strengthening health sy stems - vriddhi: scaling...
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National RMNCH+A Unit (NRU) supported by USAID
Strengthening health SyStemS
• To accelerate the pace of interventions for Ending Preventable Child and Maternal Deaths (EPCMD) Government of India (GOI) launched the Reproductive Maternal Newborn Child and Adolescent Health (RMNCH+A) strategy in 2013.
• Based on continuum of care principles and focusing on a life cycle approach, the strategy is holistic in design, and encompasses comprehensive interventions across life stages under one umbrella.
• Under the strategy GOI has identified 184 High Priority Districts (HPDs) which constitute the poorest performing 25% districts across the 30 states of the country for focused strategic technical support.
• The strategy emphasizes and channelizes support from development partners with one partner agency identified as a State Lead Partner (SLP) to function as a single point for coordinating technical assistance across the states of the country.
DR. GUNjAN TANejANATIONAL TECHNICAL LEAD, USAID - VRIDDHI
DR. RAjeev GeRAProject Director, USAID – VRIDDHI
DR. PAwAN PATHAkNational Lead NRU, USAID – VRIDDHI
DR. AjAy kHeRADeputy Commissioner (Incharge) Child Health, MOHFW, GOI
• The objective is to identify gaps at delivery points in real time to address them locally, at sub-district, district, state or national level.• It implies a regular and dependable interaction with service providers during
onsite visits to health facilities.• Helps identify and solve problems, improve services and advance skills and
knowledge.• A standard SS checklist was introduced by GOI in October’2014 to establish a
uniform mechanism for collecting relevant information, which facilitates multi-level analysis and generates data for action.• USAID supported VRIDDHI - Scaling up RMNCH+A Interventions project was given
the responsibility to design and roll out the SS system across all HPDs.• A three day training package was developed at the national level through a
consultative process involving the MoHFW and all RMNCH+A SLPs.
• One national and six zonal trainings were conducted between February to April 2015 wherein representatives from all state governments, SRU and DLMs were trained on the package.• The system is since being implemented across the HPDs under the technical
leadership of MoHFW, GOI and in close collaboration with state governments and SLPs.• The data helps GOI and state governments to ascertain the status of readiness of
the health facilities and monitor the trends for progress.• DLM, SRUs and NRU are responsible for ensuring continuity, and sharing and
dissemination of findings to feed into annual District and State Level Plans.
Supportive Supervision model impacts nearly
The NaTioNal RMNCh+a SuppoRTive SupeRviSioN MeChaNiSM
Reach
Life Cycle and Continuum of Care Approach Adopted in RMNCH+A
RMNCH+A Partnerships
The achievement of goals is therefore linked across different life stages and even has an intergenerational dimension
Across Lifestages Across Levels of Care
• National RMNCH+A Unit (NRU) at Ministry of Health and Family Welfare, Goverment of India
• State RMNCH+A Units (SRU) in each state
• District Level Monitors (DLMs) in the HPDs
BMGF
UNICEF
NIPI
TATA TRUST*
UNFPA
USAID
Map of India showing state level lead development partners
* Madhya Pradesh earlier supported by DFID
Baseline findings (Major observations during the first visit to facilities) Trends: Maternal Health: Intrapartum Period
essential Commoditiesl1 l2 l3
(N=2845) (N=3055) (N=672)
Injection Oxytocin 56% 84% 91%
Injection Magnesium Sulfate 35% 74% 90%
Hemoglobinometer 80% 89% 93%
Partograph 36% 62% 68%
Vit K1 32% 54% 63%
Bag and Mask (size 0,1) 48% 77% 89%
Functional Radiant Warmer (RW) 18% 70% 87%
NBCC & Functional RW 16% 63% 89%
OPV (cold chain points) 23% 90% 96%
ORS and Zinc 73% 78% 77%
PPIUCD Forceps 11% 39% 76%
IUCD, Condom and OCP 58% 71% 79%
IUCD, Condom, OCP and ECP 37% 51% 58%
MCP Cards 87% 85% 85%
practicesl1 l2 l3
