetric emergencies. Women who undergo deliveries at home and develop complications often find it difficult to be transported to a referral unit. Under the current RCH Programme Provision has been made to assist women from indigent families in 25% of the sub-centre in selected States to provide a lump sum corpus fund to Panchayat through District Family Welfare Officers. Since , the scheme has been extended to all the States and UTs. Rs lakhs have been released 16 States based on the proposals received from them.Three Delays Responsible for Maternal DeathsDelay in deciding to seek care (Individual & family)Lack of understanding of complicationsGender issues, Low status of womenSocio-cultural barriers to seeking carePoor economic conditions of the familyDelay in reaching care ( Community & System)Lack or underutilization of transport fundsNon availability of referral transport in remote placesLack of communication networkDelay in receiving care (System)Poor facilities, personnel and SuppliesPoorly trained personnel with indifferent attitude
13New initiatives taken under RCH II Training of MBBS doctors in anesthetic skills for emergency obstetric care for 18 weeksTraining of MBBS doctors in emergency obestetrics skills like caesarean section for emergency obstetric care for 16 weeksSetting up a blood storage centres at FRUs according to of India guidelines.Vandematram Scheme – a Public private partnershipLaunched on 9th Feb. 2004A Public Private Partnership with the involvement of Federation of Obstetric and Gynachological Society of India and Private Clinics.Aim :To involve and utilize the vast resources of specialists/ trained workforce available in the private sectorThe scheme intends to provide free antenatal and postnatal check, counseling on nutrition, breastfeeding, spacing of birth etc.Any OBG specialist, maternity/Nursing home, and any lady doctor/MBBS doctor providing safe motherhood services can join the schemeEnrolled ‘Vandematram’ doctors will display ‘Vandematram’ logo in their clinicIron and Folic Acid Tablets, oral pills, TT injections etc. will be provided for free distributions to beneficiaries
14Janani Suraksha Yojana Modified The National Maternity Benefit scheme on 12th April 2005100 % centrally sponsored schemePromotes institutional delivery among poor pregnant womenCash assistance with institutional care during ANC, Delivery & PNCBenefit given to female age 19 & above (urban & rural) , up to first 2 live births & in low performing states up to 3 live births.Special dispensation for 10 states with low institutional delivery ( LPS)ASHA- Link between beneficiary & govt.in LPS—other states are HPSAcheivement: from a modest beginning of 7.39 lakh beneficiaries in , the number has risen ten-fold to lakh beneficiaries in
15Safe Abortion Services Increasing access to safe abortion services by popularizing manual vacuum aspiration (MVA) technique at PHC level for early pregnancyControl of RTI /STDsPlanned & implemented in close collaboration with National AIDS control Organization (NACO)NACO is supporting to set up STD clinics up to the district levelEach district are assisted by two laboratory technicians on contract basis for testing blood ,urine for RTI / STD testAim: To reduce maternal mortality & morbidity from unsafe abortion.Assistance from central government is in the form of training of manpower, supply of MTP equipment, Provision for engaging doctors trained in MTP to visits PHCs on fixed dates to perform MTP
17Neonatal & Child Health component Key StrategiesIncrease coverage of skilled care at birth for newborns in conjunction with maternal care - Pre-service IMNCI is underway in 62 medical collegesImplement a comprehensive IMNCI approach - a newborn and child health package of preventive, promotive and curative Currently being implemented in 193 out of 612 districtsNavjaat Shishu Suraksha KaryakramIntroduction of Hepatitis-B Vaccine in routine immunizationBASIC NEWBORN CARE ANDRESUSCITATION PROGRAMTRAINING MANUALImmunization programmes aim to reduce mortality and morbidity due to vaccine preventable diseases (VPDs).Following the successful global eradication of smallpox in 1975 through effective vaccination programmes and strengthened surveillance, the Expanded Programme on Immunization (EPI) was launched in India in 1978 to control other VPDs. Initially, six diseases were selected: diphtheria, pertussis, tetanus, poliomyelitis, typhoid and childhood tuberculosis. The aim was to cover 80% of all infants. Subsequently, the programme was universalized and renamed as Universal Immunization Programme (UIP) in Measles vaccine was included in the programme and typhoid vaccine was discontinued. The UIP was introduced in a phased manner from 1985 to cover all districts in the country by 1990, targeting all infants with the primary immunization schedule and all pregnant women with Tetanus Toxoid immunizationRIMS SOFTWAREROUTINE IMMUNIZATION MONITORING SYSTEM (RIMS) is a computerized implementation, to enter data, generate reports and perform queries. The system is presently developed in Microsoft ACCESS as a standalone CD version. It is user friendly and no special training is required to operate the system. Online system is under development in a different platform using other database and programming tools.The data are collected at district level from PHCs /Reporting Units in the standard pre-designed UIP format and entered on five broad categories namely (A) Immunization & Vitamin A, (B) Vaccine Supply, (C) VPD Surveillance, (D) Status of Cold Chain Equipment and (E) AEFI (Adverse Event following immunization).The system is capable of performing data analyses and generating useful reports for the use of UPI managers at all levels i.e. district, state and national. RIMS will be very useful tool to monitor UIP program as reports from all the 600 districts will be collected in a short period and then analyzed automatically by the software
