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

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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.
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TanejaG, etal. BMJ Glob Health 2019;4:e001162. doi:10.1136/bmjgh-2018-001162
India’s RMNCH+A Strategy: approach,
learnings and limitations
Gunjan Taneja,1 Vegamadagu Suryanarayana-Rao Sridhar,2
Jaya Swarup Mohanty,3 Anurag Joshi,4 Pranav Bhushan,5 Manish Jain,6
Sachin Gupta,7 Ajay Khera,8 Rakesh Kumar,9 Rajeev Gera 10
Practice
To cite: TanejaG, SridharVS-R,
MohantyJS, etal. India’s
RMNCH+A Strategy:
approach, learnings and
limitations. BMJ Glob Health
2019;4:e001162. doi:10.1136/
bmjgh-2018-001162
Handling editor Soumyadeep
Bhaumik
Additional material is
published online only. To view
please visit the journal online
(http:// dx. doi. org/ 10. 1136/
bmjgh- 2018- 001162).
Received 10 September 2018
Revised 29 March 2019
Accepted 30 March 2019
For numbered afliations see
end of article.
Correspondence to
Dr Rajeev Gera;
gerarajeev@ gmail. com
© Author(s) (or their
employer(s)) 2019. Re-use
permitted under CC BY-NC. No
commercial re-use. See rights
and permissions. Published by
BMJ.
ABSTRACT
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 efciency and
effectiveness within the public healthcare delivery system
of the country. 184 High Priority Districts were identied
across the country on a dened 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, dened 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.
INTRODUCTION
Access to adequate, acceptable and quality
healthcare services is important towards
achieving ‘Universal Health Coverage’.1 India
has faced the burden of inadequate and poor-
quality health services for a prolonged period
that has led to high mortality and morbidity
and unmeasurable adverse health outcomes
among the vulnerable population groups.2
According to an estimate (2013), with a large
annual birth cohort of about 26 million live
births and 158 million children in the age
group of 0–5 years, India accounts for the
largest number of deaths in under-five years
age group—nearly 1.5 million annually, of
which around 0.8 million newborns die within
28 days of birth.3
To reduce inequity in healthcare services
and improve reproductive, maternal,
newborn and child health outcomes, India’s
Ministry of Health and Family Welfare
(MOHFW) launched the ‘National Rural
Health Mission’ (2005) and the ‘National
Urban Health Mission’ (2008). These were
Summary box
Based on an inclusive and comprehensive approach,
India’s Reproductive, Maternal, Newborn, Child and
Adolescent Health (RMNCH+A) Strategy aims to
improve outcomes across 184 poor-performing dis-
tricts of the country.
Recognising the interdependence of RMNCH+A
Interventions across the life stages, the strat-
egy prioritised districts for implementation of
evidence-based, high-impact interventions by gal-
vanising support from development partners and es-
tablishment of a concurrent monitoring mechanism
for measuring improvements across healthcare fa-
cilities in the High Priority Districts.
Variable responsiveness of health systems across
the states, over-reliance on partner agencies, lack
of a dedicated monitoring and evaluation framework
and an inability to address social determinants of
health might have limited the impact of the strategy.
Learnings and limitations of the strategy have paved
the way forward for designing holistic implemen-
tation frameworks by engaging all relevant stake-
holders and adopting a systems-based approach
towards improving healthcare service delivery.
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Table 1 Indicators used for identication of High Priority Districts
Theme
Nine states
(Annual Health Survey data)
Remaining states/UTs
(District Level Household Survey-3 data)
Maternal health Maternal mortality ratio
% of safe deliveries
% of mothers received at least three antenatal care visits
% of safe deliveries
Child health Infant mortality rate
% of children 12–23 months fully
immunised
% of children 12–23 months fully immunised
% of children aged less than 6 months who are
exclusively breast fed
Family planning Total fertility rate
Contraceptive prevalence rate (modern
methods)
% of births of order 3 and above
Contraceptive prevalence rate (modern methods)
UT, union territories.
