Question : IMPLEMENTATION OF RCHP

THE MINISTER OF STATE FOR HEALTH & FAMILY WELFARE (SHRI SUDIP BANDYOPADHYAY)

(a): The Reproductive and Child Health Programme Phase-II (RCH-II), under the National Rural Health Mission integrates several health interventions, strategies and schemes aimed at improving maternal and child health care in the country. The programme is operational from 2005- 2012 and focuses on reducing maternal mortality ratio, infant mortality rate and total fertility rate. A detailed note on the programme interventions under each of the components is attached at Annexure-I.

(b): Details of funds allocated and released under RCH-II programme during each of the last three years and the current year is attached at Annexure-II.

(c): Under RCH-II programme, the infant mortality has decreased from 58 in 2005 to 50 per 1000 live births in 2009.

Annexure-I

Note on Reproductive and Child Health Programme, Phase-II(RCH-II)

Background

Reproductive and Child Health, Phase II (RCH II) is a comprehensive sector wide flagship programme, under the bigger umbrella of the Government of India’s (GoI) National Rural Health Mission (NRHM), to deliver the RCH II targets for reduction of maternal and infant mortality and total fertility rates. RCH II aims to reduce social and geographical disparities in access to, and utilisation of quality reproductive and child health services. Launched in April 2005 in partnership with the state governments, it is consistent with GoI’s National Population Policy-2 000, the National Health Policy-2001 and the Millennium Development Goals.

RCH programme is being implemented with flexible programming approach by allowing the States to develop need based annual plans known as State Programme Implementation Plan. It also has a monit oring system in place to assess the State’s progress against set target.

A gist of the key interventions and progress under RCH programme is given below:

I. Maternal Health interventions

1.1 Demand Promotion: Janani Suraksha Yojana (JSY): It is a national conditional cash transfer scheme to incentivise women of low socio economic status to give birth in a health facility.

Scale of Cash Assistance (in Rs) for Institutional Delivery:

Category	Rural Area	Urban Area 

Mother’s	ASHA	Mother’s	ASHA	Package	Package	Package	Package

In LPS	1400	600	1000	200

In HPS	700	200	600	200

In HPS	700	600

Effective from April 1, 2009, Effective from June15,2010 for facilitating institutional delivery among tribal women residing in the rural areas of Notified Tribal Areas of Andhra Pradesh, Gujarat, Karnataka, Maharashtra, Tamil Nadu, Himachal Pradesh, West Bengal, Kerala, Andaman and Nicobar Islands, Dadra & Nagar Haveli, Daman & Diu and Lakshadweep.

JSY has seen a phenomenal growth since its inception in 2005 as per the following details:

Year	No. of beneficiaries	Expenditure	(in lakhs)	(in crores)

2005-06	7.39	38.29 

2006-07	31.58	258.22 

2007-08	73.29	880.17 

2008-09	90.37	1241.33 

2009-10	100.78	1473.76 

2010-11	113.38	1618.39

Figures are provisional

The table above shows that there has been a phenomenal increase in the number of JSY beneficiaries since the launch of JSY i.e. from 7.39 lakhs in 2005-06 to 31.58 lakhs in 2006-07 to 73.29 lakhs in 2007-08 to 90.37 lakhs in 2008-09 to 100.78 lakhs in 2009-10. As per the provisional reports for 2010-11 nearly 113.37 lakhs mothers have been benefitted under JSY.

Further, as per the Coverage Evaluation Survey, 2009 conducted by UNICEF, the institutional deliveries have gone up to 72.9%, JSY scheme is being considered as one of the contributing factor.

1.2 Strengthening of health services

1.2.1 Ensuring early registration of pregnancy, Ante Natal Care and Post Natal Care services: Full ANC has increased from 18.8% (DLHS-III) to 26.5 %( CES-2009, UNICEF).

