INDIA

Dr. I.Selvaraj

B.Sc., M.B.B.S., D.P.H., D.I.H.,PGCH&FW(NIHFW)

INDIAN RAILWAY MEDICAL SERVICE
Post Graduate student in Community Medicine(M.D)
Department of Community Medicine / SRMC & RI (DU )

MILES STONE IN MCH CARE IN INDIA

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
2005 RCH PROGRAMME PHASE-2

IMR

MMR

%BPL

INDIA

70/1000

408/1LLB

26.1

KERALA

14/1000

87/1LLB

12.72

UP

84/1000

707/1LLB

31.15

BIHAR

63/1000

707/1LLB

42.60

RAJASTHAN

81/1000

607/1LLB

15.28

TN

19. 2/1000

130/1LLB

21.12

SOURCE: NATIONAL HEALTH POLICY 2001

TOTAL
POPULATION(IN
MILLIONS)

846.3(Census 1028.6
1991)
(Census
2001)

SEX RATIOS
(FEMALES/1000)

927 (Census
1991)

933(Census
2001)

CRUDE BIRTH
29.5 (SRS
RATE
1991)
(PER1000POPULA
TION)

25 (SRS
2001)

CRUDE DEATH
RATE(PER1000
POPULATION)

8.1(SRS
2001)

9.8 (SRS
1991)

MAJOR CAUSES OF M.M.R

DIRECT CAUSES

HEMORRHAGE 29.6%
PUERPERAL COMPLICATION 16.1%
OBSTRUCTED LABOUR 9.5%
ABORTIONS 8.9%
TOXAEMIA OF PREGNANCY 8.3%

INDIRECT CAUSES

Anaemia
Pregnancy with TB
Pregnancy with malaria
Pregnancy with viral hepatitis

MMR IN SELECTED COUNTRIES (2000)

COUNTRY

MMR(1L/LB)

INDIA

407

SRI LANKA

92

BANGALADESH

NEPAL

380
740

CHINA

56

JAPAN

10

SINGAPORE
UK

15
14

USA

14

SWITZERLAND

ESTIMATED MMR MAJOR STATES INDIA(2000)

STATES

MMR/1L LB

ANDHRA PRADESH

154

BIHAR

451

GUJARAT

29

KARNATAKA

195

KERALA

195

MADHYA PRADESH

498

RAJASTAN

677

TAMIL NADU

76

UTTAR PRADESH

707

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
WOMENS LITERACY AND WOMEN EMPOWERMENT
TIME BARRIER
ECONOMIC BARRIER
BARRIER TO HAVE HEALTH PERSONNEL AT GRASS
ROOT LEVEL

RCH PROGRAMME
15.10. 1997

Objectives
ReductionofMaternalMorbidityand
Mortality(MMR)
ReductionofInfantMorbidityand
Mortality(IMR)
ReductionofUnder5Morbidityand
Mortality(U5MR)
Promotionofadolescenthealth
Controlofreproductivetractinfections
andsexuallytransmittedinfections.

 The first phase of the programme had

started from 1997
To bring down the birth rate below 21
per 1000 population
To reduce the infant mortality rate
below 60 per 1000 life born
To bring down the maternal mortality
rate below 400 per one lakh.
Eighty per cent institutional delivery,
100 per cent antenatal care
and 100 per cent immunization of
children

Vertical Programmes

Integrated Service Delivery

Camp Oriented

Client Oriented

Target Oriented

Goal Oriented

Quantity Oriented

Quality Oriented

Camp Oriented

Sterilization
Camps

IUD Camps

Immunisation
Camps

Client Oriented

Full Range of RCH

Services
Need Based

Target Oriented

Goal Oriented

Performance by

Performance by
Quality

Numbers
Top Down
Target Driven
To the Govt. System

Bottom up
Client Need Based
Community
Participation
To the Clients,
Community

Safe Motherhood Services

- Essential Care for All
- Early Identification of Complications
- Emergency Services those who are in need

