Annual Project Report

ANNUAL PROJECT REPORT

VRIDDHI: Scaling up RMNCH+A Interventions

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

ANNUAL PROJECT REPORT October 01, 2016 - September 30, 2017

Scaling Up Interventions in Reproductive, Maternal, Neonatal, Child, and Adolescent Health (RMNCH+A)

USAID Cooperative Agreement No. AID-386-A-14-00001

Submitted by:

IPE Global Limited IPE Global House, B-84, Defence Colony, New Delhi - 110 024 www.ipeglobal.com

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Table Contents EXECUTIVE SUMMARY ...... 4 THE CARE AROUND BIRTH APPROACH ...... 6 THEMATIC INTERVENTIONS ...... 10 REPRODUCTIVE HEALTH ...... 10 MATERNAL HEALTH ...... 10 NEWBORN AND CHILD HEALTH ...... 13 ADOLESCENT HEALTH ...... 14 KNOWLEDGE MANAGEMENT ...... 15 MONITORING AND EVALUATION ...... 17 STATE ACHIVEMENTS ...... 19 ANNUAL ACTIVITY HIGHLIGHTS: DELHI ...... 19 ANNUAL ACTIVITY HIGHLIGHTS: HARYANA ...... 20 ANNUAL ACTIVITY HIGHLIGHTS: HIMACHAL PRADESH ...... 21 ANNUAL ACTIVITY HIGHLIGHTS: JHARKHAND ...... 22 ANNUAL ACTIVITY HIGHLIGHTS: PUNJAB ...... 23

ANNUAL ACTIVITY HIGHLIGHTS: UTTARAKHAND ...... 24 NATIONAL RMNCH+A UNIT (NRU) ...... 25 JOHN SNOW INC. (JSI) ...... 28 PLANNED ACTIVITIES VS. ACCOMPLISHMENTS -YEAR 3 ...... 31 PROJECT CONTACTS ...... 41

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

EXECUTIVE SUMMARY

Vriddhi: Scaling up RMNCH+A Interventions project has worked closely with governments and key stakeholders (at national and state levels) to facilitate the increase the off-take of RMNCH+A interventions. In year 3, the project has worked towards scaling up key interventions such as Strengthening Care around Birth, Community based Advance Distribution of Misoprostol, Block Level Implementation Strengthening Support (BLISS), Urban Health and Nutrition Day (UHND). Apart from this, the project has continued to provide techno-managerial support to government policies and programs. The project team as a whole has established itself as an important technical resource for the National and state Governments and its work is being recognized and appreciated across stakeholders. Figure 1: Project brochures Highlights of Year 3 activities:

National level: The project team continued its technical support for GoI programs and policy documents. Reports from onsite monitoring of PMSMA and feedback of the visits were compiled and shared with the maternal health division, MoHFW on a monthly basis. A concept note was developed on managing and tracking HRPs identified through the PMSMA platform, in collaboration with maternal health division and Jhpiego. Other support included technical inputs for national RMNCH+A intensification plan, standardizing the recording formats of various maternal health programs and interventions, support in developing monitoring indicators for RMNCH+A for the Prime Minister’s Office and monitoring of National programs including National Deworming Day and Mission Indradhanush. The project team has been participating regularly in various task forces and technical core groups and through these contributed to policy and program support. Vriddhi supported the revision of the MDR surveillance guidelines and the preparation of an implementation plan for its roll out across the country.

Vriddhi participated in the USAID partner Consultation on ‘Addressing Key Drivers of Maternal and Newborn Mortality’ on October 05, 2016, it also organized the event on behalf of USAID. The different USAID partners and stakeholders presented diverse approaches and methods for improving Intrapartum care. The knowledge hub team of Vriddhi set up a market place at the USAID’s partner’s meeting to disseminate information on project strategies and interventions.

Figure 2: Consultation on Addressing Key Drivers of Maternal and Newborn Mortality

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

The Annual Project Review of the Project was held in February 2017. Representatives of USAID, top management from IPE Global and JSI attended the meeting. The entire team came together to discuss the progress till date, achievements, challenges and the way forward for the next one year. During the meeting, the revived and redesigned RMNCH+A website was launched under the domain name www.rmncha.in Figure 3: Launch of VRIDDHI website

National Consultation for Developing Strategic Roadmap to Engage Private Health Sector: A national consultation for developing a Strategic Roadmap to Engage Private Health Sector for Maternal, Neonatal and Child Health was held on February 21, 2017 in New Delhi where a roadmap was developed to engage private sector providers in RMNCH+A service delivery within the project geography. Joint Secretary (RMNCH+A), MoHFW, Ms. Vandana Gurnani chaired the meeting and attendees included Deputy Commissioners from MoHFW, representatives from the 6 USAID supported state governments and partner agencies. The meeting provided a platform to discuss and deliberate upon the experiences till date and gather thoughts on the modalities to initiate and strengthen this engagement across the 6 states

Supportive Supervision (SS): SS continued in year 3, and a total of 21,421 visits have been made across 182 districts in the country. States transitioned to the revised SS checklist, which has a facility and a community component. This process was facilitated by the national RMNCH+A unit (NRU), who facilitated regional and state level training workshops and introduced the new web based software /data entry tool. Aiming to digitize data and improve its usage the NRU designed an RMNCH+A toolkit app for MoHFW. The app brings all relevant RMNCH+A data from different sources (like NFHS, DLHS, AHS, Census, SRS, HMIS, SSV) on a single platform for each state and respective districts of the country. The app brings data to the fingertips for policy makers, managers, program implementers and researchers.

Care around Birth Approach: The Care around birth approach was introduced in two phases Technical Intervention package – I (TIP I - universal interventions for all mothers and newborns) and TIP II (complication management). Together the two sets of technical packages of the Care around Birth approach cover all major interventions enlisted to improve maternal and child survival as part of WHOs QoC framework.

During the year, the evidence based practices of TIP I were further strengthened and the TIP II package was designed and rolled out across the project states. The phase II trainings were rolled out in all the project supported HPDs and a total of 651 service providers have been trained. The scale up has begun, the approach has been scaled up to 9 non HPDs in the state of Delhi.

