Reproductiv e Strengthening RMNCAHN Services Key Focus Areas

Reproductiv e Strengthening RMNCAH+N Services Key Focus Areas Vandana Gurnani JS (RCH) Ministry of Health and Family Welfare Government of India Nutrition Maternal Adolescent Newborn Child

Outline • • 2 Overview Decoding the Unfinished RMNCAH +N agenda RMNCAH+N Key Focus Areas Aspirational District Approach

Key RMNCH+A Indicators Maternal Mortality Number of maternal deaths (death of a woman while pregnant or within 42 days of termination of pregnancy) Ratio (MMR) per 100000 live births Neonatal Mortality Number of neonatal deaths (less than 28 days of age) per 1, 000 live births Rate (NMR) Infant Mortality Rate (IMR) Number of infant deaths (under one year of age) per 1, 000 live births Under-Five Mortality Number of child deaths (dying before reaching the age of five) per 1, 000 live births Rate (U 5 MR)

Maternal Mortality Ratio 600 556 500 400 300 India MMR Decline 77% 385 216 200 130 100 0 1990 Between 1990 and 2015 Global (MMEIG Estimates: 1990 -2015) Global MMR Decline 44% Compound annual rate of decline increased significantly from 5. 8% to 8. 01% India(MMEIG Estimates: 1990 & 2015) & SRS 2014 -16 Between 2007 -09 & 2011 -13 to 2011 -13 & 2014 -16

Under- 5 Mortality Rate 126 India U 5 MR = Global U 5 MR 93 39 1990 For the FIRST time 2016/17 Global- IGME Estimates (1990 -2017) India- 1990 -IGME Estimates (1990 -2017) & 2016 - SRS Share among deaths ∝ Share of births

However, the road ahead is much steeper…!!

Saving Mothers and Children is in your hands!! In India, One pregnant woman dies every 4 hours One child dies every 30 seconds

Target 100 by 2020 Gl h Ra ar jas Ut th an ta r P ra de sh Od ish a As sa m M ad hy a P Bi a di ra la In Ke d) lan Fin t ( es 3 3 11 46 Target 23 by 2025 8 55 52 50 47 45 43 39 237 201 199 180 173 165 130 MATERNAL HEALTH al B ob d m sa As a an an kh ra tta th jas Ra ish Od h ar sg tti d an di a In kh ar hh a / U UP P/ C M /Jh ha r Bi la ra Ke ) ee ce t ( Gr es l B ob a Gl RMNCAH+N- At a Glance CHILD HEALTH (U 5 MR)

Child Mortality Status – Uttar Pradesh Indicators Rate Deaths Contribution to U 5 Deaths Under 5 Mortality Rate (U 5 MR) 39 9. 6 Lakhs --- Infant Mortality Rate (IMR) 34 8. 4 lakhs 87% Neonatal Mortality Rate (NMR) 24 5. 9 Lakhs 71% Early Neo-natal Mortality Rate (ENMR) Deaths on Day of Birth 18 4. 4 Lakhs 75% - 1. 8 Lakh 40% 9

RMNCH+A- Family Towards smaller, happier, and healthier families Planning 35% Decline in Total Fertility Rate NFHS 1 (1992 -93) – NFHS 4 (2015 -16) 2. 2 National Family Health Survey IV (2015 -16)

RMNCAH+N- At a Glance Contraceptive use (MCPR) 47. 8 48. 5 IFA coverage in Pregnant women 30. 3 15. 2 50. 3 57. 9 Pregnant women who are anemic Full Immunization coverage Children with Diarrhoea received ORS 35. 8 42. 5 42. 7 Complementary feeding Early Initation of Breast Feeding 7. 9 Teenage Pregnancy Source: NFHS 3 & 4 52. 6 41. 6 23. 4 16 ANC Coverage 2005 -06 50. 6 26 Under weight (under 5) 2015 -2016 62 43. 5 51. 2 37 0 10 20 30 40 50 60 70 11

