Reproductive & Child Health interventions :

1. Reproductive & Child Health interventions: Status and issues at a glance…. Dr. RakeshKumar, Joint Secretary (RCH), Ministry of Health & Family Welfare Government of India

2. Current Status (All India) • 12 States and UTs have achieved the national target for IMR • 21 States and UTs have achieved national target for TFR. • Only Kerala and Tamil Nadu have achieved all 3 RCH goals.

3. Maternal Health - Full Antenatal Check-up Significant Rural –Urban Variation across 9 states; Orissa & Chhattisgarh and UP & Bihar reflect the two extremes With in a State, the maximum variability of 28.0 reported in Jharkhand. Across 284 districts, Full ANC ranges from 0.6% in Balrampur (UP) to 30.6% in Jagatsinghpur ( Odisha)- a variability of more than 28.9% points.

4. Maternal Health Issues • Irregular & Incomplete reporting on DPs • Less than 50% FRUs conducting C- section with low numbers • Only about 50% of 24X7 PHCs have a delivery load of 10 or more per month • Underutilized DPs Delivery Points aim to provide comprehensive care at the 17,000 health facilities that are performing above a certain benchmark. Key actionable points • Regular performance monitoring of DPs • Prioritization of resources including rational deployment of manpower • Regular reporting by States like Rajasthan, MP, Haryana, Orissa • Less than 40% FRUs conduct C sections in AP, Bihar, Chhattisgarh, Jharkhand, MP, Odisha, Rajasthan, Uttarakhand

5. SafeDelivery Significant Rural –Urban Variation across 9 states; Jharkhand & Chhattisgarh and Rajasthan & MP reflect the two extremes With in a State, the maximum variability of 67.0% points reported in UP. Across 284 districts, Safe Delivery ranges from 22.0% in Balrampur(UP) to 96.3% in Indore ( MP)- a variability of more than 74.3 % points.

6. Institutional Delivery Significant Inter-State variation across 9 states; Institutional Delivery: Ranges from 34.9% in Chhattisgarh to 76.1% in MP. With in a State, the maximum variability of 59.8 reported in Odisha. Across 284 districts, Institutional Delivery ranges from 16.8% in Balrampur(UP) to 91.6% (Odisha)- a variability of more than 62.7% points.

7. Maternal Health Issues • Poor tracking of severe anemia cases by majority of the states due to lack of orientation of frontline workers, coordinated IFA supply and Hb testing equipments Tracking of Severe Anemia Key actionable points • Orient all frontline workers on diagnosis and line listing of pregnant women with severe anaemia. • Coordination between supply of IFA tablets, availability of trained laboratory technicians & testing equipments, referral linkages for treatment. • Odisha, J&K and M.P have started tracking and reporting on severely anemic women at Delivery Points

8. Maternal Health Maternal Death Review (MDR) Issues • Irregular and under reporting • Both FBMDR and CBMDR are in place in very few states • Poor quality review confining to medical causes rather than identifying sytemic gaps Key actionable points • State level team to orient, train and mentor the service providers & field functionaries • Dissemination of findings of analysis of maternal deaths to all stakeholders • Prioritize constitution of FBMDR committees at DPs (FRUs and above) • No. of States reporting regularly has increased from 9 to 20 in a period of 6 months (Sept 2011 to March, 2012) • States of MP, Assam, Odisha & Punjab have taken a no. of initiatives to improve MDR process

9. Maternal Health Safe Abortion Services Issues • Poor reporting by the states, only 12 states have reported on 6 monthly formats • Status of deployment & utilisation of skills of the already trained providers is not reported • Absence or lack of functionality of District level MTP Committees Key actionable points • Need to prioritize on expanding availability and access to quality services in public sector (particularly “Delivery Points” • Link CAC training to posting at specified “Delivery Points”. • Activate DLCs to optimally utilise and regulate private sector providers. • Strategise to disseminate visible IEC/BCC messages on safe abortion services. • MP & Maharashtra have reported more than 50% trained providers providing MTP services.

10. Maternal Health RTI/STI Services Issues • Lack of convergence with SACS at the state level. • Irregular availability of drugs in the field. • Poor Linkage with the adolescent friendly clinics • Testing of PW for HIV not done on regular basis • No focus on elimination of congenital syphilis Key actionable points • Convergence with SACS • Procurement of Syndromic drug kit and RPR Testing kits. • Linkages with AFHS. • Ensuring testing of HIV in PW at delivery points. • Testing of all PW at the DPs for syphilis.

