Hlc a l t l ~I'rogrammcs

Nutio~~n o prevention, arrest or slowing of acute nietabolic as well as chronic cardio-vascular-

renal coq~plicationsof the disease.
@ identification of subject with partial or total physical handicaps due to the disease,
and to ensure their rehabilitation with emphasis on optinial organ or body fUnction,
3) @ Level one is early identification of the cases by health workeg, doctors at PHC,
CHC and hospital specialist doctors through surveillance.
@ Level two is case detection at hospital level through specialists and manpower
training.
@ Monitoring and evaluation at national level by All India Institute of Medical
Science, Department of Medicine.
Chcck Your Progress 6
1) @ Training of nlanpower (medical and other technical support manpower) in-clinical
and diagnostic aspects of non-communicable diseases.
@ Carrying out of su~lreysand screening programmes in the conmiunities for early
detection of these disorders.
O Providing Sentinel Surveillance for these diseases for the cases reporting at
Hospitals.
9 Ensuring adequate care of case referred from peripheral instihltions for diagnosis
,
and treatment and proper feedback.
O Organisation of health education activities in hospital areas such as OPDs and
Indoors.
@ Rehabilitation [Link] due to these non-communicable diseases.
2) O To ensure optimal allocation of resources provided to h e m in the district for
programme activities.
O To develop suitable monitoring parameters/indicators bascd on field visit reports,
meetings and review of reports and special surveys.
3) - Input ' I
- Process
- Output
- Outcome

2.10 FURTHER READINGS

Government of India 1998-99, Annual Report, DGHS, New Delhi,

s sIndia - A
Government of India 1985, Natiorjal Programme for Control of B l i ~ ~ h ein
Report, DGHS, New Delhi.

Government of India 1995, Conference of Centlnl Council of Health and Family Wefire,
Ministry of Health and Family Welfare, New Delhi.
. ...-
Government of India 1996, National Cancer Control Progrmnote I~tdia:Present Statifs,
DGHS, New Delhi.

Government of India 1994, Report on Advocacy Policy Meeting 011 Iodine Deficiertcy Lf

Disorders, Ministry of Health and Family Welfare.

'
ICMR 1988-89, Bienrtial Report National Cancer Registiy Progranlnte-All ~ ~ i d e r ~ t i o ~ o g i ~
I
Strmy.

ICMR 1996, Salt consumption Pottern in In& - An ICMR Tmk Force Sttmcly, New Delhi

ICMRBulletin 1996, Control oflDD through Safe Use of IodisedSaIt, Vol. 26, No. 6.
 TH PRO
Structure
3.0 Objectives
3.1 Introduction
3.2 Evolution o f the R C H Programme
3.2.1 Transition from MCH and FP to Family Welfare and CSSM Programme
3.2.2 Need for Holistic Approach towards Women's Development
3.2.3 International Conference on Population and Development (ICPD) and Programme of
Action (POA)
3.2.4 India's Commitment towards ICPD, POA and Launching of RCH Programme *
3.3 Objectives ofRCH Programme
3.4 Paradigm Shift in the R C H Programme
3.4.1 Target-free Programme Based on Community Needs Assessment
3.4.2 Decentralised Participatory Planning
3.4.3 Integrated RCH Package
3.4.4 StateIDistrict Specific RCH Strategy
3.4.5 Greater Emphasis on Quality of Care
3.4.6 Comprehensive Integrated Training with District as Coordinator
3.4.7 Involvement of the Panchayati Raj System m

3.4.8 Increased Involvement of NGOs and Private and Corporate Sector

3.4:9 Area Specific IEC Campaigns
3.4.1 0 Gender Concerns
3.4,11 lncreased Male Participation in the Programme
Q
3 5 Components a n d Packages o f Services under RCH Programme
3.5.1 Recommended Package of Services under RCH Programme
3.5.2 Programme Interventions
3.5.3 Safe Motherhood Components
35.4 Child Survival Components
3.5.5 Safe Abortion Services
3.5.6 Contraceptive Services for the Eligible Couples
3.5.7 Prevention and Management of RTIs and STIs
3.5.8 Adolescent Health Services
3.5.9 Special Care Components- Cancer and Infertility Services
3.6 Organisation a n d Infiastructural Facilities for Implementation of RCH Programme
3.6.1 Organisational Set-up for Delivery of RCH Programme
3.6.2 lnfrastructural Facilities for Delivery of RCH Services
3.6.3 Special Facilities and Projects under RCH Programme
3.6.4 Role of Hospitals in Implementation of RCH Programme
3,7 Managerial Dimensions of RCH Programme
3.7.1 Community Needs Assessment Based Decentralised Planning
-
I
3.7.2
3.7.3
Human Resource Development and Capacity Building
Management of Material Resources
3.7.4 Funding and Reimbursement Prooedures under RCH Programme
3.7.5 Management lnformation System (MIS)
C
3.7.6 Monitoring of RCH Programme
3.7.7, -
Partnership Development Intersectoral Cooperation and Involvement of NGOs
3.8 Improving Quality o f Services
3.9 Let Us Sum Up '

3.10 ~nswfkito Check Your Progress

National H e a l t h Programmes
3.0 OBJECTIVES
After going through this unit, you should be able to:
@ describe briefly the evolution of RCH programme in India;
@ explain the paradigm shift in the programme;
@ describe components of the programme and packages of services under the each
component;
@ explain the role of hospitals in the implenlelltation of the programme;
@ explain various programme lnanagelnellt dimensions; and
, @ list measures for improvillg the quality of services under the programme.

3.1 INTRODUCTION
In this unit you will learn about the genesis and components as well as service packages in
relation to one of the most important national programmes, viz. Reproductive and Child
Health (RCII) Prograrnnle. You will also learn the organisntional set-up and infrastructural .
facilities for delivery of seivices under the programme. In addition, you will also be briefly
oriented to solllc of the special projects and facilities envisaged under the programme.
Further, you will learn about the role of hospitals in implementing the RCH programme.
Towards the end you will learn about the specific managerial dimensions of the programme
as well as measures to be taken for improving the quality of RCH services so as to ensure
client satisfaction with the services.

3.2 EVOLUTION OF THE RCH PROGRAMME

3.2.9 Transition from MCW and FP to Family Welfare CSSM Programme
Poor health status in ternls of high mortality and morbidity anlong women and children in
India had been a major concem for public liealtli professionals even before attainment of
independence. Efforts to provide services to this vulnerable section of the population were
initiated under Maternal and Child Health (MCH) services. Major hospitals in urban areas as
well as Primary Hcalth Cwtres (PHCS) in the rural areas were responsible to render these
services since independexe. The rapidly growing population of the country and its social
and economic 6onsequen:es on development and quality of life of people was another
concern for the socio-economic development planners. The result was the launching of the
e
National Family Planning Programme since the first five year plan period. With the
advancement of technology, various other interventions for the improvement of the health of
this section of population could be possible and during the seventies, program~~es/schemes
like imrnunisation against vaccine preventable diseases, nutritional interventions like iron
and folic acid supplementation, vitamin A supplementation ctc. were initiated.

Even though the fanzily planning programme and MCH programme were being inlplen~ented
in a vertical manner, it was understood that fertility regulation was extremely important for
maintenance of healtlt of the mother and child. Similarly, it was also appreciated that couples
will accept contraceptive services to prevent pregnancy, only if su~vivnlof their existing ,.
children is ensured. This realisation of the close inter-relationship between family planning"
and MCHprogrammes led to the government's inajorpolicy decision to integrate family
planning with MCH and nutrition services.

Later during the seventh five year plan period, separate prograinnles were also initiated
towards controlling two major killer diseases among children. These were OralRehydration
Therapy for preventing deaths among children due to dehydration from diarrhoea and acute
respiratory infection control programme to control morbidity and mortality due topneumonia-
Objectives of all these programmes were convergent and aimed at improving the health of
mothers and young children and to provide them facilities for prevention and treatment of
 major disease conditions. These prograrnrnes were implemented in the country separately,
though concurrently. While all the above mentioned progranunes did have beneficial ;esults,
[he separate identity of each programme was causing problems for their effective
nianagenlent and their impact on health status of wolnen and children could not be as visible
as expected. ll~erefore,during the 8"' five year plan period, all these programmes and
services viz. antenatal, intranatal and post~latalcare; cluld health services including
inmlunisation, management of diarrhoea, and ART, were all integrated under the Child Survival
and Safe Motherhood (CSSM) Programme which was implemented since 1992.

3.2.2 Need for Holistic Approach towards Women3s Development

Even though CSSM prograrnnle was inlple~nentedall over the country with equal enlphasis,
the position regarding its performance and achievements was not unifornl tl~roughoutthe
country. States like U.P., M.P., Bihal; Rajasthan, Orissa and JLkK which showedperfomance
at much lower level than the national level were also those which were nlore populous and
hence, unless perfornlance in these states did not improve, the national level perfornlance
also would have remained depressed. Integrated efforts towards improveme~itof the health
status of women and children with infrastructural strengthening and resource inputs
commensurate with the specific needs of the stateslregion became essential with a holistic
approach towards overall socio-eco~~omic development and in particular for women's
empowernlent.

3.2.3 International Conference on Population and Development (ICII'D)

and Programme of Action (POA)
In the context of evolving a holistic appronch to child survival and safe n~otherhoodas
explained above, the International Conference on Population and Developnlent (ICPD) which
was 3rd in the series of decadal populatiol~conferences, held in Cairo in 1994, came at an
opportune time. At this conference, representatives of about 180 countries reached a new
consensus about how world population issues should be approached. It was agreed that
population policies should address social development beyond family planning, especially
the advancement of women, and that fanlily planning should be provided in the context of
comprehensive reproductive health care. Thc Cairo Programme ofActio11(POA) defined
reproductive liealth in a comprehensive fashion for the first time.

The definition states that "reproductive heulth is a state of conzplcte pllysical, nlentnl aid
social well being aud not merely the ubserrce of disease or infirmity in all matters relating
to the rep'[Link] system and to itsfilnctiorrs clizdprocesses".
Reproductive health therefore implies that people are able to have a satisfying and safe sex
life and that they have the capability to reproduce and the freedom to decide if, when and
how often to do so. Implicit in this last condition are the right of men and wonlen to be
informed and to have access to safe, effective, affordable and acceptable methods of
family planning of their choice, as well as other methods of their choice for regulatio~iof
fertility which are not against the law, and the right of access to appropriate health care
services that will enable women to go safely througl~pregnancy and child birth and provide
couples with best chance of having healtl~yinfant. In line with this definition, reproductive
health should broadly include family planning; snfi pi-egnancy and delivery seivices;
prevention and treatment of RTIs and STls; irfoi*~~zation
and counseling on sexuality;
and other women's health services.

