V
Reproductive Health
R.N. Gupta
The central theme of the present chapter is Reproductive Health (RH) - a concept and approach to the delivery of government health care services to both men and women, including adolescents. The explicit objective of the discussion and citations from different sources in this chapter is to provide credible information deemed necessary for conceptual clarity and good understanding of RH and its important components, viz. the concept, objectives, approach and strategy, definition, scope, elements, principles, and finally, the national Reproductive and Child Health (RCH) programme. However, at the outset of the discussion, it is felt mandatory to trace its health background and look into the transition as to how the health concept transformed into the reproductive health concept. Accordingly, the chapter opens up with perception and definition of health.
The aspiration, thus, is that this scheme of the present chapter should help not only in understanding the RH but also in identifying your role as a teacher or trainer in its preventive, promotive and rehabilitative aspects that could be played by educating students/trainees and sensitizing masses for its manifold benefits. Your role as a service provider or doctor becomes more critical when the question of understanding of the client/patient’s RH needs and problems, reproductive rights, etc. becomes poignant and the need for your information, education, communication and counselling skills and delivery of high quality RH care becomes imperative, especially in the backdrop of the users’ perspective yielding into satisfaction.
Perception & Definition of Health
Health, for quite long time, could hardly find a place in our common man’s need hierarchy, despite the motto, health is wealth advocated by those people who knew the benefits of it and had access to the services. Food, shelter, occupation and other socio-economic amenities remained predominantly the common man’s felt-needs. Due to lack of awareness and sensitivity, his perception of health has been that a person who is visibly not sick and looks stout, is healthy as against a lean and thin looking person presumably unhealthy. In his such perception, mental and social elements rendering the man weak and unfit to do his routine chores, earn livelihood and lead a normal life, generally do not find reflection. Absence of infirmity or disease and good physical appearance seemed to dominate until recent past as the only indicators of his perception of health. He could not perceive his health as an essential element to improve his quality of life. It were the development processes initiated through government’s Five Year Plans starting from early 1950’s, dissemination of information and continued emphasis on literacy, health, population control measures and use of media, which sensitized a large section of people, influenced their thinking process, attitude, and enabled them to perceive and understand things in their right perspective.
As a result, now a common man’s perception of health is more than merely absence of infirmity or disease, i.e. complete well being that could enable him to do his routine work, earn livelihood and lead a good life. Now, he knows considerably about his rights, demands for the same and wants to remain healthy. The swelling crowds to health quacks, private practitioners, dispensaries, hospitals, and pharmaceutical shops testify this change in common man’s perception of health and the resulting health behaviour.
Health is an essential input to human resource development culminating into behavioural transformation that influences the quality of life and status of society:1 Health, more appropriately, public health was elaborately defined in 1920 by C.E.A. Winslow as the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community efforts for sanitation of environment, the control of communicable infections, the education of individual and personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits to enable citizen to realize his birth-right of health - health and longevity.2 George Rosen viewed public health in 1963, as a significant functional system of the community, that may be understood as community action in the interest of health.2 John B. Grant has described community health care a less narrow term than public health as personal services whose aim is to protect, promote, and restore health of individuals. He finds it as a part of a spectrum that includes environmental services at one end and educational services at the other.3
Health is seen globally as human right and defined as per the constitution of the World Health organization (WHO), as a state of complete physical mental and social well-being which results when disease free people live in harmony with their environment and with others.
If you carefully analyze this definition, you will find that two-third of its elements, i.e. mental, related to state of mind and social, related to life style, seem to have much to constitute the concept of health and contribute to human health. This suggests that the mental and social elements of an individual can take care of his physical element to a large extent. Accordingly, ‘health’ may be defined as:
Health is a way of life - a normative behaviour, and measure to prevent infirmity, ailment and promote general well being of the individual.