11. JananiSurakshaYojana (JSY) JSY PERFORMANCE: 2005-12 JSY PERFORMANCE 2012-13 (I qtr) • All India achievement for the I qtr is 82%. • Majority of States have reported more than 70% achievement . • Low performing states are: JH & Manipur (41%), Haryana (44%), Himachal (50%)

12. Maternal Health JSY Issues • Poor monitoring and random verification of JSY beneficiaries • Delays in payments in most of the States (Jharkhand, Bihar, MP, UP, Manipur, Andhra Pradesh) • JSY admin expenses used for non-JSY activities (Uttarakhand, Bihar) • Less no. of mothers getting JSY benefit for home delivery (esp. Bihar, Assam, UP, Rajasthan) • Grievance redressal cells yet to be established • Delays in JSY reporting to GOI (almost all States) Key actionable points • Monitoring and random verification of JSY beneficiaries to be initiated. • Payment of incentive before women being discharged • JSY admin expenses to be used only for JSY activities such as monitoring and IEC • Eligible BPL pregnant women need to be paid home delivery assistance • Grievance redressal cells to be established • JSY reports need to be sent timely to GOI

13. Child Health-Neonatal period Aim is to operationalise Newborn care corner at each delivery point and make one special newborn care unit functional in each district ; Cover all newborns for first 6 weeks of life through Home Based newborn Care Issues • Slow progress in the setting up of sick newborn care units in HFD • Paucity of trained manpower; 53% of the units have adequate MOs and 40% adequate Nurses • Equipment lying unutilized in many units especially in NBSUs • Slow pace of trainings resulting in incorrect clinical practices. • Disconnect between different level of newborn care facilities; weak linkages with the community based programme (HBNC) • Record keeping and timely reporting requires attention • Mentoring & supervision by state level institutions missing Key actionable points • Saturation of all delivery points with Newborn Care Corners; • Facility Based Newborn Care trainings to be linked with posting to specified units • Developing at least one State level Resource Center to support trainings, observership and mentoring process • Convergence of newborn care facilities with the HBNC • Establish effective referral linkages( district specific) between newborn care facilities (NBCC, NBSU and SNCU).

14. State specific issues in Neo-natal care

15. Nutrition, ARI, Diarrhea Community and facility based management of Diarrhoea and Pneumonia is a priority, promote infant and young child feeding practices through the health system and home based newborn care Issues • Low awareness among providers regarding iron supplementation guidelines resulting in very low coverage • Low use of Zinc with ORS in cases of diarrhoea • Underutilisation of Nutrition Rehabilitation centres , outcomes not monitored and national treatment protocols not being followed by many states • Limited focus on IYCF in State PIPs • Slow pace of child health trainings especially F-IMNCI Key actionable points • Reinforce anaemia and diarrhoea management guidelines; stock management of ORS, Zinc and iron syrup/tablets • Establish State level Resource Centres to guide IYCF and Nutrition interventions • Active promotion of IYCF practices in health facilities through all MCH contacts • Review and strengthen linkages of community based program and AWC to NRCs

16. Child Nutrition, ARI and Diarrhoea

17. Fully Immunized Children (AHS-2011) Full Immunization State of Odisha has the maximum variation among the districts min 11.9 to max 82.9 and next is UP

18. Routine Immunization • Year 2012 declared as Year of Intensification of Routine Immunization • Immunization weeks being conducted across the country • Hepatitis B vaccine universalized Issues • Missed out/hard to reach/ high risk area with low immunization coverage • Areas missed due to vacant sub-centers • Poor cold chain maintenance • Inadequately trained human resource • Low coverage of Hepatitis B, especially the birth dose • Poor demand generation and awareness activity at field level Key actionable points • Mapping of such areas, updating microplan to incorporate them, covering these areas on highest priority • Ensuring Alternative vaccinators until vacancy filled • Ensure trained refrigerator mechanics for each district and training of all health workers • Implement Hep B-birth dose at all health institutions conducting delivery. Improve coverage of Hep B • Design BCC plan at community/district and state level