1.2.2 Essential and Emergency Obstetric Care, including:

1.2.3

# Skilled Attendance at birth (domiciliary & health facilities) – Nearly 32291 nursing personnel (Staff Nurse, ANM/LHV) have been trained in SBA, as on Sep, 2011.

# Opertionalizing facilities- 2510 First Referral Units (FRUs) hve been set up till June 2011which includes 566 District Hospitals, 713 Sub-Divisional Hospitals and 1231 CHCs and other level hospitals. As on June 2011; 7823 Primary Health Centres (PHCs), 4000 community Health Centres (CHCs) and 949 facilities other than CHCs at or block level but below district level have been elaborated as 24 x 7 facilities.

# Multi-skilling of doctors to overcome shortage of critical specialities -training on Life Saving Anaesthesia Skills (LSAS) and Emergency Obstetric Care (EmOC). 1070 Medical Officers have been trained in LSAS and 601 Medical Officers have been trained in Comprehensive EmOC which includes C-section, as on Sep, 2011

# A 10 day training on Basic Emergency Obstetric Care (BEmOC) Skills has been initiated in the states for which training of Master Trainers is currently under progress at NIHFW, New Delhi.

1.3 Strengthening referral systems through Public Private Partnership (PPP), voucher schemes, referral funds at all levels

1.3.1 Referral transport: Funds for referral transport of mother have been provided to all the states under Janani Suraksha Yojana. In order to further strengthen the referral services, funds have been provided for the States for implementation of the following referral transport schemes:

# Swasthya Vaahan Sewa No.102 in Haryana

# Centralised Accident & Trauma Services (C.A.T.S.)in New Delhi

# Janani Express Yojana in Madhya Pradesh

# Ambulance Scheme in West Bengal

# Emergency Management and Research Institute (EMRI) Service in Andhra Pradesh, Assam, Gujarat, Karnataka, Uttarakhand, Goa, Rajasthan Tamil Nadu, Madhya Pradesh and Meghalaya

# Emergency Medical Services in Bihar

# Janani Suraksha Vahini in Karnataka

# JSY Helpline & ambulance services in Jharkhand

# Rural Ambulance to Transport Women with Obstetric Emergencies and Sick Newborns in Tripura

1.4 Safe Abortion Services: Under The RCH programme following strategies have been adopted:

1.4.1 Provide at least MVA (Manual Vacuum Aspiration) upto 8 weeks at 24 x 7 PHCs and MCH Level 2 facilities

1.4.2 Provide comprehensive MTP services at all FRUs and MCH Level 3 facilities (District Hospitals and sub-district level facilities) including MVA/EVA/MMA.

1.4.3 Encourage private and NGO sectors to provide quality MTP services.

1.4.4 Spread awareness regarding safe MTP in the community and the availability of services thereof.

1.4.5 Train Medical officers in safe MTP techniques.

1.4.6 Train ANMs, ASHAs and other field functionaries to provide confidential counseling for MTP and promote post-abortion care through these workers.

1.4.7 Comprehensive Safe Abortion Care –Training and Service Delivery Guidelines have been disseminated to the States.

1.5. Village Health & Nutrition Days (providing community level comprehensive Maternal and Child Health and family planning, including immunization): A total of 2.7 Crore Village Health and Nutrition Days have been organized till March 2011(NRHM- MIS) since the launch of NRHM.

II. Child Heath & Immunization Interventions:

2.1. Integrated Management of Neonatal & Childhood Illnesses (IMNCI) which includes Pre-service and In-service training of providers, improving health systems (e.g. facility up-gradation, availability of logistics, referral systems), Community and Family level care. IMNCI is being implemented in 433 districts across the country and 492611 health personnel have been trained in IMNCI till October 2011.

Home Based New Born Care (HBNC): A new scheme has been launched to incentivize ASHA for providing Home Based Newborn Care. ASHA will make visits to all newborns according to specified schedule up to 42 days of life. The proposed incentive is Rs. 50 per home visit of around one hour duration, amounting to a total of Rs. 250 for five visits. This would be paid at one time after 45 days of delivery, subject to the following:

a. recording of weight of the newborn in MCP card

b. ensuring BCG , 1st dose of OPV and DPT vaccination

c. both the mother and the newborn are safe till 42 days of the delivery, and

d. registration of birth has been done

This will be confirmed through recording in MCP cards & ASHA visit from.