later merged into the ‘National Health Mission’ with an
overarching objective to strengthen the public health-
care infrastructure and quality of health services and
secure an enhanced financial support for overall health
system strengthening (HSS). Owing to these efforts and
investments in the public healthcare sector, the country
has made steady progress towards curbing the deaths
among mothers and children. The ‘Maternal Mortality
Ratio’ improved by a 5.2% average annual rate of reduc-
tion from 600 per 100 000 live births (1990) to 200 per
100 000 live births (2010). ‘Under-Five Mortality Rate’ in
India declined at a much faster pace as compared with
the global average and registered a 3% average annual
rate of reduction from 114 deaths per 1000 live births
(1990) to 61 deaths per 1000 live births (2011), against
the global average of 87 and 57, respectively.4–6
CONCEPTUALISATION OF INDIA’S ‘REPRODUCTIVE, MATERNAL,
NEWBORN, CHILD AND ADOLESCENT HEALTH STRATEGY’
Despite the ongoing efforts and progress achieved, the
country’s healthcare system reflected a critical imbal-
ance characterised by high out-of-pocket expenditure
stemming out from the deficiencies in the public sector’s
capacity to deliver basic healthcare. The areas and
population groups having the greatest need for quality
healthcare services could not get an appropriate share
from the existing public health services.7–9 Hence, the
situation demanded a comprehensive vision for public
healthcare services, encompassing both preventive and
curative aspects for a broader range of beneficiaries
and health conditions, and necessitating leveraging of
new resources.10 Building on these aspects, MOHFW in
consultation with stakeholders developed India’s ‘Repro-
ductive, Maternal, Newborn, Child and Adolescent
Health Strategy’ or ‘RMNCH+A Strategy’. The strategy
was launched during the ‘National Summit on Call to
Action for Child Survival and Development’ in February
2013,11 and guided by the central tenets of universal
care, entitlement and accountability, it laid a renewed
emphasis on high-impact health interventions and
addressed strengthening of healthcare services especially
in the poor-performing geographies of the country.12
APPROACH ADOPTED IN THE REPRODUCTIVE, MATERNAL,
NEWBORN, CHILD AND ADOLESCENT HEALTH STRATEGY
India’s RMNCH+A Strategy was unique as it recog-
nised the fact that maternal and child health cannot be
improved in isolation and need to be effectively weaved
with adolescent, family planning and nutrition-based
interventions. The ‘Plus’ within the strategy focused on
continuum of care with linkages between the interven-
tions targeted at various stages of life-cycle from newborn
to the reproductive age, with focus on adolescence as a
distinct life stage. It laid focus on linkages between home
and community-based services to facility-based care, and
between referrals and counter-referrals between and
among the health facilities at the primary, secondary and
tertiary levels.12
The ‘RMNCH+A Strategy’ was based on innovative
approaches and management reforms, like selection of
poor-performing areas and high-impact healthcare inter-
ventions, enhancing responsibility of development part-
ners and establishing a concurrent monitoring system
within the healthcare delivery system to improve its effi-
ciency and effectiveness as described in the following
section.
Selection of ‘High Priority Districts’
India is a union of 29 states and seven union territories
(UT) comprising 718 districts with a vast and variable
geographical expanse. The country is characterised
by wide interstate and intrastate disparities in terms of
distribution, availability, utilisation of public healthcare
services and the health status of its citizens contrib-
uting towards poor health outcomes.13 14 Under the
‘RMNCH+A Strategy’, underperforming districts named
as ‘High Priority Districts’ were identified to facilitate
focused planning and implementation. To achieve this,
state/UT-wise ranking of districts was done based on
defined sets of mortality and outcome indicators selected
from the most recent evaluation survey findings for the
respective states/UTs. Likewise, ‘Annual Health Survey’
(2012–2013) was considered for nine states, while ‘District
Level Household Survey-3’ (2007–2008) was considered
for the remaining states/UTs (table 1). Within each state,
25% poorest performing districts were selected based on
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Figure 1 High Priority Districts (India).
the performance of selected health indicators. Addition-
ally, the tribal predominant districts and those affected
by insurgent and rebel groups were also selected. Like-
wise, 184 ‘High Priority Districts’ were taken up across
the country for focused efforts under the strategy. The
number of targeted beneficiaries in these ‘High Priority
Districts’ comprised nearly 8.3 million pregnant women
and 7.6 million infants annually, accounting for almost
25% of the annual cohort of pregnant women and
infants in India.15 Moreover, the strategy also embarked
on differential planning with 30% additional resource
allocation per capita by the state governments for each
‘High Priority District’ under the National Health
Mission (figure 1).
Prioritisation of high-impact Reproductive, Maternal,
Newborn, Child and Adolescent Health Interventions
The ‘RMNCH+A Strategy’ focused on promotion, adop-
tion and context-specific adaptation of evidence-based,
high-impact interventions across different life-cycle
stages including newborn, childhood, adolescence and
the reproductive age groups. These interventions were
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Figure 2 The Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) 5*5 Matrix.
selected based on the available scientific evidence docu-
menting their efficacy and impact on reducing maternal
and child, mortality and morbidity. The interventions
were summarised in the form of ‘RMNCH+A 5×5 Matrix’
specifying five critical interventions in each of the five
thematic areas, viz reproductive health, maternal health,
newborn health, child health and adolescent health.