Health does not and should not connote necessarily medicine, rather a state contrary to morbid condition.5
Health Concept and Development
Historically, the concept of health with its reflection in modern system of medicine and treatment came to India with the British rule. It functioned as a close-system, limited "especially to British residents in India, Government employees and military personnel."6 As a result, it created the impression of an alien system among the majority of people unable to identify it with their indigenous systems of medicine, which until then and later, were being resorted to by the needy. on the other hand, it was grossly inaccessible to the common masses.1 This situation had indicated the need for modern health care. As a result, "some efforts were made to provide health facilities, like control of epidemics, setting up of civil hospitals in some urban areas and a few rural dispensaries in outlying areas. obviously, neither the health care planning nor medical education were based on the health needs of the people."6 A National Planning Committee was constituted with Pandit Jawaharlal Nehru as its Chairman in 1938, who appointed a Sub-Committee on National Health under the Chairmanship of Col. S.S. Sokhey. During 1946, the prevailing health condition in the country was assessed by the Development Committee, popularly known as Bhore Committee, and health development measures were suggested using modest criteria for increasing hospital beds, providing specialized services at district hospitals, and primary health care concept for rural areas. In 1961, the Mudaliar Committee reviewed the progress of the implementation of the Bhore Committee’s recommendations and suggested measures for speedy implementation of the recommendations for achieving the targets. Prior to this, the launch of the First Five Year Plan in 1951 and Community Development Programme in 1952 had also laid considerable emphasis on health and women development in the country. In order to make health services accessible to people and meet their health needs, the Chadha Committee suggested in 1965 the training of the rural health workers in order to make them multi-purpose health workers (MPWs). The Mukherjee Committee in 1966 and Jangalwala Committee in 1967 reviewed the progress and made necessary recommendation. This suggestion of training of rural health workers was reiterated in 1973 by the Kartar Singh Committee. By now, the ‘health concept’ had became more clear and the suggestion could be considered feasible for implementation as part of the Primary Health Care Scheme of the Union Government, particularly in 1975 when Srivastava Committee had recommended the use of rural manpower resources for health care delivery to the masses on the lines of the voluntary agencies. To this effect, the Indian Council of Medical Research (ICMR) had sponsored a three-centre Task Force study with Dr (Mrs) Sushila Nayar, Dr. L. Ramachandran and Dr (Mrs) Kamala Gopal Rao in Wardha, Gandhigram and Aligarh respectively with objective of assessing the feasibility and effectiveness of involvement of rural school teachers in primary health care system.1 Our conceptual clarity, thinking and efforts in health seemed to have had the influence of the contemporary innovative thinking and development that were taking place in our neighbouring country China. Dr. John, Grant’s proposition of use of ‘lay people’ in health care advocated in 1939 and later, the use of ‘barefoot doctors’ appear close to the spirit of Col. Sokhey Committee’s recommendations made in 1940 and Srivastava Committee’s recommendations made in 1975. It was J.P. Naik’s persistent efforts to promote community self-reliance in health matters that received strong support when the new government (Janata Party) in 1977 adopted the policy of entrusting the people’s health to the people’s hands by training the community health workers (CHWS) chosen by the people themselves and Raj Narain being the then Union Minister for health implemented the CHW Scheme, though in haste and before any logical conclusion of the ICMR study.1Later, the Indian Council of Social Science Research (ICSSR) and ICMR made a joint panel that constituted 4 subgroups to study different aspects of health in India. Keeping pace with the contemporary development, the ICMR and ICSSR had organized jointly a symposium on "Alternative Approaches to Health Care" at the National Institute of Nutrition, Hyderabad in 1976, a National Conference on "Evaluation of Primary Health Care Pprogrammel at ICMR, New Delhi in 1980, and a National Workshop on "Appropriate Technology for Primary Health Care" at ICMR, New Delhi in 1981. While these developments were taking place in the country, the concept of primary health care through non-medical village health workers was emphasized by the WHO at the Alma-Ata Conference in 1978 which reinforced our national efforts.
In subsequent years, critical appraisal was made of the health policies and approaches adopted in the previous Five Year Plans. The Planning Commission constituted in 1980 a working Group on Health for All by 2000 AD to identify in programme terms, the goal for Health for All by 2000 AD, and outline with that perspective, the specific programme for the Sixth Five Year Plan. "A long term perspective plan was outlined for achieving the Health for All. The National Health Policy was officially adopted by the Parliament in 1983. Health for All" principles and strategies were incorporated in the Sixth (1980-85), Seventh (1985-90) and Eighth Five Year (1992-97) Plans. The focus in these plans had been on the improvement in health indicators including achievement of NRR-1 by 2000 AD, national health policy; consolidation of national health infrastructure, involvement of NGOS, biomedical and social research; human resource development, revised strategy, etc.
