RCH PHASE-II
Revised
By
Dr.I.Selvaraj,I.R.M.S
B.Sc., M.B.B.S., (M.D COMMUNITY MEDICINE).,D.P.H.,D.I.H PGCH&FW (NIHFW, New Delhi)., M.I.P.H.A
Sr.D.M.O (Selection Grade Officer)/ S.Rly (on Study Leave)
INDIAN RAILWAY MEDICAL SERVICE
• India is the second most populous country in the world.
• It has 2.4% world’s land area with 16.7% world
population.
• Total population of India is 1028.6 million. Annual growth
rate is 1.93%.
• 17.6 million Babies are born/per year.
• UP is most populous state in our country.
• 50% of the country’s population is in 5 states (UP.
Maharashtra, Bihar, WB, & AP).
• It is expected that in 2045 it may touch 1414.3 million
marks. 40.6 million People are living in urban slums in 607
cities/towns (10th five -year plan).
• Tribal people constitute 8.2% of the country’s total
population. In India women (15-45yrs) and children (<15
yrs) constitute 60% of the total population in India.
• It is said that about 30 million women experience
pregnancy, 27 million have a live birth (MOHFW, 2003).
100,000 maternal deaths and one million newborn deaths
occur annually.
• As on December 2002, the total number of
allopathic doctors registered with the MCI
was 605,800 giving a doctor-population ratio
of 1:1800, which changes to 1:800 after
accounting for registered practitioners of
Indian System of Medicine and Homeopathy
(ISM&H).
• About 74% of doctors live in urban areas,
where only 28% of population resides.
• More than 80 percent of qualified medical
doctors are in private practice and more than
1.25 million untrained, unqualified registered
medical practitioners (RMPs) provide
informal private healthcare mostly in villages
& slums.
• It is estimated that around 7000 NGOs are
involved in health related activities
MILES STONE IN MCH CARE
•1880 – Establishment of Training of Dais in Amritstar
•1902 - 1st Midwifery Act to Promote Safe Delivery
•1930 - Setting Up Of Advisory Committee on Maternal Mortality.
•1946 - Bhore Committee Recommendation on Comprehensive &
Integrated Health
Care
•1952 – Primary Health Center Net Work & Family Planning
Programme
•1956 – MCH Centers Become Integral Part Of PHCS
•1961 - Department Of Family Planning Created
•1971 – MTP Act
•1974 – Family Planning Services Incorporated In MCH Care
•1977 – Renaming Family Planning To Family Welfare
•1978 – Expanded Programme on Immunization
•1985 – Universal Immunization Programme
•1992 – Child Survival& Safe Motherhood Programme
•1996 – Target Free Approach
•1997 – RCH Programme Phase-1 (15.10. 1997)
•2005 – RCH Programme Phase-2 (01-04-2005)
•
The first phase of the programme was
started on 1997 with an aim to bring down
the birth rate below 21 per 1000 population,
to reduce the infant mortality rate below 60
per 1000 live birth and to bring down the
maternal mortality rate <400/1,00,000lakh.
80%% institutional delivery, 100% antenatal
care and 100% immunization of children
were other targeted aims of the RCH
programme.
• The 5 year RCH phase II is being launched in
TamilNadu on 2005 with a vision to bring
about outcomes as envisioned in the
Millennium Development Goals, the National
Population Policy 2000 (NPP 2000), the Tenth
Plan, the National Health Policy 2002 and
Vision 2020 India, minimizing the regional
variations in the areas of RCH and population
stabilization through an integrated, focused,
participatory programme meeting the unmet
needs of the target population, and provision
of assured, equitable, responsive quality
services.
National
Population
Policy
2000 (by
2010)
Millennium
Development
Goals
(B
y 2015)
Tenth Plan
Goals (20022007)
RCH II Goals
(2005-2010)
Population
Growth
16.2% (20012011)
16.2%
(2001-2011)
-
-
Infant
Mortality Rate
45/1000
35/1000
30/1000
-
Under 5
Mortality Rate
-
-
-
Reduce by
2/3rds from
1990 levels
Maternal
Mortality Ratio
200/100,000
150/100,000
100/100,0
00
Reduce by
3/4th from
1990 levels
Total Fertility
Rate
2.3
2.2
2.1
-
Couple
Protection Rate
65%
65%
Meet
100%
needs
-
Indicator
OBJECTIVES OF RCH PHASE-II PROGRAMME:
1.Reduction of Maternal Morbidity And
Mortality
2.Reduction of Infant Morbidity And Mortality
3.Reduction of Under 5 Morbidity And
Mortality
4.Promotion of Adolescent Health
5.Control of Reproductive Tract Infections and
Sexually Transmitted Infections.
