RMNCH+A

Shivanand Savatagi
Assistant Professor
MSRUAS, Bengaluru
Content

• Background
• Introduction
• Goals
• Coverage targets
• Implementation
• Various health programmes
• Monitoring methods
• Technical support

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Intended learning outcome

• How RMNCH+A came into existence

• Able to know about goals and targets of RMNCH+A
• Implementation of services and monitoring them

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HISTORICAL BACKGROUND

• 1950- MCH services as a basic health services in PHC

• 1952- National Family Planning Program
• 1966- All India Hospital Post Partum Program
• 1997- RCH Phase – 1
• 2005- NRHM
• 2005- RCH phase 2

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 Background
• In June 2012,

GOI, Ethiopia, USA & UNICEF convened “Global child survival call to action:
A promise to keep” summit in Washington DC

• In Feb 2013,

GOI held historic summit on the call to action for child survival &
Launched a strategic approach to RMNCH+A

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Introduction

• Heart of the GOI’s flagship public health programme, National Health

Mission

• RMNCH+A is a strategy based on provision of comprehensive care

through 5 pillars

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RMNCH+A strategic approach.??

• Comprehensive strategy for improving the maternal and child health

outcomes

• Based on evidence that maternal & child health cannot be improved in

isolation as adolescent health and family planning have an important
bearing on the outcomes

• Strategy based on concept of ‘CONTINUUM OF CARE’

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RMNCH + A

✓Including adolescence for 1st time as distinct life stage

✓Linking maternal & child health to reproductive health, family

planning, adolescent health, HIV, gender, preconception, & prenatal
diagnostic techniques
✓Linking home & community based services to facility based care

✓Ensuring linkages, referrals and counter referrals b/w primary,

secondary & tertiary levels
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Aim

• Reach the maximum number of people in the most remote corners of

the country through –

Routine
Continuum monitoring
of services of
interventions

Constant
innovations

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Goals

Health outcome goals established in the 12th five year plan

▪ Reduction of infant mortality ratio (IMR) to 25 per 1,000 live births by

2017
▪ Reduction in maternal mortality ratio (MMR) to 100 per 100,000 live
births by 2017
▪ Reduction in total fertility rate (TFR) to 2.1 by 2017

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 High priority district (HPD)
• Strategic approach: reaching geographies & population with highest burden of mortality

Identification of HPD’s
( Based on composite health index)

Differential planning for HPD’s

30% higher financial allocation: differential norms for HR, infrastructure: incentives for HR

Harmonisation of technical assistance

All partners to work with states to accelerate progress on RMNCH+A
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Management tools and job aids

✓5x5 matrix

• 5 High impact interventions in 5 thematic areas

• 5 cross cutting interventions
• 5 health system strengthening interventions

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 Implementation

• Key intervention as a “continuum of care”

• Interventions- high impact on reducing mortality & improving survival

• State specific targets should be established against existing baselines

National and state ‘Scorecard’ is introduced as a tool to increase
transparency and track progress..

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Priority interventions

• Adolescent nutrition; iron and folic acid supplementation

• Facility based adolescent reproductive and sexual health services
(ARSH) (Adolescent health clinics)
• Information and counselling on adolescent sexual reproductive health
and other health issues
• Menstrual hygiene
• Preventive health checkups

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ARSH- Adolescent reproductive and sexual
health programme
Service delivery during routine sub-centre clinics & also on fixed days and
timings at PHC’s, CHC’s, DH levels

1. Adolescent friendly health clinics(AFHC)- 6,302 AFHC’s– functional

2. Facility based counselling services : 881 ARSH counsellors
1439 ICTC counsellors- Sexual & RH counselling

3. Out reach activities- schools, colleges, teen clubs, vocational training

centers, VHND, in collaboration with self help groups
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Information and counselling on adolescent sexual
reproductive health and other health issues

• To improve knowledge, attitude & behaviours regarding sexual & repr.