Scale up of advanced community based distribution of misoprostol in other states: The dissemination of the learnings and lessons, from the pilot implementation of advanced community based distribution of misoprostol in Himachal Pradesh, at National level has generated interest amongst various states. The state governments of Gujarat and Andhra Pradesh have requested and received the package of documents and materials developed by the project for the pilot implementation of the Misoprostol program in HP, this includes flipbook and Standard Operating Protocols, forms and formats. In the month of June the project supported the Government of Rajasthan and their development partner UNFPA to conduct a state level orientation and a training of trainers, preparatory to the roll out of the intervention in the state.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Scale up of demonstration models (UHND and BLISS): State specific project interventions Urban health and nutrition days (UHND) in Delhi and Block level implementation strengthening support (BLISS) in Uttarakhand are being scaled up by the respective state governments. In the case of UHND Vriddhi had supported the state in defining the services package for UHNDs and roll out of the demonstration model in the slum areas of North West district. As the intervention matured Vriddhi extended support to scaling up UHNDs in Non HPDs with funds leveraged through the state PIP. In Uttarakhand the Vriddhi team worked closely with the state government to improve the coverage and quality of Antenatal Care services through implementation of the ‘BLISS’ Model in one block of Haridwar district. The model is now included as a part of the state initiative SaMMaN, which aims to strengthen maternal and new born care and services US Senate Foreign Relations Committee community visit in Delhi: The project team facilitated an exposure visit of the Senate Foreign Relations Committee and USAID India Mission team to an Urban Health and Nutrition Day (UHND) site in North West district in Delhi on April 19, 2017. The officials interacted with the frontline health workers and were appreciative of the work done by the Project. Participation in international and national conferences: Vriddhi participated in international and national level conferences and presented the project work which was well appreciated. NTSU participated in the Global Summit, Acting on the Call 2017 held on August 24 to 25, 2017 in Addis Ababa in Ethiopia. Two project interventions: Care around Birth approach and Supportive Supervision were included in the Ministry of Health and Family Welfare (MoHFW), Government of India (GoI) stall at the marketplace. A third intervention Community based advanced distribution of misoprostol was included in the GoI booklet of Best Practices. Vriddhi designed the RMNCH+A fact sheet for the MoHFW as well as other handouts. The team also presented papers in various other conferences such as Global Symposium of Health Systems Research, World Congress on Public Health , National Best Summit Practices to name a few.

THE CARE AROUND BIRTH APPROACH

The project has designed an approach to strengthen the quality of care, by scaling up evidence-based interventions for mothers and newborns. This has been rolled out in a total of 141 high case load facilities (delivery points) in 26 HPDs of six project focus states. The implementation of the ‘Care around Birth’ approach began in the beginning of year 2 with a baseline assessment. This was followed by the roll out of the technical interventions in two phases. In the first phase Technical Intervention package –I (TIP- I) included universal interventions for every mother and every child while in the second phase TIP II included the package for management of complications. Together the two sets of technical packages of the Care around Birth approach cover all major interventions enlisted to improve maternal and child survival as part of WHOs QoC framework. Figure 4: Care around Birth Brochure

In year 3, the evidence based practices of TIP I were further strengthened and the TIP II package was designed and rolled out across the project states. The scale up has begun, the approach has been scaled

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions up to 9 non HPDs in the state of Delhi, while in other states the intent to scale up is reflected in the annual PIP to leverage state resources. Given below are the key activities of the year:

Consolidation of TIP I activities: The ongoing activities of the first phase of implementation Technical Intervention Package (TIP)-I were further strengthened. The project team visited the intervention facilities regularly to mentor and handhold the staff, facilitated facility level quality improvement (QI) meetings to encourage local decision making and ownership, and shared progress of the intervention by presenting analyses of the project MIS data during district Experience Sharing Platforms (ESPs). All of this helped to further streamline the service delivery mechanism. State review meetings were conducted across all the 6 project states to review the progress, address gaps and identify immediate action points for states and districts. There has been consistent improvement in the evidence based practices of the TIP I package as is evident from the table below:

Table 1: Evidence based practices being strengthened as part of the TIP I

Evidence based practices in the 6 USAID States Dec 2015 Feb 2017 May 2017 Aug 2017 % pregnant women monitored using a Partograph 29% 51% 61% 88% % mothers administered Injection Oxytocin within 35% 86% 90% 96% 1min of childbirth % of case sheets where mother was monitored in 52% 82% 93% 92% the postnatal period % of case sheets where BP, Pulse & Temperature of 8% 55% 68% 77% the mother was monitored at time of discharge % of newborns in which temperature was recorded 26% 76% 84% 96% at time of birth % cases where delayed cord clamping was 36% 79% 88% 96% undertaken % newborns where Vitamin K1 was administered 53% 87% 94% 91% before discharge % newborns who were administered all three 57% 82% 83% 88% newborn vaccines (BCG, OPV zero dose and Hepatitis B birth dose) before discharge % intervention facilities monitoring newborns at 5% 78% 64% 97% discharge

Quality Improvement (QI): QI is the underlying aim of efforts to improve service provision in high priority districts. Facility level QI teams have been constituted to monitor service provision and quality at delivery points on a periodic basis and to guide improvements. The teams address both technical and programmatic aspects of interventions. QI meetings have been initiated across the HPDs since June 2016. Regular meetings are being conducted and tracked for progress. Data Reporting and Analyzing Tool were used by DTOs to capture monthly facility data which helped in keeping track of the progress of the improvement aims. A total of 975 QI meetings have been conducted during October ’16-September ’17 in all six project states, and have been instrumental in generating notable changes related to the project MIS indicators.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Table 2: Quality Improvement Activities Update

Number QI Meetings

State Total

Total Total

Facilities

Jul'17

Jan'17

Jun'17

Oct'16

Feb'17 Apr'17 Sep'17

Dec'16

Aug'17

Nov'16

Mar'17 May'17

Delhi 8 4 3 6 4 4 3 3 5 4 1 3 1 41 Haryana 31 25 23 29 28 25 26 28 29 27 27 29 31 327 Himachal 17 3 9 11 11 9 11 9 9 7 7 8 8 102 Pradesh Jharkhand 42 20 11 27 33 25 35 24 21 21 34 27 21 299 Punjab 25 7 6 7 12 3 14 17 14 15 18 19 24 156 Uttarakhand 18 5 4 4 1 3 4 6 2 4 3 4 10 50 Total 141 64 56 84 89 69 93 87 80 78 90 90 95

