STATUS OF MATERNAL AND CHILD HEALTH SERVICES IN INDIA

UNIT 6 STATUS OF MATERNAL AND CHILD HEALTH SERVICES IN INDIA Status of Maternal and Child Health Services in India Structure: 6.0 Objectives 6.1 Introduction 6.2 Genesis and Evolution of Maternal and Child Health (MCH) Services in India 6.2.1 Genesis 6.2.2 Policies and Strategies During Different Plan Periods 6.2.3 Progress and Achievements 6.3 Organisation of MCH Services 6.3.1 Rural Areas 6.3.2 Urban Areas 6.4 Recent Strategies in Reproductive and Child Health (RCH) 6.4.1 Rural Health Infrastructure Norms and Achievements 6.4.2 Current Status of Rural Health Infrastructure 6.4.3 Current Status of MCH Indicators at National Level 6.5 Let Us Sum Up 6.6 Key Words 6.7 Answers to Check Your Progress 6.0 OBJECTIVES After completing this unit, you will be able to: explain the genesis of MCH care in India; enlist the achievements of MCH services, in terms of infrastructure strengthening, performance and impact made so far; describe the present organizational structure of MCH service system in rural and urban areas; enlist the target beneficiaries and various components of services of the RCH programme; enumerate the new dimensions of the operational strategies of RCH care; and draw an outline of current status of the MCH indicators and future targets, if any. 6.1 INTRODUCTION You are aware that maternal and child health (MCH) care services are available at all the rural primary health care institutions across the country. You also know that most of the Govt. health care institutions and organizations in the cities and other urban areas also provide some or other MCH care services to variable extent. The rural institutions include Community Health Centre (CHC), Primary Health Centre (PHC) and Sub-centres (SCs). Similarly, urban institutions include district and sub-divisional hospitals, corporation or municipality health services. Besides these, people, mostly in urban areas, seek MCH care from NGOs and private medical practitioners also. In this unit, you will learn about evolution of clinic based approach for family planning to a comprehensive RCH approach through different five year plan periods. You will also learn 5

Maternal and Child Health Services about expansion of rural health infrastructure as a part of nation's commitment to Health For All by 2000 A.D. through primary Health Care. This unit also details the development of health services in the urban areas under various programmes and scheme. Finally, you will learn about current status of MCH services, norms and achievements and MCH indicators at the national level. 6.2 GENESIS AND EVOLUTION OF MATERNAL AND CHILD HEALTH (MCH) SERVICES IN INDIA 6.2.1 Genesis After independence of the country, Shri Jawaharlal Nehru, the first Prime Minister of India laid tremendous emphasis on child health. Nehruji stressed that the child health and welfare scheme should be given the first priority in national development plan. He stated, "if we do not look after the children today, we will be creating many more problems for ourselves in the future". With the establishment of planning commission in 1950 under the chairmanship of Pandit Nehru, the five-year plans were formulated. Among the strategies of national development, foremost interest was focussed on the young children. It was recorded in the 1st five year plan that nearly 40% of the total deaths occur among children under 10 years of age. Moreover, high maternal mortality and poor health status of women were also major concern. Through the first five-year plan, establishment of P.H.Cs and MCH centres were emphasized for the promotion of child health. Thereafter, in the successive plans also, greater stress were laid for strengthening the mother and child health services. This special emphasis on the programme for children were strengthened, broadened and made more comprehensive in the successive plans. 6.2.2 Policies and Strategies During Different Plan Periods In the pre independence era, few significant events like, training of Dais scheme (1880) in Amritsar, first midwifery act in London in 1902 to promote safe delivery, review of causes of maternal deaths & action plan recommended by an advisory committee on maternal mortality in India (193 1932) etc, mark the initial initiatives for MCH services in India. Following independence, health service development took place on the basis of the recommendations of successive planning committees (viz. Bhore committee, Mudaliar committee etc.) and the 5-year national plans. The terms of reference for review and recommendation of the health committees and 5 years national health plans always included, besides other things, health services for mothers and children and population control. There had been adequate emphasis on maternal and child health care services inclusive of family planning over the successive plan periods. In 1952, India was the first country in the world to launch National Family Planning Programme emphazising family planning as an urgent necessity to reducing birth rate and to stabilise the population at a level consistent with the requirement of national economy. The family planning programme thus started in the first five year plan (1951-1956) on demographic and economic considerations, since it was realised that although the country has been making some progress in the fields of education, health, economy, communication and social welfare, the fruits of this progress has not been percolated down to the masses because of simultaneous increase of population. During the first five-year plan, the approach of family planning programme was training and research oriented and not much achieved during this period. 6 During the 2nd five year plan, the service approach was introduced and family planning centres were opened. Realising that the people are not utilising expected advantages of these services, the approach was changed to extension education during the 3rd five year plan.

