Indias Reproductive, Maternal, Newborn, Child,

and Adolescent Health (RMNCH+A) Strategy

A Case of Extraordinary
Government Leadership

July 2014
The Maternal and Child Health Integrated Program (MCHIP) is the USAID Bureau for Global Healths flagship
maternal, neonatal, and child health (MNCH) program. MCHIP supports programming in maternal, newborn
and child health, immunization, family planning, malaria, nutrition, and HIV/AIDS, and strongly encourages
opportunities for integration. Cross-cutting technical areas include water, sanitation, hygiene, urban health,
and health systems strengthening.

This report was made possible by the generous support of the American people through the United States
Agency for International Development (USAID), under the terms of the Leader with Associates Cooperative
Agreement GHS-A-00-08-00002-00. The contents are the responsibility of the Maternal and Child Health
Integrated Program (MCHIP) and do not necessarily reflect the views of USAID or the United States Government.
CONTENTS
LIST OF TABLES AND FIGURES....................................................................................................................................................... ii

ACRONYMS..................................................................................................................................................................................... iii

ACKNOWLEDGMENTS.....................................................................................................................................................................1

EXECUTIVE SUMMARY....................................................................................................................................................................5

BACKGROUND.................................................................................................................................................................................9

RMNCH+A IN INDIA.......................................................................................................................................................................11

GOVERNMENT OF INDIAS EXTRAORDINARY LEADERSHIP........................................................................................................11

POLICY INTO ACTION.....................................................................................................................................................................14

WHAT IS THE RMNCH+A STRATEGY?...........................................................................................................................................15

OPERATIONALIZING THE STRATEGY: TRANSLATING COMMITMENTS INTO ACTION................................................................. 18

PROCESSES TO RESULTS.............................................................................................................................................................24

LESSONS LEARNED..................................................................................................................................................................... 28

RECOMMENDATIONSTHE WAY FORWARD............................................................................................................................... 29

REFERENCES.................................................................................................................................................................................31

ANNEXES...................................................................................................................................................................................... 33

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LIST OF TABLES AND FIGURES
TABLE 1. DESCRIPTION OF SCENARIOS FOR DATA MODELING FOR INDIA........................................................................... 12

TABLE 2. USAID-SUPPORTED HIGH-PRIORITY DISTRICTS.......................................................................................................17

TABLE 3.  ILLUSTRATIVE TABLE OF CHANGES MADE AND INITIAL RESULTS AT STATE/DISTRICT LEVEL
IN USAID-SUPPORTED STATES BASED ON GAP ANALYSIS/BLOCK MONITORING..................................................27

FIGURE 1. EXAMPLE: PROJECTED INFANT MORTALITY RATES IN 2017 UNDER ALTERNATIVE

SCALE UP SCENARIOS.............................................................................................................................................. 13

ii
ACRONYMS
AHS Annual health survey
AS&MD Additional Secretary and Mission Director
ASCI Administrative Staff College of India
BCC Behavior change communication
CHC Community health center
CPR Contraceptive prevalence rate
CSO Civil society organization
CSR Corporate social responsibility
DFID Department for International Development (UK)
DHAP District health action plans
DLHS District-level household survey
DM District monitor
DP Development partner
DPM District program manager
DPMU District program management unit
EAG Empowered action group
FBO Faith-based organizations
FLW Front-line workers
FRU First referral units
GOI Government of India
HMIS Health management information system
HPD High-priority districts
HSS Health systems strengthening
IMR Infant mortality rate
KPI Key performance indicator
LiST Lives Saved Tool
MCHIP Maternal and Child Health Integrated Program
MCTS Mother and Child Tracking System
MDG Millennium Development Goal
MMR Maternal mortality ratio
MNCH Maternal, neonatal, and child health
MOHFW Ministry of Health & Family Welfare
NGO Nongovernmental organization

iii
NHM National Health Mission
NIPI Norway India Partnership Initiative
NMR Neonatal mortality rate
NRHM National Rural Health Mission
NRU National RMNCH+A Unit
NUHM National Urban Health Mission
PC&PNDT Preconception and prenatal diagnostic technique
PIP Program implementation plan
QI Quality indicator
RCH Reproductive and child health
SLP State lead partner
SPMU State program management unit
SRS Sample registration system
SRU State RMNCH+A Unit
SUT State unified teams
TA Technical assistance
TOT Training-of-trainers
UN United Nations
USAID United States Agency for International Development
UT Union Territories
UNFPA United Nations Population Fund
UNICEF United Nations Childrens Emergency Fund
WHO World Health Organization

iv
ACKNOWLEDGMENTS
The Maternal and Child Health Integrated Program (MCHIP) acknowledges the commitment of Shri. Ghualam Nabi Azad,
former Union Minister of Health and Family Welfare, Government of India, to reducing maternal and child mortality in India.
At the Global Child Survival Call to Action, he reaffirmed Indias commitment to achieving the Millennium Development
Goals 4 and 5. Indias National Call to Action: Child Survival and Development, 2013 was an affirmation of this commit-
ment during which the Government of India launched the strategic roadmap for accelerating child survival and improving
maternal health in the near future and beyond 2015.

MCHIP thanks Lov Verma, Health Secretary, Government of India and former Health Secretary Keshav Desiraju for their
commitment and support in developing the comprehensive RMNCH+A strategy and providing strategic guidance to address
the MDGs and goals under the 12th Five- Year Plan.

MCHIP acknowledges the extraordinary leadership of Ms. Anuradha Gupta, Ex-Additional Secretary and Mission Director,
National Health Mission, for steering the process of developing A Strategic Approach to Reproductive, Maternal, Newborn,
Child, and Adolescent Health (RMNCH+A) in India in partnership with the Ministry of Women and Child Development,
Ministry of Rural Development, and development partners.

MCHIP would like to acknowledge the close collaboration and contributions by officials within the Ministry of Health and
Family Welfare and the National Health Mission, Government of India including:

Mr. Manoj Jhalani, JS (Policy)

Dr. Rakesh Kumar, JS (RCH)
Dr. Rattan Chand, Chief Director, Statistics Division
Dr. Himanshu Bhushan, DC (MH I/c)
Dr. Manisha Malhotra, DC (MH)
Dr. Dinesh Baswal, DC (MH)
Dr. Ajay Khera, DC (CH &Imm I/c)
Dr. S.K. Sikdar, DC (FP I/c)
Dr. Haldar, DC (Immunization)
Dr. P.K. Prabhakar, DC (CH)
Dr. Sila Deb, DC (CH)
D. Sushma Dureja, DC (AH)

MCHIP also acknowledges the continuous support, guidance, and cooperation of the USAID India Mission: Mr. John Beed,
USAID Mission Director, Dr. Nancy Godfrey, Chief of Health, Dr. Sanjay Kapur, Team Leader, USAID/India, Dr. Sheena
Chhabra, and Dr. Amit Shah, Reproductive Health and Family Planning Advisor. Special thanks to Ms. Nancy Powell, former
U.S. Ambassador to India (2012-2014). MCHIP also thanks Dr. Karan Singh, former JSI Country Director, and would like to
recognize the contributions of the National RMNCH+A Unit (NRU).

MCHIP would like to extend its gratitude to health officials in the six implementation states:

DELHI STATE
Dr. Vasantha Kumar Mission Director (DSHM)
Dr. D.K. Dewan Director, Family Welfare
Dr. R.K. Batra State Program Officer (RCH) Directorate of Family Welfare
Dr. Amita Raoot Chief Medical Officer (Immunization) Directorate of Family Welfare
Dr. G. Monga Chief District Medical Officer, North West District
Dr. S.K. Sehgal Chief District Medical Officer, North East District

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Dr. Meenakshi Hembram RCH Nodal Officer, North West District
Dr. Amit Saini RCH Nodal Officer, North East District
Dr. Nagmani Raj NHM Nodal Officer, North East District

HARYANA STATE
Ms. Navroj Sandhu Additional Chief Secretary and Principal Secretary Health
Dr. Rakesh Gupta Commissioner Finance Department & Mission Director (NHM), Department of Health & Family Welfare
Dr. Ravikant Gupta Director, NHM
Dr. Suresh Dalpath Deputy Director Child Health and State EPI Officer, NHM
Dr. Amit Phogat Deputy Director Referral Transport, IT and M&E, NHM

HIMACHAL PRADESH STATE

Mr. Amithab Awasti Mission Director, NHM
Dr. Deshraj Sharma Ex-Deputy Mission Director, NHM
Dr. Anuj Gupta Deputy Mission Director, NHM
Dr. Mangala Sood State Child Health and Immunization Officer

JHARKHAND STATE
Shri B.K. Tripathi Principal Secretary, Health
Shri Ashish Singhmar Mission Director, National Health Mission
Shri Manish Ranjan Ex-Mission Director, National Health Mission
Dr. Sumant Mishra Director in Chief, Health Services
Dr. Praveen Chandra Ex-Director in Chief, Health Services
Dr. A.K. Choudhary Director, Health Services (I/c) MH & Nodal Officer RMNCH+A
Dr. M.N. Lal Additional Director (In-charge Family Planning)
Dr. Ajit Prasad Deputy Director (In-charge Child Health)
Dr. Jaya Prasad Deputy Director (In-charge Adolescent Health)
Mr. Randhir Kumar State Program Manager, National Health Mission
Ms. Akai Minz State Program Coordinator, National Health Mission

PUNJAB STATE
Ms. Vini Mahajan Additional Chief Secretary and Principal Secretary Health
Dr. V.K. Gagneja State Program Manager, NHM
Dr. Karanjit Singh Director Health Services
Dr. Jatinder Kaur Director Family Welfare
Dr. G.B Singh Assistant Director, Maternal and Child Health

UTTARAKHAND STATE
Mr. Om Prakash Principal Secretary
Dr. Nidhi Pandey Mission Director, NHM (Present)
Mr. Senthil Pandiyan MD, NHM (Oct 2013-Feb 2014), District Magistrate, Haridwar
Mr. Piyush Singh Mission Director NHM (through September 2013)

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Dr. G. S. Joshi Director General Medical Health and Family Welfare
Dr. Prem Lal Additional Director, Maternal and Child Health
Dr. Saroj Naithani State EPI Officer
Dr. Sushma Datta Child Health Consultant

CONTRIBUTORS
Dr. Rajesh Singh, National Team Leader RMNCH+A, MCHIP
Mr. Niraj Agrawal, Knowledge Management Specialist, MCHIP/India
Ms. Jennifer Pearson, Program Learning and Documentation Manager, MCHIP/India
Ms. Patricia Taylor, Country Support Team Leader, MCHIP
Dr. Goverdhan K, National Technical Officer, M&E, MCHIP
Dr. Pawan Pathak, Team Leader, Newborn Health, MCHIP
Dr. Gunjan Taneja, State RMNCH+A Team Leader, Jharkhand, MCHIP
Dr. Sanket Kulkarni, State RMNCH+A Team Leader, Uttarakhand, MCHIP
Dr. Chitra Rathi, State RMNCH+A Team Leader, Delhi, MCHIP
Dr. Shailesh Jagtap, State RMNCH+A Team Leader, HR, HP, PB, MCHIP

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4
EXECUTIVE SUMMARY
The GOI is committed to protecting the lives and health of women, adolescents, and children. At the Global Child Survival
Call to Action: A Promise to Keep in 2012, Indias Honorable Minister for Health and Family Welfare Shri Ghulam Nabi Azad
assured the audience that India would remain at the forefront of the global war against maternal and child mortality. Eight
months after the event, the Government of India held its own historic Summit on the Call to Action for Child Survival, where
it launched A Strategic Approach to Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) in India.
Since that time, RMNCH+A has become the heart of the GOIs flagship public health program, the National Health Mission
(NHM).