Decoding the Unfinished RMNCAH+N Agenda 12

Maternal deaths : Causes Under 5 Deaths: Causes Source- RGI-SRS 2001 -03 Medical Causes Source- WHO 2012 Injuries 3% Measles 3% Diarrhoeal disease 12% Others 14% Pneumonia 15% ‘ 3 Delays’ • Delay in decision to seek professional care • Delay in reaching the appropriate health facility • Delay in receiving care after arriving at a hospital Neonatal causes 53% Infections 33 Prematurity 35 Asphyxia 20 13

Reproductive Maternal Newborn Child Adolescent Health + Nutrition Reproductive & Child Health Adoles- Reprodcent uctive RMNCAH+N Mater Child APPROACH nal Newborn • RMNCH+A Links maternal and child survival to other components (family planning , adolescent health, gender & PC & PNDT) • Plus denotes inclusion of adolescence as a distinct ‘life stage’ in the overall strategy • Links community and facility based care as well as referrals between various levels of health care system

Performance on Key Maternal Health % Pregnant women given 180 IFA to Indicators total ANC Registration % 1 st Trimester registration to Total ANC 33 32 28 De eg lhi ha Pu lay a du ch er Na ry ga la nd 37 M na c ha l. . . 41 Ar u an ng Te la 47 UP 51 a a 57 Go nd 57 ha r an ip u . . 60 Jh Ut M ra kh a. P M 61 ar k 63 ta ja st ha n 64 Ra In di a 66 Registrations % Pregnant Woman received 4 ANC check ups to total ANC registrations 26 20 De M eg lhi ha l Ar aya un ac h Na al ga la nd ra Ut m ta ra kh a M. . . an i Ra pur ja st ha n M izo UP ha r Go a Si kk im Tr ip ur a Bi In di a 68 64 63 62 53 51 48 48 47 44 43 37 India 83% Bihar 67 Haryana 63 Tripura 56 Punjab 54 Pudducherry 52 Delhi 51 Rajasthan 46 Arunachal P 44 J&K 38 Manipur & Mizoram 37 Meghalaya 36 Uttarakhand 25 Nagaland 15 15 Source : HMIS (18 -19)

Need to Ensure – Safe Delivery for Every Woman § 8 out of 10 Women now deliver at health facility § Still 5 million deliver at home § Half of them in UP and Bihar Institutional Delivery Other States; 49 Uttar Pradesh ; 32 • Balrampur 30. 8% • Baharich 37. 3% • Siddhartnagar 45. 3% Bihar; 19 Share of Home Delivery - India • Shravasti 48. 4% • Farrukhabad 52. 0%

Performance - Postnatal Maternal and Newborn Care Indicator % Women discharged in less than 48 hours of delivery to Total Reported Deliveries at public institutions % Newborns breast fed within 1 hour of birth to Total live birth % of newborns received scheduled home visits out of total reported deliveries National Average (HMIS) 42% States/UTs Performing worse than the National Average Uttarakhand (61%), MA (65), A&N (65%), UP (65%), Haryana(67%), Arunachal Pradesh(76%), Nagaland(79%), Jharkhand(82%) and Bihar(84%) 89% Punjab(79%), Lakshadweep(78%), Tamil Nadu(77%), Goa(74%), Delhi(73%), Telangana(69%), Daman & Diu(64%), Chandigarh(63%) 35% Uttarakhand(33%), Karnataka(31%), Manipur(27%), Delhi(25%), Maharashtra(21%), Rajasthan(21%), Haryana(14%), Arunachal Pradesh(14%), Telangana(13%), Nagaland(12%), Mizoram(11%) and Daman & Diu (1%) 17

Te m lang u & ana Ka sh m ir Ke ra Ta An mi la dh l N ra adu P ra de M sh an i NC pur T W De es l t B hi en ga Tr l ip ur a Si kk im Pu n Hi Ka jab m ac rna ha tak l P a ra de Na sh M gala ah n ar d as ht Ar ra un As ac s ha l P am ra de M sh izo ra m IN DI A Od ish Gu a M jara eg t Ut hala ta y ra a kh an Ha d ry an R M a ad ajas th hy a a Pr n Ch ade ha sh t t Ut is ta gar r P h ra d Jh esh ar kh an d Bi ha r Ja m Values in (%) Low Caesarean Section Rates Where Need is Most 45 35 30 25 20 15 10 41 40 35 31 26 26 23 21 19 18 18 18 17 16 14 13 13 13 12 12 12 11 10 9 9 6 6 6 5 Data Source: NFHS – 4 5 5 3 0