3.2.4 India's Commitment towards XCPD,POA and Launching of RCW

t Programme
Even though the sustained efforts in implementing the family welfare programme had
benefited large number of people, over the years, it has been increasingly realised that
niore need to be to completely address the health needs of women and children. It has also
been felt that the workload has been not set for the functionaries in accordance with the
actual needs of the population. In response to these needs, government had decided to
reorient the programme. At this juncture, the international consensus developed in the
 National Health Programmes ICPD, Cairo 1994, for a holistic approach to reproductive health also helped the country to
develop the Reproductive and Child Health PrZgramme in India. The RCH programme was
formally launched on 15th October, 1997 in India.
Check Your Progress 1
1) Why was the need felt for integration of different components of services into
a the RCH

programme?
............................................................................................................................................................
;

P
2) What was the majot cqnsensus arrived at ICPD Conference in Cairo in 1994?
".i.." ...................................................................................................................................................

3) When was the RCH programme formally launched in India?

.............................................................................................................................................................

3.3 OBJECTIVES OF RCW PROGRAMME

1. Objectives of the RCH programme are:

I 1) Nationwide improved quality, coverage, and effectiveness of RCH services;

I 2) Improved management performance by:

i) expanding existing monitoring system and decentralised participatory planning
I

iii institutional strengthening

iii) enhanced programme management capacity
3) Local capacity enhancement.

3.4 PARADIGM SHIFT IN THE RCH PROGRAMME

I
. The reproductive health approach extends beyond the narrow limits of family planning to I

encompass all aspects of human sexuality and reproductive health needs during various
stages of life cycle. A paradigm shift is needed for operationalising the reproductive health I

programme. A change in focus from the population control approach of reducing numbers to
a client based approach of addressing the reproductive needs of individuals, couples, and I
families is necessary.
I
I
An ideological shifi is needed which in turn would necissitate a change in the existing
culture of programme from one that focuses on achievements of targets to one that aims at; I

providing a range of good quality services. It means that instead of remaining responsible -- I
for reducing the rate of populafion growth, reproductive health programme becomes

morbidity and mortality. P

responsible for reducing the urden of unwanted and unplanned child bearing and related
*J
I

I
It is important to note that RCH programme is a more sharply defined form of family i

welfare programme. It does not seek either to disband earlier programmes or to bring into i
a wholly new programme in a vacuum. The RCH programme only seeks to fine tune the i
I

earlier programmes in an increhental manner with addition of certain service 3!

compo~entsand giving specrh.1 emphasis on certain other service components already
being provided. It seeks to bring about a holistic approach to programme 4
4
1

2
 nre constantly conscious of whether. good
i,nplernentntion so that health junctiona~~ies Reproduetiv e and Child
Health Programme
quality services are reaching the people to meet their needs.

,3.4.1 Target-free Programme Based on Community Needs Assessment

Being a signatory to the ICPD Programme of Action ratified at Cairo in' 1994, some major
programme and policy initiatives had already been taken earlier since 1994, to give shape
to the concept of reproductive health. In April 1996, even before the formal launching ofRCH
programme, Government of India took a landmark decision to withdraw the system of
estimating workload and work allotment as well as monitoring the programme, based on
centrally deteimined, method-specific contraceptive targets. Instead, it adopted a
Community Needs Assessment (CNA) based; bottom up approach, where self-estimated
workloadlgoals were used by the health personnel themselves.

3.4.2 Decentralised Participatory Planning

Planning for the services actually begins at grass-root level with members of panchayat and
Mahila Swasthya Sangh (MSS) and other villagers closely interacting with the ANM and
male health worker for deciding about the actual requirement ofvarious family welfare
services. This improves the sustainability of the programme on one hand, by generating a
sense of involvement and ownerskip among the community towards the progranune
thereby increasing utilisation of services as well as on the other hand, by ensuring ,sense of
responsibility and accountability among the workers. The plans prepared for tlie subcentres
by the local health workers which are aggregated lo make the F)HC plan in turn are
aggregated at the district level to prepare the district plan.

3.4.3 Integrated RCW Package

The process of integration of various related programmes for improving health of women
and children had been seriously attempted with the implementation of CSSM programme.
However, with the implementatio~iof RCH progranmle, this has taken a step further. It is
~ l s highly
o desirable to have an integrated approach since it would not only be more
acceptable to the community, but would also help in reducing the cost inputs to some
extent because overlapping of eoipenditure will not be necessary and integrated
implementation would optimise outcome at the field level. This integrated package
includes essential RCH package which gives basic minimum model framework of RCH
services at different levels in the district viz, cornnlunity, subcentre, PHC, FRU and district
hospital. The essential components are:

Q prevention and management of unwanted pregnancy; .

0 maternal care including antenatal, intranatal and postnatal as well as safe abortion .
services;
Q child survival services including care of new born;
Q management of RTII STI.

3.4.4 StateIDistrict Specific RCW Strategy

The main focus of RCH programme is, implementation based on actual needs of people.
Considering the variations in regard to different pararneters/indicators of RCH and
co~espondingservice needs among states and districts in the country, area specific
approach has been worked out separately for different groups of states and districts. States
and districts are classified based on indicators like, Crude BirtliRate (CBR), Total Fertility
Rate (TFR), female literacy level, percentage women registered for antenatal care,
percentage of hospital deliveries, percentage delivered by untrained attendant etc. For
backward districts which have additional needs, additional resource inputs as per
requirement are envisaged to be provided.

3.4.5 Greater Emphasis on Quality of Care

Provision of good quality care is the crux of RCH Good quality care is
difficult to be defined. However, a working definition of quality may be evolved
incorporating few elements related to services i.e.' choice of service, information provided
 '
National H c n l l l ~Programmes to clients, technical competence of service providers, inte~personalrelation between service
provider and clients, mechanism to ensure continuity of care etc. It nlay be assumed that
good quality care would increase client satisfaction which is one of the major goals of the
programme. This in turn would be expected to increase the seAice utilisation and thereby
would enable achieve!nent of the programme goals and may determine the success of the
proglanmle.

3.4.6 Comprehensive Integrated Training with District as Coordinator

In-service training of healt11personnel with due focus on practical clinical, managerial and
communication skills is a major inpl~tunder the programme towards improvement of
quality of services. An important feature of the training in future would be involvement of
the field functionaries and the Anganwadi workers as well as ft~nctionariesfrom other
health related development sectors. Planuing and nlanagemeilt of the training progranlnles
will be the responsibility of the district health authorities. Central and state governnlents
are to support the district in baining of trainers and in producing training materials,

3.4.7 Involvement of Pancllayati Raj System

Panchayati raj system is expected to play a significant role in planning for RCH services
particularly for identification of needs of local populatio~ifor RCH services. The system is
also to play a role in the implementation, particularly, financial support and transport
support for referral of woinen to hospitals for obstetric services. In addition, for
evaluation of the programme, the panchayat system is expected to extend support in
assessing the client satisfaction from services. Therefore special efforts to provide RCH
awareness to panchayat members are envisaged.

3.4.8 Iucreased Involvement of NGOs and Private and Corporate Sector

,
The programme envisages to involve personnel from NGO and private and corporate
sectors in delivery of RCH services as well as in undertaking various types of training
activities.

3.4.9 Area Specific IEC Campaigns

Information, Education, and Communication (IEC) activities have to play a major role in
RCH programme for demystifying the RCH and population issues among public.
Therefore, the Department of Family Welfare has been implementing a large IEC
programme involving various government departments, NGOs and private agencies. While
there is an attempt to evolve a national IEC strategy for RCH, emphasis is placed on
development of local area - specific communication strategies to create more demand for
RCH services and to promote informed decision making on health matters. Thus health
personnel are trained in IEC skills to motivate people to use the right kind of services for
meeting their needs. Special emphasis is also placed on inte~yersonalcommunication
(IPC) and use of local traditional media for increasing acceptance and understanding of
messages and thereby their effect and impact through behaviour change.

3.4.10 Gender Concerns

All efforts are being made to make the programme as gender sensitive as possible.*
Women's groups are involved in its planning and monitoring. In addition, the government ,+
has already initiated effoes which trigger changes in societal attitudes towards women.
Women's empowerment and awareness about gender issues in relation to various
developmental projects and programmes among all concerned are to be promoted.

3.4.1 1 Increased Male Participation in the Programme

Need for increased male participation in the RCH programme and on all issues related to I

reproductive health is being increasingly recognised. More responsibility in child rearing

practices by males i.e. more responsible parenthood among males, increased acceptance of
contraception by males as an evidence for acceptance of increased responsibiljLy towards
fertility regulation;informed decision making jointly by male and femalb partners on

d'
 reproductive health issues, male participation in RCH service provision etc. are very
important.

Check Your Progress 2

1) What was the major policy decision taken by GO1before launching the RCH programme
for giving shape to RCH concept?

2) Why do we say that t11e1;e is a paradigm shift in the RCH programme?

.............................................................................................................................................................

3.5 (COMPONENTS AND PACKAGES OF SERVICES

UNDER RCW P R O G U M M E
Reproductive health approach means that:

@ people have the ability to reproduce and regulate their fertility;

@ women can go through pregnancy and childbirth safely;
D the outcome of pregnancy is successful in terms of maternal and infant health and well
being; and
D couples can have sexual relations free of fear of pregnancy and of contracting disease.

3.5.1 Recommended Package of Services under RCH Programme

The RCH programme incorporates the conlponeilts covered under CSSM programme and
includes two additi~nalcomponents, one relating to reproductive tract infection and the
other one relating to sexually transmitted infections. As there are enormous diversities in
India, among regions and states, as well as between rural and urban areas, no single package
of serviceslcan be recommended for nationwide implementation. Basically there are two
types of packages:

I ) A ~or~lprehensive
package which at present would have limited application.
2 ) An essential package which is'fecomnlended for nationwide implementation.