The RMNCH+A strategy is based on provision of comprehensive care through the five pillars, or thematic areas, of
reproductive, maternal, neonatal, child, and adolescent health, and is guided by central tenets of equity, universal care,
entitlement, and accountability. The plus within the strategy focuses on:

Including adolescence for the first time as a distinct life stage;

L inking maternal and child health to reproductive health, family planning, adolescent health, HIV, gender, and
preconception and prenatal diagnostic techniques;

Linking home- and community-based services to facility-based care; and

E
 nsuring linkages, referrals, and counter-referrals between and among health facilities at primary (primary health
centre), secondary (community health centre), and tertiary levels (district hospital).

In developing the RMNCH+A strategy, the GOI aimed to reach the maximum number of people in the remotest corners of
the country through a continuum of services, constant innovation, and routine monitoring of interventions. In rolling out the
new strategy, the GOI emphasized high impact interventions in each of the five thematic areas of reproductive, maternal,
newborn, child, and adolescent health, and then focused its efforts, and those of its development partners, on improving
the coverage and quality of those interventions in 184 high-priority districts (HPDs) across India. Guidelines and tools
were developed and policies were adjusted. There was intensive work with state and district health teams to develop their
comprehensive Program Implementation Plans (PIP) for NHM funding and development partners, medical colleges, and
academic and research institutes were asked to harmonize and intensify their technical assistance to support the roll out.

With support from USAID and its Maternal Child Health Integrated Program (MCHIP), as well as from UNICEF, UNFPA, NIPI
and other development partners, the GOI has taken the following important steps to introduce and support RMNCH+A
implementation.

High-Priority Districts: The RMNCH+A strategy addresses Indias inter-state and inter-district variations. The Government
of India identified districts with relatively weak performance against RMNCH+A indicators and used uniform and clearly
defined criteria to identify 184 high-priority districts across all 29 states. The RMNCH+A approach is also a conscious
articulation of the GOIs commitment to tailoring programs to meet the needs of previously underserved groups, including
adolescents, urban poor, and tribal populations.

RMNCH+A Guidelines and Policy: The Ministry of Health and Family Welfare (MOHFW) at national level prepared guidelines
and technical documents that included the Handbook on Improving Maternal and Child Health through the RMNCH+A
Approach, Guidance Note for Implementation of RMNCH+A Interventions in High-Priority Districts, Guidance Note on
Block Monitoring, and Guidance Note on District-level Gap Analysis of RMNCH+A Implementation. These guidelines were
used in state and district consultations and with development and other partners to ensure a common understanding of
the approach.

Management Tools and Job Aids: The RMNCH+A 5 x 5 Matrix identifies five high-impact interventions across each of
the five thematic areas, five cross-cutting and health systems strengthening interventions, and, the minimum essential
commodities across each of the thematic areas. The 5 x 5 Matrix is an important tool for explaining the strategy in simple
terms, organizing technical support, and monitoring progress with the states and high-priority districts.

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Partner Harmonization: At the GoIs request, its development partners, including USAID, agreed to support the RMNCH+A
roll-out. This represented a paradigm shift from smaller scale, decentralized programs to providing technical support to
the GoI to formulate and implement national policy based on evolving global evidence. The GoI identified development
partners as state lead partners (SLP) and assigned them to support the National Health Mission in each of the states.
The SLPs serve as the single point of contact and accountability but coordinate with other partners and agencies working
in the state to harmonize actions across the HPDs and provide the required technical support to the state NHM. USAID,
supported by MCHIP, was assigned 33 HPDs in six states for the roll-out of RMNCH+A and the intensification of efforts to
improve maternal and child health outcomes.

National and State RMNCH+A Units: The National RMNCH+A Unit (NRU) is supported by USAID, through MCHIP, and
anchored within the MOHFW. The nine-person NRU was created to support the Ministry in monitoring the progress of
RMNCH+A implementation and intensification efforts across the states. The key role of this unit is to help all 29 states
plan, implement, and monitor RMNCH+A strategies. State RMNCH+A units (SRUs) were established in all six USAID-
supported states to coordinate activities across the HPDs and provide technical assistance to the states own program
management unit (SPMU), particularly for planning, implementing, and monitoring the delivery of priority interventions.

Gap Analysis: The effectiveness of RMNCH+A interventions depends on availability, acceptability, and utilization of
services and the quality of services delivered. Analysis at various levels is necessary to identify gaps in the delivery of a
particular intervention or set of interventions. To facilitate this analysis, GOI conceptualized a district-level gap analysis
and facility assessment approach and developed standardized tools. Results provide evidence for the district RMNCH+A
implementation plan, which should address the key gaps through short- and mid-term actions. Gap analysis also guides
the provision of technical assistance and supervision by MCHIP and other development partners. MCHIP conducted gap
analyses in the six USAID-led states, covering 36 district-level facilities, 91 first-referral units, 389 non-FRUs, 406 sub-
centers, 64 health system interviews, and 11,024 community interviews.

Block Monitoring: To ensure timely support to districts in implementing the most critical interventions, development
partners are expected to offer need-based, district-level assistance and work alongside district- and block-level
stakeholders to identify and systematically address key bottlenecks. Using a pre-determined block monitoring format
prepared by the GOI, district-level monitors, assigned under MCHIP in USAID-supported states, visited one block each
month in each HPD, beginning in November 2013. The objectives of block monitoring are to quickly assess facility- and
community-level infrastructure, human resources, provision of services, and quality and coverage of service delivery;
review progress of community outreach and home- or community-based interventions; validate data reported to the HMIS;
and gauge client satisfaction with RMNCH+A services.

Scorecards and Dashboards: The RMNCH+A strategy emphasizes the use of data for planning and implementing
interventions. Scorecards were introduced to act as a management tool for two-way feedback at all levels. Their use helps
to locate data entry and data quality issues, and underscores the importance of data cleaning and quality improvement.
In addition, 16 indicators from the health management information system (HMIS) were selected and used to develop
quarterly service delivery dashboards for monitoring. The color-coded dashboard identifies performance by states, districts,
and blocks as good (green), promising (yellow), poor (pink), and very poor performing (red), based on a composite index
and individually for the five thematic areas.

LESSONS LEARNED
Important lessons learned during the first 12 months of RMNCH+A implementation include:

S
 trong government leadership, donor harmonization, and simple tools have been key to the rapid scale up of
RMNCH+A.

T he RMNCH+A 5 X 5 Matrix has proven to be an important tool for explaining the strategy in simple terms, organizing
technical support, and monitoring state and HPD progress.

G
 ap analysis increased awareness of quality of care. Larger gaps are now being addressed through annual district
health action plans and state program implementation plans.

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 Involvement of state and district health officials in routine block monitoring has resulted in some cases in immediate
corrective actions to improve service delivery.

M
 ore attention in the second year of the RMNCH+A roll out should be given to measuring health outcomes and
improving the quality of care for mothers, newborns, infants, and young children in health facilities and communities.

THE WAY FORWARD

The RMNCH+A strategy was launched just over one year ago. Under the Government of Indias strong leadership, initial
results have been promising, but much still remains to be done to take the full RMNCH+A package to scale. The first
phase of RMNCH+A involved orientation and sensitization of a diverse set of stakeholders to the RMNCH+A strategy,
establishment of key processes for rolling out the strategy, and capacity building of different cadres of human resources.
Moving forward, MCHIP recommends that the GOI and development partners such as USAID focus on:

C
 ontinuous monitoring, supportive supervision, and feedback mechanisms to improve the quality of care and
accountability including use of key performance and quality indicators that are linked to the RMNCH+A 5 X 5 Matrix.
Testing performance-based incentives under the RMNCH+A mandate.
Leveraging the strong presence of the private sector to improve the quality of health care in urban settings.
A
 dvocacy with multiple levels of government and all stakeholders to enhance their involvement and promote
sustainability and scale up of best practices.
S
 trengthening the continuum of care from community to facility through improved community mobilization and behavior
change communication approaches.
H
 ealth system strengthening including rational deployment of human resources, availability of essential commodities,
infrastructure improvement, and the use of task shifting.
Improving inter-sectoral convergence, particularly with departments of Women and Child Development and Education,
and Water and Sanitation.
S
 ystematic documentation and sharing of innovations and best practices to enhance policy, service delivery, and
financing across states and districts: Innovations in implementation achieved by various development partners should
be captured, documented, and advocated for scale-up.

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8
BACKGROUND
THE GLOBAL CALL TO ACTION: A PROMISE TO KEEP
In June 2012, the governments of India, Ethiopia, and the United States and the United Nations Childrens Fund (UNICEF)
convened the Global Child Survival Call to Action: A Promise to Keep summit in Washington, DC to energize the global
fight to end preventable child deaths through targeted investments in effective, life-saving interventions for children. More
than 80 countries, including governments and partners from the private sector, civil society, and faith-based organizations,
and many international agencies gathered at the Call to Action, where they challenged the world to reduce child mortality to
20 child deaths or fewer per 1,000 live births in every country by 2035.

At the summit, Indias Honorable Minister for Health and Family Welfare Shri Ghulam Nabi Azad
assured the audience that India would remain at the forefront of the global war against maternal
and child mortality. Eight months after the event, the Government of India (GOI) held its own historic
Summit on the Call to Action for Child Survival. With over 250 participants present from approximately
40 countries and all 28 of Indias states, the GOI used the occasion to launch Indias ambitious new
Reproductive, Maternal, Newborn, Child and Adolescent Health strategy, now known as RMNCH+A,
to accelerate mortality reduction amongst the countrys most vulnerable women and children. This
document provides an overview of the development of the strategy and the processes to roll out the
strategy in 33 high-priority districts in the six USAID-supported states.

MATERNAL AND CHILD SURVIVAL

According to the 2013 Millennium Development Goal (MDG) report, although the global maternal mortality ratio (MMR) has
declined by nearly half since 1990, the decline falls far short of the MDG target of 109 per 100,000 by 2015 and is still 15
times higher in developing than developed regions (UN 2013). Of the estimated 287,000 maternal deaths that occurred in
2010, India accounted for 56,000, or 19% of the global total (WHO 2012).

A childs survival is inextricably linked to the health and the survival of its mother. Globally,
7.6 million children died in 2010 before reaching their fifth birthday (UNICEF 2011) and only
five countries, including India, collectively accounted for more than half (nearly 3.75 million)
of all these deaths. Child mortality rates are particularly alarming in India, where every year
more than 300,000 babies die at birth and approximately 1.45 million children die before
their fifth birthday (Save the Children 2013). These data underscore the need to prioritize
interventions addressing maternal and child mortality in India and other underperforming
and high-burden countries.

