Improving Maternal and Child Health
1. Project Svetana
Project Svetana, supported by Global Fund for AIDS, TB and Malaria (GFATM), is working in 361 districts of 22 states/UTs from January 2018 to March 2021 covering both Public and private health facilities. SAATHII is implementing the project with support of three implementing partners, Swami Vivekananda Youth Movement (SVYM), National Coalition of People living with HIV in India (NCPI+) and Gujarat State Network of People living with HIV/ AIDS (GSNP+).
In 22 states/UTs, Project Svetana is catering the services to an Estimated Pregnant Women of 1.4 Crores (46.5%) and providing PPTCT cascade of services to Estimated Positive Pregnant Women of 14774 (64.8%). Svetana’s strategy aims to test all pregnant women for HIV, and ensure that both the mother and baby of positive women are alive and healthy. Svetana therefore undertakes the following measures:
- To test all pregnant women for HIV
- To put positive pregnant women on Antiretroviral Treatment (ART)
- To test the spouses of all the HIV + women
- To undertake early infant diagnosis for all children within two months of age and follow up with them until 18 months of age.
The following diagram describes the implementation strategies both at the public and private health care settings:
- Reaching out to beneficiaries : The program reached out to 10.45 million pregnant women with HIV counselling and testing services and increased private sector engagement to more than 28,130 Private facilities, increased private sector reporting by 93%, reaching more than 21,672 Positive pregnant women with outreach services. About 3284 Psositive Pregnant Women (PPW) are linked to Social schemes like nutrition, Pension, and insurance.
- Follow up of Positive Pregnant women and Mother-Baby Pairs: To facilitate PPTCT services to positive pregnant women and their babies, around 1,58,423 contacts made to 21,672 beneficiaries by 235 Field Coordinators (FC) and 95 Program Officers (PO). Out of these contacts, 71,290 were in-person contacts and the rest were phone follow-ups. These contacts were done for positive pregnant women across ‘newly identified’, ‘delivery’ and ‘other infant diagnoses up to 18-months’ follow-up cohorts.
- Svetana Target and Achievement (Apr-19 to Mar-20)
- COVID -19 Response : Due to COVID-19, lockdown, the field level activities were significantly affected. However the Śvetana national provided detailed guidelines to state partners on program implementation and management of PPTCT cascade follow up during lockdown period. In March 2020, the Field staff provided counselling services to PPW and about 266 ANC and PNC were provided ART through home delivery, 106 infants received ARV and CPT, 3 ANC were assisted for delivery, and 589 general PLHIV received ART, One PPW received nutrition support through Svetana Staff.
A Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCH+A), TB and Health Systems Strengthening initiative supporting the Ministry of Health and Family Welfare in expanding availability and strengthening quality of health services in public and the private sectors was implemented with the funding support of United States Agency for International Development (USAID).
Three broad strategies being deployed are i) Strategic Information, (ii) Establishing and piloting institutional framework for sustained engagement, and (iii) Quality improvement. These actions will collectively result in equitable yet profitable models, an enabling environment, inceased capacities of stakeholders, technical support and resources for private sector engagement.
Component 1: RMNCH+A and TB Services Among Tea Garden Workers of Assam
The state of Assam has the highest maternal mortality ratio (MMR) and third highest infant mortality ratio (IMR) in the country. Available data suggest that tea gardens contribute significantly to these outcomes: the Upper Assam division with 65% of the state’s tea gardens reports the highest MMR; 40% or more maternal deaths may be among women from tea garden communities, though they represent 20% of the population. Since neonatal deaths are closely related to maternal health indicators, and an estimated 70% of infant deaths in India occur in the neonatal period, it is likely that they also drive up the IMR. Further, 16% to 18% of the tea garden workers in Assam are believed to be suffering from TB. , The populations in tea gardens are underserved by health care services as facilities in the gardens lack well-trained personnel and infrastructure, and public facilities are hard to access owing to geography and connectivity.
Project Sambhuya aims to reduce maternal and neonatal mortality, and increase the identification and treatment of TB in the tea gardens of Assam through an integrated intervention. The project contributes to USAID’s priorities of ending preventable maternal and child deaths and the global FP2020 goals through improving the quality of family health (FH) services in the private sector, enhancing community access to services and increasing the efficient use of available resources for FH programming.