Even if the facilities for implementiilg the comprehensive package are inadequate in most
parts of the country, the goal should be to expand the implementation of services
incrementally and in a phased manner, by utilising the lessons learnt from programme
experience.

l'he following services are included in a comprehensive reproductive health service

package:
*
@ prevention and management of unwanted pregnancy
@ services to promote safe motherhood
@ services to prom~techild survivnl
@ nutritional services for vulnerabli; groups
@ prevention and treatment of reproductive tract infections and sexually transmitted
diseases
@ prevention and treatment of gyn~aecologicalproblems
@ screening and treatment of brealst and cervicavuterine cancer
0 reproductive health services for adolescents
National Health Programmes @ health, sexuality and gender information, education and co~~nseli~lg
@ establishment of effective referral systems
The essential reproductive health package however excludes the management of
gynaecological problems as well as screening and management of cancers.
3.5.2 Programme Interventions
The RCH programme is implemented in India based ona differential approach. Inputs in all ,

districts have not been kept uniform because efficient delivery will d e p q d upon the
capability of the health system in a district. Therefore, basic facilities are proposed to be
strengthened and streamlined specially in the weaker districts as the better-off districts
already have such facilities and the more sophisticated facilities are proposed for the
relatively advanced districts which have acquired the capability to make use of them
effectively. All the districts have been categorised into A (best performance), B (medium
performance), and C (poor performance) on the basis of CBR, and female literacy rate which
reasonably reflect t h e ' R status
~ ~ of the district.
Following are the interventions in all the districts:
@ Child survival interventions (as available under CSSM programme)
@ Safe motherhood interventions(as available under CSSM programme)
@ Facilitation for operationalisation oftarget-free approach
8 Institutional development
9 Integrated training package
@ Modified Management I~lformationSystem
IEC activities and counseling on health, sexuality and gender
@ Urban and tribal areas RCH package
District subprojects under local capacity enhancement
RTVSTI clinics at district hospitals where not already available
@ Facility for safe abortions at PHC by providing equipment, conkactual doctors etc.
Enhanced community participation through panchayats, women's groups and NGOs
Minor civil works
Prpision of lab technicians for lab diagnosis of RTUSTI and for EOC
Adolescent health and reproductive hygiene.
3.5.3 Safe Motherhood Components
Some of the programme components are briefly described below:
1) Antenatal Care
All pregnant women should get registered with the health facility and should receive routin.
care and timely screening for identification of risk factors through at least three check up .
Each pl;egnant woman should also receive two doses of Tetanus toxoid immunisation at
interval of at least one month. In addition, special emphasis is given on control of anaemia
among pregnant women through promoting consumption of Iron and Folic Acid (IFA) tablets
.$tldalso by educating women regarding consumption of iron rich food. All pregnant women
r ie expected to consume prophylactic dose of IFA and when found anaemic on screening
through haemoglobin estimation, therapeutic dose of IFA is to be consumed.

One of the essential requirements for preventing maternal mortality and morbidity is to
ensure safe delivery by every pregnant woman. It is safest to deliver babies in a health
institutionihospital under care by trained personnel[ In case it is not possible, it is to be
ensured that deliveries at home take place under safe and hygienic suiroundings and are
assisted by trained persolinel, preferably by ANMLHV or at least by trained birth
attendants. Delivery by relatives an4 friends and untrained dais are not safe and are to be
discouraged. In case of any complications, referrals should be made to the First Referral
 Units (FRU) for management of obstetric emergencies. Thus under RCH programme, these
services are ensured under "essential obstetric care".
3) Esselltial Obstetric Care
rCr
~~selltTa1 obstetric care includes those items of obstetric care which any pregnant woman
!-equires if there is no complication during pregnancy or delivery. These items basically .
include:
o registration of pregnancy in the first 12-16 weeks of pregnancy
o at least three prenatal check ups by ANM or in dispensary or other health facility for
providing check up for essential body parameters through blood pressure checks,
routine investigations like urine, haenloglobin etc.
o counseling
@ detection of complications of pregnancy if any

9 referral to PHCIFRU in case of pregnancy complications

0 assistance during delivery and three postnatal check ups
@ detection of complications during delivery and referral.
4) Emergency Obstetric Care
Emergency obstetric care is an intervention for preventing maternal mortality and morbidity.
The complications of pregnancy such as anaemia, haenlorrhage, obstructed labour, and
sepsis are major causes of maternal mortality and morbidity. Ifthese complications are
detected early and managed appropriately, maternal mortality and morbidity can be reduced
substantially. If three check ups by ANM at antenatal and three at postnatal stage are
e~lsuredby competent supervision, most of such complications can be detected and
managed before they become life threatening. The ANM is expected to refer the cases with
con~plicationsduring pregnancy or delivery to PHCIFRU. For ensuring effective emergency
obstetric care under RCH programme, the FRUs are strengthened through supply of
equipment kits, emergency obstetric care drug kits, provision of consultant anaesthetist etc.
5) Postnatal Care
Postnatal period which starts from delive~yof placenta upto 42 days from delivery also
requires special attention for preventing maternal mortality and morbidity. Postpartum
haemon-hage and puerperal infection are major causes ofmaternal mortality. At least three
postnatal check ups are to be ensured for each pregnant woman.
* 3.5.4 Child Survival Components
Ensuring survival and proper growth and development of every new born baby is extremely
important. Inspite of various efforts made in the past and achievement of reduction in infant
nlortality in India, [Link] and mo~~bidity
among children are still major concerns for health
care providers and administrators.
Major causes of infant and child mortality and morbidity include:
@ prematurity,
@ respiratory infections,
0 diarrhoea1 diseases,
1 9 umbilical cord infection in the new born babies,
I . @ birthinjuries,
I 0 . congenital malformations,
I

nutritional deficiencies, and

F
i @ certain vaccine preventable infections etc.

I Accordingly, the strategies for improving child survival and development include:

[ strengthening esseatial new born care,

I appropriate management of diarrhoea,

N n t i u ~ l a l H e a l t l ~P r o g r a m m e s @ appropriate management of ARI,
@ sustaining high levels of immunisatiorl coverage,
0 nutritional interventions like nutrition subplernentation e.g. vitamin A prophylaxis,
supplementaiy feeding etc.
e improved maternal care, and
@ promotion of birth spacing.

1) Essential New Born Care

Inspite of decline in iilfant mortality, neonatal mortality still colltributes to a major proportion
of infant deaths. High incidence of low birth weight among babies is a conzmon contributory
factor in neoilatal deaths. Major causes of neonatal mortalitv have been identified as
hypothermia, asphyxia and infections. Simple cost effective indigenous technology is
available to provide essential new born care at the field level to manage the direct causes of
neonatal mortality. Provision of essential new born care will thus not only improve overall
quality of services provided by peripheral health facilities but also contribute to decreasing
neonatal mortality and morbidity.
Emphasis is placed on the following:
@ Ensure five cleans i.e. clean hands, clean surface, clean razor blade, clean cord tie, clean
cord stuinp (no applications).
@ Eyecare.
e Cleaning new b o r ~by~ wiping with soft and clean clothes and not by bathing to avoid
hypothermia.
0 Assessment of birth weight to identify low birtli weight babies who need special
attention.
Resuscitation of new born baby who does not ciy soon after birth.
@ Early breast feeding initiation and exclusive breast feeding for initial 3-4 months
@ Prevention of infection through clean hygienic psactices.
Q Imn~unisationagainst vaccine preventable diseases.
2) Control of Diarrl~oea
Diarrhoea is a major cause of mortality and morbidity among young children. Dehydration
caused by loss of fluids from the body is the main cause of death and hence under the
programme, efforts are made to ensure prcvcntion and correction of dehydration in children
through Oral Rehydratioil Therapy (ORT). Through health education to mothers, messages
regarding need for cleanliness during handling of food as well as on how to manage
d i a ~ ~ h o at
e ahome by mothers and when to seek help from health personnel are also
disseminated.
3) Control ofvitamin A Deficiency
Vitamin A deficiency is responsible for night blindness and in certain cases, irreversible
blindness among children. Deficiency of vitamin A also can increase the risk of death among
children particularly when they are suffering from measles or [Link] and
management of vitamin A deficiency is an important iiltervention under RCH
[Link] child between the age of 9 months and 3 years is given 5 doses of vitamin
A concentrate i.e. first dose of 100,000 International Units (IU) at the age of nine months,
second dose of 200,000 IU at the age of 16 months and thereafter 3 more doses of 200,000 IU
each at six monthly intervals. Nutrition education regarding use of colostrum, usc of vitamin
A rich food etc. are also ensured.

4) Acute Respiratory Infection (ARI) Control

Acute Respiratory Infection (ARI) is a major cause of morbidity among young children.
Majority of ARI are self-limiting. However, pneumonia, a serious manifestation ofARI is a
major cause of mortality also. Timely and correct diagnosis, treatment and referral can save
most children with pneumonia. Therefore, prevention and management of ARI has been
i~lcludedas another important intervention under the RCH programme. The primary health
care personnel should detect the case of pneumonia among children based on guidelines on
signs and symptoms and provide treatment with effective antibiotics viz. Cotrimoxazole as
per guidelines for doses. Serious cases of pneumonia should be identified aud timely referral
be made to save children's lives.

5) In~munisationServices
In addition to the routine imrnunisation services expected to be provided to all infants and
young children as per approved schedule, the Government of India have accepted the goal
of achieving eradication of polionlyelitis and elimination of neonatal tetanus from this
country. The strategy adopted for polio eradication is througll pulse polio programme being
in~plelllentedall over the country. In~portanceis also given on surveillance of vaccine
preventable diseases.
3.5.5 Safe Abortion Services
As you might be already knowing, complications of abortions performed under unhealthy
surroundings using unl~ealtllyand crude procedures is one of the major causes of maternal
n~[Link] morbidity. Medical Ternmination of Pregnancy (MTP) is therefore made possible
under certain co~lditionslaid down under the MTP Act (1971). However, MTP should not be
considered as a mecha~lis~ll for restricting family size or as nlethod of contraception for
avoiding unwanted births in a routine. In India, it has been observed that often MTPs are *
still performed in unauthorised places where the required essential facilities are not available
and son~etin~es even the person performing is also neither qualified nor experienced and thus
cause maternal deaths and morbidity on a much larger scale. Under RCH programme specific
emphasis is given on ensuring women's access to safe abortion services by increasing
improved facilities and trained manpower for provision of MTP se~vices.

3.5.6 Contraceptive Services for Eligible Couples

Since couples have to be assisted in deciding about the right time for having children, they
have to be informed and have access to safe, effective, affordable and acceptable methods of
contraception of their choice. Thus provision of contraception services is an important
interve~itionunder RCI-I programme. There is a growing concqn anlong policy decision
makers and planners in India that the overenlphasis laid on females as the main target groups
for accepting contraception services, particularly sterilisation se'rvices, in the past, is not
likely to achieve the desired de~l~ographicgoal. Hence more emphasis is now being placed on
increasing method choice including reversible contraceptive methods both for females and
males. For increasing male participation in acceptance of contraception, facilities for
providing Non Scalpel Vasectonly (NSV) are also being expanded. Added importance is also
being given to strengthen sexuality and gender information, edqcation and counseling with
the aim of ensuring informed choice of methods by clients. Supportive counseling and follow
up services are also being organised for acceptors.
3.5.7 Prevention and Management of RTIs and STIs
RTls and STls form a major group of infections which cause considerable extent of morbidity
among both males and females and prevention and appropriate clinical management of these
conditions have been included as important components under RCH programme. RTIs
include a variety of bacterial, viral and protozoal infections in thereproductive tract. Some of
these RTIs are sexually transmitted and pose threat to lives of both sex, particularly for
women. RTIs inay result from unhygienic procedures related to delivery and abortions and
infections due to overgrowth of organisms ilormally found in genital tract, in addition to
sexually transmitted infections.