2.2 Facility Based Newborn and Child Care:

# 293 Sick New Born Care Units (SNCUs) have been established till October 2011;

# 1134 New Born Stabilisation Units (NBSUs) have been established till October 2011;

# 8582 New Born Care Corners (NBCs) have been established till October 2011.

2.3. Navjat Shishu Suraksha Karyakram (NSSK) is a programme aimed to train health personnel in basic newborn care and resuscitation. 44,977 medical personnel have been trained in NSSK till October 2011.

2.4. Infant and Young Child Feeding: Promotion of early initiation of breast feeding (within one hour of delivery) and exclusive breast feeding till 6 months and timely complementary feeding with continued breast feeding is emphasized under the infant and young child feeding programme.

2.5. Nutritional Rehabilitation Centres (NRC) to treat severe acute malnutrition amongst children. 455 NRCs have been established across the country till October 2011.

2.6. Reduction in morbidity and mortality due to Acute Respiratory Infections (ARI) and Diarrhoeal Diseases: Promotion of zinc and ORS supplies is ensured.

2.7. Supplementation with micronutrients: through supplies of Vitamin A & iron supplements.

2.8. School Health Programme for screening, health care and referral for school going children: Govt. of India is providing support to the State Governments in carrying out school health programme. In the financial year 2010-11, 70165698 students in 3, 95,960 schools were covered.

2.9. Immunization Programme is one of the key interventions for protection of children from life threatening conditions, which are preventable. Under the Universal Immunization Programme Government of India is providing vaccination to prevent seven vaccine preventable diseases i.e. Diphtheria, Pertussis, Tetanus, Polio, Measles, Childhood Tuberculosis and Hepatitis B. In addition, pulse polio programme is conducted for polio eradication and Japanese Encephalitis (JE) vaccine is provided to children in JE endemic areas. Each year nearly 90 lakh immunization sessions are conducted at sub-centers and community level targeting 2.6 crore children and 3 crore pregnant mothers.

2.10 Pulse Polio ImmunizationYear 2010 has documented the lowest number of polio cases ever since the inception of Polio eradication programme in the country. There were 42 polio cases detected in 2010 compared to 741 cases of polio detected in 2009. During 2011, 1 polio case has been detected in the entire country (during January 2011 In West Bengal) as compared to 42 cases detected in 2010 (till 2nd December 2011). The progress becomes even more significant as for the past 10 months no polio case has been reported in the country which has never been foreseen in the programme. The number of affected districts has also declined from 90 in 2008 to 56 in 2009 to 17 in 2010 and to just 1 in 2011 so far(2nd December 2011)

2.11 Other major initiatives under Immunization:

# Universalization of Hepatitis B vaccine to all states in the country

# Introduction of Pentavalent vaccine (DPT+Hep B+ Hib) in Tamil Nadu and Kerala

# Establishment of State and District AEFI committees for rapid response to any adverse event following Immunization

III. Family Planning Interventions

3.1. Addressing the unmet need in contraception through

3.1.1 Assured delivery of family planning services

3.1.2 Capacity building of service providers

3.1.3 Increasing male participation through No Scalpel Vasectomy (NSV)

3.1.4 Promotion of Intra Uterine Contraceptive Device (IUCDs) as a short & long term spacing method

3.2 Family planning insurance scheme

3.3 Promoting Public Private Partnerships

3.3.1 Ensuring quality care in family planning services by establishing Quality Assurance Committees at central, state and district levels and regular monitoring

3.4 Increasing basket of choices in contraception

IV. Human Resources for health:

4.1. In order to meet the shortfall in Human resources for health, funds are provided to the States to hire staff on contractual basis. Till March 2011, 60268 ANMs, 7063 specialist doctors and 33667 Staff Nurses have been appointed.

