RMNCH+A … a continuum of care approach

1. RMNCH+A … a continuum of care approach Dr. Manisha Malhotra, Deputy Commissioner Ministry of Health and Family Welfare Government of India Conference on Healthy Gujarat “Agenda for Action”

2. The Evolution…Reproductive and Child Health Programme in India

3. RCH II: Key Principles

4. WHERE ARE WE NOW… Wide inter and intrastate disparities ! 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, 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

7. RMNCH+A …a new approach ACROSS LEVELS OF CARE ACROSS LIFESTAGES Appropriate Referral & Follow up

8. RMNCH+A approach… key features

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 • RashtriyaBalSwasthyaKaryakram (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

12. 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.

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

14. High Priority Districts .. based on Composite Health Index Based on Composite Health Index, bottom 25% districts identified in the state

15. High Priority Districts .. additional selection criteria

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. Score Card: HMIS Indicators across the life cycle Pregnancy care Scorecard: HMIS indicators across life cycle • 1st Trimester registration • 3 ANC check-ups • 100 IFA intake • Obstetric complications attended • TT2 injections Reproductive age group Child birth Postnatal care, newborn & child health

18. Score card & HIGH PRIORITY DISTRICT PERFORMANCE

19. District/Block wise variation (HPDs) (April 2012-March 2013)

20. Five key steps in District Intensification Plan

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. 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 ofHPDs • 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