Roll out of the Technical Intervention Package II: The TIP II package focusses on capacity building of the service providers and intervention facilities to manage complications amongst mothers and newborns. These include management of Postpartum Hemorrhage (PPH), severe pre-eclampsia and eclampsia, care of low birth weight newborns - Kangaroo Mother Care (KMC), management of maternal and newborn sepsis, use of ante-natal corticosteroids for preterm births and Prevention of Parent to Child Transmission (PPTCT). A Training of Trainers for the project team was conducted in the beginning of the year. This was followed by trainings across the project states covering 17 districts. A total of 651 providers have been trained on the package of complication readiness including the obstetric drills on PPH and severe pre-eclampsia and eclampsia and Kangaroo Mother Care for management of low birth weight newborns. Indicators and MIS for TIP II were finalized and project team has started collecting data on this. Following a consultative brainstorming an implementation framework for obstetric drills was also developed and circulated. Leveraging state resources for RMNCH+A services: The Care around Birth approach has been institutionalized in all six project states and the states have included scale up activities in their annual Program Implementation Plans (PIPs) with technical support from project teams. The Government of India has approved funding for activities related to Care around Birth in the project states. Technical Support for drafting of the National RMNCH+A Intensification Plan: The project team provided inputs towards drafting of the national RMNCH+A intensification plan by MoHFW which looks at increasing fund allotment to critical RMNCH+A components to further accelerate the progress towards Ending Preventable Child and Maternal Deaths (EPCMD). Scaling up the Care around Birth approach: In the last year, the Care around Birth approach has been scaled up in non HPDs in the project states. In Delhi, 67 master trainers including medical officers and staff nurses, from 9 non HPDs, were trained on the approach through the state funds. Five of the non HPDs have completed the cascading district level training for 164 labor room staff, and all facilities are conducting and recording low dose high frequency onsite trainings. State is actively monitoring the status of implementation of the Care around Birth approach - it has allocated a sum of Rs 100,000 for training and monitoring, notified 9 district level and 59 facility level nodal officers for CaB, ensured formation of 59 QI committees and since the kick off training of trainers in February 2017, it has conducted 3 state reviews of Care around birth.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

In Himachal Pradesh, the approach has been integrated with the state level Quality of Care framework which was launched in partnership with AIIMS, WHO, NHSRC, USAID ASSIST and Vriddhi. The state also trained 110 newly recruited staff nurses using the Care around Birth package. Further scale up activities have been planned in other states and a composite three day training package combining the technical interventions of TIP I and II trainings has been designed. The package was tested in Barnala district of Punjab and used to train master trainers of non HPDs in the state of Delhi. Third party assessment of Care around Birth Approach: During the year, work was initiated for a third party assessment of the Care around Birth to assess its effectiveness to improve service delivery and quality. An external agency (Centre for Operations Research and Training) was selected and the tools for the external evaluation have been finalized.

HIGHLIGHTS • Stabilization of Care around Birth phase 1 interventions in 141 supported facilities and their scale up in 9 non HPDs of Delhi state. • Design and roll out of the phase 2, Care around Birth interventions in 141 supported facilities in the 26 HPDs of 6 project states. • 124 state and district level master trainers trained in the states of Delhi, Jharkhand, Haryana and Uttarakhand • 651 service providers trained for ‘Care around Birth’ interventions • 1010 meetings of facility level quality improvement teams held in intervention facilities; these are helping to generate ownership and accountability for ‘Care around Birth’ among the facility teams • The ‘Care around Birth’ approach has been approved by GoI, through the annual PIP process, for scale up across the 6 project states • Learnings from ‘Care around Birth’ intervention have been shared at several important conferences – World Conference of Public Health in Australia, Acting on the Call Summit 2017 in Ethiopia, and at the GoI symposium on National Best Practices

Figure 5: Roll out of Care around Birth strategy

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

THEMATIC INTERVENTIONS

REPRODUCTIVE HEALTH

Vriddhi aims to strengthen delivery points with a focus on Postpartum Family Planning (PPFP) within the framework of Family Planning 2020. During the year, the project continued to strengthen the PPFP services by building capacities of counselors on the PPFP component and mentoring the counsellors at the facilities to ensure provision of quality FP services. ACHIEVEMENTS IN REPRODUCTIVE HEALTH IN YEAR 3

Strengthening Post-partum family planning (PPFP) services in 141 CaB facilities: Following initial capacity building of counsellors in knowledge and inter-personal communication, the counsellors were provided with on-job mentoring and communication materials to enhance their counselling skills and serve the clients to access quality FP services. During supportive supervision visits, training status of the providers, presence of communication material, contraceptive stocks and records were evaluated. Any gaps were promptly discussed with the facility in-charges. Recording processes were streamlined at the intervention facilities and documentation columns introduced in the delivery registers to capture information on counselling done for PPFP. Many DTOs underwent the TOT on newer contraceptives and further facilitated these trainings at district and sub-district levels. Women receiving post-partum FP Counseling increased significantly from 43% between Oct’15-Sep’16 to 72% in Oct’16 to Sep’17. 22.8% women adopted a post-partum family planning method, largely PPIUCD. Progress on the PPFP counselling and acceptors of PPFP method have been tabulated for across the last 4 quarters in the table below:

Table 3: Progress of PPFP across last 4 quarters

Quarters Number of clients counselled Number of acceptors Q1: Oct-Dec’16 33398 11915 Q2: Jan-Mar’17 31873 10941 Q3: Apr-Jun’ 17 34939 10334 Q4: Jul-Sep’17 49184 14111

LMIS software for Family Planning: The project provided programmatic support for the development of National Logistics Management Information System (LMIS) software for Family Planning (FP) commodities commissioned by the MoHFW. This software was launched on the ‘world population day’. Support Mission Parivar Vikas (MPV) activities in Jharkhand: SRU Jharkhand along with backend support from NTSU provided technical assistance to Government of Jharkhand to plan various activities under Mission Parivar Vikas.

MATERNAL HEALTH

Vriddhi under its CaB strategy has aligned maternal and newborn care interventions to reap maximum benefits in terms of survival and wellbeing of mothers and newborns. The CaB strategy builds upon the GoI guidelines regarding management of major drivers of maternal and newborn mortality. During the year, the project rolled out TIP II package which included management of complications such as postpartum hemorrhage, severe pre- 10

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions eclampsia and eclampsia and PPTCT. The project also provided continuous support to the national and state governments on key maternal health interventions such as PMSMA, Maternal Death Reviews and Maternal Anemia. In addition, lessons from community based advance distribution of misoprostol in one block of Himachal Pradesh has been scaled up to several blocks across HPDs in the states of Himachal Pradesh and Jharkhand. ACHIEVEMENTS IN MATERNAL HEALTH IN YEAR 3

