1. Reproductive and Child Health Phase II (RCH-II)
Dr. Rakesh Kumar
PG Com. Medicine

2. Situation in India
High Maternal Mortality- 100,000 maternal deaths occurs annually
High Child Mortality -2.1 million deaths annually
Unmet demand for contraception
Increasing concern over
Adolescent health,
Urban slums
Tribal health
Rural-urban / Interstate variation

3. Milestones in MCH care 1951 –Family Planning Programme
India first country to launch
1961 – Department Of Family Planning Created
Universal Immunization Programme
1992 – Child Survival & Safe Motherhood Programme
Integration of family planning , child survial, maternal strategies
1997 – RCH Programme Phase-1
Target free approach
Decentralised planning, Client-centred, quality-oriented, reproductive health approach
Till 1977 the major health activity was family planning which was changed into Family
welfare programme with Maternal and Child Health becoming an integral part of family
planning programme with the vision that reduction in birth rate has a direct relationship
with reduction in infant and child mortality.

4. RCH - 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 2002
Minimizing the regional variations in the areas of RCH
Population stabilization through an integrated, focused, participatory programme
The RCH-II, a flagship programme of the Government of India on Reproductive and Child
Health, was launched in April 2005 under NRHM. This programme has been reoriented and revitalised
to give a pro-outcome and pro-poor focus. It aims at reducing the Maternal Mortality Ratio, the
Infant Mortality Rate and Total Fertility Rate

5. Neonatal & Child Health
Components of RCH-II
RCH-II
Maternal Health
Neonatal & Child Health
Family Planning
Adolescent Health
Control of RTI & STDs

6. Maternal Health

7. Maternal Health Component
Essential Obstetric care
Emergency obstetric care
Safe abortion services
Prevention & control of RTI /STDs

8. “NISHCHAY”- Pregnancy detection kit
Services for early detection of pregnancy
Surveys indicate availability of pregnancy detection kits (NISHCHAY) with peripheral health functionaries
ASHAs performed over 82 percent of tests themselves
The 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 detection
Contraceptive provisioning (IUD/Pill) not started after ruling out pregnancy
High unsafe abortions due to late detection of pregnancy
Nishchay 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 pregnancy
HLFPPT 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 services
increased utilization of RCH and FP services
To 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.

9. Skilled Birth Attendance
Skilled Birth Attendant
Reorienting Medical Officers
Preservice & inservice training for SNs/LHVs/ANMs
Enabling Environment
Operationalising SCs/ PHCs/CHCs/FRUs for skilled attendance at birth.(Enabling Environment)
Policy decisions- ANMs granted permission
to use drugs for managing PPH
to use drugs in emergency situations before referral
to perform basic procedures at community level in emergency situations
Misoprostol

10. 24×7 Hours PHCs & CHCs Aim: -To promote institutional deliveries
-To provide the round the clock deliveries facility at health centres
50% of PHC will be upgraded to provide essential and basic emergency obstetrics care
All upgraded CHC to act as FRU to provide comprehensive obstetric care
Status – Target set for 2010
52% of targeted PHCs have been strengthened to provide 24-hour services
74% of targeted CHC’s have been operationalised as First Referral Units (FRUs)
Considerable variation in delivery and quality of services
Only 39% of FRUs and 44% of 24/7 PHCs meet all essential criteria
Across states, number of c-sections per month at FRUs range from 280 to less than 4
Number of deliveries per month in 24/7 PHCs varies from 89 to 3
BasicEmOC
Parenteral A/B
Parent.Oxytocics
Anticonvulsants
Digital removal of POC
MRP
Assisted vaginal delivery
Comp.EmOC
All functions of BasicEmOC +
Cs sections
Blood transfusion

11. Operationalisation of FRUs
All CHCs , Sub district hospital will upgraded and operationalised as FRUs
All FRUs are should provide following services:
24 hour delivery services including normal & assisted deliveries
Emergency obstetric care includes surgical intervention –Caesarian Section
New born care
Emergency care of sick children
Full range of family planning services –Laparoscopic
Safe abortion services
Treatment of RTI /STI
Blood storage facility
Essential laboratory services
Referral transport services
the Drugs and Cosmetics Act have been amended and guidelines for these Blood Storage Centers (BSCs), have been prepared and disseminated to the States

12. Strengthening 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 VHNSC
Referral 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 Deaths
Delay in deciding to seek care (Individual & family)
Lack of understanding of complications
Gender issues, Low status of women
Socio-cultural barriers to seeking care
Poor economic conditions of the family
Delay in reaching care ( Community & System)
Lack or underutilization of transport funds
Non availability of referral transport in remote places
Lack of communication network
Delay in receiving care (System)
Poor facilities, personnel and Supplies
Poorly trained personnel with indifferent attitude

13. New initiatives taken under RCH II
Training of MBBS doctors in anesthetic skills for emergency obstetric care for 18 weeks
Training of MBBS doctors in emergency obestetrics skills like caesarean section for emergency obstetric care for 16 weeks
Setting up a blood storage centres at FRUs according to of India guidelines.
Vandematram Scheme – a Public private partnership
Launched on 9th Feb. 2004
A 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 sector
The 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 scheme
Enrolled ‘Vandematram’ doctors will display ‘Vandematram’ logo in their clinic
Iron and Folic Acid Tablets, oral pills, TT injections etc. will be provided for free distributions to beneficiaries

14. Janani Suraksha Yojana
Modified The National Maternity Benefit scheme on 12th April 2005
100 % centrally sponsored scheme
Promotes institutional delivery among poor pregnant women
Cash assistance with institutional care during ANC, Delivery & PNC
Benefit 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 HPS
Acheivement: from a modest beginning of 7.39 lakh beneficiaries in , the number has risen ten-fold to lakh beneficiaries in