Recent global initiatives have renewed focus on global targets for maternal and child survival.
The Global Strategy for Womens and Childrens Health, launched by the United Nations
(UN) Secretary-General Ban Ki-moon during the Millennium Development Goals Summit in
September 2010, aims to save 16 million lives in the worlds 49 poorest countries by 2015
through enhanced financing, strengthened policies, and improved service delivery (UN 2013). At the same summit, the
Every Woman Every Child movement was established to mobilize and intensify international and national action to advance
the global strategy.

OVERVIEW OF INDIAS PROGRESS

Although India ranks among the top five countries globally in terms of absolute numbers of maternal and child deaths,
the country has made encouraging progress in tackling mortality among mothers and children. In 1990, Indias under-five
mortality rate (U5MR) was 115 per 1,000 live births, well above the global mean of 88. By 2010, it had been cut in half,
to 59 per 1,000 live births, and was just above the global average of 57. Maternal mortality also declined dramatically
during the same period, with the MMR falling from 560 in 1990 to 190 by 2013 (WHO 2014). Despite these impressive
reductions, because of Indias very large population and annual birth cohort, it still contributes more child and maternal
deaths to the global total each year than any other country.

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 Indias National Rural Health Mission (NRHM) was launched in 2005 to
improve the availability and quality of accessible health care, especially
India has made considerable
in rural areas. The NRHM has contributed significantly to Indias improved
progress over the last two decades in maternal and child health outcomes, and the Government of India (GOI)
the sector of health, which was further has taken advantage of the NRHM platform to launch a number of large
accelerated under NRHM. True to its strategic investments aligned with its MDG targets. The launch of NRHM led
vision, NRHM improved the availability to numerous improvements, including:
of and access to quality health care by
people, especially for those residing Improved availability of and access to high-quality health care, especially
in rural areas, the poor, women and for people residing in rural areas, the poor, women, and children.
children. However, latest data and S
 ubstantially increased financial resources for reproductive and child
trends emerging from the national health (RCH), health care infrastructure, and workforce.
surveys demand a cohesive approach Expanded program management capacity.
to manage child and maternal
health care. Clear articulation of the While these improvements have enabled the GOI to accelerate progress
strategic approach to reproductive, toward MDGs, Indias maternal and child health outcomes still vary
maternal, newborn, child, and significantly across and within its states. Most importantly, data from national
adolescent health (RMNCH+A) is an surveys such as the Annual Health Survey carried out in Assam and the eight
effort in this direction. empowered action group (EAG) states, which have a high burden of maternal
and child mortality, show wide inter-district variation. For example, the
Shri Ghulam Nabi Azad, statewide under-five mortality rate in Madhya Pradesh is high, but rates vary
Former Union Minis ter of widely, with a difference of 89 points between Indore (51) and Panna (140).
Health and Family Welfare, Similar inter-district variations are found in Uttar Pradesh (AHS 2011-12) and
Government of India the other EAG states. It is clear that the focus of implementation has to shift
(2009-2014)
to geographical areas of greatest concern and populations that carry the
highest burden of illness and mortality. Increased focus on the urban poor,
who face well-documented barriers to utilization that are often due to the
inequitable distribution of health services, is also needed.

Since independence, the GOI has prepared 5-year plans that outline the expenditure framework for different sectors and
that have strong ownership of the President and Prime Minister. The 12th Five-Year Plan (2012-2017) lays out Indias
commitment to the following goals by 2017:

Reducing the IMR to 25 per 1,000 live births.

Reducing the MMR to 100 per 100,000 live births.
Reducing the national fertility rate to 2.1.
Increasing the child sex ratio in the 0-6 year age group to 950.

Under the 12th Five-Year Plan, the GOI projects that it will spend
US $3 trillion on health between 2013 and 2017. India recognizes
that achieving these goals will require a broad strategy that links
reproductive, maternal, and child health services and promotes the
delivery of evidence-based interventions along a continuum of care
from household to community to health facility. This recognition led the
MOHFW/NRHM to develop a new, more comprehensive Reproductive,
Maternal, Neonatal, Child Health and Adolescent (RMNCH+A) strategy.

10
RMNCH+A IN INDIA
The RMNCH+A strategy is designed to fast-track Indias progress toward achieving Millennium Development Goals 4 and
5, while also increasing progress toward the health targets outlined in the 12th Five-Year Plan. The RMNCH+A strategy is
built upon the continuum of care concept and is holistic in design, encompassing all interventions aimed at reproductive,
maternal, newborn, child, and adolescent health under a broad umbrella, and focusing on the strategic lifecycle approach.

GOVERNMENT OF INDIAS
EXTRAORDINARY LEADERSHIP
BUILDING OWNERSHIP FROM A ONE-TIME EVENT TO A NATIONAL MOVEMENT
After the global Child Survival Call to Action in Washington, DC, the GOI redefined its national maternal and child health
agenda and planned its own National Summit on the Call to Action. The GOI established a secretariat for the activity with
support from USAIDs Maternal and Child Health Integrated Program (MCHIP), which coordinated activities with each of the
subcommittees formed. The secretariat included a team leader, technical consultant (programs/child survival), technical
consultant (data), partnership consultant, and media and outreach consultant).

The Government of India convened a steering committee and six

subcommittees, each comprised of representatives from the MOHFW and
development partners including USAID, UNICEF, UNFPA, and the Bill & Melinda
Gates Foundation. The steering committee meetings provided a unique
platform for collective decision making, shared responsibility by the MOHFW,
development partners, media, private sector, and civil society organizations, and
renewed commitment to child survival and a movement to improve reproductive,
maternal, neonatal, child, and adolescent health.

Each subcommittee was charged with a set of India-specific activities to

be conducted before the summit in February 2013, when the GOI would
demonstrate its leadership and generate renewed commitment among national,
state, and international partners to child survival.

PREPARATIONS FOR THE NATIONAL CALL TO ACTION EVENT, BY SUBCOMMITTEE ROLE

RMNCH+A STRATEGY SUBCOMMITTEE
The RMNCH+A strategy subcommittee, which was led by MCHIP, met to brainstorm the components to include in the
strategy. During one of the meetings, the subcommittee realized that Indias Reproductive and Child Health Program (RCH
II) was not in line with the current global model, which emphasizes a continuum of care approach that includes integrated
service delivery across life stages; pre-pregnancy, childbirth, post-natal period, childhood, adolescence, and throughout
the reproductive years. In RCH II, adolescent health was missing despite adequate evidence of poor adolescent health
indicators in India, including high rates and poor outcomes of teen pregnancy, low contraceptive prevalence rates (CPR)
among adolescents, and high rates of malnutrition and anemia among adolescent girls. Given the lifelong impact of these
poor health indicators, the subcommittee recognized that adolescents must receive more attention.

The subcommittee further realized that RCH II has focused on the EAG states and left out high-performing states, although
evidence from surveys (AHS 2010-11) shows that even states with high overall performance have poorly performing
districts that need special attention. This led to a recommendation to focus on poorly performing geographic regions and
populations with the highest mortality burden. The RMNCH+A strategy document was developed describing the approach
to comprehensive care across the full lifecycle and clearly articulating the roles of all partners.

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SCORECARD AND DASHBOARD
The Technical and Management Support Agency (TMSA) led this subcommittee in developing a dashboard based on health
management information systems (HMIS) data and a scorecard based on survey data to monitor district progress, validate
data, and ensure improved quality of data. The HMIS data tracks quarterly public-sector performance and provides a short-
term snapshot. The survey-based scorecard was to track medium-term performance through data sources such as the
sample registration system (SRS) and survey data, and to capture outcome and output data to provide a holistic reflection
of public and private sector performance.

A list of 16 HMIS scorecard indicators based on a lifecycle approach was selected. Indicators ask questions related to
pregnancy care, childbirth, post-natal maternal and newborn care, and people of reproductive age.

DATA MODELING
The objective of data modeling was to prioritize and create a combination of interventions that would help achieve the
lowest possible under-five mortality in the selected states. Seven thematic areasneonatal care, nutrition, maternal care,
pneumonia, diarrhea, immunization, and family planningwere identified for modeling. The data modeling subcommittee,
led by USAID, synthesized the indicators used for modeling and the references for efficacy rates based on evidence
available for the Indian context. Efficacy rates were validated to ensure greater acceptability and wider use of updated
scientific information in India. The Lives Saved Tool (LiST)1 helped determine the possible levels of coverage required to
achieve the targets set by the GOI. LiST helps estimate the mortality impact of scaling up maternal, newborn, and child
health interventions. The tool requires three sets of inputs to project the impact of interventions on mortality: 1) measures
of health status including mortality and causes of death; 2) effect sizes of interventions; and 3) intervention coverage that
is scaled up from a baseline.

TABLE 1. DESCRIPTION OF SCENARIOS FOR DATA MODELING FOR INDIA

Scenario 1 Continuation of historical trends in RMNCH+A interventions based on the National Family Health Survey
(NFHS-3) (2005-2006) and the Coverage Evaluation Survey 2009 (CES-2009). The average annual
rate of change for most interventions was 4% per year, with a maximum coverage increase of 15% for
institutional births.

Scenario 2 The coverage estimates were increased for all the interventions by a proportion such that the IMR of
25 deaths per 1000 live-births could be achieved by 2017. The requisite annual increase in coverage
estimates for RMNCH+A interventions is 22%. The projected coverage estimates are capped at a
maximum of 95% or current estimate if >95%.

Scenario 3 This scenario considers differential increase in the coverage estimates for each RMNCH+A intervention
based on the health system realities while keeping in view that the goal of IMR of 25 deaths per 1,000
live births needs to be achieved by 2017. The average annual rate of change in this scenario is 21%. The
projected coverage estimates are capped at a maximum of 95% or current estimate if >95%.

Scenario 4 This scenario is similar to Scenario 3 but has additional interventions (water and sanitation improvement,
introduction of pneumococcal vaccine, and scale up of Haemophilus influenzae type b vaccine HiB
vaccine). The average annual rate of change in this scenario is 19%, ranging from 14% to 95%. The
projected coverage estimates are capped at a maximum of 95% or current estimate if >95%.

1
For more information on the LiST tool: http://www.jhsph.edu/departments/international-health/centers-and-institutes/institute-for-international-programs/list/

12
FIGURE 1. EXAMPLE: PROJECTED INFANT MORTALITY RATES IN 2017 UNDER ALTERNATIVE SCALE-UP SCENARIOS

45 Scenario 1

40 Scenario 1

35

30

25

20
2011 2012 2013 2014 2015 2016 2017

The data modeling was conducted at the national level. It was recommended that state-level analyses and prioritization be
done to provide more insight for prioritization at the state to guide the state program implementation plans (PIPs).