Strengthening and standardizing documentation practices for Maternal Health: The project team collaborated with the MOHFW and Jhpiego to standardize the recording formats for the maternal health program. The team worked on the standardized GOI case sheets for all levels of care as a part of the national group. Technical support was provided in drafting a framework for a standard LR register that could be used across the country. Technical Support to Pradhan Mantri Surakshit Matritva Abhiyaan (PMSMA): Vriddhi provided continuous support for the PMSMA program in the project states. It supported the MoHFW in developing the protocol and tools for the evaluation of PMSMA. In the project states Vriddhi team monitored PMSMA regularly and the report was shared monthly with the maternal health division of MoHFW as well as with the HPDs. In addition the NRU team also monitored facilities in the states of Chhattisgarh, and Maharashtra in December, 2016 and shared their feedback with the respective state authorities. Vriddhi supported the identification of monitoring indicators for PMSMA to be used by states to prepare comprehensive quarterly reports. These reports included monitoring data as well as data from the system PMSMA reports. The monitoring and subsequent feedback mechanism resulted in consistent improvement across the project supported HPDs, specifically the involvement of private providers has been encouraging in the states of Delhi, Haryana and Punjab and all states have shown a steady improvement in service delivery and record keeping. The project also organized and co-facilitated the regional PMSMA review in Chandigarh which was led by Deputy Commissioner, Maternal Health, GoI. Attendees included state government officials and representatives of FOGSI, IMA, Rotary and Lions Club. Tracking of HRPs: Efforts to strengthen PMSMA and maximize its impact, highlighted a need to develop an operational plan for follow-up and tracking of High Risk Pregnancies (HRPs) that are identified during the PMSMA rounds. The project in consultation with maternal health division and Jhpiego developed a concept note to manage and track HRPs identified through the platform and this is under review by the Ministry. The process included consultations with state teams including the six project states. Discussions were also held with the various states who are working on strengthening the ANC platform. This formed the basis of developing an implementation framework, which included information flow, community level tracking, and monitoring processes and tools. Scale up of advanced community based distribution of Misoprostol: The advanced community based distribution was scaled up in Himachal Pradesh in an additional 13 blocks. An advocacy brief highlighting key milestones and innovations in implementation, the results and learning, the challenges and the steps to be taken for implementing the intervention at scale was also developed. A high level delegation from USAID Head Quarters visited the implementation site, Jhanjheli block, in March 2017, to review the field implementation of the program and understand how learnings may be transferred to other community interventions. The process document of the pilot implementation of the community level advanced community distribution of misoprostol is expected to further advance this aim.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Jharkhand state has initiated implementation of the intervention in Dumka and Simdega districts. The states of Gujarat and Telangana also reached out to the project team for support to roll out the intervention in their states. The project team responded by sharing the package of materials including flipbook and various SOPs, Forms and formats that were developed for the pilot implementation in HP. In the state of Rajasthan the project team supported the state government and their lead TA agency UNFPA to conduct a state level ToT for advanced community distribution of misoprostol. The project also helped the state to develop an action plan for implementation of the program in blocks identified as having high home delivery rate. Punjab Anemia Action Plan: A document on the operational framework for addressing maternal anemia was developed for the state of Punjab. The document was shared with the state and a consultative meeting is being planned to get inputs from all stakeholders prior to finalizing the document. Respectful Maternity Care (RMC): A situational analysis of public health facilities to assess their readiness to practice RMC was conducted in states of Jharkhand, Haryana and Delhi across urban, rural and tribal population. The study also captured the perceptions of the providers on client rights under RMC. The qualitative assessment was done through observation, key in-depth interviews and focus group discussions with the providers and clients. The recommendations for key action points feasible for implementation of RMC were grouped under Policy, Product, People, and Practice. Review of MDSR Guidelines and developing training content: The project had been closely involved with the review and revision of the GoI Maternal Death Surveillance and Response (MDSR) and Maternal Near Miss Review (MNM) guidelines. The project team through its participation in the national core committee contributed in the development of a training module for MDSR. Vriddhi alongside national experts will support and co-facilitate sessions at regional ToTs / workshops planned by MoHFW. Consultation with GoI: Vriddhi contributed to policy and program support by participating in various task forces and technical core groups. The support includes: • As a part of TRG (Technical Resource Group), attended the first meeting of the group conducted under the joint chairpersonship of Dr. Suneeta Mittal, ex Professor & Head of Department, AIIMS and Dr. Prema Ramachandran. The project team participated in Bottleneck Analysis and contributed towards the WHO report on ‘State of Mothers in India 2016’ • Contribution to a Guidance note on ‘Care for High Risk Pregnant Women’ being developed by MoHFW. • Developing standard templates for PMSMA and ANC registers at health facilities. • A framework on Respectful Maternity Care for the RMC training module for National skill labs • Included in the expert group and working group developing the advance skills lab manual. • Revising and updating the GoI maternal health protocol posters and suggesting possible themes for developing new posters. Status papers/ Articles: VRIDDHI developed status papers / articles on: 1. Desk Review on Iron supplementation in pregnancy – alternative regimens & salts 2. Implementation of Community Based Advance Distribution of Misoprostol in Himachal Pradesh (India): Lessons and Way Forward 3. Integrating Vitamin A and deworming

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

NEWBORN AND CHILD HEALTH

The health and wellbeing of newborns and children remain as a primary public health goal. Consonant with international developments, a number of evidence-based interventions aimed at reducing mortality and improving the wellbeing of newborns have been initiated as part of the CaB strategy. During the year the interventions under TIP II were rolled out which includes Kangaroo Mother Care, care of low birth weight newborns, antenatal corticosteroids and newborn sepsis. VRIDDHI has also supported the national and state governments in planning and monitoring of various programs such as Mission Indradhanush, roll out of vaccines such as measles rubella and pneumococcal conjugate, Child Death Reviews and National Deworming Day. Given below are key highlights of the year ACHIEVEMENTS IN NEWBORN HEALTH IN YEAR 3

Expert Group meeting on Child Death Review (CDR) software: The project team facilitated the National Expert Group Meeting held to review CDR software being used in the country. The meeting was conducted under the chairmanship of Deputy Commissioner (In-charge) Child Health, Government of India and was attended by officials from MoHFW, NHSRC, select state government representatives and partner agencies. The meeting provided a platform to review the software and also initiate actions based on the recommendations. Kangaroo Mother Care services rollout for PNC ward: Vriddhi is working on increasing the coverage of LBW infants with KMC services. On the one hand it has demonstrated implementation models for strengthening KMC services at the Special New-born Care Units (SNCUs) in the two project districts of Gumla and Haridwar. On the other hand the project is working on extending the cover of KMC services to newborns who have low birth weight but are not eligible for admission to SNCUs. For this an initial rapid assessment of facilities for status of KMC services was done, which included a qualitative component of finding out perceived barriers and challenges. The latter was done through informal interactions with project team, who shared their experience at intervention facilities. Solutions for key barriers were brainstormed and are now being implemented in the Vriddhi supported high case load delivery points across the 6 project state. The learnings from this initial intervention have been consolidated into an operational plan to roll out KMC for all delivery points. The operational plan includes the concept of KMC corners for the Postnatal care (PNC) wards, use of local resources for perceived challenges and roadmap for implementation. The indicators to track progress of this intervention are included in the TIP II MIS of Care around Birth and are being monitored monthly. The Child Health Division of MoHFW has been briefed on the KMC plan and are watching out for the results. Development of Pneumonia Control Framework for Himachal Pradesh: The state of Himachal Pradesh is implementing a pneumonia control program in collaboration with Vriddhi. An initial situational analysis and several rounds of discussions with the state government helped to develop the framework for the operational plan and identify components / areas that needed strengthening. The operational framework for Pneumonia control in HP has been drafted and awaits finalization by the state government. The document envisions an integrated approach that includes supportive interventions such as Vitamin A supplementation, PCV vaccination, and identification and management of pneumonia in community etc. The framework includes a roadmap for strengthening ongoing components as well as a plan for the roll out of new activities.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Support to national and state level programs: Vriddhi has supported the national and state governments in the launch and monitoring of national programs / drives. Given below are some highlights in year 3:

• Supported the rollout of Pneumococcal Conjugate Vaccine (PCV) in Himachal Pradesh • Supported the Measles Rubella (MR) vaccine strengthening campaign in the state of Himachal Pradesh • In all the states the project supported the planning and monitoring of National Deworming Day (NDD). HP team supported the district level planning and monitoring of the February round of NDD.

