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

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41,4

86

38,5

85

33,7

79

33,7

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23,9

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21,6

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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…