Rural Health Infrastructure
India after having signed the Alma-Ata Declaration in 1978, became committed to attaining the goal of ‘Health for All’ by 2000 AD through its primary health care approach. In this context, the Government revised its strategy and laid down national norms for providing and strengthening health infrastructure and aimed to make the services easily accessible to rural and tribal population all over the country and thus ensure a better population coverage. Under this approach, a 3-tier health care delivery system is made functional with 3 types of health institutions and different cadre of staff. For re-structuring or creation of these institutions, the laid down national population based norms and their existing numbers as on 31st December 1996 are as under:
Table - 1 : Population Norms for Rural Health Institutions
| Health Institution | Population Norm | No. functioning | ||
| Plain area | Hilly & Tribal areas |
|||
| 1. | Sub-Centre (SC) : | 5,000 | 3,000 | 1,33,498 |
| 2. | Primary Health Contre (PHC) : | 30,000 | 20,000 | 21,889 |
| 3. | Community Health Centre (CHC) : | 120,000 | 80,000 | 2,433 |
Source : GOI Bulletin on Rural Health Statistics in India, December, 1996.
These health institutions are provided with the following category of staff. The staff in position as on 31st December, 1996 is given against each category.
Table - 2 : Rural Health Staff in Position
| Category of Staff | Staff in Position | |
| 1. | Auxiliary Nurse Mid wife (ANM): | 1,33,481 |
| 2. | Multi-purpose Worker (MPW) - Male: | 60,521 |
| 3. | Health Assistant (HA) - Female/Lady: Health Visitor (LHV): |
18,022 |
| 4. | Health Assistant (HA) - Male: | 17,,172 |
| 5. | Doctor at PHC: | 27,721 |
| 6. | Specialists: a) Surgeon b) Obs. and Gyn c) Physician d) Paediatrician Total specialists at CHC: |
713 595 624 531 2,717 |
| 7. | Radiographer: | 11293 |
| 8. | Pharmacist: | 19,749 |
| 9. | Lab Technician: | 9,719 |
| 10. | Nurse Midwife (NM): | 15,336 |
| 11. | Block Extension Educator (BEE): | 5,6I5 |
Source : GOI Bulletin on Rural Health Statistics in India, December, 1996
Health Indicators, Goals and Achievements
After having understood health and health infrastructure, it is imperative to know about health indicators and health impact of our health care system in terms of achievements corresponding to those indicators and goals set for – ‘Health for All’ by 2000 AD. They are as under. The population figures are given in the table 3 for reference.
Table - 3 : Health Indicators, Goals and Achievements
| Indicator | Goal for 2000 AD | Achievement Level |
| Population (1991 census) : Rural : |
846.3 million 74.3 % |
|
| Sex Ratio (1991) : | 927/1000 males | |
| Crude Birth Rate (1996 - SRS): Urban : Rural : |
21.0 - - |
27.4/1000 21.4 19.3 |
| Crude Death Rate(1996-SRB): Urban : Rural : |
9 - - |
8.9/1000 6.5 9.7 |
| Infant Mortality Rate (199 ) Males : Females : |
60 |
72/1000 73 75 |
| Child Mortality Rate (0-4): | 10 | 23.7/1000 (1993) |
| Perinatal Mortality Rate | 30-35 | 44.3 (199 ) |
| Maternal Mortality Rate: | Below 2 | 4.37 (1992-93) NF |
| Antenatal Care : | 100 | 82 % (199 |
| Life Expectancy at Birth : Males : Females: |
64 yrs. - - |
61.4 yrs. (1996) 61.5 yrs. (1996) 62.1 yrs. (1996) |
| Delivery attended by : Trained Birth Attendants : Babies born with Low Birth Weight : |
100 10 |
48.8% (1993) 30% (1992) |
| Immunization coverage : BCG DPT 87.03 % ( " ) Measles T.T. 2/Booster |
100 100 100 100 |
93.12% (1996) 88.16 % ( " ) OPV 100 78.91 % ( " ) 76.73 % ( " ) |
| Couple Protection Rate : | 60 | 46.5 % ( " ) |
| Net Reproduction Rate : | 1.00 | -- |
Source : GOI, 8 (i-v) PFI (vi) and FICCI (vii)
Transformation of Health into Reproductive Health
Our National Family Welfare Programme (NFWP) should be accredited for paving the way to the onset of the process in which health initiatives transformed into reproductive health (RH) concept and approach. In order to understand this process of transformation, it is important here to make a brief review of the NFWP.