Health(incl. gender based violence)
• Life skills based adolescence education programme- screening &
appropriate referrals with de-addiction centers
• ‘Kishori samooh’ under SABLA scheme (ministry of women and child
development)
“Nehru Yuva Kendra Sangathan” – teen clubs under ministry of sports
and youth affairs

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Scheme for promotion of menstrual hygiene in
rural areas

• Promotes better health hygiene among adolescent girls (aged 10-19

yrs)
• High quality and safe products are made available to girls and
environmentally safe disposal mechanisms are made accessible
• Sanitary napkins are provided under NRHM brand “Free days”
• Napkins are being sold to adolescent girls by ASHA’s

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Preventive health check ups & screening for diseases,
deficiency & disability

• Bi-annual screening is undertaken for students(6-18 yrs) enrolled in

govt. & govt. aided schools
• screening, basic health services & referrals; immunization; micronutrient
supplementation(IFA & vit.A) and de-worming
• Children in need of secondary & tertiary care will be entitled to free Rx
through Rastriya Swasthya Bima Yojana/state health insurance
scheme/NRHM
• Requires convergence with Dep. Of Education i.e Sarva Siksha Abhiyaan
& Rastriya Madhyamik Shiksha Abhiyaan

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Pregnancy and Childbirth

➢Priority interventions
1. Delivery of antenatal care package and tracking of high risk
pregnancies
2. Skilled obstetric care
3. Immediate essential newborn care & resuscitation
4. Emergency obstetric & new born care
5. Post partum care for mother & child
6. Implementation of PC & PNDT Act(pre-conception & pre-natal
diagnostic techniques act-1994)
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Pregnancy and Childbirth

1. Preventive use of folic acid in peri-conception period

promoting use of folic acid in planned pregnancies 3 months before &
after conception

2. Antenatal care package and tracking of high- risk pregnancies-

Pregnancy testing kits are supplied under brand name Nishchay to sub
centres & through ASHA’s
Universal access to full antenatal package- MCTS (mother & child
tracking system)- enables to monitor service delivery

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3. Skilled obstetric & essential newborn care & resuscitation

Operationalizing delivery points: health system now

assessed against a minimum benchmark of performance
( no. of deliveries conducted/ month)

Janani suraksha yojana(JSY) was launched- conditional cash transfer for

institutional care during delivery & immediate post partum period

Janani shishu suraksha karyakram (JSSK) - reduce out of pocket expenses

related to maternal &newborn care
Free ambulance service
4. Emergency Obstetric & new born care-
Health centres designated as delivery points have been made functional
24X7
MCH wing is established at high case load facilities to expand health
infrastructure for maternal & newborn care

5. Post partum care for mother & baby

- 48 hrs stay at health facility is mandated for institutional delivery

-postnatal home visits by frontline workers irrespective of place of delivery-
atleast 3 postnatal visits to mother & 6 to newborn to be made within 6
weeks of delivery
5. Postpartum IUCD insertion and sterilisation

PPIUCD insertion by trained providers at district and sub-district

hospital level only and upto subcenters currently providing delivery
services
Medical officers are trained in ‘Minilap’ for provision of postpartum
sterilisation in high case load facility
RMNCH counsellor is placed
6. Implementation of PC&PNDT Act-

Formation of PC&PNDT cells at state/district level;

Establishment of statutory bodies (strengthening of monitoring
mechanisms, including state inspection and monitoring committee,
online maintainence, analysis & scrutiny of records mandated under
act and digitilisation of reg. records
Newborn and childcare

➢Priority interventions
• Home based newborn care and prompt delivery
• Facility based care of the sick newborn
• Integrated management of common childhood illnesses
(diarrhoea,pneumonia, and malaria)
• Child nutrition and essential micronutrients supplementation
• Immunisation
• Early detection & management of defects at birth, deficiencies,
diseases and disability in children (0-18 yrs)
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Through the Reproductive Years

➢Priority interventions

▪ Community based promotions and delivery of contraceptives

▪ Promotion of spacing methods (interval IUCD)
▪ Sterilisation services
▪ Comprehensive abortion care (includes MTP act)
▪ Prevention & management of sexually transmitted and reproductive
infections

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 Health system strengthening for RMNCH+A
services
1. INFRASTRUCTURE

• New construction & renovation of existing facilities

• Delivery points
• Maternal and child health (MCH) wing
• Human resource
✓Recruitment & rational deployment of HR
✓Strengthening sub centres through additional human resource
✓Placing adequate staff as per IPHS norms
✓Multiskilling of medical officers & Empowering nurses for MCH & family planning at
facilities
✓Capacity building of health providers
✓Performance appraisal
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2. Policies on drugs, diagnostics, equipments, procurement system and
logistics management

3. Quality of care: Quality Certification by district and state quality assurance

cells
Scorecard

• Health management information system – based dashboard

monitoring system

• The choice of dashboard monitoring system are based on life cycle

approach

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Indicators for scorecard

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Delivery points

• Delivery care serves as important indicator to assess facility function

• Thus concept of delivery point emerges from this presumption

• Health facilities designated as L1,L2,L3

L1- min. 3 normal deliveries per month
L2- min. 10 deliveries per month including complications
L3- min. 25-50 per month including C- Section

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MCH Wing

• Established at high case load facility with adequate provision of beds.