Screeningldiagnosis of RTIsI STIs is based on identifying groups of easily recognised signs

and symptoms (syndrome). Even though some men and many women remain asymptomatic,
common signs and symptoms observed are:
@ vaginal discharge in women which look and smell differently from normal discharge.
genital ulcers in both men and women,
d
National Health Programmes @ lower abdominal pain in women.
@ scrota1 swelling when testis is affected.
@ enlarged, inflamed inguinal lymph glands inmen and women.
@ neonatal conjunctivitis.
Apaii from individual suffering, RTIISTI can also lead to complications and longterm
sequelae like:
0 infertility;
0 ectopic pregnancy;
@ irregular menstruation;
@ cancer of anus and genitals;
@ abortion and stillbirth;
@ infections in new born; and
@ increased risk of transn~issionof HIV infection.
Provision of services for prevention and management of RTIISTI has been included as an
important intervention under RCH programme by increasing facilities for diagnosis and
management as well as through health education and counseling.
3.5.8 Adolescent Health Services
The adolescent period is important for several reasons. Not only that they are the future
parents who need to be prepared for future parenthood, because of the practice of marriage
of very young girls in many parts of the country, adolescent girls are exposed to hazards of
pregnancy when they are not emotionally and physically ready for child bdring. Health
programme for the adolescent girls have special significance because their effects are not
only on the health and nutrition of the adolescent girls themselves, but also have long-term
intergenerational effects by reducing the risks of low birth weight and minimising child
mortality. It is felt that integrated p r o g r a m s for family life and reproductive as well as
general health, education, employment and other related services need to be provided for,
this hitherto neglected some segment of population.
3.5.9 Special Care Components -Cancer and Infertility Services
1) Screening and Treatment for Cervical Cancer and Breast Cancer
Cancer is one of the important causes of morbidity and mortality in both developed and
developing countries. Most common among cancers of reproductivi system in developing
countries is cervical cancer and breast cancer is also not uncommon. Cervical cancer
screening is one important intervention for prevention but at present, limited screening
facilities are available for Indian women. Facilities for breast cancer also are inadequate
except advice for self-examination by women as well as routine examination by professional
and auxiliary personnel in different health institutions,
2) Prevention and Treatment of Infertility
Since child bearing is highly valued and can have serious social consequences in Indian
women, infertility is perceived to be a very serious problem. Since infertility could be a sequel
of STIs, interventions for management of STIs would be helpful in tackling infertility.
Diagnosis and management of infertility due to major causes require sophisticated facilities
and therefore services for treating infertility can be provided only in limited health facilities in
India,
Check Your Progress 3
1) List the components of comprehensive packages of RCH services
................~.......'....,,..*...*...~................*.*....,,..,.,...,........,....,.,,.,.,,,..,...,.,,,,.,.....,,....................,........'...
 .",

2) What are the reasons for classifying districts into A, B, and C categories? .cpro~Iurtiveand Child
Health Progrnmm
.............................................................................................................................................................

3) What are the components of essential obstetric care?

..............................................................................................................................................................
... ..........................................................................................................................
................................

4) What are the special inputs for emergency obstetric care under the RCH programme?

5) Mention the major causes of maternal mortality in India.

..............................................................................................................................................................

6) Mention the major causes of infant and child mortality in India.

..............................................................................................................................................................
..............................................................................................................................................................
7) List the important components of child survival service package.

...a..*. '...... ........................................................................................................................

8) What are the common signs and symptoms of RTIs/STIs?
............. ......................................................................................................................................

9) Mention one major health hazard among female adolescents in India.

. . . ..............,,......
. I . . ,......................... ,a. #.................. ..,.,...

3.6 ORGANISATION AND INFRASTRUCTURAL

FACILITIES FOR IMPLEMENTATION OF RCH
PROGRAMME
3.6.1 Organisational Set-up for Delivery of RCH Programme
Even though the family welfare programme has been reoriented with a new name and new
focus as already explained, the machinery for implementation of the programme remains more
or less the same except that there are few changes in terms of the nature of support and
assistance from Central Government to the State Governments. Further, the focus is also on
more active involvement of the community and local panchayat with the aim of decentralised
approach to the programme planning and implementation. The major inputs under the RCH
progrmrne will be directed more towards improving the already existing facilities and services
to bring them within easy reach of the community, and the traditio~lalitems for creation of
additional posts in health institutions and construction of new buildings will be only minimal.
N:\tioiial Hcnltl~Programmrs At the national level, the programme is being steered by the Depart~llentofFarnily Welfare.
The major responsibility of inlplementing the programme lies with state governnie~ltsunder
tlie Directorate of Health and Family Welfare a~ltlDepartment ofFanlily Welfare, specifically,
witli programme mallagenient responsibility assigned to the State Director of Family Welfare
and State RCH Officer. It is also realised tliat for seckiiig larger and faster in~proven~ent
in
RCH indicators, it is in~portantto [reatdistricts as units of iniplementation. T h ~ is
s because,
~iioststates tlte RCH service needs as well as implen~en$tionsit~iationdiffer from district to
district. Further, the emphasis on decentralised progralllnte planllilig and mallagenlent also
necessitates this specialJocus on districts.

Tlie district health administration system with the District Civil Surgeon/Chief Medical and
Health Officer assisted by the District RCH Officer is responsible for planning,
implementation and monitoring of these services witli the active participation of the .
panchayati raj system.

Infrastructural Facilities for Delivery of RCH Services

- 3.6.2
The national health policy of India (1983) clearly indicated tliat goal of Health For All (HFA)
in this country is to be achieved through con~prehensiveprimary health care approach. RCH
services are no exception to this. The 11eaftl1~infrast1uct~11.e
for delivery of primary health care
in rural areas of the country is responsible for delivery of RCH services (as one component
of priniary health care) to the rural population through the vast network of Primary Health
Ceiltres (PHCs), Subcentres, Conl~uullityHealtli Centres (CHCs) as well as FRUs establi'shed
over the years.

While general obstetric and child care will be provided by nlfAdical,paraniedical and auxiliary
personnel viz. Medical Officers, LHVs, ANMs, illale health workers and male supel-visors,
Lab technicians etc. at tlie level of PI-IC and subcentres, specialised care from obstetricians
and paediatricians will be available from the CHCs/FRUs onwards. Tlie Anganwadi worker
under the ICDS scheme also plays a very iniportant role in rendering tlie ECH services,
particularly the nutrition component, tl~rougligrowth monitoring of children and
supplementary feeding to children and pregnant and lactating mothers.

The next higher level of specialised services are available at the district level from district
hospital specialists. MTP services are envisaged to be made available froni PHCs and efforts
are being initiated to strengthen the existing facilities with additional inputs at these levels of
institutions to fulfil the prescribed criteria according to MTP Act, for ensuring that adequate,
good quality services areaavailableto tlie needy. Referral of suspected cases oTRTI/STI by
the ANMs is supported by diagnosis and nia~iagementby Medical officers with assistance
of laboratory technicians at the PHCs. Specialised facility for RTIISTI will be nude available
in all district llospitals and even in sollle of the subdivisional hospitals.

In addition, the NGOs ~nedicalsystem will be illvo1ve.d in providing many RCH services and
facilities. The Indian Systen~sof Medicine and Homeopathy (ISM and H) which are known to
be efficacious will also be used in a substantial nlaniler in providing RCI-I services. With
regard to contraceptive services, the PHC and CHC functionaries and medical officers will
render all possible services. The postpartum units at the sub-district and district levels will
also participate il! rendering these selvices. Special teams will be prepared with appropriate
training and additional facilities (equipment and other supplies) for undertaking sterilisatioil
operations, both laparoscopic and minilap, for females and NSV for males.

In the urban areas, due to the availability of big hospitals with adequate general and
specialised facilitim,' RCH services are available to the majority of population within easy
reach. However, the slum dwellers in urban areas, whose lumber is gradually increasing in
India, are at a disadvantageous position regarding RCH services and special efforts are
required for making services available to then;. Urban Health Posts under the Urban
Revamping Scheme and the Urban MCH & FW Centres are expected to render these services
"
with referral support from the urban hospitals. Due to the inadequacies in their functioning,
special schemes are being envisaged to be initiated for the urban slunls.
 Similar schemes are also envisaged for the tribal population, which again constitutes a
sizeable segment in India atrd are often not sufficiently covered by the existing health care
delivery System.

3.6.3 Special Facilities and Projects under RCH Programme

1" order to ensure availability of specific services and facilities to all under theprogramme,
special efforts are made to give special support on selected components to certain needy and
backward areas. Some of these are briefly described below.
*
1) Twcnty-four Hour Delivery Scrviccs a t PHC

One of the major causes ofmaternal lnortality and morbidity is lack ofattention by trained
hands at the time delivery in tlle rul'al areas. This is particularly so in the case of deliveries
taking place durillg night time when trained personnel like ANM or Medical offmers are not
available at PHC. It has been a major criticism that health personnel posted at PHCs and
subccntres do not have their lligllt halts at these institutions, and usually they stay
somewhere away from these instihrtiolls. Under the RCI-I programme institutio~laldeliveries
are encouraged and attempt is being made to set up 24 hour delivery services in CHCs/PHCs
in as many districts as feasible.
The arrangement in this regard would involve a mechanisn~for a doctor to be available on
call, a nurse being available beyond normal working hours in the CI-ICIPHC and cleallliness
servicc being available beyond normal workillg hours. The latter two can be arranged on
contract basis or by appointing some recently retired persons available in the same locality.
'I'here is provision for payment of honorariun~to the doctor of CHCIPHC at the rate of Rs.
2001- per delivery conducted between 8 p.m. and 7 a.m, on duty and also to the contractual
nurse.
2) Referral System aud Transport to Indigent Familics through Patlchnyats
, Lack of tinlely and appropriate refersal services has been one major responsible factor for
higll nlaternal mortality in ~ u r aareas,
l and many cases requiring such referral, fail to receive
specialised care when needed. Therefore, under the RCH programme, strengthening of the
FRUs has been taken up as priority activity. A total of 1748 FRUs were identified and
equipped under CSSM programme, but many of them have not become fully functional
because of shortage of specialists, equipment and drugs. Under RCH programme, FRUs are
being strengthened through:
supply of drugs and medicines.
provision for appointtncnt of contractual'staff.
provision of laparoscopes.
provision for providing emergency obstetric care, and for those requiring surgical
interventio~s,blood tratlsfusion and anaesthesia.
provision for consultant anaesthctist for emergency obstetric care etc.
The~veaklyperforming states and particularly of tlle C category districts, the comlunication
infrastructure is weak and the econonlic status of many families is also very low. Because of
this, even when women are referred for delivery to higher specialised institutions away horn
the village, often they don't avail this service and deliveries get conducted by untrained
hands available in the village wl~ichoften end in undesirable oufcomes for the mother and
the baby. In order to overcome this problem, under RCH programme, provision is made to
make available some fixed amount with the local panchayat in selected subcentre areas
through District Family Welfare officers, so that avangements for referral of women from
indigent families can be made. This assistance is to be used only for procuring and paying
for the transport for carrying the wonlell to CHCIPI-IC for delivery.
3) Additional Programme for Urban Slun~s

With the increasing number of slums in the urban areas, and with the realisation that health
status of women and children in these slunls is paorer than even the national average due to
poor sanitary and health facilities, special efforts are being taken to improve the RCH.
N:ttiol~alH c n l f l ~Prograrnnlcs At the national level, the programrlle is being steered by the Depa~lmentof Family Welfare.
The major responsibility of implementing the programme lies with state governments under
the Directorate of Health and Family Welfare and Deparmlent ofFamily Welfare, specifically,
with programme management responsibility assigned to the State Director ofFamily Welfare
and State RCI-I Officer. It is also realised that for seeking larger and faster imp~~ovementin
RCtI indicators, it is important to treat districts as units of implementation. This is because, 111
most states the RCI-I service needs as well as implementation situation differ from district to
district. Further, the enlphasis on decentralised programme planning and management also
necessitates this specialJocus 011 districts.

