PRIORITIZING INVESTMENTS IN INDIA TOWARDS ACHIEVING MDG 4 & 5 Dr. Rakesh Kumar, Joint Secretary (RMNCH+A)
18% 20%
16%
28%
22%
33%
0%
5%
10%
15%
20%
25%
30%
35%
Population Child Births MaternalDeaths
NewbornDeaths
Under FiveDeaths
Extreme Poor
Extreme Poor : People living on < 1.25 USD / Day (World Bank report -2010)
INDIA’S CONTRIBUTION TO GLOBAL BURDEN
INDIA'S CONTRIBUTION TO GLOBAL BURDEN
Mortality Global India
Maternal Deaths 287,000
44,000
Neonatal Deaths 2.85 Million
730,000
Infant Deaths 4.8 Million
1.05 million
Under 5 Deaths 6.6 Million
1.27 million
Data Source : UN Interagency estimates 2013
INDIA’S PROGRESS ON MDG 4 IN GLOBAL CONTEXT
90
126
48 49
Global India
1990
2013
47% Decline 61% Decline
INDIA’S PROGRESS ON MDG4
Compounded annual rate of decline (Under 5 Mortality Rate)
1990-2008 2008-2013
3.3%
6.6%
NRHM Impact
126
69 64 59 55 52 49
0
20
40
60
80
100
120
140
1990 2008 2009 2010 2011 2012 2013NRHM Launch
(2005)
4.0%
Under 5 Mortality Rate (1990-2012 )
Compounded annual decline rate
Und
er 5
dea
ths,
per
100
0 liv
e bi
rths
TEN states have achieved the MDG 4 target of 42 Andhra Pradesh (41), Delhi (26), Himachal Pradesh (41), Jammu & Kashmir (40), Kerala (12), Karnataka (35), Maharashtra (26), Punjab (31), Tamil Nadu (23), West Bengal (35)
CAUSES OF UNDER 5 DEATHS : INDIA
Data Source : 2012 CHERG Estimates for Causes of Under 5 Deaths for Year 2010
• Neonatal causes account for 52% of Under 5 deaths.
• Pneumonia (15%) and Diarrhoea (12%) major killers after 1st month
• Malnutrition underlying factor in 35% of deaths
• Infections continue to be a major killer
80% of Under 5 deaths are caused by Neonatal causes, Pneumonia & Diarrhoea
INDIA’S PROGRESS ON MDG 5 IN GLOBAL CONTEXT
MMR in India has declined much faster than the global MMR
380
560
210 167
Global (MMEIG Estimates: 1990-2013
India (MMEIG Estimates: 1990 & SRS2011-13)
1990
2013
45% Decline 71% Decline
ACCELERATED PACE OF DECLINE IN MMR
327 301
254
212 178 167
0
50
100
150
200
250
300
350
SRS 1999-01 SRS 2001-03 SRS 2004-06 SRS 2007-09 SRS 2010-12 SRS 2011-13
Decline in Maternal Mortality Ratio
5.8%
5.5% 4.1%
% annual compound rate of decline
5.7%
Launch of RCH II/ NRHM in 2005
NINE states have achieved the MDG 5 target of 141 Andhra Pradesh (92), Gujarat (112), Haryana (127), Kerala (61), Karnataka (133), Maharashtra (68), Punjab (141), Tamil Nadu (79), and West Bengal (113).
6.2%
Haemorrhage, 38%
Sepsis, 11%
Hypertensive disorders, 5%
Obstructed Labour, 5%
Abortion, 8%
Other Conditions,
34%
9 Causes-Source:RGI-SRS 2001-03
3 Delays
• Delay in decision to seek professional care
• Delay in reaching the appropriate health facility
• Delay in receiving care after arriving at a hospital
Social determinants of health play a major role
Medical Causes
CAUSES OF MATERNAL MORTALITY
8 EAG STATES CONTRIBUTE…
▪ 50% of India's
Population
▪ 60% of Child Births
▪ 71% of Infant Deaths
▪ 72% of Under 5
Mortality
Four EAG States Account for >2/3rd of Maternal Deaths
2,21
,935
83,3
86
80,0
68
66,5
21
41,4
86
38,5
85
33,7
79
33,7
26
32,7
57
27,5
82
23,9
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21,6
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21,3
20
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15,4
76
10,7
71
7,14
8
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8
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Four EAG States Account for >1/2 of Neonatal Deaths
1590
0
6000
4400
4300
2100
1900
1700
1700
1500
1400
1400
1400
1300
900
700
600
500
300
THEREFORE, AN URGENT NEED TO TARGET PRIORITY AREAS AND ACTIONS BY FOCUSING ON..