18RCH II: Child Health strategy IPHS StandardsCapacity buildingHealth system strengtheningIMNCIASHA/HWHBNCStrengthening the existing interventionsCare at birthFacility / HomeThe IMNCI approach is the centrepiece of newborn and child health strategy in RCHI II.Integrated Management of Neonatal and Childhood Illness (IMNCI)Integrated Management of Childhood Illness (IMCI) strategy, which has already beenimplemented in more than 100 countries all over the globe, encompasses a range ofinterventions to prevent and manage five major childhood illnesses i.e. Acute RespiratoryInfections, Diarrhoea, Measles, Malaria and Malnutrition. It focuses on preventive,promotive and curative aspects, i.e it gives a holistic outlook to the programme.Government of India recognizes the need to strengthen child health activities in thecountry. In order to do so and introduce IMCI in the country, a Core Group was constitutedwhich included representatives from Indian Academy of Pediatrics (IAP), NationalNeonatology Forum of India (NNF), National Anti Malaria Program (NAMP),Department of Women and Child Development (DWCD), Child-in-Need Institute (CINI),WHO, UNICEF, eminent Pediatricians and Neonatologists, and the representatives fromMinistry of Health and Family Welfare Government of India. The Adaptation Groupdeveloped Indian version of IMCI guidelines and renamed it as Integrated Managementof Neonatal and Childhood Illness (IMNCI).The major components of this strategy are:• Strengthening the skills of the health care workers• Strengthening the health care infrastructure• Involvement of the communityThe first two components are the facility based IMNCI and the third is the commnity basedIMNCI.The major highlights of Indian adaptation are:• Incorporation of neonatal care as it now constitutes two thirds of infant mortality• Inclusion of 0-7 days• Incorporating National guidelines on Malaria, Anemia, Vitamin A supplementationand Immunization schedule• Training schedule reduced from 11 to 8 days• Training begins with sick young infant upto 2 months• Proportion of training time devoted to sick young infant and sick child is almostequalThe Government has initiated implementation of the IMNCI strategy in fourdistricts each in nine selected states of Orissa, Rajasthan, Madhya Pradesh, Haryana, Delhi,Gujarat, Uttaranchal, Tamil Nadu and Rajasthan .Improved Referral Care of New born & sick childrenBCC AND COMMUNITY MOBILIZATION
19“Navjaat Shishu Suraksha Karyakram” A new programme on Basic Newborn Care and ResuscitationHigh Neonatal Mortality Rate despite substantial reduction in childhood and infant mortalityNearly two-thirds infant deaths each year occur within the first four weeks of life, and about two-thirds of those occur within the first week.Although childhood and infant mortality in India has reduced substantially during the last decade, the rate of neonatal mortality is still high. Nearly two-thirds infant deaths each year occur within the first four weeks of life, and about two-thirds of those occur within the first week. Thus, the first days and weeks of life are critical for the future health and survival of a child
20Village Health and Nutrition Days Child health cont…MoHFW has developed a comprehensive New Born and Child Health policyVillage Health and Nutrition DaysOrganized at AWCs for service provision in the RCH-II & NRHM, and also as a platform for intersectoral convergenceOver lakh VHNDs have reportedly been carried out across states inNearly 70 percent of planned sessions are being held and on average there are clients per VHNDVHND promises to be an effective platform for providing first-contact primary health carean important tool under NRHM for the convergence of all activitiesThe VHND is to be organized once every month (preferably onWednesdays, and for those villages that have been left out, on any otherday of the same month) at the AWC in the village. This will ensureuniformity in organizing the VHND. The AWC is identified as the hub forservice provision in the RCH-II, NRHM, and also as a platform for intersectoralconvergence. VHND is also to be seen as a platform for interfacingbetween the community and the health system.quality of the VHND needs to be improved
22New Interventions in Family Planning (GOI) Addressing the unmet need in contraception throughAssured delivery of quality family planning servicesDeveloping skilled manpowerIncreasing basket of choices - through several trials by GoI including injectables (Cyclofem and NetEn), Centchroman, and a five-year multi-load IUCD.Intensive promotion of Non-Scalpel vasectomyPromotion of IUDs as a short & long term spacing methodPromotion of Emergency Contraceptive PillsImproving awareness of FP ( e.g, FP counsellors located at Comprehensive Emergency Obstetric and New Born Care (CEmONCs) in MP and Jan Mangal couples in Rajasthan
23Infertility management % of couples are infertile.Medical, ethical and legal issues involved.Guidelines for ART (Assisted Reproductive Technology) has been prepared in 2005.Draft bill on ART is awaiting legislation.