The district health administration system wiih the District Civil ~ u r ~ c o n 1 ' ~ h~iee df i c aand
l
Health Officer assisted by the District RCH Officer is responsible for planning,
implementation snd monitoring of these services with the active participation of the .
pancllayati raj system.

I~ifrastructuralFacilities for Delivery of RCH Services

- 3.6.2
The national health policy of India (1983) clearly indicated that goal of Health For All (HFA)
in this country is to be achieved through comprehensive primary health care approach. RCH
services are no exception to this. The heaitheinfrastmcture for delivery of primary health care
in rural areas of the country is responsible for delivery of RCI-I services (as one conlponent
of primary health care) to the rural popillation through the vast network of Primary Health
Centres (PHCs), Subcentres, Community I-Iealth Centres (CHCs) as well as FRUs established
over the years.

While general obstetric and child care will be provided by n~tdical,paramedical and auxiliary
personnel viz. Medical Officers, LHVs, ANMs, male health workers and ~nalesupervisors,
Lab technicians etc. at the level of PI-IC and subcentres, specialised care from obstetricians
and paediatricians will be available from the CHCsORUs onwards. Tlle Anganwadi worker
under the ICDS scllenle also plays a very important role in rendering the ECH services,
particularly the nutrition component, d~rougligrowtll nlonitoring of children and
supplementary feeding to cllildren and pregnant and lactating mothers.

The next higher level of specialised services are available at the district level from district
hospital specialists. MTP services are envisaged to be made available from PHCs and efforts
are being initiated to strengthen the existing facilities with additional inputs at these levels of
institutions to fulfil the prescribed criteria according to MTP Act, for ensuring that adequate,
good quality services [Link] to the needy. Referral of suspected cases oTRTI/STI by
the ANMs is supported by diagnosis and management by Medical officers with assistance
of laboratory technicians at the PHCs. Specialised facility for RTIISTI will be made available
in all district hospitals and even in sollle of the subdivisional hospitals.

h~addition, the NGOs medical system will be invo1ve.d in providing many RCH services and
facilities. The Indian Systems ofMedicine and Homeopathy (ISM and H) which are known to
be efficacious will also be used in a substantial nlanner in providing RCH services. With
regard to contraceptive services, the PHC and CHC fuilctionaries and medical officers will
render all possible services. The postpartum units at the sub-district and district levels will
also participate in rendering these services. Special teams will be prepared with appropriate
training and additiollal facilities (equipment and other supplies) for undertaking sterilisatioi~
operations, both laparoscopic a ~ minilap,
~ d for females and NSV for males.

In the urban areas, due to the availability of big hospitals with adequate general and
specialised facilities; RCI-I services are available to the majority of populatio~iwithin easy
reach. However, the slum dwellers in urban areas, whose number is gradually increasing in
India, are at a disadvantageous position regarding RCH services and special efforts are
required for making services available to then;. Urban Health Posts under the Urban
Revamping Scheme and the Urbah MCH & FW Centres are expected to render these services
h"ti referral support from the urban hospitals. Due to the inadequacies in their functioning,
special schemes are being envisaged to be initiated for the urban slums.
 Similar schcn~esare also envisaged for the tribal population, which again constitutes a
sizeable segment in India and are often not suffjciently covered by the existing health care
delivery system.

3.6.3 Special Facilities and Projects under RCH Programme

In order to ensure availability of specific services and facilities to all under theprogranlme,
special efforts are made to give special support on selected components to certain needy and
backward areas. Some of these are briefly described below.
*
I ) Twenty-four Hour I)elivery Services a t PHC

One of the nlajor causes of maternal inortality and morbidity is lack ofattention by trained
[lands at the time delivery in the lural areas. This is particularly so in the case of deliveries
taking place during night time when trained personlie1 like ANM or Medical offners are not
available at PHC. It has been a major criticism that health personnel posted at PHCs and
subcentres do not have their night halts at these institutions, and usually they stay
somewhere away from these instibltions. Under the RCI-I programme institutional deliveries
are encou~.agcdand attempt is being made to set up 24 hour delivery services in CHCs/PHCs
in as many districts as feasible.
The arrangement in this regard would involve a mechanism for a doctor to be available on
call, a nurse being available beyond normal working 11oul.s in the CHCIPHC and cleanliness
service being available beyond nol-ma1 working hours. The latter two can be arranged on
contract basis or by appointing some recently retired persons available in the same locality.
'I'here is provision for payment of honorarium to the doctor of CHCIPHC at the rate of Rs.
2001- per delivery conducted between 8 p.m. and 7 a.m. on duty and also to the contrachlal
nurse.
2) Referral System and Transport to Indigent Families tllrougl~Paricl~ayats

, Lack of timely and appropriate referral services has been one major responsible factor for
high maternal molZality in ~ u r aareas,
l and many cases requiring such referral, fail to receive
specialised care when needed. Therefore, under the RCH programme, strengthening of the
FRUs has been taken up as priority activity. A total of 1748 FRUs were identified and
equipped under CSSM programme, but many of them have not become fully functional
because of shortage of specialists, equipment and drugs. Under RCH programme, FRUs are
being strengthened through:
supply of d ~ v g and
s medicines.
provision for appointment of contractuaPsta tf.,
provision of laparoscopes.
provision for providing emergency obstetric care, and for those requiring surgical
interventiods, blood transfiision and anaesthesia.
pro\rision for consultant anaesthetist for emergency obstetric care etc.

T h ~ ~ v e a kperforming
ly states and particularly of the C category districts, the comunication
infrastructure is weak and the economic status of many families is also very low. Because of
this, even when women are referred for delivery to higher specialised institutions away friom
the village, often they don't avail this service and deliveries get conducted by untrained
hands available in the village which often end in undesirable outcomes for the mother and
the baby. In order to overcome this problem, under RCH piogran~me,provision is made to
make available some fixed amount with the local pallchayat in selected subcentre areas
through District Family Welfare officers, so that arlangeme~ltsfor referral of women from
indigent families can be made. This assistance is to be used only for procuring and paying
for the transport for carrying the won1e11to CHCIPHC for delivery.
3) Additional Programme for Urban SIunls
With the increasing number of slums in the urban areas, and wjth the reatisation that health
status of women and children in these slums is poorer than even the natio~lalaverage due to
poor sanitary and health facilities, special efforts are being taken to improve the RCH'
 services in these areas. The Llrban Health Posts and Urban Health and Family Welfare
Centres are expected to provide comprehensive integrated services oiMCH and family
planni~igto the slum dwellers. They are also supposed to function in close coordillation with
the Urban ICDS projects. However, since their functioning has been found to be
unsatisfactory, a special committee was appointed to examine the situation and give
suggestions for improvement. The following have been reconlmended:

i) A primary health centre for each slum with population of 15,000 having a doctor and 2-3
paramedics to provide outdoor services. These would be set up and managed by the
concerned urban local body on a project basis.
ii) For clusters of slums having smaller population, a mobile clinic to be sanctioned to
medical NGO and having facilities at par with a centre mentioned above and it will visit
each slum on a fixed day during fixed hours to provide primary health care services.
iii) Some selected health NGOs may be assisted if they set up maternity clinics in or near
urban slunls.

State governments are requested to submit project proposals prepared in this regard for each
city for consideration for sanction by GOI.

4) Special Progrn~nmefor Tribal Areas

Because of the poor con~nlunication,low literacy status, as well as poor socio-economic

conditions, despite having basic health infrastructure in place in most part of the tribal areas
in the country, the situation regarding reproductive health of the tribal population is
generally poor. Hence, under the RCH programme, special RCH care package is envisaged to
be provided to this population group. A special conunittee was appointed to examine the
situation and make recommendations for the provision of services to the tribal population.
Major reconlmendations ofthe conunittee are:
i) Despite having infrashucture like CHCIPHC etc. many staff positions in these
i~lstitutionsremain'vacant due to want of accom~[Link] availability of drugs and
consumables is poor in these institutions. Thus, the programme would provide for
financing constivction of housing for staff and also for provision of diugs in these
institutions.
ii) The state government will nuthorise committees at district level under chai~manshipof
District Magistrate, to advertise locally and appoint doctors and other staff on contract
basis against vacancies till regular appointments are made.
P) Due to the com~nunicationgap between the tribal population and the government staff,
tribal population do not generally avail the available services. In order to bridge this gap,
district level comnlittees are envisaged to assist local NGOs to engage tribal youth after
training to work with local conmiunity forpromotiilg RCH infomiation and to act as link
between the health infrastiucture and the community.
5) Special Programmes for Adolescents
Adolescents (10-19 years) constitute a large segment of the population (21.4% of the total
estimated population) of India wllich is of special significance for whom reproductive health
programme should be designed and in~plen~ented. Teenage pregnancy poses serious health
hazard for both mother and child. Further, in the context of increasing prevalence of STIs and
HIV infection, it is important that adolescents and youth are adequately informed about safe
sex and sexuality. It is important to remember that the reproductive health needs of married
and unmarried adolescents are different, which are mostly unmet needs and also that the
adolescents' behaviour gets influenced seriously by various types of messages from
different media, which are often conflicting and confusing.
Programmes directed to address the above nlentioned problems of adolescents are almost
nonexistent except s o q e progra~nmesby ceitain NGOs. These cover HIVIAIDS education
and sexuality for youtll as well as on reproductive and sexual health programme for women
including adolescent girls. However, government has initiated some activities like ICDS
 sc11enle which has recently extended its activities to include adolescent girls, particularly out
of school girls who cannot be reached through the school health activities. Training is the
major conlponent for adolescent girls in the prograinme under ICDS, which focuses on
'motherhood skills such as nursing, first-aid, child health and nutrition care. Fresh packages
of services for this group are under consideration. A draft policy on youtldadolescent issues
is ullder debate which proposes measures to ensure young people to have access to all
illformation and services including reproductive health and to promote social environment
that prevents diseasesJproblems like HIVJAIDS, substance abuse etc. Under the RCH
programme, specialised counseling and IEC materials are envisaged to be provided by NGOs
and proposals are being invited fi-om NGOs in this regard.
3.6.4 Role of Hospitals in Irnpleme~~tatio~~
of RCH Programme
Hospitals are important component of the health care delivery system which may be
classified into different categories. This grouping may be based on size of hospital in terms
of number of beds available; types of services'provided (generallspecialised); by location
(urbaidiural); according to the system of medicine practised (Allopatl~yJAylirvedaI
Hon~oeopathy);by ownership (public/private/NGO/corporate) etc. Irrespective of the type of
a hospital, it is involved in providing outpatient and inpatient services and provide generally
promotive, preventive and curative, and in sonlc cases rehabilitative services also. Hospitals
geilerally can play very important roles in implenlentation of various natioilal health
programmes including RCH
I-Iospitals forill important elenlent of the referral system wherein the referred cases from the
primary care facilities can get consultative as well as curative services from spzcialists from
the hospitals. Obstetric and pediatric cases referred from peripheral institutions are treated
on general or emergency basis at iiospitals.
I-lospitals having enough clinical cases and competent clinical experts in different
specialities, can be actively involved in providing cliilical skill based training to various
health care personnel. Under RCM programme, training in integrated RCH service for primary
health care personnel, MTP, laparoscopic sterilisation. minilap, NSV, IUD insertion etc. can be
provided from hospitals.
Details of iilfornlation on births and deaths that take place in the hospitals including reliable
data on causes of deaths are expected to be reported to the health adlninist~ativeauthorities
regularly. This information is very valuable for preparing action plan for RCH services in
districts.
Patients suffering from various epidemic prone diseases attend the hospitals for medical care.
tlospitals can play a very important role in preventing the epidemic by sending timely
infornlation about unusually increased number of cases to the health authorities in the
district.