The concern for population control together with development could be traced in pre-independence era when our great leader Mahatma Gandhi stressed the need of birth control in 1925 and Dr. Radha Kamal Mukherjee Sub-Committee on Population submitted its report to the National Committee of Indian National Congress in 1940. In view of Mahatma Gandhi, "there can be no two options about the necessity of birth control but the only method handed down from ages past is self control."9. Based on Mukherjee’s report, the National Congress passed resolution that "while measures for the improvement of the quality of the population and limiting excessive population pressure are necessary, the basic solution of the present disparity between population and standard of living lies in the economic progress of the country on a comprehensive and planned basis. However, in the interest of social economy, family happiness and national planning, family planning and limitation of children are essential and the states should adopt a policy to encourage them.9The above concern could be operationalized in the postindependence era when family planning was given importance in the First Five year Plan (1951-56) with budget outlay of Rs.65 lakh and Goverment of India was globally accredited as the first country to have launched it in 1951 as a National Family Planning Programme following clinical approach. During the Second Five Year Plan (1956-61), 4,165 Family Planning Clinics were set up in the country and support was given to family planning research. The outlay was increased from the previous plan to Rs. 5 crore for this plan period. The Third Five Year Plan (1961-66) with Rs. 27 crore outlay witnessed reorganization and expansion of FP programme, shift in its approach from clinic to extension, involvement of opinion leaders, stress on information, education and motivation of eligible couples, establishment of the Deptt. of Family Planning in the Ministry of Health (1966), fixation of targets, and introduction of intrauterine device (IUD)/Lippes Loop (now Copper T-200). Though, during this plan period, the male sterilization (vasectomy), which is a permanent method of family planning, was most popular and remained so until early 70’s, the woman focus in the programme could also built up because of the introduction of the IUD in the programme. As the gynaecological examination that became necessary, reproductive health problems started drawing attention. Since the response from women was not encouraging for family planning and the family planning programme as such had nothing to attract women on the one hand and high IMR/MMR prevailed on the other, the programme was integrated with MCH services during the Inter-Plan Period (1966-69). The nomenclature of the programme was also changed from National Family Planning Programme (NFPP) to National Family Welfare Programme (NFWP). The ‘cafeteria approach’ was officially adopted in the programme but sterilization was emphasised and incentives to the doctor, motivator and acceptor were pushed.
Where the integration of the programme with MCH offered immunization to children against preventable killer diseases, and to pregnant mothers against tetanus, iron folic acid tablets against anaemia,, and facilities for antenatal check up and delivery, women’s other reproductive health problems drew considerable attention. As a result, during the Fourth Five Year Plan (1969-74), Urban Family Welfare Centres and Post-partum programme were given due attention and in 1972, the Medical Termination of Pregnancy (MTP) Act was enacted and post-abortion contraception emphasized. In these later efforts also, women’s reproductive health problems continued to draw government attention. Despite these efforts and increase in the plan outlay, i.e. Rs.82.9 crore for the Inter-Plan Period (1966-69) and Rs.285.80 crore for the Fourth Plan Period (1969-74), neither the programme could show desired results nor women’s reproductive health problems could receive due services. Effective integration between FP and MCH could also not take place at many places as different health programmes were still being implemented as vertical programmes. Also, the outcome of the Bucharest Population Conference (1974) that "the development was the best contraceptive" infused in the minds of many Indians the need for change in the approach to the programme. As a result, during the Fifth Five Year Plan (1974-78), the programme was intensified with Rs.285.50 crore outlay, National Population Policy Statement formulated (1976) and the "beyond family planning measures" including social engineering given emphasis alongside the programme. This culminated into intersectoral linkages and female literacy, increase in the age of marriage of girls from 15 years to 18 years and boys from 18 years to 21 years, and use of intensive mass media were also emphasised. This period witnessed a turning point as the development could be linked with FP and women issues and their problems started getting more attention. A 20-point development programme with MCH and Primary Health Care was made during the Sixth Five Year Plan (1980-85) with Rs.1010 crore outlay. National Health Policy was also formulated in 1983.