24Adolescent HealthAdolescents (age 10-19) constitute over 23% of the population in India, numbering 230 millionEarly marriage and early pregnanciesUnmet needs of adolescentsContribute to MMR,TFR and IMRHIV: 35% new cases in the age group15-24Malnutrition and anaemia rampantLimited use of existing resources
25Adolescent Reproductive & Sexual Health (ARSH) Strategy Overall objective of ARSH Strategy is to contribute to the RCH II goals of reduction of IMR, MMR and TFR. Objective to be met by:Reducing teenage pregnanciesMeeting unmet contraceptive needsReducing number of teenage maternal deathsReducing incidence of STIs andReducing proportion of HIV positive in years age group
26Component of ARSH: Adolescent friendly health services Detection and treatment of anemia, RTI/STDs , de-addiction psycho-somatic problems and other problemsHIV detection and counselingEasy and confidential access to MTPAntenatal care and advice regarding child birthAdolescent health counseling servicesTo provide counseling related to Growth and development; Nutrition; Reproductive and child health; Marriage and parenthood & Life-skill educationOther Sectors:MOYAS: Initiatives on awareness and life skills, UTA and Adolescent Empowerment SchemeDepartment of Education: Adolescence Education ProgramDWCD: KISHORI SHAKTI YOJANA –To improve the health and nutritional status of girlsBALIKA SAMRIDHI YOJANA –To Delay the age of marriageServices provided at PHCs, CHCs, FRUs and district hospitals in the selected districts through routine OPDs and “Adolescent Health Clinics” conducted at least once every week
27ARSH : Progress so farRCH-II ARSH Strategy approved as part of National and state RCH-II PIPSelf learning module for rural youth and health care providersMOHFW RCH-II ARSH Training Sub-Group constituted & developed a training design document.
28Achievements so far … Indicator DLHS-2 (2002-04) DLHS-3 (2007-08) Percentage received full ANC coverage16.5%19.1%75.3%(66.2%)Institutional delivery (%)40.9 %47%66.1%(52.6%)Full Immunization Coverage (%)45.9%54.1%58.8%(78.4%)Exclusive breast feeding for at least six months among children age 6-35 months (%)22.7%24.9%Children with diarrhoea receiving ORS (%)30.3%33.7%37.8%(33.2%)Percent using modern contraceptives45.2%47.3%66.9%(60.9%)Total unmet need21.4 %21.5%9.6%(13.0%)
29Achievements so far … Indicator NFHS-II (1998-99) NFHS-III (2005-06) M.H(NFHS-III)Percentage received atleast 3 ANC visits44.2%50.7%75.3%Institutional delivery (%)33.6 %40.7%66.1%Full Immunization Coverage (%)42.0%43.5%58.8%Children with diarrhoea receiving ORS (%)26.9%26.2%37.8%Percent using modern contraceptives42.8%48.5%66.9%Total unmet need15.8 %13.2%9.6%
30RCH II Goal Indicators RCH II GOAL INDICATOR ALL STATUS (Source of data)RCH II / NRHM goal (2012)Maternal Mortality Ratio (MMR)398(SRS 1997)301(SRS 2003)254(SRS 2008)<100Infant Mortality Rate (IMR)716053<30Total Fertility Rate (TFR)3.33.02.72.1