▪ Adopting continuum of care:
▪ Across life stages
▪ Service delivery platforms with equal focus on community & hospitals
▪ Equity issues and reaching the unreached
▪ Matching the investments with the disease burden
Need to ensure Effective Coverage, Equity in the centre-stage of the Planning
Reproductive, Maternal, New-born, Child & Adolescent Health : Links maternal and child survival to other components (family planning , adolescent health, gender & PC & PNDT)
Plus denotes
inclusion of adolescence as a distinct ‘life stage’ in the overall strategy Links community and facility based care as well as referrals between various levels of health care system
Adolescent Health
Package
Reproductive Health
package
Antenatal & Intrapartum care package
Newborn Care package
Postpartum family planning, spacing
methods
Under five child health package
CONTINUUM OF CARE APPROACH (RMNCH+A)
REACHING THE UNREACHED
National Health Mission
Continuing systems strengthening under NRHM Launch of NUHM
RMNCH+A…
Prioritising resources for marginalised and underserved populations… (30% extra fund allocation) 184 “High Priority Districts” (DHAPs)
Harmonisation
Harmonised managerial and technical support by Development Partners… extending beyond thematic/ organisational expertise
Rajasthan
Tripura Mizoram
Manipur
Nagaland
Arunachal Pradesh Sikkim
Jammu & Kashmir
Uttar Pradesh
West Bengal
Haryana
Uttarakhand Chandigarh Punjab
Himachal Pradesh
Bihar
Dadra and Nagar Haveli
Puducherry Tamil Nadu
Kerala Lakshadweep
Goa
Karnataka
Meghalaya
Maharashtra
Assam
Daman and Diu
Gujarat Madhya Pradesh Chhattisgarh Orissa
Jharkhand
Andaman & Nicobar Islands
Andhra Pradesh
BMGF
DFID
NIPI
UNFPA
UNICEF
USAID
Focus on : • Rural and Urban Poor • Tribal & Minority
groups • Hard to Reach Areas • Girl Child
184 HIGH PRIORITY DISTRICTS (HPDS) ACROSS 29 STATES
SHARPENING THE EQUITY FOCUS: HIGH PRIORITY DISTRICT APPROACH
Maternal Health Initiatives Creating demand for services ▪ Janani Suraksha Yojana (JSY) -2005, a conditional money transfer
scheme bringing pregnant women to the public system for institutional deliveries. More than 16.6 million women delivered in public health facilities last year costing $ 275 mn USD.
Eliminating out-of-pocket costs ▪ Janani Shishu Suraksha Karyakram (JSSK)-2011: CASHLESS services
at public health facilities as an entitlement for ALL pregnant women and sick infants, including free drugs, consumables, diagnostics, blood, to and fro transport, and diet during stay
▪ Referral transportation – network of ~20,000 ambulances
Improving access ▪ About 16,000 “Delivery Points” identified for strengthening
▪ 8743 PHCs made functional 24x7; and 2653 First Referral Units (FRUs)
▪ Dedicated MCH Wings: ▪ 28,000 new beds across 470 hospitals
▪ 100-bedded wings in 174 hospitals
▪ Project cost ~ 600 million USD
Improving coverage of services ▪ Skilled Birth Attendance (SBA): 70,000 nurses trained
▪ Emergency Obstetric Care (EmOC) ▪ 1,300 Medical Officers imparted skills in EmOC services
▪ 1,800 Medical Officers trained in Life Saving Anaesthesia Skills
▪ Safe Abortion services operationalized
Strengthening Monitoring
▪ Institutionalised Maternal Death Reviews across the country, both Facility Based and Community Based
▪ Software rolled out to track women and children from pregnancy to 2 years post-delivery (MCTS) to ensure no services are missed
▪ Till date, >59 million mothers and >49 million children registered.
▪ National Facilitation Centre to validate service provision
▪ Supportive supervision for RMNCH+A checklist
Policy Decisions to Strengthen Maternal Health ▪ Misoprostol distribution by ASHAs to prevent PPH in home delivery
cases
▪ Calcium supplementation during pregnancy
▪ Screening during pregnancy for Gestational Diabetes, Hypothyroidism, and Congenital Syphilis
▪ De-worming during pregnancy
▪ Breast and Cervical cancer screening
▪ Training of Surgeons for Caesarean section
▪ 3-day hands-on training programme for intra-partum and newborn care
▪ Guidelines for up-gradation of labor rooms
▪ Institutional deliveries increased from 47% in 2007 to 78.6% in 2013…..however, home deliveries are prevalent in some areas.