Another significant development giving impetus to women reproductive issues was the resolution of the United Nations’ (UN) Population Conference, held in Mexico City in 1984, that "abortion was not a family planning method" and related protest raised by Sweden that "the tragic public health consequences of unnsafe abortion were not being addressed".10 However, the vision of Indian Govt. remained intact for population control following development approach, women health and child survival measures in particular. As such, the FP integration with MCH was reiterated, Child Survival and Safe Motherhood (CSSM) programme with UNICEF support implemented and non-government organizations (NGOS) were involved in the programme.By now, the women health and development had become critical issue. the slow pace of FP performance and steep decline in male participation in the programme, stabilised the programme focus on women, both for spacing methods (IUD and Oral Pill) and permanent method of sterilization.
As the focus of the programme was building up on women, many NGos joined hands in raising their consensus voice against women issues and problems, like low status - self esteem, gender inequity, discrimination; poor health, inaccessibility to health care services, low literacy, unemployment, etc. and built pressure on the government for action. In 1990, extensive countrywide consultations with researchers, NGOs and activists were held to discuss the chapter on Women and Development for India’s Eighth Five Year Plan.11 As the fortune was awaiting, National Development Council was set-up, National Population Policy formulated and human resource development became the main stake in the Eighth Five Year Plan (1992-97). "In 1994, a national debate to discuss women’s health and FP issues was sponsored jointly by the Ford Foundation and United Nations Fund for Population Activities (UNFPA) to bring together different constitutencies including the government, NGOS, activists and researchers in about 20 meetings organised at district, state and national levels. The outcome of these discussions was reflected at the international level through the preparatory meetings and at the International Conference on Population and Development (IPCD) in Cairo in September 1994. These discussions... "resulted in a widespread recognition of the problems confronting poor women and a clearer definition of their needs in the inter-related areas of health, education, employment and legal rights".11 The breakthrough could be witnessed in the. Cairo Conference so far as the women issues are concerned. Governments from 184 countries reviewed the population programme objectives in view of sustainable development and the human rights dimension was articulated in terms of reproductive rights of all individuals. The Programme of Action of this Conference highlighted the far reaching consequences of gender inequity, in developing countries, like gender based violence, unsafe abortion, mortality, high fertility and other issues related to reproductive health of women.12 The impact of the outcome of this conference was quite strong and instant in Indials case due to the receptive climate already built over the years since similar thinking and programme endeavours were ongoing here. In fact, it was the Cairo Conference impact and review of sector programmes in India that expedited Government’s decision for implementation of reproductive health, hitherto reproductive and child health (RCH) initiative in the country.The programme witnessed a paradigm shift in its policies and implementation whereby ‘demographic orientation’ changed to ‘client centred’ approach and clients’ reproductive rights, and reproductive needs became priorities in the programme. This led disbanding with the ‘target’ approach and target-free decentralized PHC based planning approach started receiving advocacy for implementation, and vertical nature of the programmes changed into integrated holistic approach. This is how the health got transformed into reproductive health concept. To bring due focus on child health in this concept, the Government of India has adopted the nomenclature popularly known as RCH.
Reproductive Health Concept
Human sexuality and reproductive health are two inseparable entities of human life. They influence each other, compliment/supplement each other, and shape the reproductive profile of both, male and female in the society.
There is a general feeling that the RH, interchangeably RCH concept is not new, as the maternal and child health, sexually transmitted disease (STD) related and all other services or programmes did exist before. But as has already been referred to above, they were available as vertical programmes, instead integrated services. Also, such programmes and services were not focussed nor the approach of service delivery was holistic. But there are health scientists, policy and programme administrators and social scientists who decipher RH as a new concept since it imbibes all these above attributes in its scope which extends even beyond these recognising reproductive rights and reproductive health as important elements of development that includes fertility regulation besides other important variables.