CIVIL SOCIETY ORGANIZATIONS (CSOS), FAITH-BASED ORGANIZATIONS (FBOS), AND FOUNDATIONS

This subcommittees objective was to determine what technical assistance and other support civil society might provide,
and what provisions would ensure the sustainability of their support. The subcommittee was led by Save the Children,
one of the consortium partners under MCHIP. Group members decided to conduct a mapping exercise of candidate CSOs
and FBOs at two levels: state level for the eight EAG states, and district level in 264 high-focus districts (selected during
RCH II project as poorly performing districts) to identify and engage the community-based organizations in components
of RMNCH+A strategy. Nongovernmental organizations (NGOs), CSOs, and FBOs were mapped by thematic expertise and
willingness to contribute to RMNCH+A, and their written commitment was obtained. The subcommittee also recommended
potential roles for participating organizations and the platforms they could provide to generate demand for RMNCH+A
services at various levels.

PRIVATE SECTOR
The private sector subcommittee, led by UNICEF, focused on determining how
to leverage private sector resources (including financial and human resources) There are many areas in which
and expertise in supply chain management. The India Institute of Corporate the private sector can add a lot of
Affairs took the lead by preparing an outline for engaging the private sector in value, either by filling a critical gap
RMNCH+A. The subcommittee suggested a three-pronged approach for involving or supplementing efforts of the
the private sector to achieve results for child survival: government.
C
 orporate Social Responsibility (CSR)to finance activities and projects under
Ms. Anuradha Gupta,
the Child Survival Call to Action. The subcommittee proposed using CSR as an
Ex-Additional Secretary and
obligation for companies to create a child survival fund that could be used for Mission Director, NHM
implementation of child survival projects. Companies are mandated to spend
2% of their average profit over the previous 3 years.
Market-based approachesincluding social marketing of commodities to create sustainable and long-term solutions.
Innovationsleveraging skills and expertise from the private sector.

MEDIA
The GOI recognized that media needed to be involved as a stakeholder before, during, and after the National Summit.
Subgroups were formed to prepare strategies for different phases: before the event to create a buzz and generate
awareness of the upcoming summit; during the event to support coverage and take advantage of heightened attention;
and after the event to sustain momentum and assure follow through on commitments made. Key components of the

13
 media plan included creating a branding concept for Indias child survival
initiative (For Every Child in India was chosen); developing messages
Reproductive healthwhich primarily
and materials; outlining a media outreach plan; developing a digital
addresses family planningwas platform; and engaging celebrities in the event and message.
being promoted more as a population
stabilization strategy and less as a
CONVERGENCE AND COMMITMENT AT NATIONAL AND STATE LEVELS
strategy to improve maternal and
child health outcomes. Thus, it was During preparations for the National Summit, the RMNCH+A strategy
implemented as a stand-alone, isolated subcommittee recognized the need for the involvement of other
ministries. These included the Women and Child Development Ministry,
program without articulating the critical
which operates a vast network of Anganwadi Centres in every village
inter-linkages with our interventions in
and provides immunization, well-child care, antenatal care, and nutrition
maternal and child health. services including iron and folic acid supplements to adolescents; and the
Ministry of Rural Development, which works to improve water, sanitation,
Ms. Anuradha Gupta
and hygiene practices in the communities. The MOHFW worked with these
ministries from the planning phase to the launch the RMNCH+A strategy
through the roll-out. This collaboration ensured that all stakeholders
understood the policy and their roles and responsibilities.

POLICY INTO ACTION

INDIAS CALL TO ACTION - FEBRUARY 2013
In order to galvanize unified efforts of all stakeholders, the Call to Action: For Every Child in India Summit took place in
February 2013 in Mahabalipuram, Tamil Nadu. The summit was led by the MOHFW with participation from the Department
of Women and Child Development. Policymakers, international and national experts, public health practitioners,
representatives from private sector, and media professionals attended the landmark meeting. Major topics of
presentations and discussions included leadership dialogue, the roadmap to child survival and development, partnership
building, accountability, tracking progress, and innovation and research.

The consensus at the summit was that while India has made impressive progress, it must focus on key high-impact
interventions, with special emphasis on poorly performing locations and key populations. Such a focused approach would
lead to substantial reductions in maternal, neonatal, infant, and under-5 morbidity and mortality resulting from the most
common causes. Another key theme was that though India has launched many flagship health and nutrition programs
that have led to improved maternal and child survival, the country still needs to develop and implement a strategy to
link various interventions and schemes under one umbrella to provide holistic and comprehensive services to the entire
spectrum of beneficiaries, including infants, children, adolescents, adult women, and pregnant women.

The GOI launched its new RMNCH+A strategy at the summit to meet this need. Indias Call to Action was the beginning of a
national movement, becoming a shared platform for ministerial collaboration and inter-ministerial dialogue at national and
state levels. The summit was designed as a forum for broad participation combining global and Indian expertise at which
goodwill ambassadors, the private sector, civil society, the media, and faith-based organizations would share experiences
and challenges; celebrate successes in maternal, newborn and child survival; and commit themselves to the challenges of
implementation.

The planning stages for the RMNCH+A strategy did not focus on urban populations as a priority group. However, during
the Call to Action Summit, it was agreed that India cannot accelerate reduction in MMR and NMR without addressing the
needs and health status of the urban poor and migratory populations, and furthermore that services for the urban poor
must be tailored because traditional service delivery is not possible. The need for full access suggested opportunities for
involving the private sector, including NGOs and CSOs. Hence, in June 2013, the National Urban Health Mission merged
with the National Rural Health Mission (NRHM) to become the National Health Mission (NHM) to take a holistic approach
to services for and give equal attention to urban poor and migratory populations.

14
WHAT IS THE RMNCH+A STRATEGY?
The RMNCH+A strategy promotes links between various interventions across thematic areas to enhance coverage
throughout the lifecycle to improve child survival in India. The plus within the strategy focuses on:

Including adolescence as a distinct life stage within the overall strategy.

L inking maternal and child health to reproductive health and other components like family planning, adolescent health,
HIV, gender, and preconception and prenatal diagnostic techniques.
Linking home- and community-based services to facility-based services.
E
 nsuring linkages, referrals, and counter-referrals between and among health The interdependence of various
facilities at primary (primary health Centre), secondary (community health components of continuum of care
centre), and tertiary levels (district hospital). is well recognized. In other words,
reproductive, maternal, newborn,
child, or adolescent health can be
CONTINUUM OF CARE APPROACH ensured only if all the life stages are
The RMNCH+A strategy promotes links between interventions across the healthy. RMNCH+A initiative aims to
lifecycle and integrates child survival with other important health interventions. focus equally on all life stages across
This approach reflects evidence showing that mother and child health cannot the continuum of care.
be improved in isolationdata show, for example, that high-risk pregnancies
and maternal mortality rates are twice as high in adolescent mothers than in Ms. Vini Mahajan, Principal
women above age 20; that anaemia is prevalent across all age groups; and that Secretary to Govt. of Punjab,
malnutrition is responsible for 34% of under-5 deaths. (MOHFW 2013). Department of Health &
Medical Education
INCLUSION OF ADOLESCENTS
The health of adolescents has always been the weakest pillar in the continuum
of care approach, and has often been ignored and neglected, leading to early age of marriage, early childbearing, lack of
access to contraception, and lack of birth spacing. With this realization, India added A (adolescents) to the continuum of
RCH.

KEY FEATURES OF THE RMNCH+A STRATEGY

Central tenets guiding this The RMNCH+A strategy approaches include:
programme have been equity,
universal care, entitlement, and H
 ealth systems strengthening (HSS) focusing on infrastructure,
human resources, supply chain management, and referral
accountability. Our aim is to
transport measures.
protect the lives and safeguard
the health of women, adolescents, P
 rioritization of high-impact interventions for various lifecycle
and children and this has been the stages.
driving force for reaching out to the Increasing effectiveness of investments by prioritizing geographical
maximum numbers in the remotest areas based on evidence.
corners of the country through Integrated monitoring and accountability through good governance,
constant innovation and calibration use of available data sets, community involvement, and steps to
of interventions. address grievance.
B
 road-based collaboration and partnerships with ministries,
Dr. Rakesh Kumar, departments, development partners, civil society, and other
Joint Secretary (RCH), stakeholders.
MOHFW
Overall, the entire strategy can be visualized as having three major
components: design, implementation mechanisms, and performance
monitoring.

The RMNCH+A strategy provides a strong platform for delivery of services across the entire continuum of care, ranging
from community to primary health care, as well as first-referral level care to higher referral and tertiary level of care. This

15
 integrated strategy is expected to promote greater efficiency while reducing
The RMNCH+A document directs duplication of resources and efforts in the ongoing program. The RMNCH+A
document provides a comprehensive approach to improving child survival and
states to focus their efforts on
safe motherhood, and operational guidance to implement this approach during
the most vulnerable population the next phase of the National Health Mission.
and disadvantaged groups in
the country. The document also
emphasizes the need to reinforce IDENTIFICATION OF HIGH-PRIORITY DISTRICTS: FOCUS
efforts in those poor performing ON EQUITY
districts that have been identified
as the high-focus districts. Districts lag behind in terms of health and possibly most other development
indicators require additional planning and implementation support and receive
Mr. P. K. Pradhan, a 30% higher budget allotment for implementing the strategy. The RMNCH+A
Ex-Secretary Health and approach is a conscious articulation of the GOIs commitment to tailoring
Family Welfare, programs to meet the needs of previously underserved groups including
Government of India adolescents, the urban poor, and tribal populations.

The RMNCH+A strategy addresses Indias inter-state and inter-district

variations. The Annual Health Survey (AHS) 2010-11 shows uneven progress both between and within Indian states. The
GOI identified 184 high-priority districts (HPDs) across 29 states. This was a landmark shift because the 264 previously
designated HPDs were all from the eight EAG states and Assam. RMNCH+A recognizes that high-performing states also
have poorly performing districts that need attention and vice versa.

The 184 HPDs were selected based on a relative ranking of districts within a state using AHS 2010-11 data and data from
the eight EAG states (Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chattisgarh, Rajasthan, Odisha) and
Assam. District Level Household Survey (DLHS-3) 2007-08 data for other states and Union Territories (UTs) in India were
also considered. Based on these indicators, the lowest-performing 25% of districts within each state were designated as
HPDs. Tribal districts and those affected by left-wing extremism lying within the bottom 50% were also incorporated in the
overall list of HPDs.

HARMONIZATION AND COMMITMENT OF DEVELOPMENT PARTNERS AND

INTENSIFICATION OF EFFORTS
Following the summit, a national consultation on intensifying We are very glad that development
efforts to improve MCH outcomes in HPDs was held in April 2013. partners have aligned their
The meeting was attended by representatives of MOHFW and
approaches to ours. They are now
development partners. The objectives of this consultation were to:
working with the state governments
D
 iscuss the road map for actions to follow the Call to Action as a consortium led by a partner and
Summit. we have assigned different states to
O
 rient partners to HPDs and the governments plan to intensify different partners so that together we
action for improving maternal and child health. can get move forward with this shared
D
 iscuss mechanism for harmonizing partners technical vision of RMNCH+A and make sure
assistance for integrated programming and monitoring for that it is implemented in earnest.
RMNCH+A interventions.
Ms. Anuradha Gupta
A principal meeting topic was that harmonizing technical support
with RMNCH+A activities would add value to NRHM and accelerate
achievement of the desired health outcomes, especially in high-
priority districts. GOI expects that development partners will go beyond their individual expertise and complement other
development partners within states to provide technical support on the entire spectrum of RMNCH+A interventions. The
MOHFW makes sufficient resources available to the states under the NRHM, meaning that development partners can
draw upon their existing strengths and local presence in states and districts to assist the government at various levels in

16
planning, implementing, and monitoring the entire spectrum of RMNCH+A interventions. Strategies adopted or approved
by the MOHFW should be promoted at national scale, but there is significant scope under health systems strengthening for
innovation of service delivery mechanisms. Successful innovations must be recognized and best practices shared at the
national level through a formal mechanism.