Child Survival
Services

Family Welfare
- Increased access to
Contraceptives
- Safe Abortion
Services

Healthy
Mother
&
Child

Prevention and
Management of
RTI /STI

Adolescent Health Care and

Family Life Education

COMPONENTS OF RCH PROGRAMME

Prevention and management of unwanted
pregnancy
Maternal care that includes antenatal, delivery, and
postpartum services
Child survival services for newborns and infants
Management of reproductive tract infections and
sexually transmitted infections

REPRODUCTIVE HEALTH ELEMENTS

Responsible and healthy sexual behaviour

Intervention to promote safe motherhood
Prevention of unwanted pregnancy
To increase accessibility of contraceptives
Safe abortions
Pregnancy and delivery services
Management of RTI/STD
Referral facility by government/private
sector for pregnant women at risk
Reproductive health services for
adolescents
Screening and treatment of infertility,
cancer & other gynecological disorders

CHILD SURVIVAL ELEMENTS

Essential New Born Care
Prevention and management of vaccine
preventable disease
Urban measles campaign
Neonatal tetanus elimination
Surveillance of vaccine preventable diseases
Cold chain system
Polio eradication : pulse polio programme
ARI control programme
Diarrhea control programme and ORS programme
Prevention and control of Vitamin A deficiency
among children
Baby Friendly Hospital Initiative (BFHI)

STRATEGY
BOTTOM-UP PLANNING
COMMUNITY NEED ASSESSMENT
APPROACH
DECENTRALISED PARTICIPATORY
PLANNING & IMPLEMENTATION
STRENGTHENING INFRASTUCTURE
INTEGRATED TRAINING PACKAGE
IMPROVED MANAGEMENT SYSTEM
INTERVENTIONS
MONITORING & EVALUATION

ANTE NATAL CARE

Early registration of pregnancies (12 16 weeks)
Minimum 3 antenatal visits (20,32,36 weeks) checkups
Anaemia prophylaxis ( Iron and Folic acid tablets)
Two doses of TT
Minimum investigations( Weight, B.P,Blood group, Rh
typing, Urine examination,VDRL,HIV (TRIDOT TEST)
Identification of high risk group, Early detection of
complication of pregnancy & timely , safely referral
to FRU
Treatment of worm infestation with Mebendazole
Health education on diet, breast feeding, care of
breast, personnel hygiene during pregnancy,& family
planning

COMPLICATIONS DURING ANTE-NATAL, INTRA NATAL, AND POST

NATAL PERIOD & WHERE TO REFER
AVERAGE TIME
INSTITUTION TO
FROM ONSET TO
WHICH TO BE
COMPLICATIONS
DEATH
REFRRED

1.APH
2.PPH

12 HRS
2 HRS

FIRST LEVEL
REFERAL CENTER

SEVERE
TOXAEMIA

2 DAYS

PHC/CHC

RUPTURED
UTERUS

24 HRS

FLRC

OBSTRUCTED
LABOUR

3 DAYS

FLRC

SEPSIS ( AFTER
ABORTION,
DELIVERY)

6 DAYS

PHC/ CHC/FLRC

SEVERE ANAEMIA
( CHF IN LABOUR)

2 HRS TO 1 DAY

FLRC

PACKAGES OF SERVICES AT FRU

VACCUM EXTRACTIONS
ADMINISTRATION OF ANAESTHESIA
BLOOD TRANSFUSION
CASEAREAN SECTION
MANUAL REMOVAL OF PLACENTA
CARRY OUT SUCTION CURETTAGE FOR INCOMPLETE
ABORTION
INSERTION OF INTRAUTERINE DEVICES
STERILIZATION OPERATION

TYPES OF KIT for FRU

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

INTRANATAL CARE
Delivery by trained personnel
(100%)
Institutional delivery (80%)
Care at birth ( Five cleans:
Clean Birth Canal,Clean surface
for delivery,Clean Hands,Clean
Cutting, & Clean Cord)

POST NATAL CARE

3 post natal check-ups of mothers after
delivery
Breast feeding early & exclusive breast
feeding
Spacing minimum 3 years between two
pregnancies