15. Safe Abortion Services
Increasing access to safe abortion services by popularizing manual vacuum aspiration (MVA) technique at PHC level for early pregnancy
Control of RTI /STDs
Planned & implemented in close collaboration with National AIDS control Organization (NACO)
NACO is supporting to set up STD clinics up to the district level
Each district are assisted by two laboratory technicians on contract basis for testing blood ,urine for RTI / STD test
Aim: 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

16. Neonatal & Child Health

17. Neonatal & Child Health component
Key Strategies
Increase coverage of skilled care at birth for newborns in conjunction with maternal care - Pre-service IMNCI is underway in 62 medical colleges
Implement a comprehensive IMNCI approach - a newborn and child health package of preventive, promotive and curative Currently being implemented in 193 out of 612 districts
Navjaat Shishu Suraksha Karyakram
Introduction of Hepatitis-B Vaccine in routine immunization
BASIC NEWBORN CARE AND
RESUSCITATION PROGRAM
TRAINING MANUAL
Immunization 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 immunization
RIMS  SOFTWARE
ROUTINE 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

18. RCH II: Child Health strategy
IPHS Standards
Capacity building
Health system strengthening
IMNCI
ASHA/HW
HBNC
Strengthening the existing interventions
Care at birth
Facility / Home
The 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 been
implemented in more than 100 countries all over the globe, encompasses a range of
interventions to prevent and manage five major childhood illnesses i.e. Acute Respiratory
Infections, 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 the
country. In order to do so and introduce IMCI in the country, a Core Group was constituted
which included representatives from Indian Academy of Pediatrics (IAP), National
Neonatology 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 from
Ministry of Health and Family Welfare Government of India. The Adaptation Group
developed Indian version of IMCI guidelines and renamed it as Integrated Management
of 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 community
The first two components are the facility based IMNCI and the third is the commnity based
IMNCI.
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 supplementation
and 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 almost
equal
The Government has initiated implementation of the IMNCI strategy in four
districts 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 children
BCC AND COMMUNITY MOBILIZATION

19. “Navjaat Shishu Suraksha Karyakram”
A new programme on Basic Newborn Care and Resuscitation
High Neonatal Mortality Rate despite substantial reduction in childhood and infant mortality
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.
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

20. Village Health and Nutrition Days
Child health cont…
MoHFW has developed a comprehensive New Born and Child Health policy
Village Health and Nutrition Days
Organized at AWCs for service provision in the RCH-II & NRHM, and also as a platform for intersectoral convergence
Over lakh VHNDs have reportedly been carried out across states in
Nearly 70 percent of planned sessions are being held and on average there are clients per VHND
VHND promises to be an effective platform for providing first-contact primary health care
an important tool under NRHM for the convergence of all activities
The VHND is to be organized once every month (preferably on
Wednesdays, and for those villages that have been left out, on any other
day of the same month) at the AWC in the village. This will ensure
uniformity in organizing the VHND. The AWC is identified as the hub for
service provision in the RCH-II, NRHM, and also as a platform for intersectoral
convergence. VHND is also to be seen as a platform for interfacing
between the community and the health system.
quality of the VHND needs to be improved

21. Family Planning

22. New Interventions in Family Planning (GOI)
Addressing the unmet need in contraception through
Assured delivery of quality family planning services
Developing skilled manpower
Increasing 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 vasectomy
Promotion of IUDs as a short & long term spacing method
Promotion of Emergency Contraceptive Pills
Improving 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

23. Infertility 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.

24. Adolescent Health
Adolescents (age 10-19) constitute over 23% of the population in India, numbering 230 million
Early marriage and early pregnancies
Unmet needs of adolescents
Contribute to MMR,TFR and IMR
HIV: 35% new cases in the age group15-24
Malnutrition and anaemia rampant
Limited use of existing resources

25. Adolescent 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 pregnancies
Meeting unmet contraceptive needs
Reducing number of teenage maternal deaths
Reducing incidence of STIs and
Reducing proportion of HIV positive in years age group

26. Component of ARSH: Adolescent friendly health services
Detection and treatment of anemia, RTI/STDs , de-addiction psycho-somatic problems and other problems
HIV detection and counseling
Easy and confidential access to MTP
Antenatal care and advice regarding child birth
Adolescent health counseling services
To provide counseling related to Growth and development; Nutrition; Reproductive and child health; Marriage and parenthood & Life-skill education
Other Sectors:
MOYAS: Initiatives on awareness and life skills, UTA and Adolescent Empowerment Scheme
Department of Education: Adolescence Education Program
DWCD: KISHORI SHAKTI YOJANA –To improve the health and nutritional status of girls
BALIKA SAMRIDHI YOJANA –To Delay the age of marriage
Services 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

27. ARSH : Progress so far
RCH-II ARSH Strategy approved as part of National and state RCH-II PIP
Self learning module for rural youth and health care providers
MOHFW RCH-II ARSH Training Sub-Group constituted & developed a training design document.

28. Achievements so far … Indicator DLHS-2 (2002-04) DLHS-3 (2007-08)
Percentage received full ANC coverage
16.5%
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 contraceptives
45.2%
47.3%
66.9%
(60.9%)
Total unmet need
21.4 %
21.5%
9.6%
(13.0%)

29. Achievements so far … Indicator NFHS-II (1998-99) NFHS-III (2005-06)
M.H
(NFHS-III)
Percentage received atleast 3 ANC visits
44.2%
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 contraceptives
42.8%
48.5%
66.9%
Total unmet need
15.8 %
13.2%
9.6%

30. RCH 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)
<100
Infant Mortality Rate (IMR) 71 60 53
<30
Total Fertility Rate (TFR)
3.3
3.0
2.7
2.1

31. THANK YOU