ADOLESCENT HEALTH

Vriddhi endeavors to strengthen the adolescent health component of the RMNCH+A strategy. The activities under adolescent health contribute towards strengthening the MoHFW’s Rashtriya Kishor Swasthya Karyakram (RKSK) the umbrella adolescent health program. The thrust of Vriddhi interventions has been on strengthening ‘Adolescent Friendly Health Clinics’ (AFHCs) and thereby to improve both availability and quality of services for adolescents ACHIEVEMENTS IN ADOLESCENT HEALTH IN YEAR 3

Mentoring visits and Monthly feedback report to Adolescent Health division, MoHFW: Vriddhi project supported strengthening of AFHCs in government hospitals. The process involved preparing joint facility plans with government and facility in-charges and follow-up on-site mentoring and supportive supervision to deepen the impact. The District Technical Officers were involved in providing monthly mentoring and supportive supervision visits. The achievements and gaps were discussed in district and state review meetings for corrective actions. During this year, 850 visits were made to AFHCs, which helped improve the service delivery mechanisms through on-site mentoring. Additionally, Weekly iron and folic supplementation (WIFS) program was monitored at 234 schools and 107 Aaganwadi Centres (AWCs). Table 4: Quarterly visits to AFHCs, AWCs and Schools Quarter Number of AFHC visits Number of schools Number of AWCs visited visited Q1 221 47 18 Q2 211 70 33 Q3 214 64 29 Q4 204 53 27 Total 850 234 107

Total operational AFHCs increased from 79 in Oct 2015 (baseline) to 105 in Sept 2017. A total of 79,911 adolescents received services in these AFHCs since last year. Communication materials for Adolescent Friendly Health Clinics (AFHCs): The project developed communication material prototypes for AFHCs. These included signage and service boards and IEC material for health promotion and Non Communicable Diseases (NCDs) among adolescents. In addition posters on anemia, menstrual hygiene and job aids for Body Mass Index (BMI) calculation and growth charts were also developed by state teams. Continued support to central and state AH divisions: The achievements and gaps in adolescent health programs were discussed in district and state review meetings for corrective actions. Around 45 convergence, 14

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions review and orientation meetings were facilitated at National, State and district levels this quarter. The monthly status reports were also shared with the ministry which provided an overview on the implementation of various adolescent health programs operational in the project states. Project states and district teams were involved in planning and monitoring of National Deworming Day.

KNOWLEDGE MANAGEMENT

The knowledge management function of Vriddhi in the past year has focused on the consolidation and documentation of the key project activities. In the past year, knowledge hub has produced a number of documents that include photo story on the project, training package on Care around Birth in English and Hindi, job aids for service providers, to name a few. Knowledge Hub team also contributed in disseminating learnings and achievements through the project website, and twitter handle and also through participation in national and international forums. Some of the key highlight of activities are as follows: • Improving project visibility- The knowledge hub team set up a market place at the USAID’s partner’s meeting at The Claridges Hotel, New Delhi. Information regarding key program strategies and programs was disseminated during the event through the display of posters in this marketplace • Collected information on best practices for developing Figure 6: Marketplace display stories- The team initiated the process of regular interactions with the teams in the different states and the DTOs at the district level. The team completed one round of conference calls with each state team and individuals interactions with most of the DTOs within the team. The objective of this interaction was to understand the activities in the field, identify potential stories (for documentation purposes) and also understand the challenges faced by the DTOs

• Tracking changes in the intervention facilities- The knowledge hub team also developed data collection formats for each district to record facility level changes after the roll out of the Care around Birth strategy including training. The team is also regularly tracking the number people being trained as part of the strategy • Launch of the project website- The www.rmncha.in website was revived and redesigned. It provides and overview of the project as well as details and updates of project interventions and work. The website was launched at the annual project review meeting by Mr. Ashwajit Singh (M.D. IPE global Ltd) and Dr. Amit Shah, USAID in February 2017

• Support in developing training materials for care around birth roll out- The knowledge hub team supported the technical team in development of the training materials especially IEC materials for the TIP 2 training. The team was also involved in adapting the materials from TIP 1 in local languages to be used by service providers in the facility

• Presentation of project work at national and international level conferences: The team presented project work and learnings at various national and international conferences during the year. A brief summary is as follows:

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

 November 2016 The 4th Global Symposium on Health Systems Research at Vancouver, Canada: “Strengthening Health Systems by institutionalizing a robust Supportive Supervision mechanism in High Priority Districts in India”  February 2017 IAPSM at Kolkata, India: - Exploring the status of Existing Feedback Mechanism in Government Facilities Perspective from one of the High Priority Districts in Jharkhand - Using systems approach for strengthening MDR process and improving maternal care in Panipat, Haryana - Development of a Novel tracking format for instilling Systems Thinking Approach in implementation of The Janani Suraksha Yojana (JSY) in one of the High Priority District in the State of Jharkhand  February 2017, IPHA at Jodhpur, India - “Celebrating the Labour Room Assessment Fort-night, Using the Campaign Mode Approach for Strengthening Labour Rooms for Better Care of Mothers and Newborns – A study from Saraikela- Kharsawan District in Jharkhand  April 2017 World Public Health Congress in Melbourne: Four papers were presented - Care around Birth, Community Based Advance Distribution of Misoprostol, Strengthening Adolescent Friendly Health Clinics (AFHCs) and Post-Partum Family Planning (PPFP) practices  May 2017 The national conference on ‘Developing Quality Essential Health Care Services’ in Mumbai: Project supported interventions - “Labor room standardization for high case load facilities in high priority districts in Haryana” and “Using maternal death review data for identifying health systems gaps and programmatic actions” presented  July 2017 MoHFW sponsored National Convention on Best Practices in Public Health was held in Indore, Madhya Pradesh: Two posters presented ‘Health systems strengthening – Institutionalizing RMNCH+A Mechanism in India’ and ‘Care around birth – An integrated approach to improve the quality of care during the intrapartum and immediate postpartum period’ experiences from Delhi state  August 2017 Acting on the Call 2017 at Ethiopia: Two project interventions: Care around Birth approach and Supportive Supervision were included in the Ministry of Health and Family Welfare (MoHFW), Government of India (GoI) stall at the marketplace. A third intervention Community based advanced distribution of misoprostol was included in the GoI booklet of Best Practices. Vriddhi designed the RMNCH+A fact sheet for the MoHFW as well as other handouts. • Development of project communication strategy: The project communication and dissemination strategy was drafted by the Knowledge Hub team along with the NTSU. List of the products along with the thematic areas were listed and inputs were taken from the SRU team as well to include state specific documentation requirements in the plan. Based on this plan the process for hiring an agency has been initiated for implementing the plan. The knowledge hub team also developed a photo documentation on the project journey. The photo story was an audio visual which described the project journey from the inception of the project till the current stage. The product was well appreciated and was Figure 7: Job Aids shared widely with key stakeholders