▪ For such areas, focus now is Skilled Birth Attendance + Community based distribution of Misoprostol (Initiative to prevent PPH in home deliveries)
▪ Identification and notification of villages with >20% home delivery
▪ Advance distribution of Misoprostol to women who are unlikely to deliver in an institution
Identification of High Risk Pregnancies and Birthing plan
SBA FOR HOME DELIVERIES
▪ Competency based skill lab training package for enhancing the skills of service providers (doctors / nurses / ANMs)
▪ Can be used for both in-service & pre-service training
▪ 8 skill stations in each skill lab ▪ Ante Natal Care ▪ Intra natal Care ▪ Complication management in Mother and New Born ▪ New Born Care ▪ Family Planning Infection Prevention ▪ Counselling ▪ Documentation
STRATEGIC SKILL BUILDING-SKILL LABS
• Certain key tasks can be entirely taken up by AYUSH doctors and nurses, with adequate skill building – SBA, CAC, IUCD, RBSK
Task shifting
• Establishment of nodal centres • Strengthening of GNM and ANM schools • Competency based certification
Pre-service nursing
education
• Phase-wise assessment of skills of in-service workers
Skill assessment
• Low dose high frequency • Adaptive to requirements of facilities • Initiated for FP services; to be extended to all
areas
Onsite training
STRATEGIC SKILL BUILDING
UNSAFE ABORTIONS 8% MATERNAL DEATHS
• Culture of Silence, Social Stigma, Lack of awareness on legality & availability of services Community
• Suboptimal resources- equipment, drugs, trained providers, irrational deployment
• “Conscientious objection” of service providers, linking of PCPNDT and MTP Acts-barriers to access
Services
• Lack of commitment to CAC services. • Non-functional District Level Committees • Post Abortion IUCD • MTP Act doctor-centric
Policy
Effective IEC/BCC
Campaign
Prioritize services at “Delivery Points” , Capacity Building,
Advocacy, improved
monitoring reporting,
Amendments
FP-2020: INDIA’S COMMITMENT
▪ FP central to achieving Universal Health coverage
▪ Increased financial commitment to 2 billion USD by 2020
▪ Ensuring FP services to 48 million new users by 2020
▪ Sustaining coverage for 103 million existing contraceptive users
▪ Expanding the basket of services and availability of free contraceptives (HDCs/ESB, PPIUCD, PAIUCDs, Injectable & implants?)
▪ State plans constructed and being rolled out, trainings initiated
Effective implementation for accelerated achievement of MDG 4& 5
PREGNANCIES IN ADOLESCENTS & YOUNG PEOPLE
Source: Special Bulletin on maternal mortality in India, 2010-12 SRS
15-19 years 7%
20-24 years 39%
Motherhood in Childhood- Adolescent Pregnancies
More than 21,000 young mothers die every year 15-24 years
46%
• Delayed age of marriage, • Ensuring Spacing at Birth • Home Delivery of Contraceptives • Post-partum IUCD • Rashtriya Kishor Swasthya Karyakram • Working with Other Departments
Steps taken
Healthy Lifestyle
Violence free living
Improved nutritional
status Substance
misuse prevention
Reproductive and Sexual
Health
Mental and Emotional Well
Being
RKSK Objectives
ADOLESCENTS IN THE CENTRE-STAGE NEW ADOLESCENT HEALTH STRATEGY
• Adolescent Friendly Health Clinic (AFHC)
• Walk-in clinics in Sub Health Centres
• Focus on Inter-personal Communication
• Use of mass and mid media, and new-age media channels (social networking, SMS gateways, etc.)
• Peer Education (PE) • Quarterly Adolescent Health
Day (AHD) • Weekly Iron and Folic Acid
Supplementation Programme (WIFS)
• Menstrual Hygiene Scheme (MHS)
Convergence with other departments/ schemes within and outside Health & Family Welfare
NEW ADOLESCENT HEALTH STRATEGY…
INDIA NEWBORN ACTION PLAN (INAP)
India envisions a health system that eliminates preventable deaths of newborns and stillbirths and where:
- every pregnancy is wanted
- where every birth is celebrated, and
- where women, babies, and children survive, thrive, and reach their full potential.
Targets to achieve single digit NMR and SBR by 2030
▪ Launched on 18th September, 2014 to fulfil Country’s commitment in response to the Global Every Newborn Action Plan (ENAP).