Additionally, emphasis was also given on five cross-cutting
and five HSS interventions focusing on infrastructure,
human resources, supply chain management and referral
transport measures (figure 2).16
Involving the development partners
The ‘RMNCH+A Strategy’ gave high reliance to part-
nerships and targeted to leverage and harmonise the
technical assistance across the RMNCH+A spectrum.
Concerted efforts were undertaken to galvanise the state
governments and development partners working at the
national and subnational levels through a series of steps
as follows:15
Periodic consultations were organised by the national
ministry for establishing strategic dialogue with the
development partners. The partners were nominated
in technical advisory and resource groups consti-
tuted for development and dissemination of training
material and operational guidelines for RMNCH+A
Interventions.
At the national level, a ‘National RMNCH+A Unit’
was constituted with support from the US Agency
for International Development supported Maternal
and Child Health Integrated Program (MCHIP)
and ‘Vriddhi’ (Scaling up RMNCH+A Interventions)
Projects and was anchored within the MOHFW. It
coordinated technical assistance from the national
and state-level partners, conducted periodic visits to
the health facilities to measure progress and recom-
mend actions, and monitored implementation of
RMNCH+A Interventions in the states/UTs and
‘High Priority Districts’.
In the states, partners providing significant level of
technical support were nominated as ‘State Lead
Partner’ for the respective states. These lead part-
ners were entrusted with the role to constitute and
administer ‘State RMNCH+A Units’ within the state
health departments to coordinate with other partner
agencies working in the states, extend support to
government health officials and staff in rolling out
high-impact RMNCH+A Interventions and monitor
implementation and progress under the overall guid-
ance of the ‘National RMNCH+A Unit’ (figure 3).
In the ‘High Priority Districts’, one ‘District Level
Monitor’ was recruited by the lead partner to work
under the guidance of respective ‘State RMNCH+A
Units’ and support district health departments
in planning and monitoring implementation of
RMNCH+A Interventions.
Gap assessment at public health facilities
Public health facilities in India are categorised into three
levels, viz L1, L2 and L3 based on the availability of ante-
natal, intranatal and postnatal care service sets (table 2).17
L1 health facilities provide primary care, while L2 and
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Figure 3 Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) State Lead Partners.
Table 2 Levels of public health facilities and the services available
Level Type Services
Level 1 Health subcentres and non-24×7 primary
health centres (PHC)
Deliveries are conducted by skilled birth attendant.
Equipped with newborn care unit
Minimum of three deliveries conducted every month
Level 2 Basic level
All 24×7 PHC, and non-FRU community
health centres (CHC)
Provide basic emergency obstetric care (BEmOC) services
Conducting deliveries and manage complications not requiring
surgery or blood transfusion
Equipped with either newborn care unit or newborn stabilisation
unit
Minimum of 10 deliveries conducted every month
Level 3 Comprehensive level
First referral units (community health
centres, subdivisional hospitals and
district hospitals)
Hospitals with facilities to manage complications, including
C-section and blood transfusion.
These are equipped with newborn stabilisation unit or special
newborn care unit
Minimum of 20–50 deliveries conducted every month
C-section, caesarean section; FRU, rst referral unit.
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L3 categories catering to the major proportion of bene-
ficiary load provide basic and comprehensive obstetric
care services, respectively, and serve as referral facilities.
The ‘RMNCH+A Strategy’ envisaged strengthening of all
three categories of public health facilities.
Before implementation of RMNCH+A high-impact
interventions a gap assessment exercise was conducted in
‘High Priority Districts’ by the respective State Lead Part-
ners to measure the functionality status and readiness of
public health facilities to deliver high-impact RMNCH+A
Interventions. This entailed collection of information
regarding geographical mapping of different categories
of health facilities, availability of health infrastructure
and human resource, and analysis of existing gaps in
terms of availability, accessibility, utilisation and quality
of RMNCH+A services. The findings of the assessment
were used to guide facility-level action planning and
implementation.
Institutionalisation of ‘Reproductive, Maternal, Newborn, Child
and Adolescent Health Supportive Supervision’
Various national-level reviews conducted from time to
time identified absence of supportive supervision as a
critical bottleneck in improving the performance of
health staff and quality of healthcare services. The key
challenges underlying this gap included inadequate
number of supervisors within the system, lack of skills
and training, and unavailability of policy and clear guide-
lines for supportive supervision and concurrent moni-
toring.12 The RMNCH+A Strategy recognised the need
to strengthen supportive supervision of service providers
to bring integration of primary care services, improve
quality and enhance skills and application. Under the
strategy, a supportive supervision model was institutional-
ised as an external concurrent monitoring mechanism to
track progress and generate evidence to facilitate actions
for strengthening high-impact RMNCH+A Interventions.