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

• Identification and hiring of specialists: The project documentation needs are varied and urgent. The knowledge hub team has initiated the process of identifying specialists, agencies and individual consultants for developing its communication materials including printed products and videos.

• Monthly update of website: The team has been regularly updating the project website with relevant materials. The team has been collating short stories from the field and updating the website, in addition to this the content on technical interventions is also being updated according to the need.

• Development of communications material and other products: The knowledge hub initiated development of communication material relating to care around birth technical intervention package – 2. In addition to this the team also supported Haryana SRU in designing the Haryana Newborn Action Plan. • Video documentation: Video documentation of the newborn health component on Kangaroo Mother Care and feeding of low birth weight babies was completed and they have been uploaded on the project website and shared. The obstetric drills also were video filmed during the last quarter of the year and currently the footage is being edited for developing the final product. • Process documentation: Process documentation on the two interventions of “community based advance distribution of Misoprostol” and “Care around Birth approach” have been initiated.

MONITORING AND EVALUATION

The project monitoring, evaluation and learning (MEL) plan implementation focused on monitoring and quality assurance of the project MIS to track project interventions and identify areas for action and strengthening - activities included data validation, analysis of project MIS for use by districts and states, and repeat assessment of labour rooms. A third party evaluation of the core project intervention the care around birth approach has also been planned. A brief description of the monitoring and evaluation activities follows. Data Validation Exercise across the Care around Birth intervention facilities: As follow-up to strengthen quality of CaB MIS data, internal Data Validation mechanism was established during Oct-Dec’16. The data validation exercise aimed to make consistency checks of the project data and help, to take action to further improve the data collection and collation practice. As a first step, towards finalization of the internal data validation process, few key indicators were identified for data validation and a checklist was developed and tested in two facilities in Godda District of Jharkhand. Based on the field testing, the list of data items to be checked, team composition and number of facilities to be covered was finalized. The data validation exercises were conducted in a total of 74 facilities across 23 districts in the states of Delhi, Jharkhand, Haryana, Punjab, Himachal Pradesh and Uttarakhand during the year. Generation of monthly project MIS data from Care around Birth intervention facilities: Monthly data was collected from the Care around Birth intervention facilities and was analyzed to identify issues and provide feedback. This was done from project to government counterparts for action to improve practices and from National to state and district teams to strengthen internal quality control. Thus trends in state level performance of key indicators over time was shared with state and national level teams for initiating follow- up action to accelerate the improvement process for indicators that are lagging. Further, a two day M&E team meeting was held at Delhi office to discuss the emerging challenges in improving quality of data of any particular data items, reasons therein; areas of strengthening DTOs capacity to use CaB MIS tool; and data validation process. As part of the ongoing activity, the M&E team supported the project in compiling and sharing findings of project MIS and Supportive Supervision data

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

MEL Plan: As per new guidelines a project Monitoring, Evaluation and Learning (MEL) plan was drafted which was shared and finalized in consultation with Dr. Subrato Mondal, Project Management Specialist (MEL), USAID/India. Care around Birth third party assessment: The project team initiated work on an external third party assessment of the Care around Birth, to assess the possible improvements achieved as part of the intervention and make mid-course adjustments. This tender process was initiated, the request for proposals (RFP) advertised, the bids evaluated and Centre for Operations Research and Training (CORT), Vadodara was hired. The methodology and sample size for the Mid Term Assessment were finalized and the study tools are being finalized. Labor room reassessment exercise: A repeat labor room assessment in intervention facilities was conducted by the project team to identify the improvements achieved till date and identify components that need to be further strengthened. Comparative analysis of facility level improvements made by the project was shared in a national level workshop and follow-up discussions were done for bringing about further improvements in the prioritized facilities. Data Quality Assessment exercise undertaken in a project district: A DQA exercise was undertaken by the USAID India Mission team in Jharkhand and Uttarakhand to review the overall M&E framework of the project. An intensive exercise was undertaken in the states and it provided a platform to assess the data recording and reporting practices of the project and further improved the processes as required. TIP II baseline assessment: To understand facility readiness for TIP II as part of the Care around Birth exercise, a checklist to capture critical TIP II indicators was drafted and the assessment initiated across the intervention facilities. The MIS format was finalized for collecting monthly data on monitoring indicators for Technical Intervention Package II (TIP II) and data collection was initiated. Data Usage Workshops in Haryana: SRU Haryana was the lead facilitator for conducting 12 batches of workshops in 8 districts in which 401 district level participants were trained.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

STATE ACHIVEMENTS

ANNUAL ACTIVITY HIGHLIGHTS: DELHI Population (Projection 2017) Scale up of Care around Birth Approach: In the last year, Persons 21896000 the Care around Birth approach has been scaled up in 9 Male 12175000 non HPDs in Delhi state. A total of 67 master trainers were Female 9722000 trained, these included medical officers, specialists and Infrastructure staff nurses. Five districts have already completed No. of District 11 cascading district level training and 164 labor room staff No. of HPDs 2 have been trained. Onsite low dose high frequency Facilities and position trainings are being held and duly recorded at all selected No. of District 47 facilities. # Hospitals State is actively monitoring the implementation of Care No. of Sub 9 around Birth approach - it has allocated a sum of Rs Divisional/Referral 100,000 for training and monitoring, notified 9 district Hospitals# level and 59 facility level nodal officers for CaB, ensured No. of Community 25 formation of 59 QI committees and since the kick off Health Centers training of trainers in February 2017, it has conducted 3 Functional# state reviews of Care around birth.