- Tea garden health care providers’ capacity to deliver maternal and neonatal health and TB services strengthened: The training of 64 Medical Officers and 328 nurses from 131 TGHFs and 58 MMUs led to a 26% average increase in clinical knowledge scores and 53% average increase in clinical skills, from baseline. With respect to the management of postpartum hemorrhage and eclampsia that cause the majority of maternal deaths, 35% and 27% improvement was observed respectively.
- Increase in coverage of target population and preparedness to deliver services: After just six months of program implementation, the number of pregnant women identified doubled, women provided FP commodities increased by nine times, and the number of TB patients diagnosed increased by 80%. Total quarterly antenatal care visits facilities rose by almost three times, deliveries increased by more than four times, and postnatal care visits grew by 1.3 times. In addition, labour room practices were strengthened with a 21% increase in the availability of essential trays, 13-35% improvement in availability of drugs in the labour room, and 12-36% improvement in infection control commodities availability.
- Inclusion of tea garden health facilities in government Family Planning Logistic Management Information System (FPLMIS): Family planning commodities were frequently unavailable at TGHFs at baseline, e.g. condoms at 81%, daily oral contraceptive pills at 68%, and weekly pills at 97%. SAATHII advocated with NHM Assam to include TGHs and MMUs in the FPLMIS to enable the provision and tracking of the requisite FP commodities to these facilities from the government supply. The NHM accepted the suggestion and mapping of facilities and capacity building of TGHF staff on using the FPLMIS software has been carried out. This process will be taken forward in the coming months.
- Training of ASHAs on Participatory Learning and Action (PLA) techniques budgeted in state Program Implementation Plan: SAATHII piloted a set of PLA activities with ASHAs in the tea garden areas and advocated with NHM, Assam, to budget for training of ASHAs on PLA, in the state PIP. Consequently, the state budgeted for it in its PIP for 2019-20, which was approved by the government of India, and training of ASHAs in the state was initiated.
Component 2: Technical Support for Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)
Project Sambhuya provided technical support to the NHM in monitoring the PMSMA and collating good practices. The activities and accomplishments carried out at national and state level are presented below:
1. Process Evaluation of PMSMA
- A roadmap was prepared after taking into account the status of various antenatal care indicators in different states of India and the findings and recommendations from the Process Evaluation of PMSMA was shared with NHM.
- The Process Evaluation of PMSMA covered:
- 18 districts in 9 states
- Nearly 619 stakeholders were interviewed
- Interviewees included private providers, personnel of departments other than health, pregnant women and community members, apart from Government officials at state, district and facility levels
- Nearly 15% of interviewees were from private sector
2. Facilitating PPP USG
- SAATHII prepared the guidelines for the engagement of the private sector for the service purchase model of PPP USG. These included guidelines, RFP and contract templates for engagement of the private sector for purchasing PPP USG services and shared with NHM
State Level Accomplishments:
- An estimated 3,50,000 pregnant women would have benefitted from improved services at PMSMA sites between January 2018 and September 2019
- Technical support to GoMP resulted in finalization and roll out of state-specific guidelines for tracking and follow up of high-risk pregnant women
- 3,300 personnel trained at district and block levels on identification, tracking and follow-up of high-risk pregnant women in 14 districts (including 8 intervention districts)
- (High-Risk Pregnant women) HRPW line list prepared in 61% of the sites.
- 45% of the sites formed sector level teams for follow up of HRPW.
- Implemented innovative approaches such as follow up of HRPW during Mahila Swasthya Shivirs and conducting of PMSMA at PHC level in Gwalior
- Ultrasonography (USG) enabled in 8 sites across five districts through Public-Private Partnership (PPP) mode. This enabled at least 1,500 pregnant women avail USG services in last one year.
- PMSMA registers were used for proper documentation of pregnant women in 100% of the sites.
- Advocacy with GoMP resulted in state government budgeted for and obtaining NHM funds to provide a nutritious diet on PMSMA days. This diet consisted of Iron and protein-rich refreshment (dry fruit laddoo and seasonal fruit) and was provided at 100% of the sites.
- Token system for crowd management and public address system for group counselling and IEC were used in more than 85% of the sites. These had been procured through the funds provided by NHM.
- Advocacy with Lions Club resulted in support for distributing 3,000 certificates to private practitioners to motivate them.
- Volunteer students from Nutrition schools across Bhopal and Sagar were mobilized to provide counselling to pregnant women on PMSMA day. 1,500 pregnant women were counselled on good nutritious practices during pregnancy.