By 1974, in a very sound conceptual move, family planning services were incorporated with MCH care. The programme was re-named as Family Welfare Programme. The rationality of this change was the understanding that reduction in birth rate has direct relationship with reducing infant mortality. Status of Maternal and Child Health Services in India Thus, since the 7th plan, implemented during 1984 1989, family planning programme was evolved with the focus on health needs of women of reproductive age and children below the age of 5 years in one hand and provision of contraceptives and sterilisation services to the desirous people on the other. But in the field level and in practical terms, it simply shifted the focus of MCH care to centrally driven,target oriented family planning programme with major emphasis on sterilisation. Thereafter, in order to reduce morbidity and mortality of infants and young children due to few vaccine preventable diseases, the Universal Immunisation Programme was started during 1985 1986. In view of the fact that diarrhoea was a leading cause of death among children, the Oral Rehydration Therapy (ORT) programme was also started during the seventh plan. Thereafter, the ARI control programme was also started to reduce the deaths due to pneumonia in children. To overcome the constrains of managing multiple health interventions directed towards mothers and children, all these programmes were integrated under child survival and safe motherhood (CSSM) programme, which was implemented from 1982. The Family Welfare programme received set back due to overemphasis on sterilisation and also subsequently due to target oriented approach. Keeping in view these shortcomings, from first April 1996, the family welfare programme is being implemented on the basis of "target free approach". A decentralised participatory planning approach has been introduced. The process of integration, which was initiated with the CSSM programme, has taken further step in 1994, when the International Conference on Population and Development held in Cairo recommended that the participant countries should implement unified programme on reproduction and child health. Since October 1997, the family welfare programme has been re-oriented, re-named and focussed to provide an integrated package of women and child health services. This new programme is known as Reproductive and Child Health (RCH) Programme. 6.2.3 Progress and Achievements Over the last 50 years, efforts were made to build up the essential primary health care infrastructure and skilled manpower with increasing funds, provided under National Health and Family Welfare programme and others like Minimum needs programme, 20 point programme etc. As a result, a vast network of primary health care institutions have been built in the rural areas, supported by Secondary and Tertiary level institutions in urban areas at districts, subdivisions and cities. The state govt. supported for health manpowers in these institutions. The govt. of India also provided additional manpowers to improve the outreach of family welfare services and funds for essential drugs, vaccines and contraceptives. All these initiatives have improved the outreach and performance of family welfare programme. The technological advances, improved quality and coverage of health care resulted in rapid fall of Crude Death Rate from 25.1 (1951) to 9.8 (1991). The reduction of Crude Birth Rate (CBR) has been comparatively less and declined from 40.8 (1951) to 29.5 (1991). As a result, Annual Exponential Population growth has been over 2% during the period 1961 to 1991. During the eighth-plan period (1991-1996) the Annual Growth Rate declined to 1.9%. There was spectacular achievement in reduction of IMR (148 in 1951) to 80/1000 live births (SRS 1991). But decline in maternal mortality rate was negligible. The performance of MCH services has been remarkable. Registration of pregnant women has increased to 65%. The coverage of TT immunization and supplementation of folifar tablet has also increased to 67% and 58% respectively. Institutional delivery also showed gradually increasing trend. 7