Development partners including USAID, UNICEF, and UNFPA realized that they could play a significant role at the national,
state, and district levels as the country accelerates the pace of implementation. The need was to establish a mechanism
for harmonized technical support to national and state government efforts to achieve the MDG and 12th Five-Year Plan
goals. Partners immediately agreed to shift priorities to commit to the RMNCH+A roll-out. This represented a paradigm
shift from assistance with small-scale, decentralized interventions to direct coordination with government of India to build
country ownership and country-led ability to develop policy based on evolving global evidence.

The GOI identified six development partners (USAID, BMGF, DFID, UNICEF, UNFPA, and the Norway India Partnership
Initiative) as state lead partners (SLP) for implementing the strategy. These SLPs were assigned to support the health
department in the respective states, particularly the NRHM (NHM) (See Annex 1). The SLPs are the single point of contact
and accountability. The lead partner coordinates with other partners and agencies working in the state to harmonize the
actions across HPDs and provide the required technical support to the state NRHM. The SLP also convenes a monthly
meeting with all the district partners (DPs) in that state to review progress and discuss any challenges. Each HPD is
assigned one technical expert, called a district monitor (DM), who is drawn from DPs in the state. DMs are responsible for
overall monitoring of RMNCH+A interventions in that district under the guidance of the state lead partner.

USAID, supported by MCHIP, was assigned 33 HPDs districts in six states (shown in Table 1) for the roll-out of RMNCH+A
strategy and intensification of efforts to improve MCH outcomes in the targeted districts (see Annex 2 for maps of USAID-
supported states).

TABLE 2. USAID-SUPPORTED HIGH-PRIORITY DISTRICTS (33)

STATE DISTRICTS

Delhi (2) North East North West

Harayana (7) Bhiwani* Mewat

Hissar Panipat
Jind Palwal
Mahendargarh*

Himachal (4) Chamba Lahaul & Spiti

Kinnaur Mandi

Jharkhand (11) Paschimi-Singhbhum, Latehar

Saraikela-Kharsawan Lohardaga
Godda Gumla
Sahibganj Simdega
Pakaur Dumka
Palamu

Punjab (6) Sangrur Barnala

Muktsar Mansa
Gurdaspur Pathankot*

Uttarakhand (3) Haridwar Tehri

Pauri
*Proposed by state governments and included as HPDs

17
 Technical support was to be provided at multiple levels to allow a flow of information from the block level through the
national level. Attendees agreed that the SLPs would, in coordination with DPs working in a given state, spearhead the
establishment of mechanisms at the district, state, and national levels to provide technical support for intensification. At
the district level, a RMNCH+A coordinator, identified from among the DPs, would monitor specific activities in the district. A
technical advisor located at the state level would provide support. SLPs and DPs constitute the state-level RMNCH+A Unit
(SRU) and are tasked with engaging the state government and ensuring the flow of information to the central level through
a newly created National RMNCH+A Unit (NRU).

OPERATIONALIZING THE STRATEGY:

TRANSLATING COMMITMENTS INTO ACTION
DEVELOPMENT OF THE RMNCH+A 5 X 5 MATRIX AS A MANAGEMENT TOOL
To facilitate the implementation of the RMNCH+A strategy across the
The 5 X 5 matrix serves as a ready continuum of care, MCHIP worked with MOHFW and other DPs to develop
the RMNCH+A 5 X 5 matrix. The matrix guides health officials, partners, and
reckoner. We use it in our internal
programmers in the selection of:
meetings. All interventions mentioned
in the matrix have been planned Five high-impact interventions across each of the five thematic areas.
and are being implemented or are in Five cross-cutting and health systems strengthening interventions.
pipeline for implementation.
The minimum essential commodities across each of the thematic areas.
Dr. Suresh Dalpath, Deputy
Director, CH&I, Government of
The matrix is easy to remember and allows states and development
Haryana
partners to continuously focus on 25 actions for desired outcomes. When
implemented with high coverage and high quality, these interventions are
expected to have a great impact on reducing maternal and child mortality and morbidity.

The RMNCH+A 5 X 5 matrix has been translated into Hindi and regional languages for use by front-line workers (FLWs) and
managers. During its supportive supervision and review visits, the GOI tracks the FLWs orientation on the matrix to ensure
that all cadres of health functionaries are familiar with the matrix and are using it as a planning and management tool.

The matrix has been widely circulated and is displayed in offices of the MOHFW, state, district, and block health offices
including health facilities.

18
DEVELOPMENT OF RMNCH+A GUIDELINES AND TECHNICAL DOCUMENTS
The following guidelines and technical documents were prepared by the MOHFW in collaboration with development
partners, including USAID through MCHIP:

H
 andbook on Improving Maternal and Child Health through
RMNCH+A approach: This is a shorter version of RMNCH+A
strategy document that provides guidance to a broad range of
stakeholders. The handbook is suitable for medical officers and
program managers at various levels of implementation because
it describes the strategic approach and the continuum of care
concept. The handbook is expected to facilitate understanding
of the seemingly complex set of interventions required to
improve maternal and child health in India.
G
 uidance Note for Implementation of RMNCH+A Interventions
in High-Priority Districts: This note provides information
on how the HPDs were selected and details the roles and
responsibilities of DPs and other stakeholders in RMNCH+A
implementation. The note gives a brief overview of steps to assess gaps in implementation and develop a district action
plan that clearly specifies the technical support that the district will create to address these gaps and improve overall
coverage, utilization, and quality of services.
G
 uidance Note on Block Monitoring: To ensure that districts receive timely support to implement the most critical
interventions, the DPs are expected to offer need-based district-level assistance, and to work alongside district- and
block-level stakeholders to identify key bottlenecks and address them systematically. This guidance note outlines how to
conduct this collaboration
G
 uidance Note on District-level Gap Analysis of RMNCH+A implementation: This document offers broad guidance
on the processes and expected outcomes of the district-level gap analysis, a rapid assessment of gaps in service
availability, accessibility, utilization, and quality. The results of this initial rapid assessment are used to develop the
district RMNCH+A implementation plans that address key gaps through short- and mid-term actions.
K
 ey Performance Indicators and Quality Indicators: To monitor the
performance of the interventions identified in the RMNCH+A 5 X 5 matrix,
MOHFW, with support from the BMGF Innovations Project, has developed a The aim of introducing key
list of key performance indicators (KPIs) and quality indicators (QIs) for use performance indicators (KPIs) and
by program managers at all levels across the country, with special focus quality indicators (QIs) documents
on the 184 HPDs. Key performance indicators are ways to periodically is to provide a better understanding
assess the performance of organizations, departments, employees, or of the progress and performance of
programmes. Quality indicators are statistical measures that give an RMNCH+A implementation at state/
indication of output quality or process quality. Accordingly, KPIs and QIs district level. KPIs and QIs will identify
need to be defined in a way that is understandable, meaningful, and where performance is good and
measurable.
meeting desired standards, and where
Scorecards and Dashboards: All RMNCH+A activities emphasize effective use performance requires improvement to
of data for planning and implementing interventions. The RMNCH+A strategy assure accessible high-quality health
provides an opportunity to identify action points. Data from DLHS and AHS
care throughout the country.
data were used to develop a 19-indicator National Child Survival Scorecard,
and states are encouraged to develop similar state-level scorecards. Dr. Rakesh Kumar
In addition, the focus is on using critical HMIS indicators across the
lifecycle to develop quarterly service delivery dashboards to aid concurrent
monitoring. The color-coded dashboard identifies performance by states, districts, and blocks as good (green), promising
(yellow), poor (pink) and very poor performing (red) based on a composite index and also individually for the five thematic
areas. Because it is based on concurrent data, performance can be tracked on a quarterly basis and variations or
downturns can be identified and analyzed to ensure that intervention areas are prioritized accordingly.

19
The idea behind developing scorecards was to strengthen and streamline HMIS as a single source of data management
to facilitate sharing of feedback at different levels and data use for planning and monitoring progress. Scorecards have
been introduced at the national (depicting performance of states), state (depicting performance of districts) and district
(performance of blocks) levels. They act as a management tool, providing two-way feedback at all levels. Also, their
use helps to locate data entry and data quality issues and underscores the importance of data cleaning and quality
improvement.

Pictorial graphs on the dashboards make it easy to see progress over time, and motivate functionaries to sustain progress
and take corrective actions. Development partners provide mentoring on the use of scorecards through MCHIP at the
national level.

Scorecards were designed to be used widely, from front-line service provider s to state and national officials. Since their
introduction, scorecards have been used in monthly review meetings at various levels, including the national, for improved
governance. A limitation, however, was the inability to develop facility-based scorecards.

FORMATION AND FUNCTION OF NATIONAL RMNCH+A UNIT (NRU)

The National RMNCH+A Unit (NRU), a nine-member team supported by USAID through MCHIP, was anchored within the
MOHFW under leadership of the Joint Secretary Reproductive and Child Health (JS-RCH) and the Deputy Commissioner,
Child Health and Immunization (CH&I). The NRU was created to support the Ministry in monitoring the progress of
RMNCH+A implementation and intensification of efforts across the states. The key role of this unit is to assist all 29 states
in planning, implementation, and monitoring of RMNCH+A strategies.

Specific responsibilities of the NRU include liaising with departments of health to coordinate and monitor the
intensification of efforts in the HPDs, coordinating with regional SLPs /state NRHMs for facility assessment, situational
analysis, and scorecards; presenting key trends to JS-RCH; sharing best practices and cross-learning within regions; and
promoting adaptation of innovations.

Since inception in July 2013, NRUs have:

Facilitated five national RMNCH+A review meetings and 13 state consultations on RMNCH+A strategy implementation.
P
 rovided supportive supervision visits in 47 districts of 11 states to augment the implementation of RMNCH+A
interventions and support district-level program officers and district monitors.
Facilitated gap analyses in 179 districts and block monitoring in more than 500 blocks.

20
 Screened state PIPs to ensure that gaps identified through gap analysis exercises were reflected in the DHAPs.
S
 upported the drafting of key performance indicators and quality indicators to assess progress of RMNCH+A at the
district and state levels.

FORMATION AND FUNCTION OF STATE RMNCH+A UNITS (SRUS) AND

STATE UNIFIED TEAMS (SUTS)
State RMNCH+A Units (SRUs) were established in all six USAID/MCHIP-supported states. The SRU coordinates RMNCH+A
activities across all the HPDs within the states and provides technical assistance to the state program management unit
(SPMU) particularly for planning, implementing, and monitoring strategies for delivery of priority interventions in the HPDs.