ilospitals can play an important role in surveillance of important diseases i.e. routine
.[Link] of selected disease conditions even when not an epidemic. Certain hospitals have
been identified as sentinel surveillance centres for specific diseases. For example, vaccine
preventable diseases, diarrhoea1 diseases, HIV infectioil etc.
I-Iospitals can also be iilvolved in rendering health educatioidIEClcounseling to patients,
relatives etc.
Hospitals can also contribute to the improvenlent of service compollents under RCIi
programme through conducting clinical and operatioilal research.
. Check Your Progress 4

1). Mentioil the important health infrastructure facilities for delivery of RCH services in the
rural areas.
"".'..!".......................#............6..<.................+..................................~......................*...............................
National Heatth Programmes 2) What arrangements are provided for ensuring 24 hour institutional delivery services at
PHCs under RCH programme? '

3) How is the panchayat involved in provision of referral servtces under RCH programme?

4) What are the special provisions

. for
, delivery of RCH services in the urban slums?
..............................................................................................................................................................

5) Mention the different roles which hospitals can play for effective implementation of RCH
programme.

3.7 MANAGERIAL DIMENSIONS OF RCH

PROGRAMME
The RCH programme is being implemented all over the country by the different health
institutions and personnel of the health care delivery system at various levels in the
hierarchy. As already mentioned, there has been a major paradigm shift in the programme
which needs to be understood by all concerned with its implementation. Health and hospital
managers who are responsible for implementing the programme have to perform number of
management functions. In view of the objectives of the programme as well as the paradigm
shift in the programme and approach, it becomes clear that special attention needs to be
placed on programme management at different levels. The major managerial dimensions
include:
@ participatory, decentralised, community needs assessn~entbased progranlme planning.
organising special programmes/schen~es/projectsunder RCH.
resource procurement and their management.
ensuring quality of care.
management information system.
monitoring and supervision etc.

3.7.1 Community Needs Assessment Based Decentralised Planning

From 1st April, 1996, the Family Welfare Programme was implemented all over India based on
Target Free Approach ( F A ) . Till then, the workload under the programme at different levels
in the health care delivery system and the achievements of the programme were assessed on
the basis of targets given from the central government for different individual contraceptive
methods. This led to a situation where, achievement of contraceptive targets in pure numbers
became an end in themselves. Not only that this top-down approach did not consider the
clients' felt needs and choices, it also undermined the importance of quality of services and .
even forced many health personnel to over-report their achievements and inflate their
performance. It is under this background that the GO1stopped the practice of fixing targets
for services from above. It is important to understand that TFA does not mean the license to
do no work. The population goals still remain the same as before and after targets from above
 are withdrawn, the health workers are expected to consult families and local communities in
beginning of every year in order to assess their nektts and preferences and then work
out for themselves the workload and activity plan for the coming year. This is to be done by
'the ANM with the help of Male health worker, through consultation by her with the
Angallwadi worker, TBA, members of the Mahila Swasthya Sangh, as well as local panchayat
, members. The ANM is to work out the requirements for each service, based on estimates
by her, using the data on various local relevant events like births, deaths, etc.

For example, to estimate the probable number of pregnancies that may occur in &nyarea, the
following formula may be used:

Probable Number of Pregnancies = Population of the Area x Birth rate of the area
(districustate)
Once the probable number ofpregnancies is estimated, this also will be the probable number
ordeliveries that an ANM can expect in her area. The number of antenatal registrations to be
expected would be the probable number ofpregnancies with an additional 10% of that
number to account for abortions.
The iorkload of different ANMs under one PHC when added up along with appropriate
addition ofrequirements fbr specific activities bf the PHC also like MTP, institutional
deliveries at PHC, would determine the workload or requirement for that PHC. Similarly,
requirement at district level would be worked out by adding up the requirements for all PHCs
along with requirements for specific activities undertaken at district level institutions like
district hospitals etc.
After implementing the TFA approach for about 18 months, the experience was reviewed and
based on the feed-back and deliberations among experts, certain modifications to improve
the approach were made and it was renamed as Conununity Needs Assessment (CNA)
Approach and the manual provided for helping the ANM in her performance was also
*
accordingly modified and renamed.
A number of forms are prescribed under the progranme, for enabling the preparation of
action plan at different levels in wllicll the reports nlust be made by the ANM for the
subcentre plan, in-charge medical officer for the PHC, by incharge doctor for the FRUI
subdistrict hospital, and by incharge medical officers at the district hospitals, and by District
Family Welfare Officer for the wl~oledistrict, which ultimately will be sent to the state
government alld Department ofFamily Welfare, GOI.
After identifying the needs and resource requirements for meeting the identified needs, an
activity plan needs to be developed wherein the persons responsible for various activities
are identified and a logical framework indicating sequence of activities as well as indicators
of achievement along with means of verifying the indicators are spelt out.
3.7,2 Human Resource Development and Capacity Building
I'or impleme?ting RCH prognmnle, a large number and categories ofhealth personnel nt
different levels in the hierarchy are involved. One of the major responsibilities of the offtcials
responsible for implementing RCH progranlrne is to manage the human resource involved
and ensure their professional capacity developnlent. One essential component of human
resource management is to equip them with appropriate knowledge and skills for enabling ,
them to perform theirjob responsibilities most efficiently through training and ret~aining.
Even though most of these personnel are trained in the past for providing health care to
women and children, there are wide variations in the quantity a'nd quality of training received
by them. Moreover, mostly these training efforts were vertical in nature concentrating on
individuaI/compartmenta1service components and hence lacked in a cornprebensive and
integrated approach. With the introduction of RCH programme, it is important that all health
personnel involved are reoriented to the changetshift in emphasis in the programme as well
as to the new additional components of services. It has also been felt that a deviation from
*
the previous knowledge based training to a more skill/competency based training is
, necessary for ensuring delivery of good quality services to the clients to achieve their
satisfaction.
Y r t i o ~ i a l Health Prograrnrncs Accordingly, major investment is envisaged to be made on proper in-service training of the
health personnel with special focus on skilllcompetency developmen1 through practical
hands-on training. Because of the large number of personnel to be trained and in view of the
complexity of the programme, a need for coordinated efforts for the whole country is felt.
Hence, instead of leaving this responsibility entirely to the state health and fainily welfare
department, the GO1 have designed a separate training management system for RCH.

This system is to be made functional through the already existing network of training
infrastructure in the countiy. The National Institute of Health and Family Welfare (NIHFW)
an autonomo?is institution in New Delhi has been appointed by the GO1 as the National
Nodal Agency for coordination of the training activities all over the country. The nodal
agency is supported in this activity by 16 Collaborati~lgTraining Institutions (CTIs) located
in different parts of the country, belonging to both government and non-government
sectors. At the peripheral level, various training institutions of health personnel includiilg
ANMILHV training schools, Health and Family Welfare Training Centres (HFWTCs), District
Training TeamsIBureau etc. are expected to provide training to the different categories of
health personnel.

Under RCH Progranme, the training of health personnel should minimally cover the following
areas:

1) Reproductive health concepts, components, and new focus in the health programme.
2) Technical knowledge and skills for providing various services related to components of
RCH i.e. maternal health, child health, contraception, RTIISTI management etc.
3) Comnlunication skills, especially for conmlunicating with clients for service, conlmunity
memberslpanchayat members, functionaries from other health related sectors,
adolescents and also for mobilising community resources for RCH etc.
4) Management [Link] for planning based on comn~unityneeds, material resource
management like drugs, vaccines, equipment, etc, maintaining records and reports etc.

Accordingly, the different types of training activities envisaged under RCH programme
include:

1) Awareness generation training for health functionaries, functionaries from health related
sectors including panchayati raj system at grass-root, district and state levels.

2) Skill development training courses which are of four types viz.

@ integrated foundation skill based course for primary health care functionaries to
render integrated RCH services as part ofprinlary health care at ANMILHV schools1
HFWTCs;
@ specialised skill development courses like MTP, Laparoscopic sterilisation, nliililap
sterilisation, NSV for doctors and IUD insertion for ANMILHV at identified training
institutions/l~ospitals;
0 specialised management training for the state, divisional and district level
programme managers at identified managenlent training institutions; and
0 specialised training in communicatio~lfor skill upgradation among IEC personnel of
central, state and district levels at identified communication training institutions.

For integrated training in RCH or primary health care personnel, whilc the NIHFW will train
the master trainers from faculty of CTls, the CTIs in turn will train trainers from peripheral
training institutions who will train the peripheral health functionaries on RCH service
components.

Role of Health Adn~inistratorsin Training under RCH

As already described regarding paradigm shift in the RCH programme, under the new
approach adopted for implementation of the programme, it is ellvisaged to have
L-oll~prehensive, integrated training with district as the organiser/coordinato~~/implementor
, \ , ~ I Isupport from centre and state. The district is to function as the basic unit and district

b;lsed training plans are to be prepared for all types of training activities according to the
actllal training needs. The district authorities are to be assisted by the CTIs in this regard.
fllese plans are to be approved by the State RCH Co-ordination Committee and sent to the
nAtional nodal agency, NIHFW for release of funds for in~plen~enting the training. The
District FW Officer, assisted by the district training centres will coordinate with the training
institutions to ensure that the health personnel of the district are nominated and relieved for
tile training regularly. The DFWO will also coordinate with the related departments and
~anchayatiRaj system in the district to organise awareness generation training for
f~~~ctionaries from health related sectors.

