1. 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

2. The Evolution…Reproductive and Child Health Programme in India
Evolved from RCH Phase I ( ) to RCH Phase –II ( )
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.

3. 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’

4. 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

5. 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

6. 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, )
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 ). For boys of the same
age group it is lower than normal at 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 years in both women and men. It was found that there has
been no change in the prevalence of anaemia among women aged and 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).

7. 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

8. 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

9. 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

10. 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

11. 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

12. New initiatives contd..
About 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 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.

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

14. 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 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

15. 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

16. 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

17. 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
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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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