Guided by the MOHFW, the RMNCH+A Supportive
Supervision model was led by the partner agencies and
integrated all five thematic areas for focused support and
on-job facilitation.18–21
Preparations for the institutionalisation of the
RMNCH+A Supportive Supervision were initiated soon
after the launch of RMNCH+A Strategy and involved
development of standardised tools comprising a uniform
supportive supervision checklist (online supplementary
file 1) for use across all High Priority Districts, comput-
er-based (Microsoft Excel) tool for uniform compila-
tion of observations made across the health facilities,
training package for the supervisors and standard oper-
ating procedures regarding data collection, compilation,
sharing at various levels, actions taken and follow-up.
The RMNCH+A Supportive Supervision mechanism
was rolled out from January 2015 in all 184 High Priority
Districts and involved periodic visits to the health facili-
ties by the ‘District Level Monitors’ to assess availability
and quality of services using the standardised checklist
and provide on-job mentoring to the concerned health
facility staff. The checklist helped data collection on
141 critical RMNCH+A parameters through on-site
assessment, direct observation, record review and inter-
action with the facility-level staff during the supportive
supervision visits. The supervisor teams also sometimes
comprised state and district government officials and
additional representatives from partner agencies. The
observations made during the visit were first shared with
the facility-level staff followed by facilitation in prepara-
tion of facility-level action plans. The visits also entailed
sensitisation and mentoring of the staff about national
guidelines for adoption of correct practices and key
observations and the action points were shared during
the review meetings at district, state and the national
level to initiate required corrective actions (figure 4).
PROGRESS MADE
Data from RMNCH+A Supportive Supervision visits
conducted over a 2-year period between January 2015
and December 2016 were compiled at the National
RMNCH+A Unit to assess the improvement in terms of
availability of equipment and supplies and healthcare
services at the public health facilities. During this period,
health facilities were prioritised for strengthening based
on the delivery load, services offered, available infrastruc-
ture and in discussion with the district health department.
These prioritised facilities were visited more frequently
to follow and facilitate the corrective actions. Therefore,
during analysis, the data pertaining to the health facilities
which were visited for three times or more were disaggre-
gated, and observations made at the time of first visit and
the last visit to these facilities were compared to measure
progress.
Overall, 17 893 supportive supervision visits were
conducted at 6678 health facilities in different categories
during the 2-year period in the High Priority Districts
(table 3).
Out of these facilities, 2348 (35% of total facilities
visited) were prioritised for strengthening including 556
facilities in L1 category, 1354 in L2 category and 438 facil-
ities in L3 category. During the supportive supervision
visits by the District Level Monitors and other representa-
tives to the selected health facilities, on-site support was
provided to the concerned staff in terms of reorientation,
capacity building and to identify gaps and measures to
correct them. During each visit, the standard checklist
was used to capture the concurrent status with respect
to the availability of equipment, amenities and ongoing
practices. The information was collected through direct
observation (eg, availability and functionality of supplies
and equipment, implementation of key practices), review
of records since last visit (eg, labour room records and
filled partographs) and discussion with the staff (eg,
family planning and service delivery at the community
level). This information was computerised into an Excel-
based data sheet. These compiled data were analysed on
periodic basis to reveal progress and gaps to guide focused
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Figure 4 Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Supportive Supervision: feedback and
feedforward mechanism. MOHFW, Ministry of Health and Family Welfare.
Table 3 Health facility level-wise distribution of supportive supervision visits
L1 L2 L3 Total
Public health facilities providing delivery services visited for RMNCH+A Supportive
Supervision
2911 3088 679 6678
Total supportive supervision visits made 5300 8866 3727 17 893
High-delivery case load health facilities, which were visited for three times or more 556
(19%)
1354
(44%)
438
(65%)
2348
(35%)
RMNCH+A, Reproductive, Maternal, Newborn, Child and Adolescent Health.
actions during the subsequent visits. Thematic area-wise
key outcomes over a 2-year period are summarised in
tables 4–6 (online supplementary file 2).
LEARNINGS
The RMNCH+A Strategy has been a unique example of
adopting a comprehensive and holistic approach towards
addressing the major causes of morbidity and adverse
outcomes among the vulnerable population groups and
geographies having inadequate health services across the
entire country.
Recognising the inclusiveness and interdependence
of RMNCH+A components, prioritisation of poor-per-
forming districts, targeted implementation of evidence-
based high-impact RMNCH+A Interventions, active and
coordinated engagement of partner agencies and focused
support to high case load health facilities in the High
Priority Districts through the RMNCH+A Supportive
Supervision mechanism are some novel systems that
were established through the strategy, thereby contrib-
uting towards a system-based approach to improve health
outcomes. The progress and issues were tracked using
selected key performance and actionable indicators
instead of broad parameters, which helped in facilitating
specific and focused action plans.