NEW STRATEGY
EMPOWERED ACTION GROUP HAS BEEN
CONSITUTED ON 20.03.2001
TRAINING OF DAIS IN 156 DISTRICTS 18 STATES/UTs
2001-2002
RCH CAMPS & RCH OUT REACH SCHEME
GADCHIROLI MODEL TO TAKE CARE OF HOME
BASED NEONATEL CARE IN 2002
KANGAROO MOTHER CARE TO TAKE CARE OF LOW
BIRTH WEIGHT INFANTS
BORDER DISTRICT CLUSTER STRATEGY 49
DISTRICTS/17 STATES
INTEGRATED MANAGEMENT OF CHILDHOOD
ILLNESS STRATEGY TO TAKE CARE OF SICK
NEWBORNS

STEPS TO REDUCE MATERNAL

MORTALITY
HEALTH SECTOR ACTIONS
Basic antenatal , intra natal &post natal care.
skilled attendants @ every birth.
EOC & Comprehensive obstetric care.
Prevention of unwanted pregnancy &unsafe
abortions.
Joint consultations -medical disorders.
Maternal mortality audit .

STEPS TO REDUCE
COMMUNITY , SOCIETY & FAMILY ACTIONS .
HEALTH PLANNERS /POLICY MAKERS ACTIONS
community education ,motivation.

Strengthen referral system.

management protocols for obstetric
emergencies.
CME Improve quality & standard of care.
Maternal mortality audit .

STEPS TO REDUCE
LEGISLATIVE & POLICY ACTIONS
Girl children & adolescents :
nutrition , cducation ,economic opportunities.
Remove barriers to access health care.
Cost
Socio cultural factors
Safe abortions & post abortion care -MVA
Remove social inequalities- gender , age
marital status.

ACHIVEMENT OF H & FW INDICATORS IN

TAMILNADU( 1997-2002)

LIFE EXPECTANCY AT BIRTH 65

CRUDE BIRTH RATE
19.2
CRUDE DEATH RATE 7.9
NATURAL GROWTH RATE 1.1
INFANT MORTALITY RATE 51
UNDER FIVE MORTALITY RATE 15.1( R )9.7( U )
MATERNAL MORTALITY RATE 1.3
TOTAL FERTILITY RATE 1.95
COUPLE PROTECTION RATE 51.6
MEAN AGE AT MARRIAGE 21.2
ANTE NATAL CARE 98.5%
POST NATAL CARE 90%
INSTITUTIONAL DELIVERY 87.6%
DELIVERY BY TRAINED STAFF 98%
PNMR 43/1000
NNMR 38/1000
% OF LOW BIRTH WEIGHT BABIES 17%
AVERAGE BIRTH WEIGHT OF BABIES 2.7 KG
STILL BIRTH RATE 11.7/1000
IMMUNIZATION COVERAGE 100%

World Health Day 2005 Slogan

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

RCH - II PROGRAMME
01-04-2005

THE 5 YEAR PHASE OF RCH II

VISION

To bring about outcomes as

envisioned in the

1. Millennium Development Goals

2. The National Population Policy 2000
(NPP 2000)Goals
3. The Tenth Plan Goals
4. The National Health Policy 2002
5. and Vision 2020 India

1728 - FRU

PHC-22928
SUB CENTER38044

1. MATERNAL HEALTH
a) 260PrimaryHealthCentresareproposedtobetakenupfor
improvingaccesstoEssentialObstetricandNewBornCare
servicesroundtheclockinTN.AllCHC,&50%PHCstobe
madefunctionalfor24hrsdeliveryservices,&2000FRUare
proposed
b)Improvingqualityofantenatal,neonatalandpostnatalcare
byprovidingincreasednumberofantenatalcheckups,fixed
dayantenatalclinics,linkingvisitsofneonateswith
postnatalcare,empoweringtheVHNsinperforming
obstetricfirstaidandnewborncare.
c)Improvementofthereferralnetworkingsystemsby
establishingemergencyhelpline.
d)Regularconductofblooddonationcampsforthecontinued
availabilityofbloodinthebloodbanks.
e)Universalizingtheconceptofbirthcompanionshipduringthe
processoflabourinallhealthfacilitiesconductingdeliveries.
f)Operationalisationofmaternaldeathaudittoaddressthe

INFANT AND CHILD HEALTH

a.Reduction of new-born deaths, infant deaths
and child deaths by providing continuous health
care and strengthening of new-born care
infrastructure facilities.
b. Organizing counselling sessions for the
mothers.
c. Implementing integrated management of
neonatal and childhood illness as a pilot initiative
in selected districts in Tamil Nadu.
d. Operationalising infant death/stillbirth verbal
autopsy.
e. Addressing the issue of female infanticide and
foeticide.