▪ INAP aims to end preventable newborn deaths and Stillbirths by 2030
Pre-conception & Antenatal Care
Care during labour & childbirth
Immediate newborn care
Care of healthy newborn
Care of small & sick newborn
Care beyond survival
Six Pillars of INAP INDIA NEWBORN ACTION PLAN (INAP)
POLICY INITIATIVES TO STRENGTHEN NEWBORN CARE
Antenatal Corticosteroids
in Pre-term Labour
Gentamicin use by ANMs for
sepsis management in young infants
Vitamin K at birth
Scaling up FBNC
Revised guidelines for
HBNC
FACILITY BASED NEWBORN CARE UNITS
NBCC NBSU SNCU
• Supported by Unicef and being scaled up by Govt. of India nation-wide
• More than 300,000 new born enrolled with real time data on 250 + parameters available to guide action
• Scale up completed in seven states covering 245 (40%) SNCUs, all SNCUs by June 2015 – Largest data base of sick new born globally
MONITORING SOLUTION FOR SNCUs: SNCU ONLINE MONITORING AND FOLLOW UP TRACKING SYSTEM
Mother
SMS REMINDER FOR COMMUNITY & FACILITY FOLLOW-UP
SMS reminders to family and ASHA worker
on Day of Follow up
ASHA
Facility Follow Up By SNCU Doctor
Community Follow up by ASHA
HOMEBASED NEW BORN ON SCHEDULED DATES
▪ Strengthening Routine Immunisation Program (Indradhanush Initiative)
▪ Polio Endgame Strategy
▪ Measles elimination and Rubella control-2020
▪ Hib containing Pentavalent vaccine
▪ MNTE – 2015
▪ New vaccines; Rota, MR, Adult JE and IPV
65 % full immunization coverage
On 27thMarch 2014, India along with South-East Asia Region of WHO certified polio free
UNIVERSAL IMMUNIZATION PROGRAMME
REDUCING PNEUMONIA & DIARRHOEA DEATHS: INTEGRATED MANAGEMENT (GAPPD)
▪ Exclusive Breast Feeding in 0 - 6 months/IYCF practices
▪ Immunization (Measles, Hib and Pneumococcal, Rota vaccine)
▪ Adequate nutrition and complementary feeding
▪ Improved quality of fuel for cooking to reduce air pollution ▪ Solid fuel increases pneumonia incidence by 80%
▪ Improved Care Seeking
▪ Appropriate Case management at all levels ▪ Community case m/m can reduce pneumonia deaths by 32% ▪ Oxygen (35% reduction in pneumonia mortality) ▪ Antibiotics (Oral and Injectable) ▪ ORS and Zn
▪ WHO-UNICEF supported consultation on GAPPD on 14-16 October, 2014
INDIA’S INTENSIFIED DIARRHOEA CONTROL FORTNIGHT (IDCF) LAUNCHED 28TH JULY, 2014
..with the objective to kick-start diarrhoea control efforts
WEEK 1
ORS distribution & counselling - home visits by ASHA
Establishment of ORS-Zinc Corners
Hand washing demonstration and practice in schools
Breastfeeding initiation immediately or within 1 hour
IYCF demonstration and counselling sites
Medical management of under nourished children at health facility
WEEK 2
Capacity building for IDCF implementation
Intensive Awareness generation
Multisectoral involvement – AWCs, Schools PRI, etc.
COMMON ACTIVITIES FOR WEEK WISE THEME
Helped improving ORS and Zn coverage in the country
•Newborn screening at public health facilities by existing health service providers
•Screening through ASHAs during home visits from birth – 6 weeks
•Screening by mobile health teams
Screening
• Early Intervention Centre at District hospital for further assessment and act as a referral linkage to appropriate health facility
Referral • Free of cost services
including surgical interventions in District Early Intervention Centre or at pre-identified tertiary level institutions
Management
1.5 million babies born with a birth defect, 9.6% of all newborn deaths and 4% of U5M
RASHTRIYA BAL SWASTHYA KARYAKARAM (RBSK) UNIVERSAL SCREENING OF CHILDREN INITIATIVE
270 million children targeted, 30 conditions to be treated (including surgery) free of cost
CROSS-CUTTING AREAS BEING STRENGTHENED
▪ Moving beyond numbers – Quality improvements
▪ Strengthening HR, strategic skill upgradation, task-shifting-multiskilling of doctors
▪ Using data for decision; Gap analysis, HMIS, MCTS, MDR, SNCU
▪ Strong monitoring and supportive supervision
▪ Strategic communications/BCC
▪ Commodities and logistics management
▪ Strengthening community processes; engagement with NGOs and private providers
▪ Ensuring accountability
OUR LAST MILE EFFORTS..
..to achieve MDG 4 & 5 in the next 309 Days are.. ▪ Strengthening quality facility based delivery care, with complete referral
linkages, and ensuring misoprostol administration in home deliveries
▪ Sustaining efforts for reduction in Neonatal mortality – operationalising INAP
▪ Accelerating immunization coverage & new vaccines
▪ Addressing forgotten killers – Pneumonia and Diarrhoea – intensifying IDCF efforts and rolling out GAPPD activities
▪ Focussing prevention and adequate management of malnutrition – scaling up Facility & Community Based Management of Acute Malnutrition
By making Health a ‘Social Movement’
INDIA IS COMMITTED TO IMPROVE THE HEALTH OF ITS MOTHERS AND CHILDREN, AND ACHIEVE THE MDGs…