Scaling up newborn programming in India: agenda setting, policy formulation and implementation

Session 3B Wednesday 17th April 2013

Dr. Rakesh Kumar Joint Secretary Ministry of Health and Family Welfare Government of India

Outline of presentation Trends, rate of decline of mortality Magnitude, diversity, inequity Milestones for agenda setting Strategic approaches

Recent policy decisions

Trends in Child, Infant and Neonatal Mortality Rates

80
Deaths per 1000 live births

74
U5MR IMR

NMR, IMR, U-5MR trend, India (SRS data) 69 64

70 60 50

58

58

57

55

59 53 50 47 33

55 44 31

NMR

40
30 20

37
ENMR

37

37

36

35

34

26

28

28

29

27

27

25

2004

2005

2006

2007

2008

2009

2010

2011

24

Steady decline seen in U-5MR (74 to 55 in 6 yrs) and IMR (58 to 44 in 8 yrs) Decline in neonatal mortality has been disproportionately slow Little change in the Early Neonatal Mortality Rate Neonatal Mortality now constitutes 56% of the total U-5 mortality and an estimated 820,000 of the 1.45 million under-5 deaths annually (SRS 2011) 77% of neonatal deaths take place in first week of life.

Annual Rate of decline in Under Five & Neonatal Mortality Rates

-9.1

2001

2002
-7.5

% annualchange over previous year in U5MR % average annual change over previous year inNMR
STAGNANT

2003 2004 2005 2006

-2.7 0 0 0

National Rural Health Mission in 2005-06 Major Health Systems Strengthening

2007 2009 2010 2011

A 6% decline noted for the first time during this phase of NRHM

-7.2 -7.8
-6.8
-10 -8
-6.1

-2.9 -2.9

-6

-4

-2

India: Challenges-Magnitude, Diversity, Inequity

Demographic: 1.2 bn people, 26 m birth cohort Geographical: 35 States/UTs, 640 districts, 6000 blocks, 600,000 villages Infrastructure: 0.15 m Sub centers, 24000 PHCs, 4400 CHCs, 640 District hospitals Health Workforce: 0.86 m ASHAs, 0.17 m ANMs Inequities: Urban-rural, socio-cultural, economic, religious, castes & tribes, gender, regional disparities
80
Deaths per 1000 live births

70 60 50 40 30 20 10 0
27 25 49 44

Urban- rural disparity (NMR)

Rural Urban
44 41 41 41 41 40 39

38

36

34

24

22

24

23

23

22

21

21

19

17

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Inter-state disparities
Kerala Tamil Nadu Maharashtra Delhi 7 15
Neonatal Mortality Rate Districts with minimum NMR

Intra-state disparities
STATE , RANGE ASSAM 20 BIHAR 26 Districts with maximum NMR

18 18

Kamrup (30)
Patna (22)

Dhubri (50)
Khagaria (48) Panna (66)

Rajasthan Uttar Pr. Odisha Madhya Pr. 0 10 20 30

37

40 40 41 50

Bhopal (28) Anugul (31)

MADHYA PRADESH 38 ODISHA 44

40

Bolangir (75)

Coverage of key interventions across life stages

Adolescence Girls marrying below 18 years (DLHS) Any modern method for family planning (DLHS) Mothers who had full antenatal check-up

43.4 47.3 26.5 68.7 72.9 76.2

Pre-preg Pregnancy

Mothers who had three or more ANC Institutional Delivery Skilled birth attendance (CES 2009)

Delivery
Postnatal

Early initiation of breast feeding (<1 hour)

Post Natal visit to mothers within 2 weeks Postnatal 3 checkups for newborns within 10 days Exclusive breastfeeding

33.5
60.1 45.4 36.8 62.6 61 74

Neonatal

Complementary Feeding (6-9 months) Full Immunization Children received measles vaccine

Vit. A Supplementation (1st Dose )

64
53.6
0 10 20 30 40 50 60 70 80 90

Infancy

ORT or Increased fluid in Diarrhoea

Data source: CES 2009;DLHS 3

Agenda setting: Key milestones

Child Survival Call to Action: A Promise Renewed, held in Washington (June 2012), co-hosted by Govts. of USA, Ethiopia & India RMNCH+A Coalition Govt led multi-stakeholder platform on lines of Global PMNCH Indias Call to Action: Child Survival and Development held in Mahabalipuram (February 2013) Launch of RMNCH+A Strategic Approach Commitments from all partners, constituencies and stakeholders Differential planning and implementation for High Priority Districts Guidelines developed for intensification of RMNCH+A interventions in these districts

Developmental Partner harmonization Plan of Action developed

Strategic approaches defined State-specific annual targets for accelerated decline in mortality

Strategic Approach 1: RMNCH+ A and Identification of Programme Drivers..