Maternal and Child Health Services The child survival initiatives like UIP, ORT and control of ARI and vit. A supplementation etc. have all helped to reduce the infant and child mortality. The eradication of polio is also within reach. Check Your Progress 1 1) Mention five important milestones of development of MCH services in India. 2) State the achievements and short falls of MCH services. 6.3 ORGANISATION OF MCH SERVICES 6.3.1 Rural Areas The Health Survey and Development Committee (Bhore committee) recommended the establishment of a network of Sub Centres Primary Health Centres and district health organizations for an integrated, preventive promotive and curative health care. One PHC was set up in each block for a population of 80,000 to 1,20,000. On an average 6 sub centres were set up under each PHC. One of the important functions of the Primary Health Centre was to provide maternal and child health services including family planning under its jurisdiction. Later on, the PHCs have undergone substantial expansion. In order to implement Primary Health Care as envisaged in ALMA ATA conference in 1978 for achieving HFA by 2000 AD and as per recommendations of rural health scheme 1977 as well as and National Health Policy 1983, the three tier primary health care institutions were established. These include: a) One primary health centre for 30,000 population in plain areas (20,000 for hilly, tribal and backward areas). b) One sub-centre for 5,000 population (3000 population for hilly, tribal and backward areas). c) One trained Dai and one Village Health Guide for each village. Primary Health Centre (PHC) The maternal and child health care activities in PHC include: a) Planning, organization and co ordination of MCH services through the sub centres. b) Supportive supervision of MCH activities of the health workers in sub-centre areas. c) Plan, organize and supply vaccines and equipment for immunization sessions at sub centres. d) Arrange training and monthly meeting for the staff of MCH services. 8 e) Collect and compile performance reports of sub centres.

f) Undertake sterilization, other family planning measures, supervise and support the sub centre staff. Status of Maternal and Child Health Services in India g) Conduct antenatal services referred from sub centre and undertake institutional deliveries. h) Mobilize community leaders, conduct meeting and co-ordinate with other sectors like BDO, panchayat, ICDS etc. i) Support of logistics for the sub centres, health assistant, VHGs and trained Dais. Sub-centre Each sub-centre serves five thousand populations through one Health Worker (Male and Female). One Health Assistant (Male and Female) supervises the activities of six such subcentres. The MCH activities at sub-centre level include: a) Listing of eligible couples. b) Registration of pregnant women. d) Antenatal care including folifer supplementation and TT immunization. e) Immunize children against 6 VPDs and Vit. A supplementation. f) Monitor deliveries of trained Dais and conduct deliveries at the sub-centres. g) Provide postnatal care and care of new born. h) Manage anaemia, diarrhoea and pneumonia in children i) Conduct health and nutrition education, health education. j) Family planning. k) Maintain records. l) Training of Dais etc. m) Support work of Village Health Guide and Anganwadi Worker. At Village Level Trained Dai At each village, at least one-trained Dai is the key functionary to carryout MCH activities. These include motivating pregnant women for registration, conduct safe delivery, refer cases with complications, and motivate for family planning measures. She is trained at PHC and one disposable delivery kit (DDK) is supplied to her from CSSM programme. Village Health Guide The Village Health Guide also performs certain family welfare related activities by motivating couples for contraception and immunization of children etc. The AWW, a village level functionary of ICDS programme looks after child health and nutrition, health check up, non-formal pre school education, health and nutrition education for women of reproductive age. Community Health Centre The Community Health Centre (CHC) in established one in each community development block, it considered as the first referral unit (FRUs) to support the activities of all the PHCs of the block. On population norm, one CHC was considered to be developed for one Lac population. Besides family welfare and public health activities, the CHC provides the specialist curative services also. In the CSSM programme, the CHCs were considered to act as an FRU and provide emergency obstetric and emergency paediatric care. However as the requisite number of specialists was not available for posting to these CHCs, it has been decided to have at least 2-4 FRUs in each district, which may be at CHCs or sub-divisional Hospitals. 9