3. Catalyzing Pediatric TB Innovations (CaP TB)
India identifies around half of estimated pediatric TB cases, with the gaps attributable to under-diagnosis and under-reporting, especially from private health sector. The CaP TB project’s goal is to contribute to reduction in morbidity and mortality due to Pediatric TB, and it intends to generate evidence on removing critical access barriers in private sector.
The major strategies include engagement of private paediatric practitioners for provision of comprehensive paediatric TB services across 15 districts of three states and share the learning with National TB Elimination Program (NTEP) for scale-up. The project, funded by UNITAID and EGPAF is being implemented in 69 private sector paediatric sites across 15 districts of Maharashtra, Andhra Pradesh, and Telangana.
The project’s expected outcomes are:
- An enabling policy and regulatory environment at the global and national level is created to support introduction and scale-up of effective and innovative paediatric TB diagnostic and treatment interventions, including innovative models of care
- Increased demand for pediatric TB treatments through improved detection
Rapid uptake of and access to improved pediatric TB treatments for DS-TB and LTBI
- Generation of novel evidence data to inform policy guidelines
- Effective and sustainable transition to national programs achieved
CaP TB is an implementation research project with target to establish CaP TB sites and initiate research activities through baseline and intervention activities at CaP TB sites.
- Since project inception, CaP TB project identified 37% (2198) of 5984 private health facilities as pediatric practitioners in nine districts and initiated the scale-up in additional six districts during Jan-Mar 2020.
- The project team organised three state level ToTs and seven district level trainings and trained 704 pediatricians and program managers.
- 69 private pediatric sites were partnered as CaP TB sites through a tripartite MoU. The technical support to these sites led to 236039 children (50% of 470769 attendees) screened for TB and identification and provision of comprehensive pediatric TB services to 1380 (0.6%) presumptive pediatric TB children and 130 TB positive children during July 2019- Mar 2020.
In addition, CaP TB provided technical support to district NTEP units across the nine operational districts and has led to the
i. Registration of 40% pediatric facilities in Nikshay
ii. Notification of 3493 Pediatric Presumptive TB and 1033 Pediatric TB cases in Nikshay
iii. Treatment initiation for 99.8% of children with TB, with 43% on government’s free-of-cost FDC drugs
iv. 75% of children with TB registered in Nikshay Poshan Yojana nutrition support and 44% of them receiving monthly support of INR 500 for nutrition
v. Contacts traced for 58% of the pediatric index households with 1332 household members screened, and 31 out of 93 children found eligible for TB Preventive Therapy (TPT) are initiated on Isoniazid Prophylaxis.
4. Project Samaikhya
Project Samaikya, funded by UNICEF, is intended to swiftly address the issues identified by PMTCT program in the two states of Andhra Pradesh (AP) and Telangana (TS) towards reaching the Elimination goal of HIV by 2020. SAATHII, implementing the Svetana PPTCT program in AP and TS in both public and private health sector in collaboration with SACS, identified few critical barriers in terms of capacity building of service providers, policy level decisions, program review, availability of education material on PMTCT and reporting and documentation. UNICEF has identified SAATHII as a technical partner in supporting the mentioned funding and programmatic gaps in the current PMTCT program.
- More than 1200 doctors from public health facilities in the state of Andhra Pradesh were oriented on dual EMTCT in collaboration with APSACS and DACPUs.
- The entire state of TS and AP is covered for EID training to make all SA-ICTCs function as EID/DBS collection centres.
- 340 Health care providers of all cadres from 10 high load referral centres in TS were sensitised on standard work precautions, Infection prevention practices and labour room protocols.
- More than 80 DAPCU representatives were sensitized on the issues of PPTCT program and technical components of PPTCT guidelines.
- Plan for forming District Elimination committee in TS is achieved.
Training of 40 Svetana field team on optimal infant and young child feeding practices
- In AP – EMTCT modules and leaflets were printed for distribution to all levels of health care providers during state and district level consultations on EMTCT.
- In TS – Labour room protocols, EID protocols and a 4 pager on EID were printed and distributed to the participants in the respective trainings.
- Posters on EID algorithms including the revised 18 months testing were printed for distribution to all SA-ICTCs in AP and TS
The shortages of registers and consumables are addressed through Samaikya project