State Unified Team (SUTs) were formed throughout the states including those supported by USAID/MCHIP. The SUTs
comprises representatives from state governments, medical colleges, state program management unit (SPMU), and DPs
working in the state. SUTs functions as the overarching technical body supporting and reviewing implementation of the
RMNCH+A strategy in each state.

STATE AND DISTRICT CONSULTATION MEETINGS: A BEST PRACTICE

To fast-track the implementation of the RMNCH+A approach, the
Departments of Health, Medical Education and Family Welfare, The state RMNCH+A consultations received
in collaboration with USAID through MCHIP, organized state strong support from the GOI, which sent high-
consultations on intensifying and harmonizing efforts in HPDs for
level delegations led by Ms. Anuradha Gupta,
improved maternal and child health outcomes. Key objectives were:
IAS, Ex-Additional Secretary and Mission
O
 rienting state and district government officials, partner agencies, Director, MOHFW in three states (Punjab,
educational institutions, and other stakeholders on the RMNCH+A Haryana, and Delhi). Dr. Rajesh Kumar,
approach. IAS, Joint Secretary, MOHFW in two states
E
 ducating participants on HPDs and the governments plan to (Jharkhand and Himachal Pradesh) was
intensify action for improving maternal and child health outcomes. present during the consultation at Punjab.
D
 iscussing mechanisms for harmonizing technical assistance Deputy commissioners from MOHFW took
for integrated programming and monitoring for RMNCH+A part in these consultations, as did senior
interventions. members of the USAID India Mission.
The consultations were a platform for discussing child survival and
development in the states. During the consultations, participants
were sensitized to the importance of intensification of efforts in HPDs through health system planning mechanisms, such
as additional financial allocations, priority interventions across RMNCH+A, accreditation of private health institutions,
improved demand for services, and intensive monitoring and evaluation. The consultations also emphasized the
importance of developing blocks as units for implementation of all government programs.

The consultations emphasized the role of DPs in supporting implementation of the RMNCH+A strategy, and of the SLP,
who acts as catalyst, and mentors who provide technical and managerial support to the state program management
units (SPMUs) and the district program management units (DPMUs) using resources provided by the government. The
consultations also emphasized the central role of deputy commissioners in planning and implementing the strategy.
They also brought the medical colleges to the forefront to provide technical guidance to the HPDs and to strengthen the
managerial skills of district functionaries. Each district will be assigned one of the state medical colleges.

Consultations also covered several steps to be taken by each state:

Identifying gaps through situation analysis in the HPDs by assessment of health facilities, community services,
and resource mapping. Based on the resulting evidence, district health plans need to be revised. Health system
strengthening, addressing gaps, increased demand for services through behavior change communication (BCC),
multi-sectoral planning, and supply chain management must also be addressed.

21
 S
 trengthening delivery points through infrastructure upgrades, building human resources, providing essential drugs
and commodities, and setting up state-specific targets as benchmarks for RMNCH+A interventions.
Improving monitoring by strengthening the online Mother and Child Tracking System (MCTS) to follow high-risk
pregnancies, children with low birth weight, and sick neonates.
Collaborating with other stakeholders such as Panchayati Raj, the Ministries of Rural Development, Women and Child
Development Departments, and NGOs.

The state consultations were held between July and October 2013 and attended by delegates from the entire health
spectrum. These visits leveraged involvement and motivation of senior government officials.

DISTRICT-LEVEL CONSULTATIONS FOR ROLL OUT OF THE RMNCH+A APPROACH

District-level RMNCH+A orientation workshops were conducted in HPDs
with MCHIP support between November 2013 and January 2014. The
workshops were organized by the district administration in collaboration
with the lead district partner. These events provided a platform for the
formal launch of the RMNCH+A strategy in the districts. In the majority
of the districts, workshops were chaired by the district collector with
participation of important district administrators and officials including the
civil surgeon cum chief medical officer, members of DPMU, district health
officials, representatives of allied departments like Water & Sanitation,
Social Welfare, Rural Development, and Education as well as partner and
local NGO representatives. At most consultations, technical leads from
the MCHIP national team and representatives from USAID shared their
perspective and insights.

GAP ANALYSIS: PROCESS AND DISSEMINATION OF FINDINGS

The effectiveness of RMNCH+A interventions will depend on availability, acceptability, utilization, and quality of services.
Analysis at various levels to address gaps in the delivery of a particular intervention or set of interventions is necessary.

The GOI conceptualized the district-level rapid gap analysis and facility assessment approach and developed standardized
tools to facilitate it. Results from the rapid assessment provide evidence for the district RMNCH+A implementation plan,
which should address key gaps through short- and mid-term actions.

MCHIP conducted gap analysis in the six USAID-supported states to assess the availability of infrastructure, human
resources, equipment, service capacity and quality, and resources of key RMNCH+A interventions in facilities and
communities, and to assess health system capacities at the district and state levels. MCHIP began the process with a
training-of-trainers (TOT) for consultants and SRU team members on the GOI guidelines and tools. Assessment tools and
schedules were developed according to the MOHFW guidance note on gap analysis.

The assessment was conducted between October and April 2014 at the designated delivery points. Primary data was
collected with MCHIP support at 36 district-level facilities, 91 first-referral units (FRUs), 389 non-FRUs, and 406 sub-
centers. In addition, 11,024 community-level interviews were conducted among pregnant women, mothers of children
under five years of age, and adolescent girls in five USAID states.

Interviews with key stakeholders at state and district levels were conducted to assess the functioning of health systems.
The MCHIP team established mechanisms for quality assurance during the assessment exercise. The national MCHIP team
conducted joint field visits to 10% of the assessment sites and organized briefing meetings at the end of each day with the
team of investigators to provide guidance and support. District officials including the district program manager (DPM) and
members of district program management unit (DPMU) were updated periodically. In addition, data collected at 5% of the
assessment sites were re-validated by the MCHIP national/state teams in the five states.

22
The findings were compiled and analyzed to identify critical gaps in service delivery. MCHIP prepared data and fact
sheets and shared these with the DPM, civil surgeon, chief medical officer of health, and other officials to facilitate DHAP
development, and with officials at the SPMU in preparation of state PIPs.

LEVERAGING NHM RESOURCES THROUGH STATE PIPS/DHAPS

Findings from the gap analysis across districts and blocks provide a
sound evidence base, enabling district administrators to set targets and USE OF HIGHER RESOURCE ENVELOPE
strategies to be used in DHAPs, including budgets for addressing structural,
programmatic, and service weaknesses within facilities, communities, and In Tehri Garhwal, PHC Philki conducts
health systems. more than 100 deliveries per month
While planning RMNCH+A interventions, DHAPs and state PIPs can leverage with only four beds. The Uttarakhand
NHM resources. States can allocate a 30% higher resource envelope per SRU raised this issue with the
capita allocated for each HPD (within the overall state resource envelope additional director, MCH, and a joint
under NHM). This provides flexibility in planning; states can use the higher visit to PHC Philki was made. After the
resource envelope to offer incentives to medical and paraprofessional visit the state added a new ward of 20
staff as part of the difficult area allowance; incentives could include free beds to the PIP. Uttarakhand has also
residential facilities or educational allowance for two children; and support proposed 30 new delivery points in the
staff motivation and retention in HPDs. This increased resource envelope three HPDs and is budgeting for set up
aims to increase equity by ensuring that additional resources are available of newborn corners.
to people who live in areas with the greatest need.

The higher financial allocation for HPDs also facilitates creative strategies for infrastructure upgrades and provision of
essential drugs and commodities. The assumption is that the package of financial and non-financial incentives offered will
help attract and retain skilled workers in challenging and inaccessible areas.

BLOCK MONITORING
The RMNCH+As District Intensification Plan designates the block, or district subdivision, as the primary unit for
implementation and management of RMNCH+A interventions, and calls for local capacity development through mentoring
support by the district and state management units along with SRU and SUT.

To ensure timely support to districts in implementing the most

critical interventions, DPs are expected to offer needs-based,
OBJECTIVES OF BLOCK MONITORING:
district-level assistance and work alongside district- and block-
level stakeholders to identify and systematically address key
Quickly assess infrastructure, human bottlenecks.
resources, and provision of services at
the facility and community level. Using a pre-determined block monitoring format prepared by
the GOI, district-level monitors, assigned under MCHIP in USAID-
Assess quality and coverage of service supported states, visited one block each month in each HPD
delivery. beginning in November 2013. Working with state- and district-level
government representatives, the team visited first-referral units,
Review progress of community primary health centres, community health centres, and a sample of
sub-centres, and interacted with the community.
outreach and home- or community-
based interventions. As of March 2014, MCHIP staff had conducted 55 block monitoring
visits in 72 facilities in the USAID-supported states of Jharkhand,
Validate reported HMIS data. Himachal Pradesh, Haryana, Punjab, and Uttarakhand. Findings
from the block monitoring visits were shared with the DPMU and
Gauge client satisfaction with SPMU, and action plans prepared for implementing corrective
RMNCH+A services. actions in a phased manner. Follow-up visits were made to ensure
that gaps and suggestions have been addressed.

23
ACCOUNTABILITY OF DEVELOPMENT PARTNERS THROUGH MONTHLY DP MEETINGS:
AN INNOVATIVE BEST PRACTICE
One of the GOIs successful innovations in the implementation of RMNCH+A was the monthly meetings with DPs. The
meetings are chaired by AS&MD with participation of senior officials from the MOHFW, DPs, and NRU and SRU members.
This mechanism provides a very useful platform, enabling each SLP to discuss progress on HPD activities, challenges in
implementation, and to plan for next month. During these meetings, the MOHFW shares the analysis of monitoring data
from each state, sets priorities, and agrees on a corrective action plan.

PROCESSES TO RESULTS
States and districts have implemented key processes and mechanisms to utilize the data collected and address key gaps
in PIPs and DHAPs. Action plans are being updated and efforts are being made to improve service delivery and quality.

Common gaps identified by the gap analysis process included:

Infrastructure

Lack of habitable staff quarters

Inappropriate disposal of biomedical waste

Delivery Facilities

Lack of toilets attached to labor and delivery facility

Lack of partograph charts
Stockouts of key commodities including magnesium sulphate, vitamin K, misoprostol, and delivery kits

Newborn Care Services

Absence of self-inflating bag and mask

Absence of newborn digital weighing machine
Absence of mucus extractor and suction tube

Availability of Essential Medicines

Stockouts (during last three months) of amoxycillin/ampicillin

Stockouts (during last three months) of betmethsone
Stockouts (during last three months) of choramphenicol eye ointment

Availability of Essential RMNCH+A Commodities

Supply chain management was poor with wide gaps in the availability of required essential drugs and surplus supplies of
some of medicines, leaving dead unused stock.

