Describe the Reproductive, Maternal, Newborn, Child and Adolescent Health strategy.

Evolution and Structure of the Programme

• The evolution of the programme is worth tracing, since each change reflects a lesson learned:
• Maternal and child health (MCH), from 1961 — the original service
• The family planning programme (1952), the world’s first national family planning programme, later renamed family welfare in 1977 — a change made after the coercive sterilisation drive of the Emergency, to signal a shift away from targets and compulsion
• CSSM (Child Survival and Safe Motherhood), 1992
• RCH-I (1997), which introduced the target-free approach and the concept of unmet need
• RCH-II (2005), integrated within the national rural health mission
• RMNCH+A (2013), which added the "+A" for adolescents and articulated the continuum of care
• The addition of adolescents was the key conceptual advance, and the reasoning should be given — the health and nutrition of the adolescent girl determine her weight and anaemia at conception, which determine the birth weight of her child, which determines that child’s survival, growth and adult disease risk
• Therefore intervening only in pregnancy is intervening too late, and the cycle of undernutrition can only be broken before conception
• The continuum operates in two dimensions, and both should be described:
• Across time (the life cycle) — adolescence → pre-pregnancy → pregnancy → childbirth → newborn → infancy → childhood → adolescence again
• Across place (levels of care) — home and community → outreach and village health day → primary facility → first referral unit → district hospital, linked by effective referral and transport
• The strategic interventions by stage:
• Adolescent health — weekly iron and folic acid supplementation; menstrual hygiene; nutrition; preventing early marriage and pregnancy; sexual and reproductive health information; and adolescent-friendly health clinics
• Reproductive health — family planning with a range of spacing and limiting methods; management of infertility; safe abortion services; and prevention and treatment of reproductive tract and sexually transmitted infections
• Maternal health — antenatal care with PMSMA; skilled attendance at birth; JSY and JSSK entitlements; emergency obstetric care; postnatal care; and maternal death review
• Newborn health — essential newborn care; resuscitation under NSSK; home-based newborn care by the ASHA; newborn care corners, stabilisation units and special newborn care units
• Child health — immunisation; IMNCI; management of diarrhoea and pneumonia; vitamin A; nutrition and management of severe acute malnutrition; and RBSK screening

Delivery, Achievements and Constraints

• The delivery mechanisms under the National Health Mission:
• The ASHA (Accredited Social Health Activist) — a female community health volunteer, one per roughly 1000 population, selected BY and from the village, receiving performance-based incentives rather than a salary
• Her selection from the community she serves is the crucial design feature, since it gives her local knowledge, acceptability and accountability that an outsider cannot have
• Her roles — mobilising women for antenatal care and institutional delivery and accompanying them; home-based newborn and young child care visits; promoting immunisation and family planning; a depot holder for ORS, contraceptives and iron tablets; DOTS provider; and counselling and community mobilisation
• The village health sanitation and nutrition day (VHSND) — a monthly fixed-day outreach session at the Anganwadi centre, providing antenatal care, immunisation, growth monitoring, counselling and contraceptives, and bringing the health and ICDS systems together in one place
• JANANI suraksha YOJANA and JANANI SHISHU suraksha karyakram; free referral transport (102 and 108); the mother and child tracking system and RCH portal, which names and tracks each pregnant woman and child individually rather than counting aggregates
• Name-based tracking is a genuine advance, because it allows a specific woman who has missed a visit to be followed up, which aggregate reporting can never do
• SUMAN (Surakshit Matritva Aashwasan) — assuring dignified, respectful and zero-tolerance care, which addresses disrespect and abuse during childbirth, a real and under-acknowledged deterrent to institutional delivery
• The achievements, which should be stated fairly — substantial declines in maternal, infant, neonatal and under-five mortality; a large rise in institutional delivery; improved immunisation coverage; elimination of polio and of maternal and neonatal tetanus; and a falling total fertility rate, now at or below replacement level
• The constraints, stated honestly:
• Wide inter-state and inter-district disparity, which national averages conceal
• Quality of care lagging behind coverage — the recurring theme
• Shortage of specialists, particularly obstetricians, paediatricians and anaesthetists at first referral units, which is the single greatest barrier to functioning comprehensive emergency obstetric care
• Weak referral linkages and non-functional first referral units
• The ASHA being overburdened with tasks from every programme
• Poor coverage of the private sector, which conducts a large share of deliveries
• Reaching migrants, urban slums and tribal areas
• Persisting anaemia and malnutrition despite programme effort
• A high caesarean rate in the private sector alongside unmet need in the public, which is inequity in both directions
• The overall lesson that ties the answer together — India has largely solved the problem of access and is now facing the harder problem of quality; and the remaining gains depend on skilled human resources and functioning referral systems rather than on new schemes
• Adding adolescents was the conceptual advance, since intervening only in pregnancy is intervening too late
• India has solved access and now faces quality, which is the honest summary of the whole programme
• The continuum runs across time and across place, and both dimensions should be described rather than one
• A gap at any stage undermines those following, which is what makes it a continuum rather than a list
• The ASHA is selected by and from the village, which gives her acceptability that an outsider cannot have
• She is a volunteer on incentives, not a salary, which is both the strength and the weakness of the design
• The ASHA is overburdened by every programme, since each new scheme adds tasks without removing any
• Name-based tracking allows individual follow-up, which aggregate reporting can never do
• The village health day brings two systems together, health and ICDS, in one place on one fixed day
• SUMAN addresses disrespect during childbirth, which is a real deterrent to institutional delivery and rarely acknowledged
• Family welfare replaced family planning in 1977, deliberately, to signal a move away from targets and coercion
• RCH-I introduced the target-free approach and the concept of unmet need, which changed how success was measured
• India ran the world first national family planning programme in 1952, which is worth knowing as a date
• Specialist shortage is the binding constraint on comprehensive emergency obstetric care at referral units
• Give adolescent girls weekly iron and folic acid, which is the specific intervention that starts the cycle earlier
• Preventing early marriage is a health intervention, since adolescent pregnancy carries higher risk for both
• The private sector conducts many deliveries and is poorly covered by programme data and standards
• High private caesarean rates coexist with unmet need, which is inequity operating in both directions at once
• Polio and maternal tetanus have been eliminated, which are genuine achievements worth stating alongside the gaps
• Fertility is now at or below replacement, which changes the whole framing of the programme from control to health
• Referral transport is free under 102 and 108, which addresses the second of the three delays directly
• Migrants, slums and tribal areas remain hardest, and are where the residual mortality is now concentrated
• Depot holding makes the ASHA useful daily, since ORS, contraceptives and iron are available without a facility visit