E-IMNCI: a novel clinical diagnostic support system approach to strengthen effectiveness and quality of IMNCI implementation in India.

Integrated management of childhood illness is a globally proven primary care strategy to improve child survival and is being implemented worldwide in countries with high burden of child mortality. Its implementation as Integrated Management of Newborn and Childhood Illness (IMNCI) in India has been challenging.The primary objective of the present work was to assess the feasibility, acceptability and use of an adapted Integrated E Diagnostic Approach (IeDA) that provides e-Learning and improved clinical practices of the primary level health service provider auxiliary nurse midwives (ANMs) to deliver IMNCI services. This India-specific approach was contextualised to the Indian IMNCI programme based on 7 years of IeDA implementation learning from West Africa.The Integrated Management of Neonatal and Childhood Illness pilot was implemented across 80 front-line workers, 70 ANMs and 10 medical officers) in 55 facilities of 3 blocks of Ranchi district, Jharkhand. This report evaluated the feasibility of its use by ANMs only. Based on the results, it can be concluded that it is possible to implement the newly developed application. A total of 2500 cases were managed by ANMs using the application till May 2020. All ANMs used it to provide treatment to the children. 63% of ANMs used it to provide medications, 83% for counselling and 71% for follow-up as per the recommendations. The app is highly acceptable to ANMs for use as a clinical case management tool for childhood illness. There were some improvements in case management in both the age group (0-59 days and 2-12 months) of children. 78% of caregivers responded with their desire to revisit the health facility in future, highlighting the contribution of an e-tool in improving the perception of the caregiver.

Strengthening Fetal Heart Rate Monitoring during Labor with a Standard Handheld Doppler - Implementation Experience from India.

Background: India's neonatal and perinatal mortality is among the highest in the world. Intrapartum-related conditions contribute to a significant proportion of neonatal deaths and stillbirths. Fetal heart rate monitoring, a recommended norm to assess fetal well-bring, is not practiced as per standard guidelines in public health facilities. A standardized Doppler along with training on fetal heart rate monitoring was implemented across different levels of healthcare in three states. Methods: Facilities were selected purposively to implement the Doppler. Baseline data for 3 months were collected. Interviews of health providers and observation of labor were conducted quarterly. Data were analyzed through a comparison of baseline and intervention on a number of delivery and monitoring indicators. Results: Among 22,579 total deliveries, monitoring frequency increased along with increase in detection of abnormal fetal heart rate (FHR) while cesarean section and stillbirths reduced slightly. Cases never monitored reduced in the District Hospitals (7.98-2.07, P < 0.01) and in Community Health Centers (14.7-1.67, P < 0.001). Stillbirth rate reduced at the medical college (3.6-1.1, P < 0.001). Interviews with providers revealed acceptance of the device due to its reliable readings. Conclusion: The Doppler demonstrates acceptability and serves as a useful aid to improve intrapartum FHR monitoring.

Safe Delivery application with facilitation increases knowledge and confidence of obstetric and neonatal care among frontline health workers in India.

Background: Digital learning tools have proliferated among healthcare workers in India. Evidence of their effectiveness is however minimal. We sought to examine the impact of the Safe Delivery App (SDA) on knowledge and confidence among frontline health workers (HW) in India. We also studied whether facilitation to address technical challenges enhanced self-learning. Methods: Staff nurses and nurse-midwives from 30 facilities in two states were divided into control and intervention groups through randomization. Knowledge and confidence were assessed at baseline and after 6 months. Three rounds of facilitation addressing technical challenges in downloading and usage along with reminders about the next phase of learning were conducted in the intervention group. A user satisfaction scale along with qualitative interviews was conducted in the intervention group at the endline along with qualitative interviews on facilitation. Results: The knowledge and confidence of the healthcare workers significantly increased from the baseline to endline by 4 percentage points (P < 0.001). The participants who received facilitation had a higher mean score difference in knowledge and confidence compared to those who did not receive facilitation (P < 0.001). The participants were highly satisfied with the app and video was the most-watched feature. They reported a positive experience of the facilitation process. Conclusion: The effectiveness and acceptability of the SDA indicate the applicability of mHealth learning tools at the primary healthcare level. In a time of rapid digitalization of training, facilitation or supportive supervision needs further focus while on-ground digital training could be invested in to overcome digital illiteracy among healthcare workers.

A Novel Approach to Promote Evidence-Based Development of District Maternal and Newborn Health Plans in Two States in India.

Background: Maternal and child health implementation plan development in districts of India lacks systematic process and capacity resulting in suboptimal health improvements. There is ineffective and limited participation and lack of autonomy to effect changes in district priorities. Objectives: Primary objective was to demonstrate a systematic planning approach to develop evidence-based district implementation plans for mothers and children. Methods: A planning tool named RAASTA (RMNCH + A Action Agenda using Strategic Approach for evidence-based district work plans) adapted from WHO (World Health Organization) program review tools was used in the states of Uttarakhand and Jharkhand. The tool was implemented in the two states for the development of implementation plans in a 6-step process by prioritizing district health goals; reviewing maternal, neonatal, child, and family planning intervention coverage; and linking them with activity implementation status; assessing strengths, and weaknesses of previous implementation plans and developing solutions based on current gaps in intervention coverage's. Results: Tool was used for capacity building of 59 participants and also identification of prioritized activities based on their available data. Several newer activities were identified. The districts mainstreamed them as action plans, many of which were incorporated in the state Program Implementation Plan for budgetary provisions under state NHM (National Health Mission) funds. Conclusion: The use of a tool facilitated the systematic development of evidence-based district implementation plans.

Experiences From an Implementation Model of ARI Diagnostic Device in Pneumonia Case Management Among Under-5 Children in Peripheral Healthcare Centers in India.