Reproductive health can be defined as a state
in which people have the ability to reproduce
and regulate their fertility, women are able to
go through pregnancy and child birth safely,
the outcome of pregnancy is successful in
terms of maternal and infant survival and well
being, and couples are able to have sexual
relations free of the fear of pregnancy and of
contracting diseases.
RCH PACKAGE OF SERVICES
MOTHERS:
1. All pregnancies to be registered by health workers.
2. Pregnant women must be given two doses of tetanus toxoid
immunizations.
3. Pregnant women must be given iron folic acid tablets for prevention
and treatment of anemia.
4. Pregnant women must be given three antenatal checkups, which
include checking their blood pressure and ruling out complications.
5. Deliveries by trained personnel in safe and hygienic surroundings
should be encouraged.
6. Institutional deliveries should be encouraged for women having
complications.
7. Referrals should be made to first referral units for management of
obstetric emergencies.
8. Three postnatal checkups should be given to mothers after the
delivery.
9. Spacing of at least three years between children must be encouraged
CHILDREN
1. Essential newborn care like keeping the baby warm, checking the baby's
weight and giving the baby mother's first milk is important. The
premature babies or low birth weight babies need special care. Babies
with any complications should be refereed to the nearest health center.
2. Exclusive breast-feeding must be encouraged for the first three months.
Weaning or starting the baby on semisolid food should start in the
fourth month.
3. BCG, DPT, Polio and Measles immunizations should be administered to
every child meticulously to prevent death and disabilities.
4. Vitamin A prophylactic for children is necessary to prevent blindness.
5. Parents must be informed about oral rehydration therapy and correct
management of diarrhea. The availability of ORS packets in the villages
should be ensured.
6. Acute respiratory infection in children should be detected early. They can
be treated by cotrimoxazole tablets. Acute cases should be refereed to
health center.
7. Treatment of Anemia.
ELIGIBLE COUPLES
1.Promoting use of contraceptive methods
among eligible couples is important to prevent
unwanted pregnancies. Couples should be
able to choose from various contraceptive
methods including condoms, Oral pills, IUDs,
male and female sterilization.
2. Safe services for medical termination of
pregnancies should be encouraged for women
desiring abortions.
OTHER NEW SERVICES
1. A large number of people suffer in silence due to
reproductive tract infections (RTIs) and sexually
transmitted diseases (STDs). RTIs and STDs can make
people infertile. If a pregnant woman has RTIs or
STDs, it can affect the health of her child. People
suffering from such infections should be referred to
the health center.
2. Adolescents are parents of tomorrow. It is
important to prepare them for the future by
counseling them on family life and reproductive
health. This can be a sensitive topic, as it has not
been addressed before. Therefore, the involvement of
parents, Anganwadi workers, and Mahila Swasthya
Sanghs should be ensured
POOR QUALITY OF MCH SERVICES
•
Limited technical competence of service providers.
•
Lack of public health expert (Diploma in Public Health, M.D Post graduate
in Community Medicine) with epidemiological skills for micro level
planning
•
Non-availability of complementary inputs such as drugs and equipment
•
Poor client - provider interaction due to poor communication skills of
service providers and their deterrent attitude towards the clients.
•
Low motivation levels of staff
•
Staff absenteeism
•
Faulty planning and management skills at the periphery
•
Inflexible programme design
•
Lack of political support to public health
•
Financial constraints
•
Over lapping of activities and wastages of resources in the
implementation of RCH programme
•
There is no vigilance checkup
DISPARITY OF MATERNAL DEATH BETWEEN
DEVELOPED & DEVELOPING COUNTRIES
•Barrier to Receive Timely & Good Quality Care
•Barrier of Availability and Accessibility of Services
•Political Barrier
•Geographical Barrier
•Cultural Barrier
•Women’s Literacy and Women Empowerment
•Time Barrier
• Economic Barrier
•Barrier to have health personnel at grass root level
NEW STRATEGY OF RCH PHASE 
1. To constitute empowered action group
2. Training of dais
3. To conduct RCH camps & organize RCH out
reach scheme
4. Gadchiroli model to take care of home based
neonatal care
5. Kangaroo mother care to take care of low
birth weight infants
6. Border district cluster strategy
7. Integrated management of childhood illness
strategy to take care of sick newborns
8. Training of MBBS doctors in Life saving anesthetic skills for
emergency obstetric care at FRUs.
9.Strengthening of core strategy of the existing PHCs and CHCs, and
provision of 30-50 bedded CHC per lakh population for improved curative
care to a normative standard (Indian Public Health Standards defining
personnel, equipment and management standards)
10.Janani Suraksha Yojna (National Maternity Benefit Scheme) is envisaged
as a package of services, geared at reducing maternal mortality, neonatal
mortality, and female feticide and gender disparity.
11. “Vandematram” scheme-launched on 9th Feb. 2004 in all the districts of
the country with the active collaboration of the professional bodies. The
aim of the scheme is to reduce the maternal mortality and morbidity of the
pregnant and expectant mothers by involving and utilizing the vast
resources of specialists/trained workforce available in the private sector.
