REVIEW OF RMNCH+A, RCH

INCLUDING OTHER MATERNAL

HEALTH PROGRAMME AND IDSP
DR. ASHOK, JR-2
 2

Contents
 Introduction
 Historical background
 RCH Phase I
 RCH Phase II
 RMNCH + A
 IDSP
 PMMVY
 PMSMA
 References
 3

Historical Background

 During 1950s GoI introduced Maternal and Child Health (MCH) services

as basic health services in Primary Health Centers .

 1952, National Family Planning Programme launched to control

population growth in India, .

 1972, abortion was legalized .

 4

 1975: emergency declared by GoI.

1976, the disastrous forcible sterilization campaign led to the defeat of

congress Government and the new Janatha Government during 1977, ruled
out compulsion and coercion of Family Planning services and renamed
the program as ‘Family Welfare’ program .
 5

1978- Government of India launched WHO recommended Expanded

Program of Immunization (EPI).

1978-79- GoI became signatory to Alma-Ata Declaration of achieving the

Global Social Target ‘Health for all by 2000 AD’.

1985- EPI was renamed as ‘Universal Immunization Program (UIP)’ .

 6

1992- To achieve the social target and to improve the quality of services to
mothers and children, the services were integrated into a single composite
Program called ‘Child Survival and Safe Motherhood (CSSM)’ Program,
a time bound and target oriented National Program.
 7

During the International Conference on Population and Development

(ICPD) , held in Cairo (Egypt), (1994), it was resolved to provide high
quality of services to children and mothers, with a wider coverage of
women population from puberty to menopause (15–44 years), in a client
based, non-rigid, decentrallized, target-free, participatory, demand
driven approach.
 8

• September 1996, the CSSM Program and Family Welfare Program were
incorporated into a single, composite, National Reproductive and Child
Health (RCH) Program, and formally launched on 15th October 1997 by
GoI.

• In ICPD at Cairo, Fathallah, defined Reproductive Health as,

‘A state of complete physical, mental and social well-being and not

merely the absence of disease or infirmity in all matters relating to
reproductive system and its function and processes’.
 9

REPRODUCTIVE AND CHILD

HEALTH PHASE - I (RCH-I)
 10

OBJECTIVES
• The immediate objective is to promote the health of the mothers
and children to ensure safe motherhood and child survival.

• The intermediate objective is to reduce IMR, U5MR and MMR.

• The ultimate objective is population stabilization, through

responsible reproductive behavior.
 11

Strategies of RCH Program

Prevention and management of unwanted pregnancies

Maternalcare (Safe motherhood)

Child survival

Prevention and management of RTIs/STIs.

Prevention of HIV/AIDs.
 12

MAJOR INTERVENTIONS OF RCH- I

CHILD MATERNAL

• Essential Newborn Care • Essential obstetric care

• Diarrheal Disease Control • Emergency obstetric care
• Acute Respiratory Disease Control • 24 hour delivery services at
• Prevention and Control of Vitamin PHCs/CHCs
A deficiency • Medical Termination of Pregnancy
• Prevention and Control of Anemia • Control of RTI/STDs
& Immunization
 14

The neonatal care consists of care of eyes, nose, throat, skin, umbilical-cord
and rectum.
Reproductive Health
Fertility control, MTP-services, Adolescent counselling, and Prevention and
management of RTIs/STIs including HIV/AIDS.
 15

Management Strategies of RCH Program

Bottom-up Planning

Decentralized Training

Management Information and Evaluation System (MIES)

 16

Highlights of RCH -I Program

• Targetfree program from April 1, 1996 .

• Greater emphasis on quality.
• Bottom-up approach.
• Decentralized participatory planning.
• Free distribution of condoms
• Increasedmale participation and gender sensitivity.
 17

Lacuna of RCH-I

They were as follows :-

• The outreach services were not available to the vulnerable and needy .
• The management of financial resources were inadequate .
• The human resources such as doctors , nurse , health worker were deficient.
• The effective network of first referral units was lacking .
• Quality of services in PHCs and CHCs was poor.
 18

RCH- II PROGRAM

RCH-II is the continuation of RCH-I, which was for the period of 1997 to 2002.

 During the period of 2002 to 2004, planning for the implementation of RCH-II was
going on.