(N=2845) (N=3055) (N=672)
Appropriate management of high risk clients
64% 79% 86%
Fetal Heart Rate recorded at admission
44% 72% 83%
Partographs used 25% 52% 58%
Magsulf for managing eclampsia 23% 58% 86%
Uterotonics after delivery 64% 90% 96%
Promotion of skin to skin contact 72% 75% 82%
Equipped newborn care corner 21% 56% 76%
Knowledge of resuscitation 37% 63% 79%
Newborn vaccination (3 vaccines) 20% 68% 86%
Malnourished referral to NRC 62% 65% 58%
PPIUCD insertions done 5% 29% 66%
Transport provided for back drop 46% 69% 88%
HeALTH SySTeMS
STReNgTHeNINg
CoNveRgeNCe ANd
PARTNeRSHIPS
HIgH IMPACT INTeRveNTIoNS
ACRoSS LIfe CyCLe
INTegRATedMoNIToRINg &
ACCouNTABILITy
PRIoRITIzATIoN of
INveSTMeNTS RMNCH+ASTRATegICAPPRoACH
Health facilities at various Levels:
PHCs, fRus and dHsoutreach Services family/Home and
Community Care
Appropriate Referral & follow-up
5 X 5 Matrix for High Impact RMNCH+A InterventionsTo be Implemented with High Coverage and High Quality
Reproductive Health
• Focus on spacing methods, particularly PPIUCD at high case load facilities
• Focus on interval IUCD at all facilities including subcentres on fixed days
• Home delivery of Contraceptives (HDC) and Ensuring Spacing at Birth (ESB) through ASHAs
• Ensuring access to Pregnancy Testing Kits (PTK-"Nischay Kits") and strengthening comprehensive abortion care services
• Maintaining quality sterilization services
Maternal Health
• Use MCTS to ensure early registration of pregnancy and full ANC
• Detect high risk pregnancies and line list including severely anemic mothers and ensure appropriate management
• Equip Delivery points with highly trained HR and ensure equitable access to EmOC services through FRUs; Add MCH wings as per need
• Review maternal, infant and child deaths for corrective actions
• Identify villages with low institutional delivery and distribute Misoprostol to select women during pregnancy; incentivize ANMs for domiciliary deliveries
Newborn Health
• Early initiation and exclusive breastfeeding
• Home based newborn care through ASHA
• Essential Newborn Care and resuscitation services at all delivery points
• Special Newborn Care Units with highly trained human resource and other infrastructure
• Community level use of Gentamicin by ANM
Child Health
• Complementary feeding, IFA supplementation and focus on nutrition
• Diarrhoea management at community level using ORS and Zinc
• Management of pneumonia
• Full immunization coverage
• Rashtriya Bal Swasthya Karyakram (RBSK): screening of children for 4Ds (birth defects, development delays, deficiencies and disease) and its management
Adolescent Health
• Address teenage pregnancy and increase contraceptive prevalence in adolescents
• Introduce community-based services through peer educators
• Strengthen ARSH clinics
• Roll out National Iron Plus Initiative including weekly IFA supplementation
• Promote Menstrual Hygiene
Health Systems Strengthening
• Case load based deployment of HR at all levels• Ambulances, drugs, diagnostics, reproductive health commodities• Health Education, Demand Promotion & Behavior Change Communication• Supportive supervision and use of data for monitoring and review, including
scorecards based on HMIS• Public grievances redressal mechanism; client satisfaction and patient safety
through all round quality assurance
Cross-cutting Interventions
• Bring down out of pocket expenses by ensuring JSSK, RBSK and other free entitlements
• ANMs & Nurses to provide specialized and quality care to pregnant women and children
• Address social determinants of health through convergence
• Focus on un-served and underserved villages, urban slums and blocks
• Introduce difficult area and performance based incentives
uSaiD-vRiDDhi (SCaliNg up RMNCh+a iNTeRveNTioNS) pRojeCT CooRDiNaTeS aND MaNageS The SS MeChaNiSM iN The CouNTRy
Key FiNDiNgS
Quarterly trends from 10397 SS visits conducted across L3 and L2 facilities
Practices during Intrapartum period
1st and 3rd visit data trends from 1409 L3 and L2 facilities 1st Visit 3rd Visit last Visit1st Visit 3rd Visit