4.2. 8.49 lakhs ASHA workers have been appointed nationwide till march 2011 to create awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization of the existing health services and promotion of good health practices.

4.3. 15095 Programme Management staff has been appointed under the programme to support the states in providing management support in planning and execution of the programmes.

V. Programme review and monitoring

5.1. Review Missions

To assess the progress made by the States in RCH programme, annual review is being conducted. The review which is known as Joint Review Mission (JRM) is being led by GoI with support and participation from state governments and DPs. Based on the field observations an aide memoire is prepared with the recommendations and shared with the States. So, far seven JRMs have been held. The seventh JRM was held during the period from July–August 2010.

5.2. Monitoring and Evaluation

In addition to the annual review missions, several other mechanisms are put in place to assess the programme implementation of the States. The monitoring is being done both internally by the officials of MoHFW as well in support from the externally agencies.

5.2.1 As a part of internal monitoring a team of officials and consultants of the ministry regularly visits the states for a week. During the visit the team observes various technical components of the RCH programme in terms of services delivery at the health facilities. The monitoring also concentrates in the other parts of the programmes i.e. training, human resources, programme management etc. Based on the field observation recommendations in the form of report is being shared with the States.

5.2.2 Evaluation Surveys: M & E division organizes periodic surveys namely National Family Health Survey (NFHS) District Level Household Surveys (DLHS), Facility Surveys.

5.2.3 Regional Evaluation Survey (RET): RETs monitor and evaluate the programme implementation.

VI. New Strategies and Interventions under RCH programme

6.1. Mother and Child Tracking System

Government of India has taken a policy decision to track every pregnant woman by name for provision of timely ANC, Institutional Delivery, and PNC along-with immunization of the new- born. While States like Gujarat, Tamil Nadu and Rajasthan already have such a tracking system in place, others are moving ahead for adopting and expanding this system. All States have since collected data on the hard copy from 1st April, 2010 and an off-line version of the MCTS has also been launched which will speed up the data capturing status. The current position of data uploading on the MCTS Central Server is that data for around 128.90 lakhs pregnant women have been captured and for 71.17 lakhs children till 14.12.2011.

6.2. Maternal Death Review

A decision has been taken to review every maternal death both at the health facilities and in the community through formation of Maternal Death Review (MDR) Committees at district level and a task force at State Level. The purpose of the review is to find the gaps in the service delivery which leads to maternal deaths and take corrective action to improve the quality of service provision. Government order for MDR has been issued by all the states.

6.3. Differential planning & supportive supervision

In order to accelerate the achievement of the MDG goals, 264 backwards districts have been identified with special focus to reduce regional disparities and to fast track improvements in RCH outcomes by extensive district planning and ensuring supportive supervision through dedicated teams comprising officials of Ministry of Health, development partners and professionals.

6.4. Janani Shishu Suraksha Karyakram (JSSK)

A new initiative namely Janani Shishu Suraksha Karyakaram (JSSK) has been launched on 1st June, 2011, which entitles all pregnant women delivering in public health institutions to absolutely free. Under this scheme the following are the free entitlements for pregnant women and sick new born till 30 days after birth:

1. Free and cashless delivery

2. Free C-Section

3. Free drugs and consumables

4. Free diagnostics

5. Free diet during stay in the health institutions

6. Free provision of blood

7. Exemption from user charges

8. Free transport from home to health institutions

9. Free transport between facilities in case of referral

10. Free drop back from Institutions to home after 48hrs stay

While 32 of the 35 States and Union Territories have initiated implementation of the scheme, 19 have rolled out all the entitlements, 13 have also initiated implementation of the scheme except for 1 or 2 entitlements and the remaining 3 States in the North –East (Sikkim, Mizoram and Nagaland) are expected to initiate shortly. More than Rs. 1,437 crores have been allocated to the States for the year 2011-12 for prments under JSSK.