Inter-linkages between different interventions at

various stages of the life cycle

Linking child survival to other interventions such as reproductive health, family planning, maternal, newborn and child health Sharper focus on adolescents

STRATEGIC APPROACH TO RMNCH+A

Recognizing nurses as pivots for service delivery

Expanding focus on child development and quality of life

SKILLED HUMAN RESOURCES

INTERVAL IUCD AT SUBCENTRE

MCH WINGS

DELIVERY POINTS

SNCU, NBSU, NBCC

DISTRIBUTION OF CONTRACEPTIVES BY ASHA

JSY & JSSK

PATIENT TRANSPORT

COMMUNITY PROCESSES

VHND, VHSNC

WIFS

BCC

UIP

IYCF

ORS+ ZINC

PROGRAM MGT UNITS

PHYSICAL INFRASTRUCTURE

MCTS

SBA

HBNC

ADOLESCENT HEALTH SERVICES

IMNCI

PPIUCD

DRUGS + DIAGNOSTIC EQUIPMENT

Strategic Approach 2: Ensuring availability of Newborn Care at all levels

Sick Newborn Care Units
at District Hospitals and tertiary health facilities

Free healthcare at Public Health facilities (JSSK) Sick Newborns After Discharge

Newborn Stabilisation Units at FRUs; 4 bedded units Facility Based Newborn Care for sick newborn

ENC to all newborns by Accredited Social Health Activist (ASHA) 6 visits in first 42 days of life (7 visits for home delivery) Incentives to ASHAs @ 4.5 USD per newborn

Home Based Newborn Care

Sick Newborns

Newborn care Corners (NBCC) at all Delivery Points Equipped for resuscitation with trained Essential personnel Newborn Care &

Healthy Newborns

resuscitation

Strategic Approach 3: Health System Strengthening

415 MCH wings adding up 25,000 more beds [660 million USD planned in 2012-13] 16,800 Delivery points 418 Special Newborn Care Units; 1554 Newborn Stabilization Units and 13,167 Newborn Care Corners Assured Referral transport (National Ambulance Service) Augmentation of HRH Institutional delivery cash assistance scheme or Janani Suraksha Yojana (JSY) [324 million USD for 2012-13] Free assured healthcare services and referral transport for pregnant women and infant at public health facilities (Janani Shishu Suraksha Karyakram) [491 million USD allocated in 2012-13]

Strategic Approach 5: Financial Investment in Public Health Systems since 2005-06

3000

2760 2393

2500

2132
2000

1789 1582

1500

1073
1000

824

Total central funding of 13 billion USD (till 2012-13) to States under NRHM, that has special focus on MNCH

500

0 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12

Strategic Approach 4: Reaching areas & populations with highest mortality burden
Ambitious targets setting for all the states with higher percentage annual rate of decline in NMR, IMR, U5MR, MMR and TFR. MoU signed with the state Governments for accelerated and sustained improvements in Health indicators 184 High Priority Districts (HPDs) of 640 districts identified based on composite health index
differential planning & implementation, focus on underserved blocks/tribal areas, 30% more allocation of funds

Integrated Action Plan - Additional central assistance scheme for tribal and backward districts, addressing social determinants of health.

Harmonisation of techno-managerial support for integrated RMNCH+A planning, implementation & monitoring through Development Partners (includes UN agencies, foundations, bilaterals, CSOs) across HPDs

Strategic Approach 6: Robust Health Information Systems

MCTS

Web-based Mother and Child Tracking System

Monitoring

HMIS

Web-based Health Management Information System

Score card

Survey based Score cards and HMIS based Dashboard

SNCU Online

Online monitoring software for Special Newborn Care Units

Recent Policy Decisions

1. Child Screening & Early Intervention Services (Rashtriya Bal Swasthya Karyakram) Systemic approach for early identification of 4Ds: Defects at birth, Deficiency, Diseases and Disability in children 0-18 years (270 million, when scheme fully implemented) of which 26 million will be newborns

Referral
Newborn screening at public health facilities Mobile Teams Screening by ASHAs as HBNC Early Intervention Centre at District hospital for further assessment and act as a referral linkage to appropriate health facility

Free of cost services including surgical interventions at preidentified tertiary level institutions

Screening

Management

Recent Policy Decisions..

2. JSSK : Free entitlements for treatment of all infants in public health facilities

3. National Iron + initiative and WIFS covering 130 adolescents in India

4. Financial incentives to ASHAs for promoting delay in first pregnancy and

spacing and terminal methods and promotion of PPIUCD spacing methods

5. Technical Group agreed for administration of pre-referral injectable antibiotics in

neonatal sepsis and Pneumonia management by ANMs

A glimpse of new born care facilities and infrastructure in Public Health System
Newborn Stabilization Unit SNCU at district level

Newborn transport

Basic Ambulance for PW

Emergency transport vehicle