OBJECTIVES: To address pneumonia, a major killer of under-5 children in India, a multimodal pulse oximeter was implemented in Health and Wellness Centers. Given the evidence of pulse oximetry in effective pneumonia management and taking into account the inadequate skills of front-line healthcare workers in case management, the device was introduced to help them readily diagnose and treat a child and to examine usability of the device. DESIGN: The implementation was integrated with the routine OPD of primary health centers for 15 months after healthcare workers were provided with an abridged IMNCI training. Monthly facility data was collected to examine case management with the diagnostic device. Feedback on usefulness of the device was obtained. SETTING: Health and Wellness Centers (19) of 7 states were selected in consultation with state National Health Mission based on patient footfall. PARTICIPANTS: Under-5 children presenting with ARI symptoms at the OPD. RESULTS: Of 4846 children, 0.1% were diagnosed with severe pneumonia and 23% were diagnosed with pneumonia. As per device readings, correct referrals were made of 77.6% of cases of severe pneumonia, and 81% of pneumonia cases were correctly given antibiotics. The Pulse oximeter was highly acceptable among health workers as it helped in timely classification and treatment of pneumonia. It had no maintenance issue and battery was long-lasting. CONCLUSION: Pulse oximeter implementation was doable and acceptable among health workers. Together with IMNCI training, PO in primary care settings is a feasible approach to provide equitable care to under-5 children.

Care Around Birth Approach: A Training, Mentoring, and Quality Improvement Model to Optimize Intrapartum and Immediate Postpartum Quality of Care in India.

BACKGROUND: With the highest risk of maternal and newborn mortality occurring during the period around birth, quality of care during the intrapartum and immediate postpartum periods is critical for maternal and neonatal survival. METHODS: The United States Agency for International Development's Scaling Up Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions project, also known as the Vriddhi project, collaborated with the national and 6 state governments to design and implement the Care Around Birth approach in 141 high caseload facilities across 26 high-priority districts of India from January 2016 to December 2017. The approach aimed to synergize evidence-based technical interventions with quality improvement (QI) processes, respectful maternity care, and health system strengthening efforts. The approach was designed using experiential training, mentoring, and a QI model. A baseline assessment measured the care ecosystem, staff competencies, and labor room practices. At endline, the approach was externally evaluated. RESULTS: Availability of logistics, recording and reporting formats, and display of protocols improved across the intervention facilities. At endline (October-December 2017), delivery and newborn trays were available in 98% of facilities compared to 66% and 55% during baseline (October-December 2015), respectively. Competency scores (> 80%) for essential newborn care and newborn resuscitation improved from 7% to 70% and from 5% to 82% among health care providers, respectively. The use of partograph in monitoring labor improved from 29% at the baseline to 61%; administration of oxytocin within 1 minute of delivery from 35% to 93%; newborns successfully resuscitated from 71% to 96%; and postnatal monitoring of mothers from 52% to 94%. CONCLUSION: The approach successfully demonstrated an operational design to improve the provision and experience of care during the intrapartum and immediate postpartum periods, thereby augmenting efforts aimed at ending preventable child and maternal deaths.

Putting the local back into planning-experiences and perceptions of state and district health functionaries of seven aspirational districts in India on an innovative planning capacity building approach.

District functionaries have ostensibly a major responsibility to develop evidence based plans. However, this responsibility is not commensurate with skills and expertise among functionaries in many Indian states. Vriddhi project-technical partner of the government, developed a planning tool for maternal and neonatal health programmes, called RMNCH + A Action Agenda using Strategic Approach (RAASTA), which was introduced in a workshop format in two states and attended by program officers. Qualitative feedback was obtained from selected participants to understand their experience of the workshop and of the planning tool. It emerged that previous planning process had little application of local evidence based solutions. Participants appreciated the alternative approach as RAASTA equipped them to use local evidence. Several action plans derived at the workshop were included in the state plan. At the same time, apprehension was expressed by participants about translating their learnings to practical application as planning was not a central priority in their scheme of duties and tasks. Enhanced support from states in refreshing district planners' skills would be an important step. One state government has scaled up the RAASTA tool while an electronic version is being developed for future use as it demonstrates great potential to equip and aid district officials in developing evidence based plans.

India's RMNCH+A Strategy: approach, learnings and limitations.

Building on the gains of the National Health Mission, India's Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Strategy, launched in 2013, was a milestone in the country's health planning. The strategy recognised the interdependence of RMNCH+A Interventions across the life stages and adopted a comprehensive approach to address inequitable distribution of healthcare services for the vulnerable population groups and in poor-performing geographies of the country. Based on innovative approaches and management reforms, like selection of poor-performing districts, prioritisation of high-impact RMNCH+A healthcare interventions, engagement of development partners and institutionalising a concurrent monitoring system the strategy strived to improve efficiency and effectiveness within the public healthcare delivery system of the country. 184 High Priority Districts were identified across the country on a defined set of indicators for implementation of critical RMNCH+A Interventions and a dedicated institutional framework comprising National and State RMNCH+A Units and District Level Monitors supported by the development partners was established to provide technical support to the state and district health departments. Health facilities based on case load and available services across the High Priority Districts were prioritised for strengthening and were monitored by an RMNCH+A Supportive Supervision mechanism to track progress and generate evidence to facilitate actions for strengthening ongoing interventions. The strategy helped develop an integrated systems-based approach to address public health challenges through a comprehensive framework, defined priorities and robust partnerships with the partner agencies. However, lack of a robust monitoring and evaluation framework and sub-optimal focus on social determinants of health possibly limited its overall impact and ability to sustain improvements. Guided by the learnings and limitations, the Government of India has now designed the 'Aspirational Districts Program' to holistically address health challenges in poor-performing districts within the overall sociocultural domain to ensure inclusive and sustained improvements.