Stockouts (during last three months) IFA tablets (large)

Stockouts (during last three months) of IUCD kits (Suraksha)
Stockouts (during last three months) of zinc sulfate and vitamin A syrup
Stockouts (during last three months) of emergency contraceptive pills
Stockouts (during last three months) of oral contraceptive pills

24
Health Systems

A high degree of disparity was observed between the sanctioned staff ADDRESSING GEOGRAPHIC ISOLATION
and staff in position in many districts. Quality of service provision is
affected by inadequate capacity of the service providers at all levels In Uttarakhand, a palanquin service has
(specialists, general, and paramedical staff) as trainings mandated been included in the state PIP to transport
under the MNH Toolkit guidelines for the respective category of patients through difficult terrain to meet
specialists and other staff were not provided as required. Record an ambulance on the road. A palanquin
maintenance at all levels, especially sub-center level, was a major is a box-like structure with poles that
issue due to lack of awareness among the ANMs to complete required four or five men carry on their shoulders
forms and registers, high patient load, and extensive documentation and is an ancient mode of conveyance to
to be maintained. This shortcoming has a negative impact on patient
transport a single person. Today these are
outcomes, project progress, and future planning for strengthening
used symbolically for weddings and are
services. There were also major gaps in reporting of expenditures, and
maternal, infant, and neonatal death at all levels. known as dolis.

When PIPs and DHAPs are approved, GOI will track implementation and Uttarakhand is also addressing rational
allocation see if funds are being used for their intended purpose. The positioning of ambulance service in Pauri
process continues to evolve as GOI has provided supportive supervision Garhwal District to reduce travel time
checklists and block monitoring guidance, and findings are shared at the and is planning to train dais (traditional
state and district levels. birth attendants) in remote areas in safe
GOI is finalizing KPIs and QIs that were developed with the BMGF delivery and basic newborn care.
Innovations project. KPIs/QIs track both quality and coverage and were
developed as per the RMNCH+A 5 X 5 Matrix. When they are formally Jharkhand has advanced distribution of
released, states will be able to track critical high-impact interventions. misoprostol for safer home birth.
Other gaps observed include:

No defined district-level policy to fill contractual and permanent staff; no retention policy.
Inadequate emergency ambulance service; ambulance staff not trained in emergency care.
No verification or validation checks applied to check quality of data collected at various levels.
Fund flow utilization at district and block levels delays release of funds.
Resources are not allocated as per projections made to the state authority
Non-availability/delay in implementation of district-level guidelines.

In areas of cultural or geographical isolation, beneficiaries may be unable to access services. Access challenges contribute
to the low institutional delivery rates in some areas. Mechanisms to overcome this have been institutionalized such as in
Janani Shishu Suraksha Scheme (JSSK), which provides referral transport services for pregnant women through the Mamta
Vahan network (private vehicles have a memorandum of understanding with the state to ferry pregnant women to health
facilities at time of delivery). This service is also provided for infants.

Birth spacing methods are being promoted in tribal areas because permanent family planning methods are not to be
pursued. Such provision of services that can be taken up by the target population reflects a change in approach at the
state level.

Antenatal Care

Inadequate comprehensive emergency obstetric care (CeMOC)-trained doctors to manage high-risk and complicated
pregnancies.
Lack of blood sugar testing kit.
Lack of urine albumin testing kit.

25
Immunization

Vaccine stockouts, especially BCG.

No standard record-keeping registers for vaccine stock and distribution.
Incomplete microplans. Important annexure like vaccine logistics estimation, vaccine delivery plan, supervisory
schedule, and communication and contingency plans lacking.
Inadequate number of immunization sessions being monitored by supervisors.
Poor injection safety and immunization waste management practices.

Postnatal care

Beneficiaries not staying in the health facilities for 48 hours post-delivery

Low early initiation of breastfeeding
Not all newborns are examined before discharge
Large gap between reported home-based newborn care (HBNC) visits by ASHA and actual home visits.
Poor supportive supervision for HBNC by ANM/ASHA /district officials.
Poor linkages to referral facilities for transportation of sick neonates.

Family Planning

Low rates of IUCD insertion.

Need for increased capacity of delivery point health staff.
Low level of knowledge of PPIUCD services at community level.

Community-Level Interviews

Pregnant women: low report of receipt of safe motherhood booklet.

Pregnant women: low report of guidance and referral services provided with birth preparedness.
Mothers of children under five: low report of visits by ANM/ASHA within 2 days of home delivery.
Mothers of children under five: low awareness of at least two danger signs of diarrhea.
Mothers of children under five: low report of currently using any type of contraceptive method
Adolescent girls (10-19 years): low awareness about ARSH clinic at the government health facilities.
Adolescent girls (10-19 years): low report of visit to any ARSH clinic.
Adolescent girls (10-19 years): low report of counseling on menstrual hygiene by ASHA.
Adolescent girls (10-19 years): low report of procurement of sanitary napkins from ASHA during last six months.

At the facility level however, the gap analysis approach measures readiness but not quality of care provided or outcomes.
This is a limitation, but the gap analysis has proven to be an important tool in focusing state and HPD attention on
small doable actions to correct long-standing problems, including allocating their own budgets to fill gaps, requesting
supplemental resources through their PIPs, modifying their human resource strategies, and requesting technical
support from the national programs, their SRU, and development partners. The GOI has introduced block monitoring
and supportive supervision tools for continuous assessment to address gaps seen during the gap analyses and those
that might arise in the future. The table below provides an list of actions that states and HPDs have elected to close
identified gaps.

26
TABLE 3. ILLUSTRATIVE TABLE OF HOW USAID-SUPPORTED STATES AND DISTRICTS ARE ADDRESSING GAPS SEEN DURING
GAP ANALYSIS AND BLOCK MONITORING (MAY 2014)

INFRASTRUCTURE UPGRADES

J harkhand State Health Department took action to improve labor room practices in16 district hospitals, community
health centers, and primary health centers across six districts.

In 3 districts of Jharkhand, hospitals have shifted to new buildings to improve the physical infrastructure.

 ed occupancy in malnutrition treatment centers has improved from 46% in Q2 to 95% in Q4 (against state average
B
of 60%) in Lohardaga District in Jharkhand due to constant emphasis on optimizing MTC services during the block
monitoring visits and district review meetings.

In Uttarakhand, infrastructure-related gaps are being addressed in the DHPs that are funded by the state government.
One short-term action is to set up blood storage facilities and training centers in each HPD.

T here was no blood bank at the district hospital of Palwal in Haryana state. After feedback and regular follow-up, the
district hospital has procured the license for the blood bank and is recruiting staff.

DELIVERY FACILITIES

 ltrasound machine at maternity home in Mangolpuri (Dehli State) was non-functional. MCHIP advocated for district to
U
make it operational by end of May, 2014?.

In Pauri District, Uttarakhand gaps identified during block monitoring led to plan for infrastructure upgrades at delivery
points to ensure 24/7 running tap water in labor room and purchase of hydraulic operating theater table and ceiling
lights.

 aternal and Newborn Health Toolkit has been made available at all block-level health facilities to strengthen delivery
M
points in Uttarakhand according to national guidelines.

 roposal to create MCH wing at PHC Pilkhi (highest case load PHC facility in the state) included in Uttarakhands
P
2014 PIP.

Partographs have been printed and distributed to all facilities in the State of Punjab.

NEWBORN CARE FACILITIES

Newborn care corners (NBCCs) established/operationalized in 8 facilities across 6 districts in Jharkhand.

 BCC established and provided with majority of essential equipment and commodities at delivery points in Uttarakhand
N
districts of Tehri Garhwal, Haridwar, and Pauri Garhwal.

Two demonstration sites for NBCC proposed and one established in Tehri Garhwal District.

The guideline on vitamin K in the HPDs is now available and being used within 1 hour of birth in Punjab State.

COMMODITIES

 vailability of essential equipment and commodities has improved. The Uttarakhand PIP proposes the hiring of a district-
A
level logistic manager to strengthen supply chain management of RMNCH+A commodities.

 urchase of key RMNCH+A commodities from the United Funds and provisions under JSSK including purchase of
P
magnesium sulfate and vitamin K in Uttarakhand. Procurement process for vitamin A and zinc has also been initiated.

In Haryana, all commodities in the 5 x 5 Matrix are now included in the essential drug list. After the dissemination of the
gap analysis findings in Punjab State, the essential drug list was modified to include commodities as per the RMNCH+A
5 X 5 Matrix.

27
  fter feedback to education department authorities and district health officials in Mandi and Kinnaur Districts
A
of Himachal Pradesh, implementation of the weekly iron and folic acid (WIFS) program has been regularized in
some schools.

HEALTH SYSTEMS STRENGTHENING

District health action plans (DHAPs) of 11 HPDs prepared in a systematic manner for the first time in Jharkhand State.

 lock monitoring visits found that staff nurses are conducting deliveries in Delhi State yet the training calendar did not
B
plan to train staff nurses on PPIUCD. Plans have been made and approved by state officials to do so going forward.

Training need assessment for health staff has been planned in Uttarakhand.

 systematic review of existing data sources in Haryana was done by MCHIP. Based on some the recommendations,
A
an exercise of rationalization of the various indicators in HMIS (i.e. reduction of indictors that are never reviewed or
reported) was conducted. Development of an integrated portal capturing indicators from various sources across the
spectrum of RMNCH+A programs has been initiated.

LESSONS LEARNED
When the Government of India launched the RMNCH+A strategy at the National Summit on the Call to Action for Child
Survival in February 2013, there were no concrete plans or guidance for its introduction. Very soon after the national
summit, senior MOHFW and NRHM officials mobilized, enlisting the health development partners, including USAID and
MCHIP, to support the national RMNCH+A roll out, assigning a lead development partner for each state, creating national,
state, and district RMNCH+A resource units with partner support, and subsequently, as described in earlier sections of this
case study, preparing the guidelines, tools, and procedures that have turned the RMNCH+A strategy from a mere concept
to an emerging reality in 29 states and 184 HPDs across India.

With little over a year since most of the initial state RMNCH+A consultations, it is clearly too early to measure the
impact of RMNCH+A on health outcomes or even coverage levels. Nonetheless, individual states and HPDs are showing
improvements and there have been important lessons learned or reinforced that should guide RMNCH+A refinement and
expansion. The authors of this document believe that the GoIs experience, including the lessons learned, are important
to share with other governments and partners who are also launching ambitious national efforts to accelerate reductions
and eventually end preventable maternal and child death.

Indias lessons during its first twelve months of RMNCH+A implementation include the following:

S
 trong government leadershipat both national and state level--is critical when introducing a change of the magnitude
that RMNCH+A represents. From the perspective of its development partners, the GOI has provided extraordinary
leadership in the case of RMNCH+A. Not only did the strategy reach all states and HPDs in a short period of time, the
GoI also ensured collective involvement across the political spectrum through an inclusive, consultative, andcrucially
apolitical process. This increases the likelihood that even with government change, the RMNCH+A strategy will continue.
Involving and engaging district magistrates, the bureaucratic heads in the districts, and senior administrative officers
from the beginning has been part of the RMNCH+A approach. More attention should be paid to engaging officials and
community representatives in defining and monitoring the quality of RMNCH+A care as the strategy is expanded and
taken to scale.
T o ensure a continuum of care through all life stages, a technical strategy like RMNCH+As must include operational
guidelines, training modules, job aids, and an information system that guides and supports implementation. These
tools were prepared during RMNCH+A roll out, thanks to the leadership of the GOI and the active engagement of priority
MOHFW programs and development partners. The 5 X 5 matrix of high-impact RMNCH+A interventions is an important
tool for prioritizing interventions and explaining the strategy to all involved in simple terms. It also provides a simple
framework for organizing technical support, identifying program gaps, and monitoring progress with the states and HPDs.