 RCH-II was started from 1st April 2005 up to 2009, in order to strengthen/
improve the quality of services and to achieve the Millennium Development Goals
by overcoming the lacunas of RCH-I.
 19

AIMS
The aim is to reduce Infant Mortality Rate (IMR), Maternal Mortality Rate
(MMR), Total Fertility Rate (TFR) and to increase Couple Protection Rate
(CPR) and Immunization coverage, especially in rural areas.
 21

Objectives

The main objective of RCH-II is to overcome the lacunae of RCH-I by the

following measures:
▫ To develop human resources intensively.
▫ To expand RCH services to tribal areas also.
▫ To improve the quality, coverage and effectiveness of the existing family
welfare services .
▫ To monitor and evaluate the services.
 22

ESSENTIAL
OBSTETRI
C CARE

MAJOR EMERGENC
NEW Y
INITIATIVES COMPONENTS
OBSTETRIC
OF RCH II CARE

STRENGTHI
NG OF
REFERRAL
SYSTEM
 23

Essential Obstetric Care

Strengthening the quality of antenatal care by:

 Early registration of pregnancy with min 4 antenatal checkups and 3 postnatal
visits.
 Two doses of tetanus toxoid .
 One pack of Iron FolicAcid (IFA) tablets during the last trimester.
 Counseling on promotion of institutional delivery, skilled attendance at
delivery, danger signs .
Emergency Obstetric Care

Operationalizing the First Referral Units/

CHCs /PHCs to be fully functional
round the clock (24 hours).

First referral unit (FRU): It is an upgraded PHC/CHC into a 30 bedded

hospital, having a well furnished and equipped operation theater with a
newborn care corner, a labor room, blood bank and laboratory to manage
emergencies such as cesarean section, care of the newborn and sick children
and facilities for blood transfusion.
 25

Services of FRU
• Emergency obstetric care such as cesarean section
• Care of the newborn and sick children.
• Facility for storage of blood
• Ambulance and referral services.
• Training of Medical Officers (MOs) in anesthetic skills .
• Training of Auxillary Nurse Midwives (ANMs)/Female health workers to
provide obstetric first aid.
 26

NEW INITIATIVES
 Training of PHC doctors in life saving anesthetic skills for emergency
obstetric care at FRUs
 Setting up of blood storage centres at FRUs
 JSY
 Vandemataram scheme
 Safe abortion services
 Janani Shishu Suraksha Karyakram (JSSK)
 Navjat Shishu Suraksha Karyakram (NSSK)
 RBSK
 Village health and nutrition day(VHND)
 Maternal death review.
 Pregnancy tracking
 27

NATIONAL MODIFIED
MATERNITY JANANI
BENEFIT SURAKSHA
12th APRIL
SCHEME 2005 YOJANA
 28

JANANI SURAKSHA YOJANA (JSY)

• The scheme was launched on 12th April 2005 under National Rural
Health Mission (NRHM) for pregnant women of BPL families in both
urban and rural areas.
• It is 100 percent centrally sponsored scheme as a safe motherhood
intervention for promoting safe delivery with benefit of cash assistance.
 29

• The main components of JSY are early registration, micro birth planning,
referral transport , institutional delivery, post delivery visit and reporting,
family planning and counseling.

• ASHA will work as a ‘Link Worker’ between the mothers of the

community and the health system. She is responsible for making available the
institutional care for mothers during pregnancy, delivery and after birth of the
child.
 30

JANANI SHISHU SURAKSHA KARYAKRAM (JSSK)

 Launched on 1st June 2011

 Aim - To make available better health facilities for women and child

FACILITIES
FOR FACILITIES
PREGNANT FOR CHILDREN
WOMEN
 31

The following services are provided to the

mother, free of cost:

• Normal delivery or cesarean section.

• Drugs and supplements like Iron and Folic acid tabs, etc.
• Laboratory investigations of blood, urine and sonography.
• Food supply during their stay in the hospital/health center.
• Blood transfusion.
• Transportation facility .
• Exemption from all types of fees.
 32

Free services to ‘At-risk’ newborns

during the first 30 days only:

▫ Treatment and care.

▫ Drugs and supplements like infusion, cotton, dressings. etc
▫ Investigations .
▫ Blood transfusion.
▫ Transportation facility.
▫ Exemption from all types of fees.
 33

SAFE ABORTION SERVICES

In INDIA, ABORTION is a major cause of MATERNAL MORTALITY and

MORBIDITY.

Accounts for nearly 8.9 % MATERNAL DEATHS

METHODS OF SAFE
ABORTION

MEDICAL METHOD OF ABORTION MANUAL VACCUM

ASPIRATION (MVA)
 34

Newborn Care and Child Health

Strategies

▫ 1. IMNCI plus: This approach consists of integration of immunization

services, skilled care at birth and IMNCI.