Last visit is taken as at least the fifth visit or last visit (range 6 to 18)
1st, 3rd and last visit trends from 562 L3 and L2 facilities
Coverage
Supportive Supervision Checklist
C1: Name of the supervisor - C2: Designation - C3: Level of supervisor - Block / District / State /
National / Other
C4: Facility Name - C5: Facility Type - SC/ Non 24*7 PHC /24*7 PHC/Non- FRU CHC/FRU CHC/SDH/DH/AREA HOSP/other C6: Facility Level - L1/ L2/ L3
C7: Date of visit - C8: Name of Facility in-charge/nodal officer - C9: Designation of In-charge-
Data of previous month from facility
D1 Number of deliveries in facility
Total Deliveries Normal Assisted Vaginal Delivery C-section Referred out cases Live births
D2 Number of new-borns immunized before discharge
D3 IPD load
D4 OPD load
D5 IUCD inserted in facility Interval Postpartum Post Abortion D6 Sterilization done
D7 No. of clients received CAC services D8 % of women received IFA tab D9 No. of ANC clients with high risk conditions D10 HR deployed/posted in Labor Room Posted Trained in
SBA/BEmOC Trained in PPIUCD
MO ANM/Staff nurse
Female interval sterilization Female postpartum sterilization Male sterilization
E Drugs/supplies availability (If possible, verify physically) E1: Reproductive Health E3: New Born Health E7. Antibiotics E1.1: IUCD 375, 380A E3.1: Inj. Vit K(1 mg/ml) E.7.1 Antibiotics as per RMNCH+A 5X5
Matrix ( Amoxyclillin, Ampicillin, Ampicillin, Gentamicin, Metronidazole, Trimethoprim &Sulphamethoxazole, Cefrtiaxone (oral/IM/IV as applicable)
E1.2: OCP E3.2: Mucus Extractor E8: Other essential supplies &equipments(check functionality&utilization)
E1.3: ECP E3.3: Bag and mask (240 ml) with both pre & term mask (size 0,1)
E8.1 Weighing Machine
E1.4: Condoms E3.4: Clean linen/towels for receiving new born E8.2: Hub cutter with needle destroyer E1.5: Mifepristone + Misoprostol (MMA) E3.5: Sterile cord cutting equipment E8.3: Refrigerator E1.6: MVA Kit/EVA E3.6: Designated Newborn Care Corner E8.4: RTI/STI Kit E2: Maternal Health E3.6: Functional Radiant Warmer E8.5: Bleaching Powder
E2.1: Inj. Oxytocin (check whether stored in cold box/refrigerator)
E4: Child Health E8.6: Oxygen Cylinder functional
E2.2: Tab Misoprostol E4.1 ORS E8.7: BP apparatus with stethoscope E2.3: Antihypertensive (alpha methyldopa/Labetalol or Nifedipine)
E4.2: Zinc (10mg & 20 mg) E8.8: Thermometer
E2.4: Inj. Magnesium Sulfate E4.2: Syp Salbutamol/Salbutamol NebulizingSolution
E8.9: PPIUCD Forceps
E2.5: Inj. Tetanus Toxoid E4.3: Syrup Albendazole E8.10: Fetoscope/ Doppler E2.6: Sterile pads E.5: Adolescent Health E8.11: Autoclave/Boiler E2.7: IFA Tablet E5.1: Dicyclomine E8.12: Running water E2.8: Pregnancy Test Kit (only at sub-centres and with ASHAs)
E5.2: Weekly Iron folic acid supplementation tablets
E8.13: Soap
E2.9: Functional Blood Bank/blood storage units
E 5.3 Albendazole E8.14: Color coded bins and bags
E2.10: Haemoglobinometer E6: Vaccines E8.15: Electricity back-up E2.11: Urine albumin kit E6.1: BCG E8.16: Toilet near LR
E 2.12: Blood grouping typing E6.2: OPV E 2.13:HIV screening E6.3: Hep B E 2.14:Hepatitis B screening E6.4: DPT E8.17: Cold box, ILR, Deep freezer
present for vaccine storage as per requirement
E2.15: Partograph E.6.5: Measles
E2.16: Protocols displayed in LR E.6.6: Syrup Vit. A
E2.17: IV Fluids E.6.7: Pentavalent vaccine (in relevant states) E 8.18 MCP cards E 2.18 Inj Dexamethasone E.6.8 JE Vaccine (where relevant)
Information captured on 141 critical RMNCH+A indicators
Des
ign
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CoNCLuSIoN• A prime example of forging partnerships to
achieve impact at scale• Within a year the country has been able to
institutionalize the model across 184 HPDs’ • Data being used for corrective action at national,
state and district levels
• The RMNCH+A SS system is a dynamic process• Checklist has been revised • A new community based checklist has been
incorporated• Zonal trainings ongoing• The mechanism will feed into a broader SS