Functional FRUs (HMIS) % of FRUs fulfilling conditionalities against the required FRUs 62 59 55 53 53 48 47 Immunization (HMIS) FIC JAMMU & KASHMIR (HMIS, April’ 18 to Feb ‘ 19) HIMACHAL PRADESH PUNJABCHANDIGARH UTTARAKHAND National: 78. 49% HARYANA DELHI ARUNACHAL PR. SIKKIM UTTAR PRADESH RAJASTHAN ASSAM BIHAR NAGALAND MEGHALAYA MANIPUR 34 33 MADHYA PRADESH GUJARAT 20 17 TRIPURA JHARKHANDWEST BENGAL MIZORAM CHHATTISGARH DAMAN & DIU D&N HAVELI ODISHA MAHARASHTRA Less than 50%-90% More than 90% TELANGANA PONDICHERRY ANDHRA PRADESH Ut ha r KARNATAKA Bi Al l In di ta ra a kh an Ha d W rya n es t B a en ga Jh l ar kh an d M ad Gu ja hy ra a t Pr ad es Ra h ja Ch sth an ha tti Ut s ta gar r P h ra de sh GOA A&N ISLANDS LAKSHADWEEP TAMIL NADU KERALA

u ad na Go a tis ga M rh izo ra m P Ut unja ta ra b kh an Te d la ng M an ah a ar as h Na t. . . ga la nd K An era la dh ra Pr a M. . . an ip ur Tr ip ur a at Ch h rk h Hi m and ac ha l. P. . . Od ish a Jh a il N m Ta ry a Ha ka . . l. . ta rn a Ka ha ac un Ar sa m ra d r. P ta Ut As t ja ra Gu a di In 0. 2 0. 4 0. 6 0. 7 1. 4 1. 6 2. 7 3. 1 3. 5 3. 6 4. 0 4. 6 4. 7 4. 9 5. 1 5. 4 5. 6 5. 9 6. 3 7. 6 Bi a Go M. . . a Ar nipu un r ac h Ja m al. . m. u & Te K. . . la ng an a K An era la dh ra Pr a Na. . . ga l M and eg ha la ya M izo ra m Tr ip ur a l. P ha kim r ha m sa Sik ac m Hi . . d. ht. . . as As ar ah M ra a nd ha rk at ak r. P Ut ta Jh a rh nd ha ak rn Ka ta r Ut t a ra ga tis at Ch h ja Gu di In 0. 8 0. 9 1. 2 1. 5 1. 6 1. 7 2. 1 2. 2 3. 3 3. 8 4. 3 4. 9 7. 7 10. 8 11. 9 12. 1 12. 4 13. 2 13. 9 14. 3 16. 3 Performance on Key Family Planning Indicators (HMIS) PPIUCD Acceptance Rate Injectable Contraceptives per 10000 Eligible Couples Source: HMIS 2018 -19 20

ECD MPV The RMNCAH +N Strategies – Issues and Challenges New Contraceptives Anemia Mukt Bharat La. Qshya Mission Indradhanush HBYC New Vaccines PMSMA MAA 21

Focus on Aspirational Districts 1 st § Out of 13 indicators, 8 are on RMNCAH+N § Develop special strategies and formulate annual plans § Ensure all schemes are implemented on priority in these districts § Undertake special visits Monitor ranking on NITI Dashboard § Focus on Intersectoral convergence § Focus on trimester registration and 4 ANC checkups § Focus on full ANC – screening for HIV, Syphilis, GDM, Hep B etc § Ensure High Risk Pregnancy Tracking and follow -up § Focus on Quality ANC under PMSMA Quality ANC and PMSMA 22