▫ 2. Strengthening of health infrastructures in PHCs, CHCs and FRUs for

care of infants and children.

▫ 3. Ensuring referral of sick neonates and children utilizing referral funds.

 35

• 4. Permitting ANMs and AWWs to administer selected antibiotics like

Gentamycin by ANM and co-trimoxazole by AWW.

• 5. Uninterrupted availability of drugs and supplies.

• 6. High quality supervision and monitoring.

• 7. Ownership of the state and district level program managers.

• 8. Efficiency of the administrative/financial system.

 36

• 9. Mobilizing the families for JSY. – Promoting healthy home care practices
for newborn and during illness like diarrhea. Improving referral of sick
neonates and children.

• 10. Promoting infant and young child feeding (IYCF) by promoting

breastfeeding practices .

• 11. Vitamin A, iron and folic acid supplementation.

• 12. Strengthening the quality of UIP to eradicate poliomyelitis, to eliminate
neonatal tetanus and to reduce mortality due to measles.
 37

CHILD HEALTH COMPONENTS

Strategy aims to reduce under-5 mortality through interventions at every

level of service delivery and child nutrition.

▫ 1. Nutritional rehabilitation centres (NRCs).

▫ 2. IMNCI- pre-service IMNCI, facility based IMNCI.
▫ 3. Home Based Newborn Care (HBNC)
▫ 4. Navjat Shishu Suraksha Karyakram (NSSK)
▫ 5. Rashtriya Bal Swasthya Karyakram (RBSK)
 38

NUTRITION REHABILITATION CENTRES

NRCs – Facility based units providing

medical and nutritional care to SAM
children under 5 years of age having
medical complication.

Presently 872 NRCs are functional

across 17 states/UTs with 9377
dedicated beds.
 39

SERVICES PROVIDED AT NRCs

1. 24 hours care and monitoring of the child

2. Treatment of medical complication
3. Therapeutic feeding
4. Sensory stimulation and emotional care
5. Counselling on appropriate feed, care and hygiene
6. Demonstration and practice by doing on the preparation
of energy dense food
 40

INTEGRATTED MANAGEMENT OF NEONATAL

AND CHILDHOOD ILLNESSES (IMNCI)

 Central pillar of child health interventions under RCH- II strategy.

It focuses on preventive, promotive and curative aspects of the

programme.

Objective is to implement imnci package at household, sub centre and

PHC level
 41

PRE SERVICE IMNCI

 Important strategy to scale up IMNCI by Government of India.

 Included in curriculum of medical colleges to generate trained IMNCI
manpower.

FACILITY BASED IMNCI

 F-IMNCI integration of facility based care package with IMNCI package.

 Management of major causes of neonatal/childhood mortality e.g. asphyxia,
sepsis, LBW, pneumonia, diarrhea, malaria, meningitis and severe
malnutrition.
 42

Facility based newborn care

HEALTH ALL NEWBORNS

SICK NEWBORNS
FACILITY AT BIRTH
MCH Level I : PHC/ Sub Newborn care corner Prompt referral
Centre (NBCC) in labor room

MCH level II : CHC, NBCC in labor room and Newborn Stabilization

First referral unit (FRU) operation theatre Unit (NBSU)

MCH level III : District NBCC in labor room and Special Newborn Care
hospital operation theatre Unit (SNCU)
 43

HOME BASED NEWBORN CARE

 Started in 2011.
 Given mainly by ASHA with the help of
AANGANWADI worker, ANM, and medical officer.
 44

 OBEJECTIVES :
To decrease neonatal mortality and morbidity through -

• Essential newborn care

• Prevention of complication
• Special care of preterm and newborns
• Early detection of illness in newborn and
provision of appropriate care and referral
• Support family for adoption of healthy
practices.
 45

 Under HBNC, ASHA make visit to all newborns upto 42 days of life.

 6 Home visits of ASHA in case of institutional deliveries – day 3, 7,

14, 21, 28, 42

 7 Home visits of ASHA in case of home deliveries – day 1, 3, 7, 14,

21, 28, 42
 46

Adolescent Reproductive and Sexual Health (ARSH)

Strategy is as follows :

• Incorporation of adolescent issues in all the RCH training programs

and all RCH materials developed for communication and behaviour
change.

• Dedicated days and dedicated timings for adolescents at PHC’s.