12.A new initiative in National Rural Health Mission (2005-2012) is
accountability. Every village/large habitat will have a female Accredited
Social Health Activist (ASHA), accountable to the Panchayat. She will act as
the interface between the community and the public healthcare system.
NEW INITIATIVES IN RCH PHASE-II
MATERNAL HEALTH
•
All Community health centers & 50% of the Primary health centers
are to be made functional for providing 24hrs delivery services.
Primary Health Centers are proposed to be taken up for improving
access to Essential Obstetric and New Born Care services round the
clock.
•
Improving quality of antenatal, neonatal and postnatal care by
providing increased number of antenatal checkups, fixed day
antenatal clinics, linking visits of neonates with postnatal care,
empowering the VHNs in performing obstetric first aid and newborn
care.
•
Improvement of the referral networking systems by establishing
emergency helpline
•
Regular conduct of blood donation camps for the continued
availability of blood in the blood banks.
•
Universalizing the concept of birth companionship during the
process of labour in all health facilities conducting deliveries.
•
Operationalisation of maternal death audit to address the issues that
have led to maternal deaths
INFANT AND CHILD HEALTH
• Reduction of Neo-natal deaths, infant deaths and
child deaths by providing continuous health care and
strengthening of new-born care infrastructure
facilities.
• Organizing counseling sessions for the mothers.
• Implementing integrated management of neonatal
and childhood illness
• Operationalising infant death/stillbirth verbal
autopsy.
• Addressing the issue of female infanticide and
foeticide.
FAMILY WELFARE
1. Higher order births will be targeted for intensified
intervention
2.
Social marketing technique for condom, promotion of IUD
insertions, familiarizing the concept of one-stop Family
Welfare Centre.
3. Increasing access to safe abortion services by
popularizing manual vacuum aspiration (MVA) technique.
4. Establishment of one-stop family welfare services at
Comprehensive Emergency Obstetric and New Born Care
(CEMONC) Centres.
5. Popularizing No Scalpel Vasectomy.
6. Availability of a wide range of contraceptive methods
MCH and other services
7. Accessibility, complete and accurate information
about contraceptive methods, including their health
risks and benefits
8. Safe and affordable services, along with high quality
supplies
9. Well-trained service providers with skills in interpersonal communication and counseling.
10. Appropriate follow-up care
11. Regular monitoring and evaluation of performance
12. A paradigm shift from individualized vertical
interventions to a more holistic and integrated life cycle
approach giving more focused attention to the
reproductive health care.
OTHER INNOVATIVE REFORMS:
1. Improved drug procurement & supply
systems to tackle the problem of inadequate
and irregular supplies
2. Improved supply of cross-matched blood in
first referral units thereby decreasing the
inter-institutional transfers for transfusion
3. Regular conduct of blood donation camps
for the continued availability of blood in the
blood banks.
4. Systematic reporting and auditing of
maternal & infant deaths
5. For monitoring purposes, standardized
systematic reporting of services rendered at
primary care level, using simple, manually
completed, computer readable forms
6. Ensuring block and district level
inter-sectoral coordination for ICDS
7. Improvement of the referral networking systems by establishing
emergency help line
8. Each community health center should have one additional post of
public health manager and public health nurse
9.A co-ordination committee of the professional medical associations viz.
IPHA, IAPSM, &FOGSI to monitor the RCH programme
10.Strengthening of IEC activities.
These activities should cover the following messages:
Ideal age at marriage, Ideal age to have a child, Small family norm,
Avoidance of higher order births, Spacing, Contraceptive acceptance,
Importance of female literacy, Anaemia control, Monitoring the weight
gain of mothers and growth monitoring of babies, Breast feeding and
importance of colostrums, Diarrohoea management, Oral rehydration
therapy, Eradication of female infanticide and foeticide, Upholding the
image of girl child and women, safe delivery, Institutional delivery,
Immunizations and nutrition. Propagation of messages through films,
Video spots, dramas, Street plays and booklets have to be undertaken.
Electronic media such as T.V. and radio have to be utilized. Audio-visual
aids will be provided in medical institutions and publication of booklet on
IEC activities.
PACKAGES OF SERVICES AT FRU
•Vacuum Extractions
•Administration of Anesthesia
•Blood Transfusion
•Caesarean Section
•Manual Removal of Placenta
•Carry out Suction Curettage for
Incomplete Abortion
•Insert Intrauterine Devices
•Sterilization Operation
TYPES OF KIT FOR FIRST REFERAL UNIT
•Kit-E – Laparotomy set
•Kit-F - Mini– Laparotomy set
•Kit-G – IUD insertion set
•Kit-H – Vasectomy set
•Kit- I – Normal delivery set
•Kit- J – Vacuum extraction set
•Kit- k – Embryotomy set
•Kit- L – Uterine evacuation set
•Kit-M – Equipment for anesthesia
•Kit-N- Neonatal resuscitation set
•Kit-O- Equipment and reagent for blood
test
•Kit-P – Donor blood transfusion set
INDICATORS OF MONITORING
&EVALUATION RCH-II PROGRAMME
1.The public health managers have to monitor the
programme.