Moreover, for the first time in the country’s healthcare
spectrum, the RMNCH+A Strategy generated shared
objectives and established partnerships through active
engagement of all stakeholders within and beyond the
government structures at the national and state levels.
Specifically, the engagement of development partners
helped leverage human and technical resource for
strengthening healthcare service delivery. An institu-
tional framework administered by the development
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Table 4 Progress achieved in maternal health-related parameters
Parameter
L1 facilities
(n=556)
L2 facilities
(n=1354)
L3 facilities
(n=438)
First visit
(baseline) Last visit
Progress in
% points
First visit
(baseline) Last visit
Progress in
% points
First visit
(baseline) Last visit
Progress in
% points
Availability of essential medicines and commodities (Source: observation and record review by monitor)
Oxytocin (injectable) 59% 75% 16 82% 93% 11 90% 98% 8
Magnesium sulfate (injectable) 39% 54% 15 73% 86% 13 88% 93% 5
Antihypertensive drugs 30% 44% 14 69% 84% 15 83% 94% 11
Misoprostol (oral) 52% 70% 18 70% 79% 9 82% 92% 10
Pregnancy testing kits 72% 83% 11 69% 79% 10 69% 83% 14
Partographs 40% 64% 24 62% 79% 17 68% 83% 15
Protocol display in labour rooms 44% 60% 16 70% 85% 15 74% 92% 18
Practices in the labour room (Source: observations and record review by monitor)
Recording fetal heart rate at time of
admission
49% 60% 11 72% 80% 8 83% 90% 7
Using partograph to monitor labour 31% 48% 17 52% 66% 14 57% 72% 15
Administering uterotonic after birth 75% 84% 9 91% 93% 2 97% 98% 1
Using magnesium sulfate to manage
pre-eclampsia
25% 36% 11 57% 71% 14 87% 90% 3
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Table 5 Progress achieved in newborn and child health-related parameters
Parameter
L1 facilities
(n=556)
L2 delivery points
(n=1354)
L3 delivery points
(n=438)
First visit
(baseline) Last visit
Progress
in %
points
First visit
(baseline) Last visit
Progress
in %
points
First visit
(baseline) Last visit
Progress
in %
points
Newborn health (Source: observation by monitor)
Availability of functional newborn care
corner inside the labour room
38% 51% 13 79% 89% 10 92% 97% 5
Availability of functional equipment at newborn care corner (Source: observation by monitor)
Radiant warmer 23% 29% 6 72% 79% 7 90% 95% 5
Bag and mask (sizes 0 and 1) 53% 71% 18 77% 87% 10 88% 97% 9
Mucus extractor 75% 88% 13 85% 93% 8 93% 96% 3
Newborn corner adequately equipped 26% 42% 16 54% 71% 17 76% 87% 11
Newborn care-related practices in the labour room (Source: observations and record review by monitor)
Skin-to-skin contact between mother and
newborn
75% 83% 8 76% 83% 7 79% 92% 13
Administering antenatal corticosteroids in
preterm babies
18% 30% 12 38% 58% 20 70% 83% 13
Provider aware of steps in newborn
resuscitation
42% 63% 21 63% 74% 11 80% 91% 11
Newborn vaccination with rst dose of
hepatitis B, oral polio vaccine and BCG
vaccines
21% 26% 5 67% 80% 13 88% 94% 6
Child health (Source: observation and record review by monitor)
Availability of oral rehydration salts and zinc
tablets
76% 83% 7 76% 80% 4 73% 84% 11
Availability of salbutamol (syrup or
nebulising solution)
27% 39% 12 58% 65% 7 69% 78% 9
Albendazole syrup for deworming 59% 74% 15 81% 89% 8 83% 92% 9
Growth monitoring at village-based
Anganwadi centres and during ‘Village
Health & Nutrition Days’
60% 65% 5 58% 69% 11 52% 60% 8
Referral of malnourished children to
nutritional rehabilitation centres
60% 68% 8 61% 69% 8 56% 60% 4
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Table 6 Progress achieved in reproductive health-related parameters
Parameters
L1 facilities
(n=556)
L2 delivery points
(n=1354)
L3 delivery points
(n=438)
First visit
(baseline) Last visit
Progress in
% points
First visit
(baseline) Last visit
Progress in
% points
First visit
(baseline) Last visit
Progress in
% points
Availability of essential supplies (Source: observation and record review by monitor)
All three contraceptives (intrauterine contraceptive device, oral contraceptive pills and
condoms)
59% 74% 15 68% 85% 17 78% 90% 12
Emergency contraceptive pills 60% 71% 11 62% 73% 11 66% 80% 14
PPIUCD forceps 16% 30% 14 40% 68% 28 76% 89% 13
Kits for manual vacuum aspiration 22% 31% 9 56% 64% 8
Availability of services at health facilities (Source: record review and discussion with facility staff by monitor)
Family planning counselling during antenatal visits 73% 85% 12 77% 85% 8 85% 92% 7
Postpartum intrauterine contraceptive device (PPIUCD) insertion service available at the
facilities
10% 16% 6 30% 51% 21 66% 84% 18
Community-based service delivery (Source: record review and discussion with facility staff by monitor)
Home delivery of contraceptives by accredited social health activist (ASHA) workers 72% 82% 10 71% 82% 11 57% 67% 10
Incentives to ASHA for promotion of delay or spacing between births 50% 63% 13 54% 72% 18 55% 64% 9
Incentives to ASHA for accompanying PPIUCD clients 30% 47% 17 36% 55% 19 47% 60% 13
partners and comprising National and State RMNCH+A
Units and District Level Monitors ensured a dedicated
team and efforts to support need-based facility-level plan-
ning, supervision and mentorship of health staff, and
guided the health department take corrective actions.
