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

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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: rmncha@ipeglobal.com 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.