New Initiatives for Maternal and Newborn Health under NRHM in India

Asia Regional Meeting, Dhaka, 3-6 May 2012 Dr. Manisha Malhotra, Asst. Commissioner, Maternal Health, Ministry of Health and Family Welfare, Govt. of India

Total Population: 1.22 Billion Number of states, UTs: 35 Population of Largest State(UP)- 200 Million Number of births per annum: 24 Million

National Rural Health Mission- Background

NRHM launched on 12th April 2005 To strengthen the hands of the State Governments in health care delivery. To allocate more financial resources for health To bring sharper focus on rural, particularly marginalized and vulnerable populations. Architectural correction through integration of vertical programmes, decentralization and communitization.
3

Overview of Goals
Indicator Goals MDG / NRHM Achievement

Maternal Mortality Ratio

100 per 100,000 Live births

Declined from 254 per 100,000 live births (2004-06) live births to 212 per 100,000 live births (2007-09)

Infant Mortality Rate

30 per 1000 Live births

Reduced from 58 per 1000 (2005) live births to 47 per1000 live births (2010) Decline in Rural IMR greater than decline in Urban IMR

Total Fertility Rate

2.1

Reduced from 3 (2003) to 2.5 (2010)

Reducing Disease Burden

NRHM: Sector-wide approach

Community Mobilisation :

Maternal Health

Family Planning
Adolescent Health Immunisation Child Health

RCH

ASHAs

Flexible financing Human Resources

NATIONAL RURAL HEALTH MISSION

Health System Strengthening

Capacity Building

Disease Control

Infrastructure strengthening

NRHM - Main Approaches

Communitize 1. Funds, functions & functionaries to local community 2. Decentralized planning 3. RKS at all levels 4. Grants to RKS and VHSC 5. Inter-sectoral convergence Improved Management 1.Management support at State, District and Block Level 2.NGOs in capacity building 3.NHSRC and SHSRC 4.Continuous skill development support More money for health More health for money Flexible Financing 1. Untied grants 2. Annual Maintenance Grants 3. Infrastructure Strengthening 4. More resources for more reforms Monitor Progress Against Standards 1. IPHS Standards 2. Facility Surveys 3. Independent Monitoring Committees at all levels

Innovation In Human Resource Management 1. Additional HR 2. 24X7 emergencies at PHC & CHC 3. Multi-skilling & task-shifting

Under NRHM, focus on Poor Performing States and Districts: Bring in technical & managerial resources to states that lag behind
Higher resource allocation to 264 backward districts with poor indicators.

Bihar

Assam
Managerial Resources
7

Other N-E states Jharkhand

Rajasthan
Chhattisgarh

Uttar Pradesh
Madhya Pradesh Technical Resources

Increased release and expenditure of funds under NRHM Rs. In crores

18000 16116.24 16000 14000 12000 10565.1 8508.87 5774.3 4433.75 3204.17 4518.68 7010.07 13216.05 12871.11

10000
8000 6000 4000 2000 0

11470.18
9625.09

2005-06

2006-07

2007-08

2008-09

2009-10

2010-11
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Release

Expenditure

Financial Allocations for NRHM

15 billion USD allocated till now 4 billion USD in current year.
Likely to increase in 12th Five Year Plan.

Innovations for retention of Human Resources

Financial incentives: Haryana, Himachal Pradesh, Karnataka, Chhattisgarh, Odisha, Sikkim and Rajasthan Regulatory: Compulsory service, Pre-Post Grad. mandatory rural services, Additional marks for rural residence for PG, - Assam, Haryana, TN. Workforce Mgmt.: Rotational posting, Recruitment rules, extending retirement age: Karnataka , Maharashtra, Haryana. Educational: Local Candidates, new courses, Assam, Chhattisgarh, West Bengal.
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Strengthening of Health Facilities

2329 Referral Hospitals have been strengthened to act as First Referral Units with CEmONC capacity which means functional OT, laboratory and blood transfusion services, 8250 PHCs are currently functioning as 24x7 PHCs. 9824 Newborn care corners, 340 Special Newborn Care Units, and 1210 Newborn Stabilization Units are established under NRHM

11

Infrastructure
Significant reduction in gaps at the level of DH and CHCs Increasing number of states have Institutional State level mechanisms for infrastructure

20251 new constructions have been sanctioned. 18883 renovations have been sanctioned.
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Mobile Medical Units (MMUs) and Emergency Referral Transport