The RH is a new conceptual reality, i.e. a shift from the rhetoric to reality that enshrined the ICPD Cairo Programme of Action for developing countries faced with population problem on the one hand and reproductive health and gender related issues on the other. With its broad base and wide scope, the focus of RH services is confined not only to women and men but extends to the children and special population of adolescents, menopausal women and older people. The concept eludes gender (male/female) inequity and class differentiation.
Where the RH concept articulates human rights into reproductive rights, particularly reproductive rights of the woman, i.e. right to information, choice of contraception, have children, when and how many, right on her own body, and safe sex, it also stresses the constellation of women centred services, easily available and accessible to them.
Objectives of Reproductive Health
The RH aims to provide need based, client centred, demand driven and high quality services to people. The Government of India’s RCH programme aims to contribute to population stabilization, sustainable development, and meeting the RH needs of women, children and adolescents within the framework of reproductive rights, gender equity and human dignity, thereby making it a composite programme.
In order to create conducive climate so as to achieve these objectives, the Government’s efforts are to use its own existing resources and wherever necessary supplement them with the support committed and received by external donors, like World Bank and European Commission.
The Government’s RCH programme aims that the "people have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the outcome of pregnancies is successful in terms of maternal and infant survival and well being and copuples are able to have sexual relations free of fear of pregnancy and of contracting diseases".13 The United States Agency for International Development (USAID) adheres to the following objectives (also as principles) of RH.141. Promoting the rights of couples and individuals to determine freely and responsibly the number and spacing of their children;
2. Improving individual health, with special attention to the RH needs of women and adolescents and the general health needs of infants and children;
3. Reducing population growth rates to levels consistent with sustainable development; and
4. Making programmes responsible and accountable to the end-users.
Reproductive Health Approach and Strategy
The RH envisages pursuance of "an integrated approach to the programmes aimed at improving the health status of young women and children. It is obviously sensible that integrated RCH programme would help in reducing the cost of inputs to some extent because overlapping of expenditure would no longer be necessary and integrated implementation would optimise outcomes at the field level. During the 9th Plan, the RCH Programme, accordingly, integrates all the related programmes of the 8th Plan.13 "The overall strategy of Government of India (Dept. of Family Welfare) is to strive for obtaining reproductive and child health arrangements for the whole of the country’s population and simultaneously to promote and make available contraceptive/terminal methods for desirous couples. It also needs to be observed that the measures through health system alone do not and cannot success in either ensuring reproductive and child health or in controlling population".13Definition of Reproductive Health
The definition of reproductive health reflects the WHO definition of health but it encompasses much more diversified areas establishing linkages and necessity for sustainable development through humane policy and programme approach, instead of demographic targets or population stabilization. Accordingly, the population issue could be tackled within the ambit of more comprehensive strategy of health care and socio-economic development, thereby gender equity, empowerment and status of women become crucial and male responsibility critical. This refers to desired world-wide shift in the attitude to recognize reproductive rights as human rights, women and adolescents’ needs and provision of service delivery.
The definition of RH contained in the Programme of Action of the ICPD, Cairo is an improved version of the WHO technical definition which was accepted by the United Nations General Assembly. It is being followed now for all practical purposes by governments and voluntary agencies world over. The definition is as under: "Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. implicit in this last condition are the right of men and women to be informed and have access to safe, effective, affordable and acceptable method of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and child birth and provide couples with the best chance of having a healthy infant . . . . It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases".15Scope of Reproductive Health
As per the ICPD Programme of Action, the scope of reproductive health within the context of the primary health care has identified 6 components. These are :161. Family planning counselling, information, education, and communication (IEC) and services;
2. Education and services for prenatal care, safe delivery, and post-natal care, especially breast-feeding, infant and women’s health care;
3. Prevention and appropriate treatment of infertility;
4. Prevention of unsafe abortion and the management of the consequences of abortion,
5. Treatment of reproductive tract infections (RTIs), sexually transmitted diseases (STDS) and other reproductive health conditions; and
6. Information, education and counselling, as appropriate, on human sexuality, reproductive health and responsible parenthood.