 47

NAVJAT SHISHU SURAKSHA KARYAKRAM

• OBJECTIVE – Training of ANMs/SNs/Doctors :

1. Newborn care ( basic and resuscitative)

2. Identification of danger signs.
3. Referral of sick born.
 48

Rashtiya bal swasthya karyakram (RBSK-2013)

• Includes provision for child health screening and early intervention

services through early detection & management of 4Ds i.e.
• Defect at birth
• Deficiency conditions
• Disease in children
• Developmental delay and disabilities
 49

RMNCH + A

R M N CH A
REPRODUCTIVE MATERNAL NEONATAL CHILDHOOD ADOLESCENT
 50

 RMNCH + A – Based on provision of Comprehensive care through five

pillars.
 It has become the heart of the Government of india’s Flagship Public
health programme, the NATIONAL HEALTH MISSION.
 51

OBJECTIVES

Health Outcome Goals established in the 12th Five Year Plan

• Reduction Infant Mortality Rate (IMR) to 25 per 1,000 live births by 2017
• Maternal Mortality Ratio (MMR) to 100 per 100,000 live births by 2017
• Total Fertility Rate(TFR) to 2.1 by 2017
 52

STRATEGIES-

• The RMNCH+A strategy promotes links between various interventions

across thematic areas to enhance coverage throughout the lifecycle to
improve child survival in India.
The “plus” within the strategy focuses on:

Including adolescence as a distinct life stage within the overall strategy.

Linking maternal and child health services to reproductive health,
family planning, adolescent health, HIV, gender, preconception and prenatal
diagnostic techniques.
Linking home and community based services to facility based care AND
 53

5 x 5 matri x for high impact RMNCH+ A interventions

 54

COVERAGE TARGETS FOR KEY RMNCH+A

INTERVENTIONS FOR 2017

• Increase facilities equipped for perinatal care (designated as ‘delivery

points’) by 100%

• Increase proportion of all births in government and accredited private

institutions at annual rate of 5.6 % from the baseline of 61% (SRS
2010)
 55

• Increase proportion of pregnant women receiving antenatal care at annual

rate of 6% from the baseline of 53% (CES 2009)

• Increase proportion of mothers and newborns receiving postnatal care at

annual rate of 7.5% from the baseline of 45% (CES 2009)

• Increase proportion of deliveries conducted by skilled birth attendants at

annual rate of 2% from the baseline of 76% (CES 2009)
 56

• Increase exclusive breast feeding rates at annual rate of 9.6% from the
baseline of 36% (CES 2009)

• Reduce prevalence of under‐five children who are underweight at annual rate

of 5.5% from the baseline of 45% (NFHS 3)

•Increase coverage of three doses of combined diphtheria‐tetanus‐pertussis

(DTP3) (12–23 months) at annual rate of 3.5% from the baseline of 7%
(CES 2009)
 57

• Increase ORS use in under‐five children with diarrhoea at annual rate of 7.2% from
the baseline of 43% (CES 2009)

• Reduce unmet need for family planning methods among eligible couples, married
and unmarried, at annual rate of 8.8% from the baseline of 21% (DLHS 3)

• Increase met need for modern family planning methods among eligible couples at
annual rate of 4.5% from the baseline of 47% (DLHS 3)
 58

• Reduce anaemia in adolescent girls and boys (15–19 years) at annual rate of
6% from the baseline of 56% and 30%, respectively(NFHS 3)

• Decrease the proportion of total fertility contributed by adolescents (15–19

years) at annual rate of 3.8% per year from the baseline of 16% (NFHS 3)

• Raise child sex ratio in the 0–6 years age group at annual rate of 0.6% per
year from the baseline of 914 (Census 2011).
 IDSP
Integrated Disease Surveillance Project
 60

Introduction
• Disease surveillance – recognized as an important tool for early detection of
outbreaks for instituting effective control measures in a timely manner.

• 1997-98: Pilot project titled National surveillance program for communicable

diseases (NSPCD) INITIATED.
• 2003: Central Surveillance Unit (CSU) established at Nirman Bhawan.
• November, 2004: World Bank funded Integrated Disease Surveillance Project
(IDSP) launched at national level for a period upto March, 2010.
 61

OBJECTIVES OF IDSP
MAJOR

To establish a decentralized state based system of surveillance for

communicable and non communicable diseases..

To improve the efficiency of the existing surveillance activities of disease

control programs and facilitate sharing of relevant information with the
health administration, community and other stakeholders .
 62

SPECIFIC OBJECTIVES

 To integrate, coordinate and decentralize surveillance activities.