The RMNCH+A Supportive Supervision exercise led
by the development partners and backed up by national
guidelines and standardised tools emerged as a unique
model to identify gaps in real time and facilitate gap-ori-
ented planning and implementation at the facility level.
The findings of the mechanism showed improvements
in terms of basic infrastructure, availability of essential
drugs, equipment and other supplies, and the service
delivery-related processes followed at the public health
facilities in High Priority Districts. This perhaps also
translated into improved knowledge and quality of care
at the health facilities.
The analysis of information captured during the
supportive supervision visits shows improvement in terms
of the availability of medicines and supplies, the prac-
tices followed by the service providers and the upkeep of
facility-level records. From the findings it is evident that
mentoring support, review mechanisms and development
of facility specific action plans translated to improved
leadership and governance resulting in improved service
delivery. Overall, the RMNCH+A Strategy and the
approaches adopted therein contributed in strength-
ening the WHO HSS building blocks towards an efficient
and responsive public healthcare delivery system.22
Building on the gains and to further intensify efforts,
the list of High Priority Districts was revised in 2017 based
on the findings of National Family Health Survey (Round
4; 2015–2016). Likewise, 209 districts were identified as
high priority based on composite index derived from
status of six indicators, viz proportion of pregnant women
who had four or more antenatal check-ups, proportion of
safe deliveries, fully immunised children, prevalence of
undernutrition, births in third order or more and use of
modern family planning methods.
LIMITATIONS
The RMNCH+A Strategy is an initiative of the National
Health Ministry and it specifically focused on actions
across the RMNCH+A spectrum and the progress
achieved. Although the strategy did help in establishing
structures and processes, the desired outcomes have
been variable as demonstrated by the findings from the
supportive supervision mechanism which reveal thematic
area-wise as well as geographic variations.
While the differential improvements as evidenced by
the Supportive Supervision mechanism might be due
to variability in capacity and responsiveness of health
systems across the states of the country, over-reliance on
development partners might be a contributing factor.
This is because while the role of national ministry of
health and partner agencies was defined well the expec-
tations of state governments and district administration
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TanejaG, etal. BMJ Glob Health 2019;4:e001162. doi:10.1136/bmjgh-2018-001162 11
BMJ Global Health
were not very specific. While the efforts of the partners
did result in improved ownership and accountability
within the government system, sustainability might be a
challenge after withdrawal of partner support. Possibly
the results might have been better if the state National
Health Mission (NHMs) and district health authorities
were in leadership capacities with partner agencies func-
tioning as catalysts.
Also, though the strategy recognised adolescents as
an important stakeholder, efforts to improve adolescent
outcomes need further strengthening. The RMNCH+A
Supportive Supervision mechanism which formed the
fulcrum of the entire strategy did not adequately address
adolescent health parameters possibly resulting in subop-
timal improvements.
In addition, besides the RMNCH+A Supportive Super-
vision mechanism, the strategy lacked a defined moni-
toring and evaluation framework. As process evaluation
was not undertaken, many of the learnings from imple-
mentation in widely variable geographies could not be
highlighted. Due to lack of substantial evidence, inte-
gration of potential learnings at the policy level is also
questionable.
Moreover, it is now well established that social determi-
nants of health play a defining role in improving health
outcomes, the strategy could have possibly expanded its
scope to address the social determinants resulting in far
more impressive gains across the High Priority Districts.