PMMVY, JSY & JSSK NITI Aayog findings in a recent field study on PMMVY: • MCP cards not filled properly - cards lacked critical information like date of immunization, ANC check-up etc. causing delays in payments of PMMVY instalments. • At national level only 36% of the registered beneficiaries under PMMVY have received their 3 rd and final instalment. Village Health Sanitation and Nutrition Days § Focus on availability and updation of MCP cards § Raise awareness about entitlements among the beneficiaries § Ensure DBT - expedite data feeding on PMMVYCAS in respect of JSY beneficiaries. § Clear back logs and ensure prompt payments § Ensure availability of free referral transport, drugs, diagnostics, diet etc § Platform to be strengthened to provide all services & counselling, not only immunization

FOR WOMEN, STILLBIRTHS, NEWBORNS, THE TIME OF HIGHEST RISK IS THE SAME 80000 60000 Birthday 40% still births 50000 20% of all U 5 MR 70000 46% of maternal deaths 30000 20000 10000 Intrapartum Stillbirths 7 6 5 4 3 2 1 da y rth Bi In tra pa rtu m 0 Birth is the time of greatest risk of death and disability Number deaths women Number deaths neonates 24

La. Qshya 54 LRs & 38 OTs National Certified 179 LRs & 158 OTs State Certified 2257 La. Qshya Facilities Focus on closure of gaps identified in baseline assessment and improve State & National level certifications

Midwifery Initiative Lancet Series on Midwifery (2014): Safe and effective midwifery care can avert 83% of all maternal deaths, stillbirths and newborn deaths. • Strengthen BSc Nursing Colleges as State Midwifery Training Institutes • Recruit State Midwifery Educators (guidelines to be shared shortly) To provide access to quality maternal and newborn health services: • Depute State Midwifery Educators for training at National Midwifery Training Institute (July onwards) promoting positive child birthing experience • Ensure respectful care • Reduce over medicalization • Start 18 month training of Nurse Practitioners in Midwifery – January 2020 onwards • Promote natural birthing by • Plan for additional Institutes and training in Supplementary PIP

Anemia Mukt Bharat IDCF & NDD • Focus on supply chain management for IFA and ensure availability and generate demand • Use Anemia Mukt Bharat Dashboards for monitoring data and initiate test and treatment. • Address non nutritional causes of anemia in endemic pockets eg: Heamoglobinopathies and malaria • Integrated Diarrhoea Control Fortnight for promotion of ORS and Zinc (28 th May – 9 th June 2019 – ensure availability and focus on unreached population) • National Deworming Day (NDD) – Focus on private school and out of school participation 27

Role of PSs and MDs in implementation of IDCF 2019 (28 May – 9 June, 2019) 1. Review of Stock positioning of ORS/ Zinc and procurement (based on Under 5 Population, estimated diarrhoeal episodes and buffer stock) 2. Inter-sectoral coordination meeting at State level and Video-conference with district officials on preparation 3. Review of Capacity building - Stakeholders (AWW, Schools, drinking water & Sanitation, tribal, PRI, IAP –private sector, medical colleges etc. ) 4. Launch of IDCF 2019 campaign and Visibility on Social media platforms 5. Review of Supportive Supervision plans (State/ Districts) and monitoring by State and District officials during fortnight (At least twice) 6. Advocacy and awareness generation campaign through local media, SHGs, local religious leaders and local groups (folk dance, nukad natak etc. ) 7. Focus on Aspirational Districts/High Priority Districts- Active engagement Development Partners / Private Providers 8. Review of preparation, mid-level implementation (corrective measures) and at the end of fortnight

New Born Care MAA Programme • Focus on capacity building of labour room staff for essential newborn care and resuscitation. • Focus on use of SNCU data for ensuring quality care at SNCUs • Ensure follow-up of newborns discharged from SNCUs • Promote Mother Newborn Care Unit for developmentally supportive care of Newborn in SNCU • Expedite implementation of HBNC and HBYC programme for community-level care to newborns • Ensure supportive supervision of frontline functionaries for home visits • Breast Feeding (1 st Vaccine) • Although institutional delivery is 78. 9%, breastfeeding within one hour of birth is only 41. 6% • Capacity building and accreditation on priority • Focus on complementary feeding from 6 months onwards 29