Surveillance of a limited number of diseases and risk factors.
To establish system for quality data collection, reporting, analysis and
feedback using IT.
To improve laboratory support for disease surveillance.
To develop human resource for disease surveillance.
To involve all stakeholders and communities in surveillance process.
 63

DISEASES & CONDITIONS COVERED UNDER IDSP

 Regular surveillance

i) Vector borne disease : Malaria.

ii) Water borne ds : Acute diarrheal ds, cholera, typhoid.
iii) Respiratory diseases : TB.
iv) Vaccine Preventable Ds : Measles.
v) Disease under eradication : polio
vi) Other conditions : RTA.
vii) Other international commitments : Plague, Yellow Fever
viii) Unusual clinical synd. : Meningococcal encephalitis/Resp. distress/
H’gic fevers/ other undiagnosed conditions
 64

Sentinel surveillance

i) STD/Blood borne ds : HIV/ HBV/ HCV

ii) Other conditions : Water quality, outdoor air quality ( large urban area).

Regular periodic surveys

i) NCD risk factors : Anthropometry, nutrition, physical activity, B.P., tobacco &
blindness.
ii) Additional state priorities : Each state may identify up to 5 additional conditions for
surveillance.
 65

REPORTING FORMATS UNDER IDSP

66
 67

ROLE OF MEDICAL COLLEGE IN IDSP

 Medical colleges are integrated and have

special role in providing following services :-
i) Reference laboratories.
ii) Quality assurance.
iii) Training:TOT, DSO,etc
iv) Epidemic investigations.
v) Surveillance of NCD.
 68

Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)

• Pradhan Mantri Surakshit Matritva Abhiyan

envisages to improve the quality and
coverage of Antenatal Care (ANC),
Diagnostics and Counselling services as part
of the Reproductive Maternal Neonatal
Child and Adolescent Health (RMNCH+A)
Strategy.
 69

It has been suggested that PMSMA will be held on 9th of every month,
wherein all the essential maternal health services will be provided at
identified public health facilities as well as accredited private clinics and
institutions volunteering for the Pradhan Mantri Surakshit Matritva Abhiyan.
Essentially, these services will be provided by the Medical Officer and
/OBGY specialist.
 70

PMSMA will help in providing

quality ANC& also detection,
referral, treatment and follow-up of
high risk pregnancies and women
having complications.
 71

Pradhanmantri matru vandana yojna(PMMVY)

• Objectives of PMMVY

• Providing partial compensation for the wage loss in terms of cash

incentives so that the woman can take adequate rest before and after
delivery of the first living child.

• 2.12 The cash incentive provided would lead to improved health seeking
behaviour amongst the Pregnant Women and Lactating Mothers
(PW&LM).
 72

Target beneficiaries

• All Pregnant Women and Lactating Mothers, excluding PW&LM who

are in regular employment with the Central Government or the State
Governments .

• All eligible Pregnant Women and Lactating Mothers who have their
pregnancy on or after 01.01.2017 for first child in family.

• The date and stage of pregnancy for a beneficiary would be counted with
respect to her LMP date as mentioned in the MCP card.
 73

Benefits under PMMVY

Cash incentives in three instalments i.e. first instalment of ` 1000/- on early
registration of pregnancy .

Second instalment of `2000/- after six months of pregnancy on receiving

atleast one ante-natal check-up (ANC) .

Third instalment of ` 2000/- after child birth is registered and the child has
received the first cycle of BCG, OPV, DPT and Hepatitis-B, or its
equivalent/ substitute.
 74

The eligible beneficiaries would receive the incentive given under the
Janani Suraksha Yojana (JSY) for Institutional delivery and the incentive
received under JSY would be accounted towards maternity benefits so
that on an average a woman gets ` 6000/-.
 75

REFERENCES
• Park’s Textbook of Preventive and Social Medicine, 25rth Ed.
• National Health Programmes of India, 11th Ed. J.Kishore,2015.
• Community Mediine with Recent Advances,3rd Edition, A H Suryakantha.
• www.mohfw.nic.in
• https://
www.google.com/search?q=rmnch&source=lnms&tbm=isch&sa=X&ved=2a
hUKEwizkazP7vDnAhUZThUIHZHZA_gQ_AUoA3oECBMQBQ&biw=10
24&bih=528
• https://wcd.nic.in/sites/default/files/PMMVY%20Scheme%20Implemetation
%20Guidelines%20._0.pdf