CONCLUSION
India’s RMNCH+A Strategy has been a historical mile-
stone in the country’s healthcare planning. The strategy
succeeded in establishing an institutional framework
and a mechanism of facility-level, need-based plan-
ning through concerted and coordinated efforts. A
recent review of data suggested that 48 of the 184 High
Priority Districts have improved and hence are no longer
included in the list of these districts.23 However, despite
the improvements and the mechanisms established, gaps
in the design and subsequent implementation make
it difficult to gauge the impact of the strategy thereby
limiting translation of learnings into long-term policy
and planning. It is, therefore, imperative to identify the
weaknesses, opportunities and the learnings gained from
this strategy through assessments and data reviews in the
coming years to guide future programmes better.
In addition, realising the importance of social determi-
nants in fostering overall improvement in January 2018,
the Government of India launched the ‘Transformation
of Aspirational Districts’ initiative in 117 districts across
the country. The initiative focuses on five themes, viz
health and nutrition, education, agriculture and water
resources, financial inclusion and skill development,
and basic infrastructure and operational and imple-
mentation components. Within the health portfolio
the initiative builds on the RMNCH+A framework to
improve outcomes in the identified aspirational districts
in a more holistic and comprehensive manner. More in
line with the United Nations’ Sustainable Development
Goals, the initiative targets to improve India’s ranking in
Human Development Index, raising living standards and
ensuring inclusive growth of all sectors.24
Author afliations
1USAID-VRIDDHI (Scaling up RMNCH+A Interventions Project), IPE Global, New
Delhi, India
2USAID-VRIDDHI (Scaling up RMNCH+A Interventions Project), IPE Global, New
Delhi, India
3USAID-VRIDDHI (Scaling up RMNCH+A Interventions Project), IPE Global, Ranchi,
India
4USAID-VRIDDHI (Scaling up RMNCH+A Interventions Project), IPE Global,
Chandigarh, India
5National Aspirational Districts PMU, Ministry of Health and Family Welfare, New
Delhi, India
6Public Health Consultant, Lucknow, , India
7Maternal and Child Health Division, USAID India, New Delhi, India
8Child and Adolescent Health Division, India Ministry of Health and Family Welfare,
New Delhi, India
9Policy Planning & SDG Integration, United Nations Development Program India,
New Delhi, India
10USAID-VRIDDHI (Scaling up RMNCH+A Interventions Project), IPE Global, New
Delhi, India
Acknowledgements The authors thank the Ministry of Health and Family Welfare,
Government of India, for leading the RMNCH+A Supportive Supervision mechanism
and BMGF, DFID, NIPI, UNFPA, Unicef, USAID and Tata Trusts for their support and
involvement in the initiative. The authors also acknowledge Arvind Kumar, Ashok
Negi and Surajit Dey for supporting the development of the data compilation tool
and data analysis.
Contributors GT contributed towards designing the Supportive Supervision
intervention, tested the implementation of the mechanism, drafted, reviewed and
nalised the manuscript. He advised data analysis and coordinated the inputs
from all the authors. VSS conceptualised the Supportive Supervision data analysis
tool, coordinated its development and undertook data analysis and interpretation.
JSM facilitated the intervention on ground, supported the development of the
resource package for the intervention and drafting of the introduction and
discussion sections. AJ facilitated the intervention on ground and supported
the drafting of the methodology and results sections. PB cleaned, managed and
analysed the data and coordinated with the various stakeholders involved in
the implementation of the mechanism. MJ drafted and edited the manuscript
and undertook data analysis and interpretation. SG reviewed and edited the
manuscript and supported the development of the technical package for the
intervention. AK conceptualised the scope of the strategy and the Supportive
Supervision intervention and contributed to critically reviewing the manuscript.
RK was associated with the conceptualisation of the RMNCH+A strategy and
approach, providedoversight and guidance during implementation and reviewed
the manuscript. RG contributed to design and development of the intervention,
provided inputs into the data management and analysis sections and also
critically reviewed the manuscript.
Funding This work was made possible by the support of the American people
through the US Agency for International Development (USAID) and its VRIDDHI–
Scaling Up RMNCH+A Interventions Project, implemented by IPE Global under the
terms of Cooperative Agreement No AID-386-A-14-00001.
Disclaimer The contents of this paper are the responsibility of IPE Global and do not
necessarily reect the views of USAID.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval The authors state that the current article describes a programmatic
intervention: the RMNCH+A Strategy across the 184 High Priority Districts (HPD)
of the country after approval from the Ministry of Health and Family Welfare,
Government of India. As this strategy was limited to improving service delivery
mechanisms and was a national government-led initiative no ethical clearance was
sought before implementation of the intervention.