Maternal and Child Health Services 6.3.2 Urban Areas The urban health organizations, which provide MCH services, are diverse in nature and different from those at rural areas. a) Unlike rural areas, the so-called Primary Health Care infrastructure and organizational design does not exist in urban areas. b) Multiple agencies provide MCH services to variable extent without geographical area demarcation. c) Expertise, quality and nature of care provided by the institutions in cities, corporation areas, municipal towns, districts and subdivisions are also variable. d) The systems of services include Govt. organisations, NGOs and private organisations. Government Health Organisations a) Govt. Hospitals These include institutions for secondary (District and sub divisional) and tertiary (Medical Colleges, state general and specialist hospitals) level of health care. The Obstetric and paediatric care provided are predominantly curative oriented, clinic based or inpatient. Preventive and promotive services like child immunization etc. also do exist. There is no provision of outreach service for MCH care. b) District Family Welfare (DFW) Centre As an integral part of district health organization the DFW unit acts as the central point for organising, planning, supply, monitoring, training and record keeping etc. of all the peripheral health care units performing MCH services. c) Municipal Corporation, Municipalities and Other Civic Bodies These organizations undertake: MCH care activities through health centre, dispensaries and outreach services by its field staff. Institutional care is relatively less often. d) Schemes and Services Besides these, the urban ICDS scheme, Urban Basic Services for the poor, Urban Family Welfare Centres, India Population Project (IPP) etc. serve predominantly in the urban slum areas. Along with other activities, MCH services are considered to be the major responsibility of most of these organizations. These organizations undertake MCH activities in geographically marked identified service areas, by different categories of functionaries by both clinic and out reach approaches. e) Health Posts Based on the recommendations of Urban Revamping Scheme (Krishnan committee), four types of health posts have been set up according to population size of urban areas and slum dwellers. These health posts provide MCH services along with other primary health care functions. NGOs and Private Health Organisations Several voluntary health and welfare organizations, private hospitals, nursing homes, clinics and private practitioners also provide MCH services according to the expertise and facilities available. The activities are mostly restricted to care during illness of children, obstetric care and child immunization services. 10

Check Your Progress 2 1) Write down the names of the rural health institutions providing MCH services. Status of Maternal and Child Health Services in India 2) List the urban health institutions which provide MCH services. 3) List the MCH care activities at PHC. 4) List the MCH care activities of SC. 6.4 RECENT STRATEGIE IN REPRODUCTIVE AND CHILD HEALTH (RCH) Some of the RCH related data is provided below for your better understanding of the MCH services. 6.4.1 Rural Health Infrastructure: Norms and Achievements Norms and Achievements (All India as on 30.6.99) Indicator National Norms Current Status 1) Rural population covered by a: General Tribal Sub Centre 5000 3000 4579 Primay Health Centre (PHC) 30,000 20,000 27,864 Commuity Health Centre (CHC) 1,20,000 80,000 2.14 lakhs 2) Number of Sub Centre Per PHC 6 5.97 3) Number of PHCs per CHC 4 7.82 4) Rural population covered by a: MPW (F) 5,000 3,000 4,688 MPW (W) 5,000 3,000 8,573 5) Ratio of HA (M) to MPW (M) 1:6 1:3.3 6) Ratio HA (F) to MPW (F) 1:6 1:6.9 7) Average radial distance (kms) covered by a: Sub Centre 2.69 PHC 6.58 CHC 18.42 11