system being developed in the country for all health programs
ACkNowLedgeMeNTS• Ministry of Health and Family Welfare, Government
of India• Departments of Health and Family Welfare, All
State Governments• District Health Administration across the 184 HPDs• Health officials and functionaries at the health facilities• USAID, UNICEF, BMGF, UNFPA, NIPI, DFID &
Tata Trusts
wAy foRwARd
LINkS MATeRNAL ANd CHILd SuRvIvAL To oTHeR CoMPoNeNTS (fAMILy PLANNINg, AdoLeSCeNT HeALTH, geNdeR & PC & PNdT) SuPPoRTIve SuPeRvISIoN (SS) HAS BeeN eNvISAged AS AN INTegRAL CoMPoNeNT of THe RMNCH+A STRATegyThe RMNCh+a STRaTegy
Prioritized Interventions
institutionalizing a robust Supportive Supervision mechanism in high Priority Districts in india
organized partner support through technical support units:
7.6 MILLIoN INfANTS in HPds’,accounting for almost 25% of the annual cohort of
pregnant women and infants in India
MoHfw/govt of India
development Partners
State Health department
National RMNCH+A unit
State RMNCH+A unit (SRu)
district Health department
district Level Monitor (dLM)
Health facilities (L1, L2 & L3)
Number and proportion of
different levels of health facilities
(Total 6,572)
10%672
47%3055
43%2845
L3 - (Comprehensive Level-FRU): All FRU-CHC/SDH/DH/area hospitals/referral hospitals/tertiary hospitals where complications are managed including C-section and blood transfusion and are equipped with a Newborn Stabilization Unit (NBSU) at CHC/SDH/others or Special Newborn Care Unit (SNCU) at DH and above.
L2 - (Basic Level): All 24 x 7 facilities (PHC/Non-FRU CHC/others) providing BEmOC services; conducting deliveries and management of medical complications not requiring surgery or blood transfusion and have either a Newborn Care Corner (NBCC) or NBSU.
L1 - All sub-centers and some non 24 x 7 PHCs where deliveries are conducted by a skilled-birth attendant (SBA) and are equipped with a NBCC.
distribution of total visits to
different levels of health facilities
(Total 15,063)31%4666
49%7404
20%2993
8.3 MILLIoN PRegNANT woMeN and
=1 million
Reproductive years
RMNCH+A Life Cycle Approach
100%
80%
60%
40%
20%
0%
apr-Jun 2015 (n=1723) Jul-Sep 2015 (n=1795) Oct-Dec 2015 (n=1846) Jan-mar 2016 (n=1735) apr-Jun 2016 (n=1889) Jul-aug 2016 (n=1266)
65%
58%
62%
59%
54%
64%
48%
53%
56%
57%
62%
63%
66%
65%
66%
69%
74%
75%
92%
93%
92%
93%
95%
95%
Fetal heart rate recorded atthe time of admission
mother’s temprature & BP recorded at the time of admission
Partograph used to monitor process of labour
antenatal corticosteroids used for preterm labour
magnesium Sulphide used to managePre-eclampsia & eclampsia
Uterotonic (Oxytocin or misoprostol) given to mother after birth
77%
91%
84%
82%
85%
84%
74%
79%
80%
81%
81%
83%
100%
80%
60%
40%
20%
0%
100%
80%
60%
40%
20%
0%Fetal heart rate
recorded at the time of admission
mother’s temprature & BP recorded at the time
of admission
Partograph used to monitor process
of labour
antenatal corticosteroids used for preterm
labour
magnesium Sulphide used to manage Pre-eclampsia
& eclampsia
Uterotonic (Oxytocin or misoprostol) given
to mother after birth
89%
84%
79%
83%
85%
90%
54%
65%
72%
52%
59%
69%
68%
69%
77%
94%
95%
97%
Pregnancy
Newborn Period
Adolescent
Childhood
feed forward and feedback structure in RMNCH+A strategy
80%
74%
82%
75%
66%
52%
62%
45%
72%
64%
93%
92%
Fetal heart rate recorded at the
time of admission
mother’s temprature & BP recorded at the time of admission
Partograph used to monitor process
of labour
antenatal corticosteroids used for
preterm labour
magnesium Sulphide used to manage Pre-eclampsia
& eclampsia
Uterotonic (Oxytocin or misoprostol) given
to mother after birth
for details, please contact: vRIddHI SCALINg uP RMNCH+A INTeRveNTIoNS/uSAId, IPe global Ltd – iPe global house B-84, Defence Colony, new Delhi – 110024, email: [email protected] DISCLAIMER: This poster is made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents are the responsibility of IPE Global Limited and do not necessarily reflect the views of USAID or the United States Government.