Implementation Models

Guided by WHO’s QoC framework and the national RMNCH+A strategy, aimed at Ending Preventable Child and Maternal Deaths (EPCMD), Vriddhi Project focusses on strengthening evidence-based practices for “Care around Birth”.

The GoI’s, Navjaat Shishu Suraksha Karyakram (NSSK) programme aimed to train health care workers on basic newborn care and resuscitation addresses care around birth issues of Prevention of hypothermia, Prevention of infection, Early initiation of breast feeding and newborn resuscitation. The training package has been recently revised with new training methodology keeping adult learning principles in mind.

In view of the prevailing pandemic situation, with attendant restrictions on travel and large gatherings, there is a need for identifying alternate ways of training using e-learning products and resources to support capacity building in the best way possible through this time and beyond.

The requirement of NSSK training rollout in state, was expressed by Jharkhand state government and acting on the request, the project developed an innovative e learning module E-NSSK. The USAID supported Vriddhi project partnered with Aastarika (A Nilekani Philanthropies Initiative) to use a digital platform for capacity building of healthcare workers on NSSK.

E- NSSK is an interactive online module which uses global best practices for training; including simple learning exercises, videos, Case scenarios, automated debriefing and rich resource for better and effective learning. This includes digitized NSSK flipbook. The E NSSK module was launched in Jharkhand, during the National Newborn week on 18th November2020 along with training session on 18th and 19th November 2020.

Access to the training module:

Vriddhi partnered with the state government to pilot Community Based Advanced Distribution of Misoprostol in Janjehli block of Mandi district. This was done to prevent postpartum hemorrhage (PPH) in home deliveries in Janjehli block, which had the highest percentage of home deliveries in Mandi district. The pilot aimed to demonstrate a feasible and replicable model for Community Based Advanced Distribution of Misoprostol for home deliveries. However, there was a continuous emphasis on institutional deliveries. The three overarching and interconnected areas of support during the implementation include:

  • (i) Health System Strengthening
  • (ii) Advocacy and Capacity Building and
  • (iii) End User Engagement
After a controlled pilot for one year, the program is being sustained by the local health system. It has been scaled upto 11 additional blocks of Himachal Pradesh, 5 districts of Jharkhand and the project also provided technical assistance to state of Rajasthan for scale up. This intervention was also presented at the Third National Summit on Good, Replicable Practices & Innovations in Public Health Care Systems in India in August, 2016.

Recognizing the period around birth is critical for maternal and newborn survival, Vriddhi’s Care around Birth (CaB) approach draws upon the WHO’s ‘Quality of Care’ framework and the national RMNCH+A strategy to improve maternal and newborn health. Using a holistic Health Systems Strengthening (HSS) approach, ‘Care around Birth’ combined innovative capacity building techniques, Quality Improvement (QI) processes and Respectful Maternity Care (RMC) practices to demonstrate visible changes in the selected high caseload delivery points over a short span of time.

Technical interventions: The technical intervention package to strengthen ‘Care around Birth’ has been designed in two phases. The first phase, Technical intervention package-I (TIP-I), lays emphasis on strengthening the universal interventions for mothers and newborns, while the second phase TIP-2 focuses on the management of complications.

Vriddhi prioritized its interventions to build upon existing strengths while targeting issues over shorter time frames. The CaB approach was customized to overcome last mile challenges in resource constrained settings and focused on improving efficiencies. Sustained improvements across intervention facilities generated acceptance for the approach. Vriddhi’s advocacy at state level has helped to mobilize financial resources to address larger systemic issues. States have provisioned funds for labor room strengthening, setting up skill labs, printing and training. In addition to mobilizing financial resources, efforts were made to build ownership in the state. Nodal officers/ staff have been appointed in state, district and facilities and pool of state level trainers has been created in all states. The CaB approach has been scaled up by the states in 41 non-HPDs with state funds. Learnings from Care around Birth are feeding into the National Labor Room Quality Improvement Initiative ‘LaQshya’. Several CaB facilities have been selected as LaQshya facilities across the project states.

Strengthening antenatal care: The BLISS model The pilot initiative, Block Level Implementation Strengthening Support (BLISS) in Laksar block, Haridwar district was designed to improve quality and coverage of ANC services with an emphasis on identification and care of high risk pregnancies, and strengthening services at sub centers. The different elements of BLISS are presented below:

Safe Motherhood and Newborn Health (SaMMaN) Initiative in Uttarakhand SaMMaN is an innovative and integrated implementation approach rolled out by the state government to improve maternal and newborn health outcomes. The initiative targets the continuum of care - antenatal care, CaB (Intrapartum and Immediate Postpartum Care) and postnatal care. It incorporates learnings from both the CaB approach and the BLISS model and will be scaled up in the state in a phasic manner. The first phase of roll out in HPDs has started. RMNCH+A Supportive Supervision: RMNCH+A Supportive Supervision is a model demonstrating partnerships to achieve impact at scale. Led by GoI, it harmonizes the support of development partners to leverage resources for an efficient and resilient health system in HPDs of India. Envisaged as a core RMNCH+A strategy for improving health service delivery, RMNCH+A Supportive Supervision was conceptualized as an external concurrent monitoring system. Vriddhi led the technical support to establish the Supportive Supervision process and continues this support through its ‘National RMNCH+A Unit (NRU)’. Between January 2015 and December 2017: 20,000 Supportive Supervision visits were made to 7,000 health facilities across HPDs. The model impacts nearly 8.3 million pregnant women and 7.6 million infants in HPDs, accounting for 25% of the annual cohort in India.

Under the Vriddhi Project, the adolescent health component of the RMNCH+A strategy is being strengthened, especially with respect to service delivery and utilization of adolescent health services. The thrust of Vriddhi adolescent health interventions has been on strengthening Adolescent Friendly Health Clinics (AFHCs). Vriddhi used a systematic approach to improve functionality of AFHCs. A rapid assessment of AFHCs in 26 project supported HPDs in six states highlighted major gaps and challenges such as lack of allocated space for AFHCs, untrained human resources, poorly maintained equipment and frequent stock-out of commodities. Vriddhi’s support include:

  1. Developing facility level plans to address gaps and supporting their implementation
  2. Task shifting and role modification are used to compensate staff shortages by expanding roles of facility staff, to include counseling and add adolescent health functions to job descriptions of available staff such as ANMs*(Auxilary Nurse Midwives) and ICTC**( Integrated Counselling and Testing Centre) counselors
  3. Training and capacity building of service providers to strengthen counseling skills and inculcate non-judgmental attitude
  4. Developing communication materials for counseling and generating awareness
  5. Supportive Supervision and onsite mentoring to iron out emerging problems and support staff
  6. Mobilizing state resources for AFHCs