No. of Urban PUHC ( 438 Strengthening of UHND in Delhi: SRU in Delhi was OPD services) entrusted with the mandate of strengthening outreach services through UHNDs. Vriddhi supported the state in defining the services package for UHNDs and roll out of the No. of Health Sub 12 demonstration model in the state. As the demonstration Centers Functional model started showing results the focus for support was Mohalla Clinic 158 on leveraging funds through state PIP for Non HPD areas. The project continued to provide support for strengthening UHND in the state. The key achievements Mortality are: MMR SRS (10-12) NA* • An amount of 1 crore and 26 Lakhs has been approved SRS (12-13) NA* for scale up of the services to other districts. IMR SRS (2012) 25 • Around 300 UHND held wherein more than 600 SRS (2013) 24 pregnant women were registered with 40 % first trimester registration SRS (2014) 20 • Four Facility review meetings were held at the SRS (2015) 18 demonstration site. Support for state level programs: During the year, SRU provided technical support to state level activities such as Mission Indradhanush, Child Death Reviews, Maternal Death Reviews, strengthening RKSK, state launch of Mother’s Absolute Affection (MAA), monitoring of PMSMA. SRU also supported the state in preparing the PIP and facilitated in provision of funds for maternal and newborn health trainings.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

ANNUAL ACTIVITY HIGHLIGHTS: HARYANA

Population (Projection 2017) Haryana Newborn Action Plan: Vriddhi has supported NHM Persons 27868000 Haryana for the development of the Haryana Newborn Action Male 15110000 Plan (HNAP) with clearly defined and comprehensive Female 12758000 methodology in consultation with NGOs, academic Infrastructure institutions, district health departments and various eminent No. of District 21 experts from the country. The project supported the state in No. of HPDs 5 organizing one day expert group meeting on newborn health. No. of Blocks 119 This was followed by state level workshops for all districts to Facilities and position facilitate the development of District Newborn Action Plan No. of District 21 Hospitals (DNAP). All 21 districts of Haryana have submitted their DNAP No. of Sub 21 to the state following this, the policy document has been Divisional/Referral finalized and printed and will be launched by the state. Hospitals Branding of AFHC Clinics: Vriddhi is also providing technical No. of Community 112 Health Centers support for strengthening of 15 AFHC clinics in 4 HPDs in Functional coordination with adolescent health division of NHM Haryana. No. of Primary 366 AFHCs are branded as ‘Mitrata’ meaning friendship, to give Health Centers the messages to adolescents that these clinics are friendly to Functional them. The logo for the AFHC clinic, signage and services board No. of Health Sub 2589 were designed. Centers Functional Mortality Support to Formative Research for Development of a MMR SRS (10-12) 146 Communication Strategy for Adolescents: Project supported SRS (12-13) 127 development of IEC material which is in line with strategic IMR SRS (2012) 42 behavior change communication strategy of Haryana. This is a SRS (2013) 41 three phased program and the first phase is being currently SRS (2014) 36 rolled out. SRS (2015) 36 Labor room standardization: The state project team has been providing continued technical assistance in strengthening labor rooms as per the new guidelines of Government of India. Technical assistance was provided in selection of obstetric HDU and ICU. The project team is currently working in state-wide implementation of the labor room strengthening plan. SRU conducted a baseline assessment of labour rooms in accordance with the new guidelines and gaps were identified for each intervention facility which was budgeted and included in the state PIP. A total of Rs.1,1,298,279/- and Rs.10,822,726/- have been budgeted in PIP for high priority districts and non-high priority districts respectively. SRU also supported the state in other activities such as Maternal and Child Death Reviews and monitoring of programmes such as PMSMA and Mission Indradhanush.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

ANNUAL ACTIVITY HIGHLIGHTS: HIMACHAL PRADESH

Population (Projection 2017) Community Based Distribution of Misoprostol Intervention: Persons 7151000 In April 2016, Himachal Pradesh initiated ‘Community Based Male 3666000 Advance Distribution of Misoprostol tablets to prevent PPH,' Female 3485000 with technical partnership from VRIDDHI. Since inception, a Infrastructure total of 1664 deliveries were reported out of which 660 (40%) No. of District 12 happened at home. Out of 660 mothers delivering at home No. of HPDs 4 594 (90%) received tablet and 559 (85%) consumed in time. No. of Blocks 77 At the same time the institutional delivery rate also increased Facilities and position from 11% at baseline to 59%. The intervention was included No. of District 12 Hospitals in the 2017-18 PIP and is being scaled up in 11 blocks in HP. No. of Sub 47 SRU developed a roadmap with sequential activities against Divisional/Referral timeline for rolling out this scale up. SRU also developed Hospitals operational guidelines, training package including training No. of Community 81 manuals for health workers, and reporting formats for all Health Centers levels, based on the learnings from the pilot implementation. Functional SRU provided technical assistance for conceptualizing and No. of Primary 489 Health Centers designing of Misoprostol MIS for reporting and analysis for Functional the scale up. A high level team from USAID headquarters No. of Health Sub 2158 visited the pilot implementation site in March 2017. They Centers Functional interacted with program implementers, frontline workers Mortality and beneficiaries to get a firsthand experience of the program MMR SRS (10-12) NA* on the ground. SRS (12-13) NA* IM/R SRS (2012) 36 Regional Care around Birth training workshops of labor SRS (2013) 35 room staff nurses of Himachal Pradesh: Three regional Care SRS (2014) 32 around Birth training workshops were organized by Himachal SRS (2015) 28 team, to train the staff nurses around labor room posted in all 12 districts of Himachal Pradesh. Total 110 staff nurses posted in labor room were trained in these three workshops. These trainings covered the TIP I and TIP II packages of Care around Birth with focus on participatory approaches and hands on training methodologies. Training on Kangaroo Mother Care and Feeding Low Birth Weight Newborns: SRU facilitated four workshops on Kangaroo Mother Care and Feeding Low Birth Weight Newborns for SNCU staff of all 12 districts of Himachal Pradesh. A total of 97 staff nurses were trained in these workshops. In addition to this, three onsite trainings on KMC practice were conducted in facilities. In district Mandi, KMC has been initiated with proper dedicated space in 4 high case load facilities. DTO facilitated the identification of dedicated space, availability of basic essential commodities and regular onsite training of staff nurses on KMC and LBW feeding during mentoring visits. To improve documentation, project team designed KMC monitoring format for SNCU and post-natal wards. State and District Level Trainings on Pneumococcal Vaccine (PCV) and Measles and Rubella Campaign: SRU supported the state in the launch and roll out of the PCV and Measles and Rubella campaign at state and district levels. Support was provided for organizing state and district level trainings and continuous monitoring of the implementation of the program.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Support to state level activities: SRU also supported the state in various other programmes as listed below:

• Development of LR register and Maternity case sheets • Strengthening MDR/CDR reporting and review system • Strengthening Adolescent Health and Rastriya Kishor Swasthya Kariyakaram (RKSK) by District Technical Officers conducting regular monitoring and providing technical support to AFHC • PPFP counselling in CaB facility • Regular monitoring of PMSMA • SRU HP designed a process for identification of High Risk Pregnancies (HRP) in routine ANC and PMSMA and referral of identified HRP to concerned health worker for further monitoring high risk women till delivery • Support in PIP 2017 and national program coordination committee meeting