Maternal and Child Health Services 6.4.2 Current Status of Rural Health Infrastructure Health Number Institution (As on 30.6.99) Sub Centres 1,37,271 PHCs 22,975 CHCs 2935 6.4.3 Current Status of MCH Indicators at National Level Indicator Current status Source and year Target 2000 AD MMR 4.08 SRS - 97 <2 IMR 68 NFHS - 2 (1998-99) <60 PNMR 42.5 SRS - 1994 30-35 U5MR 23.7 SRS - 93 10 CDR 8.9 SRS - 98 9 CBR 26.4 SRS - 98 21 AGR 1.79 SRS - 99 1.2 CPR 48 NFHS - 2(1998-99) 60 LBW 30% SRS - 98 <10 ANC (3 visits) 44% NFHS - 2 (1998-99) 100% Folifer (pregnancy) 58% NFHS - 2 (1998-99) 100% TT 2 /B (pregnancy) 82.9%67% SRS - 98NFHS - 2 (1998-99) 100% DPT 3 5% NFHS - 2 (1998-99) 100% OPV 3 63% NFHS - 2 (1998-99) 85% BCG 72% NFHS - 2 (1998-99) 85% Measles 51% NFHS - 2 (1998-99) 100% 6.5 LET US SUM UP Since independence, serious concern about high mortality and morbidity among women and children along with rapidly growing population led to MCH and family planning services as the top priority national health programme. You have learnt the genesis and gradual development of MCH services through diverse strategies and approaches during different plan periods. The reasons for integration of MCH care and family planning services as Family Welfare Programme and later on initiation of ORT programme and ARI control are also quite evident. Organizational design for delivery of MCH services in both rural and urban areas were spelt out. Subsequently, you have noticed that, since October 1997, there has been a major shift in family welfare services re-named as Reproductive and Child Health (RCH) programme. In the RCH package, along with traditional maternal and child care components, other reproductive health related issues have also been incorporated. At the end, the current status of rural health infrastructure performance and impact indicators of MCH have been presented in tabular form. 12

6.6 KEY WORDS Status of Maternal and Child Health Services in India CSSM : Child Surival and Safe Motherhood DDK : Disposable Delivery Kit FRU : First Referral Unit HFA : Health For All 6.7 ANSWERS TO CHECK YOUR PROGRESS Check Your Progress 1 1) MCH care was a priority concern since first five year plan and onwards. 2) MCH care was incorporated as a component of National Family Welfare Programme. Interventions like UIP, ORT and Pneumonia control were included in quick succession. Integrated package approach in CSSM programme Reorientation to the Reproductive and Child Health Programme. Achievements Reduction of CDR. Reduction of IMR. Immunisation coverage improved. Coverage of pregnant mother for antenatal care. Death due to diarrhoea reduced. Shortfalls Fall of CBR was not satisfactory. High CBR and low CDR led to Exponential population growth. MMR did not decline. Inter-state and inter-district variation persists. Check Your Progress 2 1) One Primary Health Centre for 30,000 population in plain areas (20,000 for hilly, tribal and backward areas). One sub-centre for 5,000 population (3000 population for hilly, tribal and backward areas). One Trained Dai and one Village Health Guide for each village. One Community Health Centre per block acts as first referral unit (FRU). 2) i) Govt. health organisations. a) District and sub-division hospitals, medical colleges etc. b) District family welfare bureau. c) Corporation, Municipalities and other civic bodies. d) Other programmes such as Urban Basic Services for Poor, Urban Family Welfare centre, IPP etc. ii) NGOs and private organizations. 13

Maternal and Child Health Services 3) The maternal and child health care activities in PHC include: Planning, organization and co-ordination of MCH services through the sub centres. Supportive supervision of MCH activities of the health worker by the health assistant PHN and Medical Officer at PHC. Plan, organize and supply vaccines and equipment's for immunization sessions at sub centres. Arrange training and monthly meeting for the staff of MCH services. Collect and compile performance report of sub centres. Undertake sterilization, other family planning measures and supervise and support the sub centre staff. Conduct antenatal services referred from sub-centre and others also and to undertake institutional deliveries. Mobilize community leaders, conduct meeting and co-ordinate with other sectors like BDO, panchayat and ICDS etc. Support of logistics for the sub-centres, Health Assistant, VHGs and trained Dais. 4) The MCH activities at sub-centre level includes Listing of eligible couples, registration of pregnant women, antenatal care including folifur supplementation and TT immunization, immunize children against 6 VPDs and Vit. A supplementation, monitor deliveries of trained Dais and conduct deliveries at the sub centres, provide postnatal care and care of new born, manage anaemia, diarrhoea and pneumonia in children, conduct health and nutrition education and health education, family planning, maintain records, training of Dais etc. 14