3.7.3 Management of Material Resources

One other major managerial responsibility of health personnel is that of managing the
different types of material resources like drugs, vaccines, other supplies like cotton, linen,
lab. reagents, contraceptives, equipment, IEC materials etc. so that effective and efficient
services call,be provided to the clients. This includes estinlating the requirement for these
items for a specific period (one yearlone montll/a quarter of a year) based on the service1
activity load; timely procurement of these items from their sources; their appropriate storage1
distribution to different levels of care as per the needs; maintaining proper records for
effcctive n~onitoringof their use; appropriate maintenance of equipment; proper disposal of
waste materials etc.

Under the RCH programme, there are specific drugs and equipment kits si~ppliedto the
subcentre, PHC, CHCIFRU levels based on the types of activities expected at these levels.
Some of these are drug kits, equipment kits, surgical sets, IUD insertion kit, normal delivery
kit, equipment for anaesthesia, equipment for neonatal resuscitation, blood transfusion set,
laboratory diagnosis kit etc. With regard to supply of these kits, in order to enable the
institutions to obtain these items issued as per their requirement, system is set up at
divisional level (one divisional supply depot for a cluster of 6- 10 districts) where suppliers
will supply each individual item in reasonably large packing. The district/FRUlPHC can get
i~idividualitems issued to them as per their entitlement under the scheme in any number of
installments throughout the year. This arrangement is expected to n~inimisewastage of the
items.

For supporting inm~unisationprogranme, cold chain has been created covering all PHCs.
Based on actual requirement, deep freezers and ILRs are also being providcd. For repair of
cold chain there is provision for Rs.500 per PHC per year.

For support to cmergency obstetric care and MTP, where some cases may require blood
transfusion, under the RCH programnle, pilot projects are being initiated with financial
support from European Commission to set up regular and reliable blood supply to PHCs and
CMCs by linking them with nearest district blood bank.

For essential new born care needed equipment is being provided to all district hospitals1
CHCsIFRlJs and PHCs at block level.

In order to make safe a b o r t i ~ nservices available to the needy, under the RCH programme,
MTP equipment is made available at institutions i.e. district hospitals1CHCs and PHCs
wherever medical officers are trained and operation theatres are available.

Clia~lgcin Procurenle~itProcedures

Since the RCH programme has major cornpollent funded under World Bank RCH plaoject,
many items of procurenlent under the programme are funded out of this project. In order to
obtain reimbursenlent from World Bank, specific procedural guidelines are to be followed.
Accordingly, the procurement capacity would be strengthened by appointing consultants to
serve as Procurement Support Agencies (PSAs) at the national and state level to assist
MOHFW or state to procure equipment, drugs and materials.
 3.7.4 Funding and Reimbursement Procedures under RCH Programme
In order to ensure smooth and timely flow of funds under the programme, funding to the
states is being routed through state level registered societies named State Committees of
Voluntary Action (SCOVA) with the exception of few states for which funds are provided
through the State Budget. All states/UTs and societies, project directors at state, district and
city and society level would be required to maintain an identifiable account of project funds
and expenditure along with activity-wise expenditure clearly differentiating funds from ,

different sources. All states are required to open a budget liead for RCH programme with two
subheads viz. National component and District sub-project component irrespective of
whether funds are routed through SCOVA or state budget. ,

3.7.5 Management Information System (MIS)

As already mentioned, the initiation of CNA approach to RCH planning involves collection/
generation of huge volume of data and their use for participatory planning with involvement
of stakeholders (women and men). Further, the items of performance to be reported on regular
basis for monitoring of the conlplex and extensive programme have also changed.
Accordingly, the MIS also has been modified and strengthened as per needs. This system
should also provide relevant information on client satisfaction and the impact of the
programme on health status of women and children.
The sources from where relevant data for demographic and vital statistical indicators can be
obtained include decennial census, National Family Health Survey conducted all over the
country in 1992-93, and Sample Registration Scheme.
For other selected infomlation the sources include routine reporting and district surveys.
Routine reports on prescribed formats are regularly to be submitted by the ANM on
prescribed dates to the PHC and PHC in turn is to send the consolidated report to the
district. The district after consolidating performance reports fion~allhealth institutions
submit the report to the state and central government authorities.
District surveys in half the districts on yearly basis is conducted using sample survey
methods for generation of information on selected RCH and population indicators including
programme process indicators. These surveys are co-ordinated by an identified national level
organisation i.e. International Institute of Population Studies (IIPS) and surveys are
undertaken by regional level institutions identified for this purpose.
In addition, for assessing the actual availability and utilisation of the RCH facilities from
subcentre to district hospital, concurrent evaluation of the programme is also being
undertaken regularly at least one district per month. These surveys would also .ascertain
quality of services and community satisfaction. For this, information from families in at least 2
villages and one urban ward will be collected through interviews. Introduction of quality and
impact indicators for monitoring and evaluation of the programme as well as the initiation of
the rapid evaluation procedures are major deviations from the previous monitoring system
for the programmk.
3.7.6 Monitoring of RCH Programme
Monitoring is the process of measuring and observing changes during implementation of the
programme. Monitoring is also a process of assessing progress in implementation in relation
to the planned schedule.
The observations/measurementsduring monitoring may be positive or negative and may
relate to resources, activities, outputs and outcome, Thus n~onitoringwill indicate whether,
@ the required resources have been provided or not.
@ available resources are being optimally utilised or not.
planned activities are being implemented as scheduled or are in progress.
@ expecred results are being achieved or not,
o any unplanned or unforeseen occurrences have taken place.
,r\le n~easin'ementof these changes is based on certain predetermined indicators. An
indicator is an indirect measure of an event or a condition. For example, an indicator to
measure reduction in neonatal tetanus incidence will be the proportion of births attended by -
trained personnel.

Indicators could be for inputs (resources), processes (activities), outputs (performance

acllieven~ents),or outcomes (effectlimpact) e.g.:

health worker population ratio is an input indicator

@ frequency of antenatal clinics is a process indicator
e percentage of children receiving measles immunisation is an output indicator
incidence of neonatal tetanus is an impact indicator

These indicators can be worked out based on data collected regularly through the
management information system. As already mentioned, the MIS has been modified to meet
the requirements of the programme and en~phasisis more on quality aspect of the
programme. Information also need to be collected on the additional components o f services .
under IZCH programme e.g.. RTI and ST1control.

Examples of few RCH indicators are given below:

Service 1)elivcry I ~ ~ d i c a t o r s

@ Percentage of eligible couples having access to co~~traceptive

services
@ Percentage of pregnant women who had received antenatal care
+ percentage of new borns receiving care
@ Percentage of childreasuffering from who received treatment with antibiotics
@ percentage of IUD users who are screened for RTIs

Indicators of Quality of Care

@ Percentage of pregnant women who had at least three antenatal check ups
@ Percentagc of laparoscopic sterilisation done adhering to the prescribed protocol
@ Percentage of ANMs who have undergone skill based training in IUD insertion
@ Percentage males and females wit11 knowledge regarding uses and side effects of
coi~trace~tive
methods
e Percentage of users of oral contraceptives receiving follow up visits from health worker.
Outcome Indicators

Low birth weight babies11000 live births

@ Incidence of neonatal tetanus cases
@ Incidence of anaemia in pregnant women
@ Proportion of deliveries among mothers less than 19 years old

Monitoring can be undertaken with the help of reviewing the MIS regularly and studying the
indicators based on the data. In addition, supervisory visits to service institutions can also
be used for monitoring during which supervisor can identify the deviations ifany, from the
expected and can give appropriate suggestions. Interviews with the community members in
the field can also help in monitoring the programme activities when the community's reaction
to the services can be understood and if there are any drawbacks in the services they can
point them out. Such interviews could be conducted also as a participatory process
involving various stakeholders to obtain feed-back on clients' satisfaction with services.
 3.7.7 Partnership Development - Intersectoral Cooperation and
Involvement of NGOs
As already mentioned under paradigm shift in the programme, the GO1 is increasingly
involving the NGOs in both service delivery and in training of health personnel under RCH
programme. The major strength of the NGOs is the flexibility in their procedures which is
different from the restrictions of need for strict adherence to rules and regulations in the
government system. Further, they also enjoy better rapport and credibility among the people.
GO1 expects NGOs to undertake various innovative efforts tl~rouglispecial projects in
finding solutions to many problems in RCH service provision of best quality. Such projects
are funded by the GOI.

The involvement of NGOs in the programme has been done through a decentralised manner.
While snlall NGOs all over the country are being involved in counseling, advocacy and for
increasing awareness among people about RCH, mother NGOs identified at rekional level
extend assistance to these small NGOs. At the same time, national level NGOs are identified
which will meticulously evaluate the mother NGOs before they are sanctioned to undertake
the different innovative projects. Not only that the NGOs are recognised as partners in RCH
programme implementation, for success of the programme there is also need to have close
cooperation and coordination between health sector and other related sectors in the
government. For example, the Women and Child development department, Rural
Development department, the Panchayati Raj system, Department of Education etc. are a few
of them which have a major complementary role to play in the effective implementation of
RCH programme. RCH administrators have to devise different mechanisms to ensure support
from these sectors. Similarly effective implementation can contribute to the health and
development of children and mothers empowerment.

Check Your Progress 5

1) What are the specific subject areas covered in training of health personnel under RCH
programme'?

2) Mention the different types of training programmes envisaged under RCH programme.
.............................................................................................................................................................

3) What are the specific roles of District health administrators in relation to training under
RCH programme?

4) What are the different sources from where data are available for effective management of
the RCH programme?

...............,.......,...,..,,..)..........,,...,,.........................................................................................................
5) What is monitoring?
 6 ) Wllat are the methods for monitoring RCH progran~n~e'?
................................ ...................................................................................................................
.......a.

.............................................................................................................................................................
....................."..................a ...................................................................................................................
7) What are indicators'?
.............................................................................................................................................................
.............................................................................................................................

.............................................................................................................................................................

3.8 IMPROVING QUALITY OF SERVICES

'rile RCH programme's ~nrtifie~npllasisis on provision of clients' need based services and
ensuring clients' satisfaction. Therefore, an important requirement for effective
implenlentation of the programme is to ensure that the quality of services is improved.
Various efforts have been initiated to ensure quality of services under the RCH programme.
Some such initiatives are described below:
@ For various service components/procedures, standards have been developed which
need to be ensured/complied with by service providers e.g. standards for nlale and
female sterilisation, IUD insertion, Oral contraceptives and MTP services, midwifery
practices etc.