Elements of Reproductive Health
Though one may deduce the elements of RH from the concept of RH as well as from its definition and scope, there seems to be some variance in the elements preferred by different sources. As referred to above, the six areas identified under the scope of RH clearly indicate elements of RH.
The WHO has identified seven basic elements as follows:
1. Responsible reproductive/sexual behaviour.
2. Widely available family planning services.
3. Effective maternal care and safe motherhood.
4. Effective control of reproductive tract infections (including STDS).
5. Prevention and management of infertility.
6. Elimination of unsafe abortion.
7. Prevention and treatment of malignancies of reproductive organs.
Besides these, the conditions and practices affecting reproductive health, like HIV/AIDS; infant, child and adolescent health; adolescent sexuality; socio-cultural, behavioural; and environmental factors have also been considered as important elements.
The UNFPA has given priority attention to 4 elements, but each of these encompasses wide array of factors and conditions affecting RH, their treatment and management. These are as :171. Family planning, including availability of a wide range of contraceptive choices, appropriate counselling, and quality of care.
2. Safe pregnancy care, including pre-natal delivery and postpartum care of mothers at the primary health care level with appropriate referral for the management of obstetric complications.
3. Prevention of unsafe abortion, including the treatment of complications, and post-abortion counselling and family planning.
4. The prevention, screening and treatment of STDs and HIV/AIDS as part of primary health care, with appropriate referral for follow-up.
Diczfalusy has listed the following elements reflecting 12 dimensions of RH, whom he calls the 12 pillars of RH:181. The status of women
2. Family planning
3. Maternal care and safe method
4. Abortion
5. Reproductive tract infections and HIV/AIDS
6. Infertility
7. Reproductive organ malignancies
8. Nutrition
9. Infant and child health
10. Adolescent reproductive health and sexuality
11. Sexual behaviour and harmful sexual practices
12. Environmental and occupational reproductive health.
Many of the elements proferred by WHO and Diczfalusy are common. It appears, all important aspects which directly or indirectly affect the reproductive health have been considered by both these sources. The identification of the elements of RH is in a way to guide the governments to develop their programmes of RH care services as much as possible comprehensive, thereby accommodating the impelling need of inclusion of socio-cultural and development related elements, and adopting an integrated and holistic approach.
The Government of India has incorporated in its RCH national programme the components related to its earlier programme of Child Survival and Safe Motherhood, STDs and RTIS.
Principles of Reproductive Health
With the objective of making the RH concept a reality, the following are the guiding principles, as referred to in the International Women’s Health Coalition issue on "The Cairo Consensus - The Right Agenda for the Right Time," 1995.191. We must begin with, and have as our ultimate objective, comprehensive, good quality reproductive and sexual health services, that foster women’s rights and empowerment, while ensuring that men take responsibility for their own sexual behaviour, fertility, and the well being of their partners and children.
2. Programmes and services should be developed to suit particular circumstances, continuancy to current requests for a "model" approach that implies "one size fits all".
3. The process must be participatory and emphasize the involvement of women, beginning with the women from virtually every country who were active with Cairo process.
4. We can utilize the resources we already have more efficiently; we do not have to wait for new money, new data, or new staff.
The encouraging advice, that the implementing governments and voluntary agencies could derive from these principles is that they should not wait for more resources rather utilize the existing ones. Further, the programmes should be developed and implemented so strategically that they should meet also the needs of special circumstances and populations besides assuring and providing comprehensive and good quality care. The most significant guidance that these principles ought to provide is emphasis on the inclusion of the women’s rights, empowerment in the RH programme, making them explicitly mandatory. This suggest a landmark departure from the earlier approach of health care to an integrated approach to RH, which is more pragmatic and holistic in nature.