2.They have to evaluate the effectiveness of the
programme with the following indicators.
ACCESSIBILITY INDICATOR
•No. of eligible couples registered/ANM
•No. of Antenatal Care sessions held as
planned
•% of sub Centers with no ANM
•% of sub Centers with working equipment of
ANC
•% ANM/TBA without requisite skill
•% Sub centers with DDKs
•% of sub centers with infant weighing
machine
•% Sub centers with vaccine supplies
•% Sub centers with ORS packets
•% Sub centers with FP supplies
QUALITY INDICATOR
•% Pregnancy registered before 12 weeks
•% ANC with 5 visits
•% ANC receiving all RCH services
•% High-risk cases referred
•% High-risk cases followed up
•% Deliveries by ANM/TBA
•%PNC with 3 PNC visits
•% PNC receiving all counselling
•% PNC complications referred
•% Eligible couple offered FP choices
•% Women screened for RTI/STDs
•% Eligible couple counselled for prevention
of RTI/STDs
•% ADD given ORS
•% ARI treated
•% Children fully immunized
IMPACT INDICATOR
•% Deaths from maternal causes
•Maternal mortality ratio
•Prevalence of maternal morbidity
•% Low birth weight
•Neo-natal mortality ratio
•Prevalence of postnatal maternal morbidity
•% Baby breast-feeds within 6 hrs of delivery
•Couple protection rate
•Prevalence of terminal method of sterilization
•Prevalence of spacing method
•% Abortion related morbidity
•Prevalence of ADD
•Prevalence of ARI
•Prevalence of RTI/ST
Source
Key Indicators
Total Fertility Rate
3.32 births per women
SRS 1997
Couple Protection Rate
48%
NFHS-2 (1998-99)
Unmet need of family planning
16 %
NFHS-2 (1998-99)
Under 5 Population
10.7%
Census of India, 2001
Females 15-44 yr age Group
22.2%
Census of India, 2001
Female literacy rate (%)
54.3%
Census of India,2001
Average age at first marriage
16.8 years for women age 20-49)
NFHS-2 (1998-99)
Average age at first Birth
19.6 years for women age 25-29
NFHS-2 (1998-99)
Maternal Mortality Rate
407 / 100,000 live births
RGI, 1998
Under 5 Mortality Rate
95 / 1000 live Births
SRS 2000
Infant Mortality rate
63 / 1000 live Births
SRS, 2004
Neonatal mortality rate
4 4/1000 live Births
SRS 2000
Perinatal mortality rate
40 /1000 Births
SRS 2000
Still Birth Rate
8/1000 Births
SRS 2000
Home Deliveries
65.4%
NFHS-2 (1998-99)
Deliveries by Skilled Birth Attendants
42.3%
NFHS-2 (1998-99)
Percentage Received ANC care (at least
1 visit)
65.4 %
NFHS-2 (1998-99)
Percentage received at least 3 visits
43.8 %
NFHS-2 (1998-99)
Received Tetanus Toxoid 2 or more
doses
66.8 %
NFHS-2 (1998-99)
Received IFA for at least 3 months
47.5 %
NFHS-2 (1998-99)
CONCLUSION:
Public health experts should be an essential part of the executive management
team and will have to play a key role in our country by identifying the major
problems in the RCH programme such as the absence of links between communities,
subcentres and referral facilities; shortages of equipment and trained staff at
referral facility; and a lack of emergency transport to adequately meet the needs of
pregnant women particularly for obstetrical emergencies. Allocation of resources
should be linked to states performance as well as to population size. They have to
identify the new indicators for performance, and allocation of resources based on
the felt need of the on priority.
Active participation of Community with involvement and support of women’s
self help groups, village health nurse, anganwadi workers, asha activist etc., will be
very effective in improving women accessibility to different components of RCH
services and increasing sensitivity to women’s needs. The private sectors role in
improving women’s health is very helpful. We have to find out a mechanism to
involve them through appropriate rules &regulations to provide the RCH Phase-II
programme to the community.
World Health Day slogan 2005 “Make Every Mother and Child Count”
reflects that health of women and children should be given higher priority at all
levels of health care system. Every one is accountable for health of mothers &
children. The World Health Day slogan 2006 “Working together for health” reflects
the involvement of health care workers to provide quality health care services to the
community. The fulfillment objective of Phase-II RCH programme is the joint effort
of community and service providers.
THANK YOU