28
 H
 armonization of development partner and GoI efforts succeeded in mobilizing external technical resources to support
the RMNCH+A roll out. However, because technical direction and support were provided by different development
partners at state, district, and block levels, coordination and harmonization across partners was sometimes a challenge.
Regular program planning and review meetings between partners, led by state and national health officials, will be
extremely important to ensure success and optimal use of technical support as RMNCH+A continues implemention.
M
 ulti-level gap analysis and continuous block monitoring played important roles in identifying strengths and weaknesses
and increasing awareness among national, district and block officials of the need to improve the quality of RMNCH+A
care. Increased involvement of state and district health officials in block monitoring (covering delivery points/health
facilities) in many cases resulted in immediate corrective actions to improve service delivery, while larger gaps, affecting
multiple blocks, were addressed through annual district health action plans and state program implementation plans in
all of the USAID-supported states. Intensive technical assistance and mentoring of functionaries at various levels was an
integral part of this component. The process is on-going and evolving.
M
 onthly meetings led by the MOHFW with development partners and increased supportive supervision by GOI officials
resulted in increased accountability for implementation of the RMNCH+A components. Scorecards were constructed
and used to visually compare and discuss the performance of blocks and HPDs during review meetings. The degree to
which the scorecards are understood and have affected the pace and results of RMNCH+A implementation should be
evaluated over the next year.
In the first year of RMNCH+A implementation, the focus has been on making the elements of the strategy known and
identifying serious gaps in the availability and use of life-saving interventions. The quality of care provided to women,
newborns, infants, young children and adolescents in health facilities and communities continues to be a serious
concern for the GoI, one that deserves more attention in the second year of the RMNCH+A roll out.

RECOMMENDATIONSTHE WAY FORWARD

The RMNCH+A strategy was developed and rolled out very quickly, yet it is already yielding
important results. The first phase of RMNCH+A involved orientation and sensitization of a diverse
set of stakeholders to the RMNCH+A strategy, establishment of key processes for rolling out the
strategy, and capacity building for different cadres of human resources. MCHIP recommends that
GOI and development partners such as USAID focus during the next phase of RMNCH+A scale up
on the following issues and actions:

C
 ontinuous monitoring, supportive supervision, and feedback mechanisms to improve
quality of care and accountability: The GoI is finalizing a set of key performance and quality of
care indicators that are linked to the RMNCH+A 5 X 5 Matrix. These should be rolled out and
used, along with simplified feedback mechanisms to raise awareness and hold officials and
providers accountable for RMNCH+A results. Supportive supervision through continuous block
monitoring, the Rapid Appraisal of Implementation in District (RAPID) approach, and other
approaches are not only important for data collection and monitoring, but also in that they
offer important opportunities for structured, on-site mentoring and coaching.
T est performance-based incentives under the RMNCH+A mandate: The GoI has developed a
strategy and indicators for incentivizing district performance and proposes to test it during the
next phase of the RMNCH+A roll out. Performance-based incentives could be an important to
ensure accomplishment of targets set out by the GOI under RMNCH+A and the 12th Five-Year
Plan. Getting the incentives right is an important aspect of the new strategy that should be
carefully studied during a pilot phase.
Increase attention to the availability and utilization of high-quality health services in urban areas: The Urban Health
Mission has been added under the National Health Mission to ensure equal focus on rural and urban health care needs.
Urban health cannot be a replica of rural health because the contexts are different. The strong presence of the private
sector must be leveraged to improve the quality of health care in urban settings. Likewise, intersectoral convergence and
the active engagement of civil society, while important in rural areas, is even more important in efforts to improve the
health of women, children and adolescents in urban settings.

29
 Increase attention under the RMNCH+A mandate to the nutritional status of women and children: In particular,
the needs of severely anaemic women and severely acute malnourished (SAM) children require increased attention.
The Government of India is initiating calcium and iron supplementation to improve maternal and infant survival, but
successful operationalization will require greater convergence with the Department of Women and Child Development,
given its presence in every village of India. Infrastructure and behavior change/communication interventions will also
be required to improve the populations access to clean water and sanitation as these are also important in reducing
the currently high levels of maternal and child malnutrition.

S
 trengthen the continuum of care from community to facility through improved community mobilization and
behavior change communication approaches: to ensure that messaging and delivery channels are consistent with
and comprehensive enough to cover the full range of RMNCH+A interventions and services.
Increase the involvement of the private sector and CSOs in the RMNCH+A roll out to ensure saturation of services in
both urban and rural areas: In 2014, the GOI added a 6% allocation within the revised NHM guidelines for community-
based organizations that is intended to facilitate their engagement and sustain their efforts in the execution of the
RMNCH+A strategy. The degree to which this allocation has reached community-based organization and how they
have used the additional resources is not yet know, but should be studied. USAID should support the GoI to facilitate
the involvement of private sector and civil society organizations in expanding service availability to all areas. An
evaluation of the initial 6% allocation for community-based organizations would be a good starting point in the effort to
institutionalize and maximize this CSO investment in the future.
C
 ontinue to focus on larger health system strengthening issues, including the rational deployment of human
resources, availability of essential commodities, infrastructure improvement, and the task shifting. The Gap Analysis
exercise in each state highlighted serious deficiencies in all of these areas. USAID implementing partners and other
development agencies should continue to provide support not only to highlight but also to help state governments
address these problems.
F
 oster innovations and systematically evaluate, document and share best practices to enhance policy, service
delivery, financing and accountability mechanisms across India: Innovations in implementation achieved by various
development partners should be captured, documented, and advocated for scale-up. Advocacy with multiple levels
of government and all stakeholders to enhance their involvement and promote sustainability and scale up of best
practices will be required.
Finally, the authors of this paperUSAID and MCHIP--believe that Indias RMNCH+A experience should be shared widely
outside of India, to inspire other countries and development agencies to develop similarly ambitious national efforts. As a
co-sponsor of the Global Call to Action for Child Survival in 2012, the Government of India has successfully harnessed
the global momentum and commitment to ending preventable child and maternal deaths and focused it at home. Indias
experience is uniquely its own, of course, but we believe that there are many elements of Indias RMNCH+A strategy,
including its guidelines, tools, job aids, and processes, that could be adapted and transferred to other settings to produce
similar results. The critical ingredient to success in India and elsewhere, however, is always strong government leadership.
The GoI has demonstrated its commitment and played an extraordinarily proactive leadership role from the beginning of
the RMNCH+A strategy development through its national roll out. We applaud their efforts and look forward to continuing
USAIDs support at national and state level during the exciting next phase of Indias national RMNCH+A implementation.

30
REFERENCES
United Nations. 2013. The Partnership for Maternal, Newborn & Child Health 2013 Report. Available at: http://www.
un.org/millenniumgoals/pdf/report-2013/mdg-report-2013-english.pdf

World Health Organization. 2012. Trends in maternal mortality: 1990 to 2010 WHO, UNICEF, UNFPA and The World Bank
estimates. Available at: https://www.unfpa.org/webdav/site/global/shared/documents/publications/2012/Trends_in_
maternal_mortality_A4-1.pdf

UNICEF. 2011. Levels & Trends in Child Mortality: Report 2011. Available at: http://www.unicef.org/media/files/Child_
Mortality_Report_2011_Final.pdf

Save the Children. 2013. Surviving the First Day: State of the Worlds Mother 2013. Available at: http://www.
savethechildren.org.uk/sites/default/files/images/State_of_World_Mothers_2013.pdf

Office of the Registrar General & Census Commissioner, India. Annual Health Survey 2011-12: Madhya Pradesh. Available
at: http://www.censusindia.gov.in/vital_ statistics/AHSBulletins/files2012/Madhya%20Pradesh_Bulletin%202011-12.pdf

Ministry of Health & Family Welfare. 2013. A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent
Health (RMNCH+A) in India.

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32
ANNEXES

ANNEX 1. HIGH-PRIORITY DISTRICTS AND STATE LEAD PARTNERS

DEVELOPMENT PARTNERS STATES HIGH-PRIORITY DISTRICTS BLOCKS

UNICEF 17 84 607

USAID 6 30 212

Bill & Melinda Gates Foundation 2 29 368

DFID 2 25 176

UNFPA 1 10 65

Norway India Partnership Initiative 1 6 27

TOTAL 29 184 1455

33
ANNEX 2. USAID SUPPORTED HIGH PRIORITY DISTRICTS FOR
RMNCH+A IN SIX STATES

PUNJAB HARAYANA HIMACHAL

P a n c h k u l a

G U R DA S
P U R

A m b a l a Y a m u n a n a g a r
A M R IT S
A R H O S H IA R P
UR

K u r u k s h e t r a
C H A M B A
L A H U L & S P I T I
T A R N T A R A N K A P UR T H
A L A
K A P UR T H
A L A K a i t h a l
K a r n a l
J A L A N D H A R R O O P N A G A R S i r s a
N A W A S H E R F a t e h a b a d
J in
d
P a n i p a t K A N G R A
L U D HI A N A M O H A L I K U L L U
F AR
ID
K O T M O G A H i s a r
F AT E
HG A R
H-
S A H I B
S o n e p a t H A M I I R P U R
B A R NA L
A K I N N A U R
F E R OZ
E P UR

P A T I A L A R o h t a k M A N D I
M U K T S AR
U N A
B H A T I N D A S A N G R U R B h i w a n i B I L A A S P U R
J ha
j j a r
S H I M L A
M A N S A F a r i d a b a d
G u r g a o n
S O L A N
M a h i n d e r g a r h R e w a r i

M e w a t P a l w a l S I R M U R

DELH UTTARAKHAN JHARKHAND

S AH IB G A NJ

G O DDA

N O R T H - W E S T
P AK UR
U T T A R K A S HI

K O DE R MA

DE O G H AR
DUMK A
D E H A R A D U N
G AR HW A
P AL A MU
C HAT R A
HAZ AR IB AG H

G IR IDIH
R UD
R A P R AY A G

W E S T
N O R T H N O R T H - E A S T C HA
M O L I
J AMTA R A
T E HR
I G A R HW
A L

L A T E HA R
R AMG AR H
DHAN B A D

C E N T R A L P I T H O R A G A R H
BOK A R O
E A S T
G A R HW
A L
L O H AR D AG A
H A R D W A R B A G E S H W A R
N E W D E L H I
R ANC HI
A L M O R A

G UML A
S O U T H - W E S T
K HUN TI

N A I N I T A L C HA

S AR AIK E L L A
M P AW
A T

S IMDE G A
S ING HB HUM E AS T
S O U T H
S ING HB HUM WE S T
U D H A M S IN
G H N A G A R

34
ANNEX 3. RMNCH+A 5 X 5 MATRIX

35
36