Rashtriya Bal Swasthya Karyakram and Early Childhood Development Rashtriya Bal Swasthaya Karyakram (RBSK) Systemic approach for early identification and management of 4 Ds - Defects at birth, Deficiency, Diseases at childhood and Developmental Delays for children of 0 -18 years • Improve coverage • Ensure referral and management of those identified with 4 Ds • Establish/ strengthen DEICs • Use of MCP card 30 • Promote play and stimulation

Adolescent Health - RKSK Focus on revised guidelines for RKSK – Partnerships with NGOs to be prioritized School Health Programme being introduced in close collaboration with MOHRD in a phased manner Reproductive Health • Expanding the basket of choice: Injectable Contraceptive MPA (Antara Program) & Centchroman pill (Chhaya) • Mission Parivar Vikas- 146 High Fertility Districts & New Family Planning Media Campaign • Most of the states score low in FP Service provision • Programmatic reach towards male clients is limited 31

In 2018, we estimate that with the use of contraceptives: Unintended pregnancies 5. 44+ Crore prevented 13. 9+ Crores 18. 2+ Lakhs Unsafe Abortions averted Women were using a Modern Method of Contraception 23, 000 Maternal deaths averted 1. 1 Crore total births averted

Immunization Coverage Improvement- Way Forward State level estimates (CES 2019) States with FIC < 70% States with FIC >70% Entire State will conduct MI Categorization of districts based on available data sources 1. Concurrent Monitoring data by partners in sizeable beneficiary survey 2. IMI Survey FIC < 70% Mission Indradhanush FIC between 70 - 90% • Intensive Monitoring • Prioritising & focussing FIC > 90% Sustain gains Key Focus Areas • Availability of updated microplans • Regular head count survey and generation of due list • Awareness generation and social mobilization • Supportive Supervision • New Vaccines - Inactivated Polio Vaccine, Rotavirus vaccine, Pneumococcal Conjugate Vaccine, Measles-Rubella (MR) vaccine 33

Decline in Sex Ratio and PC&PNDT Act • The Pre-conception and Pre-natal Diagnostic techniques (Prohibition of Sex Selection) Act, 1994 (PC& PNDT Act) was enacted in 1996 and further amended in 2003 • Prohibits sex selection before and after conception and imposes penalty. • Policy making bodies both at national and state levels-(Central/ State Supervisory Boards) • Implementation lies with the States though State and District Appropriate Authorities assisted by Advisory Committees • Monitoring mechanisms are in place at all levels- (Multidisciplinary National/ State/ District Inspection and Monitoring Committees) • Court cases have been filed, Convictions have been secured and following conviction the medical licenses of doctors have been suspended/ cancelled and ultrasound machines have been sealed for violations of the law.

Evaluating Performance Web-based RCH Portal/ MCTFC Web-based Health Management Information System for monitoring service delivery indicators Sample Registration System : Data brought out by Registrar General of India on key outcome indicators at the national & state level National Family Health Survey: All India data on key indicators through periodic surveys Coverage Evaluation Survey, Rapid Survey of Children, Common Review Missions, RMNCH+A field visits

Child Registration Coverage of EAG States Pregnant Women Registration Coverage of EAG States 50 51 36 36 30 20 15 20 0 0 M Jh Bi Bi 26 27 15 ha r 10 ha r ad arkh hy a a P nd Ut rad ta e r P sh ra de sh Ut Ind ia ta ra Ch nch ha a tti l sg ar h Or i Ra ssa ja st ha n 10 FY 2018 -19 26 30 Data as on 10 th April’ 2019 a ta ra nc ha l Or Ch iss a ha tti sg a Ra rh ja st ha n 32 45 50 40 di 40 45 In 50 57 60 Ut 60 71 kh Ut an ta d M r Pr ad ad es hy h a. P ra de sh 60 71 ar 70 66 66 70 Jh 80