19. Routine ImmunizationStates with Low Performance

20. Immunization Campaigns(Polio, Measles, JE) • WHO removed India from the list of countries with active endemic wild polio virus transmission • Measles Catch-up campaign completed in 9 states vaccinating 4.8 crore children • 62 new JE endemic districts identified and will be covered under campaign in phased manner. Issues • Risk of importation of Polio virus still persists • Introduction of Measles 2nd dose under RI after 6 months of campaign pending in many districts • Phase III of Measles campaign targeting 167 districts in 5 states starting September 2012 • Poor coverage of JE vaccine under RI in 113 JE endemic districts Key actionable points • Maintain high coverage during pulse polio round • States to issue orders for incorporation of Measles 2nd dose under RI • UP, Bihar, Gujarat, MP and Rajasthan to ensure >90% coverage • Increase JE vaccination coverage under RI in endemic districts

21. Family Planning-Total Fertility Rate Significant Rural-Urban variation across 9 large States ; Uttarakhand & Odishaand UP & Bihar reflect the two extremes. • Within a State, the maximum variability of 3.6 reported in Uttar Pradesh • Across 284 districts, TFR ranges from 1.7 in Pithoragarh(Uttarakhand) to 5.9 in Shrawasti (UP)- a variability of more than 4 children!

22. Family PlanningStatus of Key Activities

23. Family Planning Delivery of contraceptives by ASHAs at doorstep (launched in July 2011) • ASHA are delivering contraceptives at the doorsteps in 233 districts of 17 States • 231 districts have implemented except East & South Garo Hills of Meghalaya • 7 of these 231 districts are yet to send utilization reports: • Bihar (Sheikhpura) - 1 • Uttar Pradesh (LakhimpurKheri, Bhadohi, Barabanki, Kannauj) - 4 • Manipur (Ukhrul, Tamenglong), - 2 • Response from NE states (except Assam), Himachal Pradesh and Uttar Pradesh is very poor • Although Chhattisgarh and Jharkhand have reported utilisation of contraceptives, filed visits suggest that the scheme has not taken off at the field level

24. Family Planning Ensuring spacing after marriage and between 1st and 2nd child (launched in May 2012) through incentivisation of ASHAs • Services of ASHAs for counselling newly married couples to ensure spacing of 2 years after marriage and spacing of 3 years after the birth of 1st child. • The scheme is operational in 18 states (EAG, NE and Gujarat and Haryana) • ASHA would be paid following incentives under the scheme: • Rs. 500/- to ASHA for ensuring spacing of 2 years after marriage. • Rs. 500/- to ASHA for ensuring spacing of 3 years after the birth of 1st child • Rs. 1000/- in case the couple opts for a permanent limiting method up to 2 children only

25. Adolescent Health - ARSH Issues • Slow pace of ARSH Programme implementation in Uttar Pradesh, Bihar, Chhattisgarh and Himachal Pradesh • Irregular clinics with poor turn out • Hardly any referrals • Poor community mobilisation • Inadequate convergence with other departments • Inadequate reporting Key actionable points • Setting up of services (clinics) for adolescents • Ensure deployment of trained staff at ARSH clinics • Training of Human Resource • Community mobilisation and out-reach services to be strengthened • Regular reporting of activities • Formulation of State specific IEC strategy for Adolescents • Best Practices: • Implementation models by States like ‘Udaan’ of Uttarakhand, ‘Maitreyi’ Clinics of Maharashtra, Sneha Clinics of West Bengal & Yuva Clinics of AP. • Peer Educator model of Assam, Haryana can be replicated. • Working on outreach strengthening and comprehensive package of services • National Strategy for Adolescent Health in India is under construction

26. School Health Programme Issues • Biannual screening for Disease, Deficiency and Disability yet to emerge across States in the country • Dedicated school health teams not proposed by the states • Micro-planning not available • Poor mentoring, monitoring, and reporting • Poor utilization of resources approved in state Key actionable points • Closer coordination with Department of Education. • Linkages with other NRHM – components like Adolescent Health • Pooling of resource – financial, IEC and Human, National Disease control programmes • Best Practices: • Dedicated team for screening in Maharashtra • Implementation through exclusive teams – Maharashtra, Kerala (JPHN at schools), Uttarakhand, A&N island (outsourced) and in campaign mode in Gujarat, Bihar & Himachal Pradesh, with involvement of public health infrastructure in other states, Public and PPP– Rajasthan