• New comprehensive units (30/50/100 bedded) with antenatal waiting
rooms, labour wing, Essential New born Care room, SNCU, OT’s, blood
storage units, Postnatal ward

• This ensures Emergency maternal and new born care services & 48
hours stay at facility

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Monitoring, information & Evaluation
systems

• Civil registration system:

Efforts to ensure 100% registration of births & deaths
• Web enabled mother and child tracking system(MCTS)
recent initiative to link MCTS with AADHAR to track subsidies to eligible
women
• Maternal Death Review (MDR)
Identify causes of maternal deaths & gaps in service delivery

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• Perinatal and child death review
Death reports with causes of death for any child under five
• Review Missions
Annual joint review Missions by RCH division and common Review
Missions under NRHM
• Rapid programme assessments
To identify operational bottlenecks & make corrections for community
& facility based interventions
• Health management Information System (HMIS) based monitoring and
review
Following things monitored and interpreted at National,state & district
levels:
✓Full antenatal care
✓Institutional delivery
✓Sterilization procedure
✓IUCD insertion
✓Full Immunisation
✓Child and Maternal Health
Community participation

• Engage womwn systematically at community level

• Engage village health sanitation & nutrition comittes (VHSNC) & Rogi
Kalyan Samiti(RKS)
• Utilize VHND’s as platform for assured & predictable package of
outreach services
• Social audit and communitisation efforts at panchayati raj level

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Convergence & partnerships

• National vector borne disease control programme(NVBDCP)

• National AIDS control programme
• AYUSH
• National urban health mission(NUHM)
• SABLA scheme, ICDS, ARSH,WIFS
• Inter-sectoral co-ordinatin- Nirmal Bharat Abhiyan, Indiragandhi
Matritva Suraksha Yojana,
• Ministry of Tribal Affairs & Disaster management authorities

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Partnerships

• Indian academy of pediatrics (IAP)

• Federation of Obstetric and Gynaecological Socities of India (FOGSI)
• Indian Association of preventive & Social medicine (IAPSM)
• Indian Medical Association (IMA)
• NGO’s & Corporate Social Responsibility (CSR) Initiatives

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Technical Support

• Technical Support Unit (TSU) within MoHFW

• National Child Health Resource Centre
• Regional Collaborative Centres for reproductive, maternal,
newborn, child & adolescent health
• RMNCHA coalition
• Consortium for operations research on maternal & child health
• Technical Resource Group’s (TRGs)

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Conclusion

• RMNCH+A strategy has been a historical milestone in country’s

healthcare planning.
• It succeeded in establishing an institutional framework & mechanism of
facility level, need based planning through concerted & coordinated
efforts
• Recent data suggested that 48 of the 184 HPD’s have improved &
excluded from HPD’s
• Oppurtunities, learnings & weakness from this strategy can be
considered in guiding future programmes better

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 Contd..

• Realising importance of social determinants in overall improvement

In Jan 2018 GOI launched ‘Transformation of Aspirational Districts’
initiative in 117 districts
• Initiative focuses on 5 themes, viz Health & Nutrition, education,
agriculture & water resources, financial inclusion & development and
basic infrastructure and operational and implementation components.

• Within health fort-folio initiative build on RMNCH+A framework to

improve outcomes in aspirational districts- focuses on improving Human
Development Index of India.

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References

• Textbook of Preventive and Social Medicine by [Link]

• Taneja, G., Sridhar, V.S.R., Mohanty, J.S., Joshi, A., Bhushan, P., Jain, M.,
Gupta, S., Khera, A., Kumar, R. and Gera, R., 2019. India’s RMNCH+ A
Strategy: approach, learnings and limitations. BMJ global health, 4(3),
p.e001162.
• [Link]
• [Link]
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