9 A well designed training strategy which is competency/skill based has been evolved for
various health care providers. One essential step introduced in this training is
introduction of requirement of proficiency certification for the trainees from trainers after
ensuring that the trainee has actually acquired the skills to perform the service activity1
procedure.
9 Improved logistics manageluent is another essential effort initiated for ensurlng quality
of services so that right type of supplies are available of right quantity and quality at the
right time. It is envisaged to have a project which has its conlponents like setting up an
autonomous corporation at state level with state and regional level warellouses for
improved storage and distribution, use of private transport facilities for transporting
supplies at regular intervals, development of a logistics managenlent information systcnl
which will help tracking supplies and forecasting requirements and training in logistics
management.
9 Monitoring and evaluation o f the programme has also focus on quality with a
participatory approach involving all stakeholders and incorporating quality indicators
for assessment, particularly focusing on clients' satisfaction.
@ Supportive counseli~lgand follow-up services are essential elements of the progranlnle
designed to provide quality care. This is particularly so for MTP acceptors,
contraceptive acceptors, low birth weight babies etc. Follow-up contacts provide good
opportunity for continuing counseling and education and for discussing related
reproductive health issues.

IEC efforts to make the comnlunity well informed about various aspects of reproductive
health do contribute to enable the clients to make info~medchoice of services as per
their needs which would add to the quality of care.

Clreck Your Progress 6

What steps have been initiated for improvillg the quality of care under RCIl programme'!
1 s t i o n a l Health Programrncs
3.9 LET US SUM UP

In this unit, you have learnt that the Government of India have launched the Reproductive
and Child Health Programme with a view to adopt a conlprehensive and integrated approach
to the population issues and also towards ensuring women's development. The major
paradigm shift in the programme which needs to be ~~nderstood by all concerned with
implementation of the programme has also been described in this unit.
While describing the components and service packages under the progranmle, you have
been apprised that, a differential approach is adopted in the programme in terms of
cornprehensivelessential components of RCH being implemented in different districts in the
country based on their RCH status. You have also been introduced to the orga~lisational
and infrastiuchlral set-up for implementing the progra&n~ewith special en~pllasison the
various specific schemes and projects under the programme.
You have learnt about certain specific managerial responsibilities including the Con~nlunty
needs based decentralised participatory planning, modified procedures for management of
material and finance resources as well as human resource managelllent with special focus on
competency based training under tlie programme. You have also been familiarised with tlie
modified MIS and its use in monitoring the progranmle. -
As you haveunderstood, the RCH programme focuses on increasing the coverage and
improving the quality of services and thereby ensuring clients' satisfaction and you have
learnt about the various efforts initiated by the,govemnlent in achieving this goal.

3.10 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1
1) Integrated approach is desirable because,
@ couples will accept contraceptive services o~ilyif survival of their children already
bdrn is ensured;
separate identity of each programme component led to problems in their effective
management;
@ integrated approach would increase service acceptance
" by cornniunity/clients; and
, 0 overlapping and additional expenditure can be avoided. I

2) Major consensus arrived at ICPD conference in 1994 "that population policies should I

address social development beyond family planning, especially the advancenlent of

women and that fanlily planning should be provided in the co~itextof coniprehensive
reproductive health care".

3) RCH progranlnle was launched in India on 1 5IhOctober, 1997.

Check Your Progress 2
1) The policy decision before implementing the RCH progranmnle was to withdraw the
I
system ofestimating workload and work allotment as well as monitoring the family
welfare programme based on centrally determined method-specific contraceptive targets i
and instead, introducing a co~nnlunityneeds assessment based, bottom up approach for I
the same.

2) There is paradigm shift in the programme because,

0 shift from focus on achievement of target to provision of range of quality services;
0 shift from reducing population in numbers to services to meet reproductivk needs of
4
individuals and community;
0 shift fiom compartmental to an integrated approach to service delively as well as
training; ,
 shirt totvards increased involvement of community. non health sector, NGOs etc.;
and
focus on gender issues and increased male responsibility and participation towards
reproductive health matters.
!
I
1 Check Your Progress 3
I ) Conlprehensive reproductive health package irrcludei:
prevention and management of unwanted pregnancy,
0 services to promote safe motherhood,
0 se~.vicesto promote child survival,
0 lliltritional services for vt~lnerablegroups,
prevention and treatment of RTls'and STls,
@ prevention and treatment of gynaecological problems,
screening and treatment of breast and ce~+vical/
uterine cancer,
e reproductive health services for adolescents,
a health, sexuality and [Link], education and counseling, and
establishment ofeffcctive referral system.

2) [Link]~
classification of districts for RCH services are:
services are to be con~nlensuratewith the needs and facilities.
interdistrict variations exist in terms of RCH indicators like CBR, female literacy rate
etc.
Poorly perfo~mingdistricts with inadequate facilities need priority attention for
I
I resource allocation.

3) Components of essential obstetric care include:

I early registration ofpregnancy,
i at least.3 prenatal check up by trained personnel at appropriate intervals,
%. @ antenatal care should include blood pressure check, haemoglobin estimation, urine
exaniination etc. regularly,
counseling,
@ detection of con~plicationsofpregnancy if any,
@ referral to PHCIFRU for conlplications,
assistance during delivery,
ensure 3 postnatal check up, and
detection of complications during delivery, and referral.

4) Special inputs for Emergency obstetric care include strengthening oPFRUs through:
9 supply of drugs and medicines,
provision for appointment of contractual staff,
provision of laparoscope,
provision for providing emergency care requiring surgical interventions, blood
transfusion and anaesthesis, and
provision for consultant anaesthetist for emergency obstetric care etc.
h n t i o ~ ~ nt llc n t t h Progrnmn~cs 5) Major causes of maternal mortality are:

anaemia,
haemorrhage,
obstructed labour,
sepsis,
0 eclampsia, etc.

6) Major causes of mortality among infants and children are:

respiratory infections,
diarrhoea1 diseases,
umbilical cord infections in new born baby,
birth injuries,
congenital malformations,
severe malnutrition, etc.

7) The important components of child survival service package are:

essential new born care,
prevention and managemellt of diarrhoea,
appropriate management of A N ,
sustaining high level of immunisation coverage,
nutritional interventions, etc.

8) Major signs and synlptonls of RTI/STI are:

abnormal vaginal discharge in women,
urethral discharge in men,
0 genital ulcers in men and women,
lower abdominal pain in women,
scrota1swelling,
enlarged, inflamed inguinal lymph glands,
neonatal conjunctivitis etc.

9) Hazards of pregnancy when the adolescent girls are not physically and emotionally not
ready for child bearing.

Check Your Progress 4

1) PHC and its subcentres, CHC, FRU, and their medical and paramedical personnel,
Anganwadi and anganwadi worker, district and subdivisional hospital.
2) Doctor on call, nurse and cleanliness service available beyond normal working hours
through contract service, provision of payment of honorariun~for deliveries conducted
between 8 p.m. and 7 a.m. on duty and to the contractual nurse.
3) Payment of fixed amount to local panchayat in selected subcentre areas for arranging
transport for referral of women to CHCPHC for delivery,
4) Services through urban health posts, urban MCH and FW centres, urban ICDS projects,
referral hospitals, PHCs in slums (proposed) maternity homes and mobile clinics by NGOs
etc.
d

00
5) Referral services,
clinical skill-based training to health personnel,
0 providing information on births and deaths including causes of deaths,
providing timely infomiation on epidemics, surveillance of selected diseases,
health education in hospitals,
research etc.

Check Your Progress 5

1) maternal health,
child health,
a management, and
communication.

2) i) Awareness generation training for pwsonnel from health and non-health sectors
ii) Integrated skill-based training for prinia~yhealth care personnel
iii) Specialised clinical skill training on MTP, Laparoscopic sterilisation, Minilap
sterilisation, NSV etc, for doc tors
iv) IUD training for ANMLHV
v) Management skill based training for RCH programme managers
vi) Conl~nunicationskill based training for IEC personnel

3) i) Preparation of district training plans and getting approval

ii) procurement and management of funds.
iii) nomination and deputing staff for training
iv) nionitoring training
v) coordination with health and related sectors for training staff.

4) Sources of data for RCH service managenlent include:

Decennial census,
@ SRS,
@ NFHS,
District surveys, and
Routine servicc records and reports.

5 ) Monitoring is a management function which measures the changes during the

implementataion of a progranime and it checks the progress to see if activities take place
as scheduled/planned. If changes seen are of negative nature then corrective steps can
be initiated.

6) Review of reports and records

@ Supervisory visits
@ I~lterviewsand discussions with comniunity

7) Indicator is an indirect measure of an event or condition which can help in measuring

the changes.

Ctieck Your Progress 6

Steps for improving quality of RCH services include:

developnlent of standards for various service components arid ndherence to thdm,

@ appropriate competency-based training for health personnel,
@ development af procedures for proficiency certification and adherence to them to ensure
acquirement ofskills after training,'
Narionsl ~ e n l hProgrammer @ improved logistics management,
@ close supervision and monitoring,
@ counseling and follow-up services for clients, and
@ need-based information, education and communication services.
UNIT 4 HEALTH RELATED

Structure
4.0 Objectives
4.1 Introduction
4.2 Integrated-Child Development Scheme
4.2.1 Aims and Objectives
4.2.2 Organisation
4.2.3 .Services Rendered
4.2.4 Beneficiaries
4.2.5 Staff of the ICDS under Health Department
4.2.6 Criteria for Project Site 1

4.3 Water Supply and Sanitation

4.3.1 Importance of Water and Sanitation
4.3.2 Sources of Water Supply
4.3.3 Classification of Water-borne Diseases
4.3.4 Safe Drinking Water
Concept of Total Environmental Sanitation
4.3.5 '
4.3.6 Rural Sanitation
4.3.7 Organisational Structure
4.3.8 Water Testing '
4.4 Minimum Need Programme
4.4.1 Components
.4.4.2 Rural Health Services
4.4.3. Other Components
4.5 Let Us Sum Up
4.6 Answers to Check Your Progress

4.0 OBJECTIVES
After going through this unit, you should be able to:
enumerate various ongoidg national programmes related [Link];
list the objectives, services and organisation of ICDS scheme;
describe the salient features of the rural water and sanitary programme;
list the various components of minimum need programme; and
enumerate the national norms under Minimum Need Prograinme.

4.1 INTRODUCTION

In the earli& three units of this block you have learnt about the national programme for
communicable diseases, non-communicable diseases and reproductive and child health care.

In this unit, you will learn about the health related national programmes. To begin with you
will learn about the objectives, services and organisation of ICDS scheme which is an
important multisectoral programme. Thereafter you will learn about the rural sanitation and
waste programme. Towards the end of this unit you will learn about another very important
programme namely minimum need programme which was initiated in the fifth five year
plan. You will learn about its components and various norms for establishmen; of rural
health care infrastructure.