27. Menstrual Hygiene Scheme Key actionable points • Re-orientation / re-training of ASHAs regarding promotion of sanitary napkins. • Monitoring to be strengthened • Focus more on new users i.e. Girls who have not had access to any such product prior to launch of scheme. • Proper record maintenance i.e. reconciliation of delivery by HLL / receipt by State and sale of packs vis-à-vis amount of incentive paid to ASHA, as they should match • Use of incinerators and their construction through Total Sanitation Campaign / SSA funds Issues • Slow uptake of sanitary napkins • Incomplete re-conciliation of records across various levels • Hardly any counseling of AGs • Irregular reporting to MoHFW, especially by Chhattisgarh and Uttar Pradesh • Convergence required with Total Sanitation Campaign / for effecting disposal mechanisms • Status of Implementation • Total supply by HLL to States = 322 lakh packs • 2nd and 3rd quarter supplies (> 600 lakhs packs) also in place • % of consumption till 31st July 2012 = 26.3 % • States performing well (good uptake) in HP, Kerala, MP, Orissa (Out of 17 implementing States through Central Supply)

28. Weekly Iron Folic Acid Supplementation (WIFS) Key actionable points • States (UP, Chhattisgarh, Himachal Pradesh, Lakshadweep and Daman and Diu) to submit plans • Difficulties in procurement for NE states and UTs being addressed through GO on procurement of IFA and Albendazole tablets from CPSE. States need to proactively take it up • Convergence with Education and ICDS/SABLA departments • Formation of State level WIFS Advisory Committee • Trainings • Development of media plan • Regular reporting, monitoring and review of implementation Issues • No plan for WIFS submitted by Chhattisgarh, Himachal Pradesh, Lakshadweep and Daman and Diu • They also did not participate in the National Level TOTs. • Difficulties in IFA procurement for NE states and UTs • State level WIFS Advisory committees yet to be activated • Readiness Status: PAN INDIA ROLL OUT • As per State plans, 23 states to complete procurement process by end September, 2012-13, Rajasthan, Karnataka, Chandigarh, Jharkhand, Mizoram and Puducherry by October 2012. • Supply of IFA and Albendazole tablets to reach schools & Aganwadicentres by end November in 22 States / UTs except Manipur, Meghalaya, Karnataka (end December 2012) and Rajasthan (February 2013) • Training of all field functionaries to be complete by November, 2012 barring Meghalaya (in Dec 2012)

29. Adopting evidence based interventions across Lifecycle (RMNCH+A Strategy) Adolescents Reproductive age group Pregnancy Birth • Weekly Iron Folic Acid Supplementation, Preventive health check-ups; Screening for disease, deficiency and disability & referral • Provision of reproductive & sexual health services Promotion of menstrual hygiene • Family planning advice and counseling ,Provision of a range of family planning methods • Screening for STIs and its management • Access to Safe abortion & Post abortion care • Essential care during pregnancy • Tracking of pregnant women with severe anemia and case management • Access to safe abortion and post abortion FP counseling and services • Treatment of complications of s/unsafe abortions • Management of STI/RTI • PPTCT • Care during labour and delivery (at the health facility) • Skilled birth attendance for home deliveries • Emergency Obstetric care • Detection and management of postpartum sepsis & other complications in postnatal period • Home based postnatal care & support for breastfeeding • Post-partum family planning advice and provision of contraceptives • Neonatal resuscitation with bag and mask • Essential new-born care at birth and up to 6 weeks • Management of sick newborns • Promotion of IYCF practices • Routine Immunisation plus Hepatitis B, H influenza ,Pulse polio • Vitamin A & Iron Folic Acid supplementation • Use of ORS and Zinc for diarrhea • Integrated Case management of neonatal and childhood illnesses • Management of children with severe acute malnutrition Postpartum Neonatal period Childhood

30. Summary of Key Actions Imperative to closely monitor the State specific targets under RCH Define District specific targets and review accordingly Strengthen monitoring of key interventions at all levels (use Dashboard indicators); timely reporting (HMIS, MCTS) and feedback for midcourse correction Special attention to High Focus Districts; 9 states should use AHS data for District specific planning District specific strategies to be adopted to reach the ‘Unreached’ population including urban poor Strengthen referrals and linkages between various levels of health facilities to ensure Continuum of Care Emphasize on quality of care: national guidelines and protocols for management should be followed

31. Thank You