Provenance and peer review Not commissioned; externally peer reviewed.
on 6 May 2019 by guest. Protected by copyright.http://gh.bmj.com/BMJ Glob Health: first published as 10.1136/bmjgh-2018-001162 on 4 May 2019. Downloaded from
12 TanejaG, etal. BMJ Glob Health 2019;4:e001162. doi:10.1136/bmjgh-2018-001162
BMJ Global Health
Data availability statement All data generated or analysed during this study are
included in this published article (and its supplementary information les: online
supplementary le 1–RMNCH+A Supportive Supervision Checklist and online
supplementary le 2–Supportive Supervision data set).
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
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Objective As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC. Design and methods We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007–2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned. Results Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners. Conclusions IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/ , identifier: CRD42020199353.
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In this paper, authors have used operation definition of Supportive supervision to studying its role in improving immunization coverage in developing country settings. Comparison of immunization coverage before and after the initiation of supportive supervision is analyzed. Despite of methodological limitations, the study infers that supportive supervision improves immunization coverage and also serves an efficient tool to strengthen the local health system.
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When India became independent in 1947 after two centuries of colonial rule, it immediately adopted a firmly democratic political system, with multiple parties, freedom of speech, and extensive political rights. The famines of the British era disappeared, and steady economic growth replaced the economic stagnation of the Raj. The growth of the Indian economy quickened further over the last three decades and became the second fastest among large economies. Despite a recent dip, it is still one of the highest in the world. Maintaining rapid as well as environmentally sustainable growth remains an important and achievable goal for India. In An Uncertain Glory, two of India's leading economists argue that the country's main problems lie in the lack of attention paid to the essential needs of the people, especially of the poor, and often of women. There have been major failures both to foster participatory growth and to make good use of the public resources generated by economic growth to enhance people's living conditions. There is also a continued inadequacy of social services such as schooling and medical care as well as of physical services such as safe water, electricity, drainage, transportation, and sanitation. In the long run, even the feasibility of high economic growth is threatened by the underdevelopment of social and physical infrastructure and the neglect of human capabilities, in contrast with the Asian approach of simultaneous pursuit of economic growth and human development, as pioneered by Japan, South Korea, and China. In a democratic system, which India has great reason to value, addressing these failures requires not only significant policy rethinking by the government, but also a clearer public understanding of the abysmal extent of social and economic deprivations in the country. The deep inequalities in Indian society tend to constrict public discussion, confining it largely to the lives and concerns of the relatively affluent. Drèze and Sen present a powerful analysis of these deprivations and inequalities as well as the possibility of change through democratic practice.
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Background: Inter district variations in health parameters can be conducive for policy making with regards to child health status and healthcare utilization. Aims and Objectives: We carried out this study to understand district-wide variations in child health promotion practices in well performing Dakshina Kannada (DK) and poorly performing Bellary districts of Karnataka state of South India. Materials and Methods: Data was collected by cross sectional door to door community survey carried out among 2203 households of DK district and 2158 households of Bellary district. The Institutional Ethics Committee had approved this study Result: Initiation of breast feeding within 2 hours was seen in 92.2% mothers in DK and 43.2% mothers in Bellary. Higher rates of prelacteal feeds (DK 16% Bellary 68.1 %) and delayed complementary feeding (DK 39.2 % Bellary 64.9%) was observed in Bellary. Home deliveries were negligible in DK but in Bellary almost half of the mothers had delivered at home .Fever was recognized as danger sign in majority, while awareness of all danger signs was seen in 44.4 % in DK and 14.8 % in Bellary. 28 % in Bellary had delayed health seeking. Conclusion: There is inter district variation child health promotional practices and health seeking and need due consideration by health policy makers.
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Universal coverage of health care is now receiving substantial worldwide and national attention, but debate continues on the best mix of financing mechanisms, especially to protect people outside the formal employment sector. Crucial issues are the equity implications of different financing mechanisms, and patterns of service use. We report a whole-system analysis--integrating both public and private sectors--of the equity of health-system financing and service use in Ghana, South Africa, and Tanzania. We used primary and secondary data to calculate the progressivity of each health-care financing mechanism, catastrophic spending on health care, and the distribution of health-care benefits. We collected qualitative data to inform interpretation. Overall health-care financing was progressive in all three countries, as were direct taxes. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania. Out-of-pocket payments were regressive in all three countries. Health-insurance contributions by those outside the formal sector were regressive in both Ghana and Tanzania. The overall distribution of service benefits in all three countries favoured richer people, although the burden of illness was greater for lower-income groups. Access to needed, appropriate services was the biggest challenge to universal coverage in all three countries. Analyses of the equity of financing and service use provide guidance on which financing mechanisms to expand, and especially raise questions over the appropriate financing mechanism for the health care of people outside the formal sector. Physical and financial barriers to service access must be addressed if universal coverage is to become a reality. European Union and International Development Research Centre.