National Rch Programme
The Government of India, Ministry of Health and Family Welfare upholds the legitimate right of its citizens to be able to experience sound RH. Accordingly, the RCH programme mission is to provide need based, client centred, high quality services to all the citizens of the country. As reflected in the preceding pages and also visualized, the RCH programme is more significant to contribute to the population stabilization to a level that should be optimal to meet the need of national development. For this, what is contemplated important, is conformity with small family size norm. The RCH programme, thus, envisages in this direction to facilitate the availability and accessibility of the available spacing and terminal methods of family planning to the couples on the one hand and provide high quality care to the mother and child as an assurance to good health and longevity of the both on the other. The Government has taken the congnisance of the fact that for the success of the RCH programme and population stabilization, its own efforts may not be enough, the involvement of NGOs and community is, therefore, equally important. Accordingly, the programme objectives have been laid down with such crucial concerns.
Programme Objectives:
The main objectives of the national RCH programme are:131. To integrate all interventions of fertility regulation, maternal and child health with reproductive health of both men and women.
2. To make services client centred, demand driven, high quality and based on the needs of the community arrived at through decentralized participatancy planning and the target free approach.
3. To upgrade the level of facilities for providing various interventions and quality of care. The first referral units (FRUS) being set-up at Sub-district level will provide comprehensive emergency obstetric and new-born care. Similarily RCH facilities in PHCs will be substantially upgraded.
4. To improve facilities for obstetric care, MTP and IUD insertion in the PHC. Also IUD insertion in subcentres.
5. To improve the outreach of services primarily for the vulnerable groups of population who have till now been effectively left out of the planning process, e.g.
i) Design special programmes for urban slums, tribal population and adolescents.
ii) Involvement of NGOs and voluntary organizations in a big way to improve the service outreach and make the programme people’s programme.
iii) Train Indian Systems of Medicine Practitioners (ISMPS) and to support research in this area in order to improve the range of RCH services.
(iv) Make use of the Panchayati Raj System in planning, implementation of RCH services andlissessment of client satisfaction with services.
The 9th Five Year Plan outlay for the RCH programme, i.e. Rs.5112.53 crore, makes the government efforts more determined and ambitious. Whereas the financial provision is aimed to improve the infrastructural facilities, the management service delivery skills, and information system aim to make the services, including specialized ones accessible at lower level and bring success to the RCH programme.
In order to achieve these objectives, the intervention package being implemented is as under:
Programme Interventions:
For the programme interventions, all the districts have been classified into three categories according to their RCH status - (crude birth rate and female literacy.)
Category :
A - 58 districts
B - 184 districts
C - 265 districts
All the districts shall be covered in a phased manner in a period of three years, following differential interventions as under :13
| All Districts | Selected Districts |
| 1. Child survival interventions, i.e. immunization, Vitamin A (to prevent blindness), Oral rehydration (to prevent deaths from dehydration) and preventionof deaths due to pneumonia (ARI) | 1. Screening and treatment of RTI/STD at
Sub-divisional level. |
| 2. Safe motherhood interventions, e.g. ante-natal check up, immunization for Tetanus, safe delivery, anaemia control programme. | 2. Emergency obstetric care at selected first referral units (FRUS) by providing drugs. |
| 3. Operationalization of Target Free Approach | 3. Essential obstetric care by providing drugs and PHN/Staff Nurse at PHCS. |
| 4. High quality training at all levels. | 4. Additional ANMs at sub-centres in the weak districts for ensuring MCH Care. |
| 5. Strengthened managemen tinformation system (MIS). | 5. Improved delivery services and emergency care by providing equipment kits, IUD insertions and ANM kits at Sub-centres. |
| 6. Information, Education and Communication (IEC) activities. | 6. Rental to contracted PHNs/ANMs, not providing government accomodation. |
| 7. Specially designed RCH package for Urban slums and tribal areas. | 7. Facility of referral transport for pregnant women during emergency to the nearest referral centre through Panchayats in weak districts. |
8. Distt. Sub-projects under Local Capacity enhancement. |
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9. RTI/STI clinics at district hospitals (where not available). |
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10. Facility for safe abortions at PHCs by providing equipments, contractual doctors etc. |
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11. Enhanced community participation through Panchayat, Women’s Groups and NGOS. |
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| 12. Minor Civil Works. | ------------- |
13. Adolescent health and reproductive hygiene. |
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