MMUs
1951 Mobile Medical Units provided in 442 districts for delivery of health care to difficult areas

Emergency Transport

and

Referral
Response

7097 Emergency Vehicles

7458 ambulances providing referral services

added for transport

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Strengthening Community Processes

Accredited Social Health Activist (ASHA) acts as interface between community and Health System. 8.61 lakh ASHAs engaged at village level

Village Health Sanitation and Nutrition Committees (VHSNCs) are constituted at Village/ Gram Panchayat level with representation from all sections of the community including the disadvantaged sections. 5.00 lakh VHSNCs constituted
Rogi Kalyan Samitis (Patient Welfare Societies) are set up at various hospitals to encourage involvement of the community in the management of Public Health services. 30,420 RKSs constituted at the health facilities VHSNC and RKS empowered with Untied grants.

Community encouraged

Monitoring

programme

being
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Trends in Maternal Mortality Ratio

500 450 400 350 327 300 250 200 150 100 229 206 199 173 301 254 212 35% 308 461 438
Two states: Kerala and Tamil Nadu have achieved the MMR goal, while Maharashtra is close. Four states are within striking distance.

375

33%

174 149

149 127 38%

35%

1999-2001
India

2001-03
EAG & Assam States

2004-06
Southern States

2007-09
Other States

Situation of Child Health in India (SRS 2010)

IMR U5M rate

Three large states (Kerala, Tamilnadu & Maharashtra ) and 9 others have achieved MDG 4. IMR is 47 and varies but shows a differential of 51 in rural areas to 31 in urban areas. Under-five mortality rate is estimated at 59 and it varies from 66 in rural areas to 38 in urban areas. Female infants experience a higher mortality than male infants in all States (47 TOTAL; 46 MALES, 49 FEMALES)

3.5
3.2 3.1

Trends in TFR: 2000-2010 (SRS)

3 3 2.9 2.9 2.8 2.7 2.6 2.6

3
2.5 2

2.5

1.5
1 0.5

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Key thrust areas - RCH

Service guarantees in public health facilities
Comprehensive MCH care, Thrust on neo natal care
Intensification and expansion of UIP Strengthening Capacities for Implementation of PC & PNDT

Meeting the Unmet Need for contraceptionpostpartum services, ASHA & NGOs involvement

Adolescent health, School health, Operational plan for Nutrition

Training, Birth waiting homes, Dedicated 100 beds MCH wing

JANANI SHISHU SURAKSHA KARYAKRAM

Eliminating out-of-pocket expenses for families of pregnant women and sick newborns in government health facilities: Free and cashless delivery including free C-section: Free drugs including consumables, free diagnostics, free diet, free blood and free referral transport (Home to health institution, between health institutions in case of referral, drop back home )

Reaching the unreached pregnant women (nearly 7.5 million a year who still deliver at home)

JANANI SURAKSHA YOJANA: Phenomenal increase in institutional

delivery. Beneficiaries increased from 0.739 million in 2005-06 to 10.8 million in 2010-11

Janani Suraksha Yojana

A phenomenal increase
1800

162
1600
1400 1200

168

180

160

144 120 108

148
140

113.39 100.66 90.8 73.09 1241 880 1474 1618 324 m US $

120

1000
800 600

100
80 60

400

40
20 0

30.74
200 0

7.34 38 2005-06

258 2006-07 2007-08 2008-09 2009-10 2010-11

Expenditure for JSY (Rs.in Crores) Institutional Deliveries (in lakhs)

JSY Beneficiaries in Lakhs

20

Beneficiaries increased from 0.739 million in 2005-06 to 10.8 million in 2010-11

The New Strategic Initiatives

Delivery Points to provide comprehensive RMNCH services (High case load facilities fulfilling benchmarks Adolescent Health: Strengthening of this pillar, a weak area till now Menstrual Hygiene, Weekly Iron and Folic acid Supplementation (WIFS), School health programme Home Based Newborn Care : Improving community newborn care practices through involvement of frontline workers (ASHAs) Strengthening Nursing and Midwifery Cadre with focus on midwifery component

The New Strategic Initiatives

Enhanced focus on spacing methods

Contd

Ensuring training and follow-up of trained personnel in IUCD 380A Introduction of new IUCD Cu IUCD 375 Ensuring Fixed Day service delivery for IUCD at SHC and PHC level

Ensuring focus on Post-partum FP services Strengthening community based delivery of contraceptives through ASHAs 233 pilot districts Line listing of severely anemic women Web enabled MCTS