True measure of progress
With women’s health being a prominent indicator of sustainable development, India has striven to finance better health outcomes, especially in the case of maternal health
Women are strong pillars of any vibrant society. Sustained development of the county can be achieved only if we take holistic care of women. Under the National Health Mission (NHM), strategic investments have been made for Reproductive and Child Health programme for improvement of maternal health.
India has made large strides in maternal health over the past several decades, reducing its maternal mortality ratio (MMR) from 556 in 1990 to 122 maternal deaths per 1,00,000 live births in 2015, experiencing a decline of 78 per cent. With this progress, India has achieved the United Nations (UN) Millennium Development Goals (MDGs) target of 5A which was committed to reducing MMR by 75 per cent by 2015. The country is now heading towards achieving UN Sustainable Development Goals (SDG) of reducing MMR to 70 deaths per 1,00,000 by 2030. States of Kerala (42), Maharashtra (55) and Tamil Nadu (63) have already achieved SDG.
Approximately 1.38 lakh women were dying every year on account of complications related to pregnancy and childbirth which has been reduced to 32,000 in 2015. There has been an accelerated decline in MMR in India. Globally 5,32,000 mothers were dying in 1990 which has reduced to 3,03,000 in 2015 meaning reduction in India is 4.3 times more than the global reduction of 1.8 per cent during this period.
Much of the progress in reducing MMR has been due to implementation of social programmes by the Government of India, multiple donors, civil societies and other non-governmental organisations. Maternal health efforts in India emerged from policies which initially aimed at slowing down population growth through family planning in the 1950s. During that time and through the late 1980s, most of these efforts concentrated on family planning services in the form of making modern contraceptives available which protected the mother's health by delaying pregnancy and facilitating birth spacing. Contraceptive use in India multiplied several times over a period of last few decades as more than 50 per cent of all women in India were using contraceptives in 2010.
The 1990s brought a paradigm shift in India when issues relating to population growth and economic development were linked to women's empowerment, gender equality and reproductive rights. High rates of maternal mortality also emerged as a key concern in India. As a result, the GoI launched several initiatives, including the Child Survival and Safe Motherhood Programme (1992-1995) and the Reproductive and Child Health phase I (RCH-I) Programme (1997-2004) to improve women's ability to obtain maternal health services.
These programmes were developed with the recognition that improving maternal health outcomes require access to comprehensive primary care and a continuum of care through pre-conception, antenatal checkups, at the time of delivery, post-natal, and inter conception periods.
The millennium development goal (MDG), target 5A focused on reducing maternal mortality and also increase in the proportion of births attended by skilled health personnel. The government launched National Rural Health Mission (NRHM) in 2005 which aimed to increase the provision of both essential and emergency obstetrical care, improve the referral system for pregnancy complications, strengthen infrastructure enhance capacity building of care-givers and health facilities, and create incentives for the use of maternal health services, such as Janani Suraksha Yojana (JSY), which provided payments to mothers and incentive to ASHAs for institutional delivery.
The government also launched reproductive, maternal, newborn, child health plus adolescent health (RMNCH+A) in 2011, shifting focus to quality health care and adding an adolescent health component, re-emphasizing family planning, and addressing disparities across states.
During the period from 2005 to 2013, maternal health care was provided through NRHM but the health care needs of urban slums were neglected. The National Urban Health Mission (NUHM) was implemented in 2013, emphasising on providing essential primary health care services and reducing out-of-pocket expenses for the urban poor/slum dwellers.
National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM) together focus on strengthening infrastructure and capacity building of providers and facilities. Today, almost 80 per cent of live births in India take place at a health facility, compared with about 25 per cent 25 years ago.
In addition to existing public health care systems, private health sectors have their own structures and systems for the provision of maternal health care. The private health sector also delivers a large proportion of the country's maternal health services, accounting for around two-fifths of institutional deliveries.
At the community level, women's point of contact within the public health system occurs with accredited social health activists (ASHAs). Under the National Health Mission, a network of almost 10 lakh ASHAs provides health education, mobilisation and promotion through home visits and community meetings. In return, ASHAs receive performance-based compensation for promoting key maternal health services including family planning, early registration of pregnancies, antenatal, delivery and postnatal care, communicable diseases like tuberculosis (TB), leprosy, vector-borne diseases and non-communicable disease like hypertension, diabetes, etc.
They distribute pills, condoms, and iron/folic acid tablets, assist women with developing a birth preparedness plan collects sputum for TB, blood slides for malaria and provides medicines to TB patients. In rural areas, ASHAs work closely with Anganwadi workers (AWWs) and other front-line workers from the Integrated Child Development Services (ICDS) program who offer basic health and nutrition services to women and children. ASHAs and AWWs support the organisation of monthly health, sanitation and nutrition days in their communities with auxiliary nurse-midwives (ANMs) from the nearest health sub-centre.
Special schemes have been launched to address high MMR such as JSY in April 2005 that provides free drugs, diagnostic, diet, transport and blood for institutional deliveries. JSY has disbursed more than Rs 20,000 crore cash assistance to beneficiaries. On the phenomenal progress of JSY scheme, Janam Shishu Suraksha Karyakaram (JSSK) was launched in June 2011 which entitles institutional deliveries absolutely free or no expense delivery covering special care of all sick newborns.
The Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) has been launched in November 2016 to provide fixed-day assured, comprehensive and quality ANC universally to all pregnant women on 9th of every month. An IT-based mother and child tracking system (MCTS) has been implemented to ensure that every pregnant woman gets complete and quality ANC and PNC and every child receives a full range of immunisation services. State-of-the-art, maternal and child health (MCH) wings have been established to improve the quality of maternal care. National Skill Labs have been established with the support of the Liverpool School of Tropical Medicines (LSTM) for quality training. Maternal Death Review (MDR) and Maternal Death Surveillance and Response (MDSR) process have been institutionalised to identify not only the medical causes but also socio-economic-cultural determinants.
A call centre based network of 25,000 ambulances/patient transport vehicles is functional across the states. A historic and landmark policy decision has been implemented in the form of rolling out midwifery services in order to improve the quality of health care and ensure respectful care to pregnant women and reduce over-medicalisation. Labour Room & Maternity Quality improvement initiative (LaQshya) has been implemented to reduce complications and deaths of mothers and babies during the intrapartum and immediate postpartum period which contributes to the highest proportion of maternal and newborn deaths.
Additionally, in order to address widespread anaemia in India where 53.2 per cent of non-pregnant women and 50.4 per cent of pregnant women are found to be anaemic, Poshan Abhiyan-holistic nourishment and Anaemia Mukt Bharat (AMB), an intensified Iron-plus initiative have been started in March 2018 to strengthen the existing mechanism and foster newer strategies for tackling anaemia. Also, Surakshit Matritva Aashwashan (SUMAN) was launched in October 2019 which aims at assuring dignified, respected and quality health care at no cost and zero tolerance for denial of services for every woman and newborn visiting the public health facility in order to end all preventable maternal and newborn deaths.
It is rightly said that women's health needs to be front and centre and, it often is not but it needs to be, something the healthcare sector in India has been making strides towards.
The writer is the Director of Finance (NHM), Ministry of Health & Family Welfare, GoI). Views expressed are strictly personal