3. ADOLESCENT HEALTH.
a)Focusing adolescents as receivers and
providers of knowledge and function as link
volunteers in the community.
b) Utilising the services of trained adolescents
for propagating Indian System of Medicines.
c) Broadcasting and Telecasting of
programme by AIR/TV focusing adolescent,
gender and health related subjects.
d) Formation of co-ordination committee at
the district level and monitoring committee at
the State level for overseeing the AIR/TV
programme.

FAMILY WELFARE
a)While sustaining the ongoing family welfare
interventions in all districts, 19 districts with Higher
order births will be targeted for intensified
interventions.
b) Social marketing programme for condom and other
health commodities, promotion of IUD insertions,
familiarizing the concept of one-stop Family Welfare
Centre.
c) Increasing access to safe abortion services by
popularising manual vacuum aspiration (MVA)
technique.
d) Establishment of one-stop family welfare services at
Comprehensive Emergency Obstetric and New Born
Care (CEMONC) Centres.
e) Popularizing No Scalpel Vasectomy.

5. Reproductive tract infections / Sexually

transmitted infections / Cancer control.
a)Establishment of Reproductive Tract
Infection / Sexually Transmitted Infection,
early Cancer detection clinics .
b) Strengthening RCH outreach services.
c) RTI/STD clinic in selected 70 primary
health centers

Infrastructure strengthening for service

delivery
a) Construction of HSC buildings where HSCs are
currently functioning in rented premises
b) Rebuilding HSCs which are unfit for occupation.
c) Taking up of repairs/renovation and provision of
water supply/electrical works to PHCs/HSCs.
d) Need-based supply of equipment/furniture to the
HSCs and PHCs as per the standard list including gas
connections.
e) Provision of Cell phones to HSCs where large
number of deliveries take place.
f) Provision of telephones to PHCs

TRAINING
a) Skill upgradation training with focus
on improving/upgrading the skills of
health care providers.
b) Integrated skill training for peripheral
health functionaries such as VHNs, SHNs,
medical officers and health inspectors.
c) Improving managerial and
communication skills of health staff.

BEHAVIOURAL CHANGE COMMUNICATION

(BCC)
a) Social mobilisation activity against female
infanticide and foeticide by preventive
counselling.
b) Formation of HSC, Block, District level
committees for saving female babies.
c) Conducting of Kalaipayanam (travelling
street theatre) to promote social mobilization
and to improve health care among the target
population
d) Telecasting of TV serials, Radio broadcasts,
wall paintings, hoardings and glow signs for
popularizing health and reproductive health
messages in important places.

HEALTH MANAGEMENT INFORMATION SYSTEMS

IntroductionofIT-enabledHMISforplanningand
monitoringhealthservicesattheState/District/Block
levels
STRENGTHENING OF TEACHING INSTITUTIONS
Strengtheningthefacilitiesatteachinginstitutionsfor
providingoptimumobstetric,familywelfare,neonatal
childhealthservices.
ESTABLISHING URBAN HEALTH POSTS
Toprovideanintegratedandsustainablesystemfor
primaryhealthcareservicedeliverycateringtothe
requirementsofurbanslumpopulationandother
vulnerablegroups

HEALTH FINANCING
The health care expenditure in India
currently stands at 6.1% of GDP. The
private out of pocket expenditure
being 4.7% of Gross Domestic
Product (GDP). The total government
expenditure on family welfare has
shown an increasing trend from 4.9
billion in fifth plan (1974-79) to Rs.
271.25 billion in the tenth plan
(2002-07)

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
% subcenters 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 POST NATAL MATERNAL MORBIDITY
% BABY BREAST FEED 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/STDs

THANK YOU