Transcript Document

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
The Evolution…Reproductive and Child
Health Programme in India
Evolved from RCH Phase I (1997- 2005) to RCH Phase –II (2005-2012)
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.
RCH II: Key Principles
RCH II (200512) 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’
WHERE ARE WE NOW…
Wide inter and intrastate disparities !
INDICATOR
IMR
NMR
MMR
TFR
BASELINE
58
(SRS 2004)
37
(SRS 2004)
301
(SRS 01-03)
2.9
(SRS 2004)
MDG
2015
AS ON DATE
27
42
(SRS 2012)
-
31
(SRS 2011)
108
212
(SRS 07-09)
--
2.4
(SRS 2011)
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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
Why RMNCH+A approach?
Vertical compartmentalised schemes do not work if goals and targets are to be achieved !
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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
RMNCH+A …a new approach
ACROSS LIFESTAGES
ACROSS LEVELS OF CARE
Health facilities
at various
levels : PHCs,
FRUs, DH
Outreach
services
Family /
home and
community
care
Appropriate Referral & Follow up
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RMNCH+A approach… key features
Heath Systems strengthening :
Infrastructure, Human resources,
drugs & commodities, referral
transport
Five high impact interventions
across five key life stages
Convergence & partnerships
with other Ministries/ departments,
development partners, civil society
organisations & other stakeholders
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
5 X 5 matrix for High Impact RMNCH+A Interventions
When Implemented with High Coverage and High Quality
Reproductive 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.
Maternal Health
Newborn Health
• Use MCTS to ensure early registration of
pregnancy and full ANC
• Early initiation and exclusive
breastfeeding
• Detect high risk pregnancies and line list
including severely anemic mothers and
ensure appropriate management.
• Home based newborn care
through ASHA
• 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
• 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
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
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Child Health
• Complementary feeding, IFA
supplementation and focus on
nutrition
• Diarrhoea management at
community level using ORS and Zinc
• Management of pneumonia
Adolescent Health
• Address teenage pregnancy and
increase contraceptive prevalence
in adolescents
• Introduce Community based
services through peer educators
• Full immunization coverage
• Rashtriya Bal Swasthya Karyakram
(RBSK): screening of children for
4Ds’ (birth defects, development
delays, deficiencies and disease)
and its management
• Strengthen ARSH clinics
• Roll out National Iron Plus Initiative
including weekly IFA
supplementation
• Promote Menstrual Hygiene
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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
Matrix for High Impact RMNCH+A Interventions
List of Minimum Essential Commodities
Reproductive Health
•Tubal Rings
•IUCD 380-A, IUCD 375
•Oral Contraceptive Pills (OCPs) /
(Mala-N )
Maternal Health
• Injection Oxytocin
• Tablet Misoprostol
• Injection Magnesium Sulphate
• Tablet Mifepristone
(Only at
facilities conducting Safe Abortion
Services)
Newborn Health
Child Health
•Injection Vitamin K
• Oral Rehydration Salt (ORS)
•Tablet Albendazole
•Mucous extractor
• Zinc Sulphate Dispersible
Tablets
•Tablet Dicyclomine
•Vaccines - BCG, Oral Polio
Vaccine (OPV), Hep B
•Sanitary Napkin
• Syrup Salbutamol & Salbutamol
nebulising solution
•Condoms
• Vaccines - DPT, Measles
JE (19 States), Pentavalent
vaccine (in 8 States)
•Emergency Contraceptive
Pills(ECP) -(Levonorgestrel
1.5mg)
• Syrup Vitamin A
•Pregnancy Testing Kits (PTKs) Nischay
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
Adolescent Health
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
New initiatives
contd..
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About 16000 health facilities with case loads above laid down benchmarks identified as
“Delivery Points”
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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
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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”
High Priority Districts .. based on Composite Health Index
RMNCH+ A Indicators included in composite index
Maternal Health
Child Health
Family planning
(Data Source : DLHS-3)
i. % of mothers received at least 3 ANC visits
ii. % of Safe Deliveries
iii. % of Children aged 6 months and above exclusively
breastfed
iv. % of Children 12-23 months fully immunized
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
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
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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
Score
Card: HMIS
across
the life
life cycle
Scorecard:
HMISIndicators
indicators
across
cycle
Pregnancy care
1st Trimester
registration
3 ANC check-ups
100 IFA intake
Obstetric
complications
attended
TT2 injections
Child birth
SBA attending
home deliveries
Institutional
deliveries
C-Section
Postnatal care, newborn
& child health
 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
Reproductive age
group
Post-partum
sterilization to
total female
sterilization
Male sterilization
to total
sterilization
IUD insertions in
public + private
accredited
institution
HPDs
Ahmedabad
Bharuch
Dahod
Very Low
Kachchh
performing
Narmada
Surat
Valsad
Banas Kantha
Bhavnagar
Patan
Low performing
Surendranagar
The Dangs
Vadodara
Amreli
Panch Mahals
Promising
Porbandar
Rajkot
Sabar Kantha
Anand
Gandhinagar
Jamnagar
Good
Junagadh
performing
Kheda
Mahesana
Navsari
Score card & HIGH PRIORITY DISTRICT PERFORMANCE
Dahod
Kachchh
Narmada
Valsad
Banas Kantha
The Dangs
Panch Mahals
Sabar Kantha
High performance
Promising
Low
Very low
District/Block wise variation (HPDs) (April 2012-March 2013)
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
Composite Index
Good Performing
Promising
Low
Very low performing
Five key steps in District Intensification Plan
Rapid Assessment:
For gap
identification
Health Systems
Strengthening :Gap
filling & Supply
Chain Management
Engagement with
other Social-Sector
departments
Improving demand
for services
Concurrent
Monitoring &
Supportive
Supervision
Five key steps for Intensification of efforts in High Priority Districts
Rapid Assessment: For gap identification
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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
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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
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
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
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
periodically review the RMNCH+A progress of HPDs
to
– NRU to liaise with State Lead Partners, state governments,
SPMUs and DPMUs for overall implementation and monitoring
of RMNCH+A interventions
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