Action Points - Improving Kilkari performance Correct Data entry of beneficiary in RCH and MCTS with complete details such as Name, LMP/ Do. B, Mobile number IEC activity Awareness campaigns , Promotional activities to bring awareness about the schemes amongst the beneficiaries and health officials Kilkari inbox number is not being used by beneficiaries as they are not aware of the inbox number - Promote the Kilkari inbox number “ 1800 -3010 -1703” in different forums. Action plan to be prepared for all low performing districts with clear targets: Ensuring data correctness in the RCH/MCTS portal Beneficiary to be informed by ASHA about Kilkari calls During VHND ASHA and ANM to Kilkari toll free number to be inform beneficiary about Kilkari given to beneficiary calls and its benefits

Action Points for the State to improve Mobile Academy performance Instructions for dialing and starting the MA course during ASHA monthly meeting. MA toll free number is (1800 -3010 -1704). ASHAs who have not started the course to be identified and necessary instruction to be issued for completion of the course. IEC activity Awareness campaigns , Promotional activities to bring awareness about the schemes amongst the beneficiaries and heath officials Timely distribution of certificate on course completion by the ASHAs

Aspirational District Approach 39

Introduction: Aspirational Districts • NITI Aayog identified 117 aspirational districts across 28 States for transformation by the year 2022 • The districts have been identified based on the status of indicators related to Ø Health & nutrition(30%) Ø Education (30%) Ø Agriculture & Water resources (20%) Ø Financial Inclusion (10%) Ø Basic infrastructure (10%) • A set of 13 core and 31 sub-core indicators identified for demonstrating the progress on health & nutrition in these districts

NITI AAYOG: 2 nd DELTA RANKING REPORT Health & Nutrition Ranking Overall Ranking Most Improved District Virudhunagar, Tamil Nadu Nuapada, Odisha Least Improved Rank 1 2 Siddharthnag ar, Uttar Pradesh Aurangabad, Bihar 3 Koraput, Odisha 5 4 District Pakur, Jharkha nd Hailaka ndi, Assam Chatra, Jharkha nd Giridih, Jharkha nd Kiphire, Nagalan d Rank 111 110 109 108 107 Most Improved Least Improved District Chitrakoot, Uttar Pradesh Barwani, Madhya Pradesh Vidisha, Madhya Pradesh Rank 1 District Chatra, Jharkhand Rank 111 2 Pakur, Jharkhand 110 3 Hazaribagh, Jharkhand 109 Raichur, Karnataka 4 Godda, Jharkhand 108 Balrampur, Uttar Pradesh 5 Purbi Singhbhum, Jharkhand 107 Data period: June-October 2018

Additional Resource Availability • Rs. 974 cr sanctioned for Aspirational Districts by NITI AAYOG through ODA from JICA – Out of this Rs. 600 cr to be provided on challenge method ( Overall ranking and sectoral ranking) – Rs. 350 cr to be provided for new health project plan – District administration to prepare health project plan with the help of National Mentors, NHSRC and Development Partners • 60% of CSR funds of CPSE has been allocated for Health and Education in Aspirational Districts

Tools for Strengthening Health and Nutrition Status in Aspirational Districts Operational Guidelines for improving Health & Nutrition in ADs Health Atlas as a diagnostic tool for planning and monitoring in ADs Supportive Supervision Checklists for undertaking focused visits at District, Facility and Community level 43

Conduct a District – wise Review on all the Areas highlighted in this presentation Institutionalize a system of Quarterly State level RMNCAH+N Reviews Closely Monitor Aspirational Districts for Maximum Gains 44

In addition to above: • Annual Action Plans - Oversee the design and implementation of annual Plans. Use NHM flexibility to address challenges (e. g. terms of engagement of HR) • Convergence & Coordination with all concerned departments eg: WCD • Human Resource (HR): Fill up vacancies Deployment of HR • Essential Drugs and Diagnostics: Ensure free essential drugs and diagnostics at all government facilities • Validation of data: Check for completeness & correctness of HMIS data /data from RCH portal • Development Partner Support: Utilize technical support and monitoring from DPs. through Recruitment and Rational

Most Important- Remember that you literally have the power to change the world!!! Reduction of Maternal and Child Deaths in Large States Reduction of Maternal and Child Deaths in India Reduction of Maternal and Child Deaths across the world

“Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving: We have not yet valued women’s lives and health highly enough. ”