ANNUAL ACTIVITY HIGHLIGHTS: JHARKHAND Rolling out Community Based Distribution of Misoprostol for prevention of PPH: A second state level ToT on ‘Suraksha Population (Projection 2017) Community Based Distribution of Misoprostol’ was held in Dumka Persons 34069000 Male 17512000 district. The participants were oriented on the guidelines for Female 16557000 Community based distribution of misoprostol for prevention of Infrastructure Post-Partum Hemorrhage and listing of pregnant women who No. of District 24 were likely to deliver at home. They practiced counselling for No. of HPDs 11 different stages of the process, preparing the mother, the time of No. of Blocks 259 giving tablets and postnatal contacts. The training content also Facilities and position included precautions for community based distribution of No. of District 23 # misoprostol, identification of danger signs for referral to health Hospitals facility, supply and storage of misoprostol tablets and the No. of Sub 13 Divisional/Referral recording and reporting protocols. Master trainers then trained Hospitals# frontline workers in block level, a total of 310 participants ANMs No. of Community 175 and Sahiyas were trained in Jama block of Dumka, and 194 ANMs Health Centers and 594 Sahiyas from 6 blocks in Simdega district. In Simdega Functional 1400 Misoprostol tablets have already been distributed among No. of Primary 347 the Sahiyas and the ANMs. Health Centers Functional State Level Training of Trainers on Newer Maternal Health No. of Health Sub 3848 Guidelines: SRU supported the state in facilitation of state level Centers Functional training of trainers on new Maternal Health Guidelines. Director, Mortality Health Services, Govt. of Jharkhand inaugurated the training and MMR SRS (10-12) 219 participants were Consultants, DRCHOs, Medical officers, District SRS (12-13) 208 Program Managers & Development partners. A total of 73 IMR SRS (2012) 38 SRS (2013) 37 participants were trained. SRU also supported the district and SRS (2014) 34 block level trainings in the seven USAID supported districts. SRS (2015) 32 Intensification of supportive supervision visits in Jharkhand: The new Supportive Supervision checklist has been introduced and 19 facility and 13 community visits were made using the new checklist. The Supportive 22

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Supervision visits have now been planned to be intensified using the new checklist and using the new tool for data entry and analysis. Jharkhand Newborn Action Plan (JNAP): The project team has facilitated in the review of Jharkhand Newborn Action Plan (JNAP), supported the Family Planning cell in the rollout of the district level trainings on newer contraceptives as well as carrying out regular Supportive Supervision for strengthening Adolescent Health Cell. Support to state level programs: SRU also supported the state in Task Force Meetings, Maternal Death Reviews, Kayakalp Assessments, trainings on Swachta guidelines and participated in State Review Mission visits along with state government officials.

ANNUAL ACTIVITY HIGHLIGHTS: PUNJAB Population (Projection 2017) WIFS Strengthening: A desk review followed by a Persons 29372000 rapid assessment of WIFS program found several Male 15871000 implementation gaps in the program. Based on the Female 13502000 findings and recommendations an implementation Infrastructure framework was developed. The framework was No. of District 20 tested in Barnala district. In the pilot site a supply chain mechanism was established to ensure No. of HPDs 5 uninterrupted supply of Iron Folic Acid and this No. of Blocks 142 resulted in 100% stock at all 666 Anganwadi centres Facilities and position and 308 Schools. Standardized registers and reporting No. of District Hospitals 22 formats based on the GoI guidelines were made available at all delivery sites and this has ensured for No. of Sub 41 prompt and accurate reporting. The demand for IEC Divisional/Referral was strengthened using a customized IEC display, the Hospitals Nutrition and health education (NHED) component of No. of Community Health 150 Centers Functional WIFS was strengthened by introducing a monthly NHED calendar at most of schools and AWC. A No. of Primary Health 428 supportive supervision check list was developed and Centers Functional used by both project staff and state counterparts this uNo. of Health Sub Centers 2950 helped to institutionalize the mechanism and there is Functional regular monitoring of the program. Mortality Support for state level programs: During the year, MMR SRS (10-12) 155 SRU provided technical support to state level SRS (12-13) 141 activities such as Mission Indradhanush, Intensified IMR SRS (2012) 28 Diarrhea Control Fortnight, Maternal Death SRS (2013) 26 Reviews, strengthening RKSK and monitoring of PMSMA. SRS (2014) 24 SRS (2015) 23

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

ANNUAL ACTIVITY HIGHLIGHTS: UTTARAKHAND

Strengthening Antenatal Care: Block Level Implementation Strengthening Support (BLISS) Model: The Vriddhi state team working in close consultation with the state developed the BLISS Model for improving ANC Service delivery in the State. The intervention which began in March Population (Projection 2017) 2016 and is expected to impact approximately 3800 pregnant Persons 10761000 women annually in block Laksar alone. Male 5498000 Female 5263000 The model has continued to evolve and its scale up to other Infrastructure HPDs has been initiated. Given below are the key interventions No. of District 13 under BLISS: No. of HPDs 3 Primarily for addressing the first two delays No. of Blocks 95 Facilities and position • Institutionalization of Fixed ANC Day every Monday at Sub No. of District 20 center Level. This has been scaled-up State wide as Hospitals SaMMaN Divas wherein ANC services are provided every No. of Sub 19 Monday at Sub center Level and the ANC Clients are Divisional/Referral specifically screened for Danger Signs and conditions Hospitals especially Anemia & Leucorrhea (RTI/STI) No. of Community 61 Health Centers • Focus on early ANC Counselling along with regular Functional measurement of 5 ANC Goals at field level No. of Primary 278 • Ensure availability of Key ANC Commodities at all levels of Health Centers care Functional • Competency enhancement of care providers through, No. of Health Sub 1880 Cluster Based Learning at Learning Labs based at Block PHC Centers Functional Level and Supportive Supervision during Fixed ANC Days Mortality • Use Data for Decision Making – Performance Scorecards & MMR SRS (10-12) 292 Surveys SRS (12-13) 285 In a short period of time, BLISS Model implementation at IMR SRS (2012) 34 Laksar has resulted in improved ANC performances and SRS (2013) 32 institutional delivery rates. Results comparisons (HMIS Data) SRS (2014) 33 for the year 2015-16 & 2016-17 have been presented below: SRS (2015) 34 I. 3.6% increase in 3 ANC Checkup II. 23% increase in Anemia detection III. 1.7 times more High B.P. cases Detected IV. 30 times increase in 100 IFA Distribution V. 22.5% increase in reported Institutional Delivery VI. 28.6% increase in reported % Safe Delivery to total deliveries reported VII. 30.2% decrease in Non SBA Home Delivery Rates The encouraging results from the BLISS Model Strategy was reviewed at State Level. Subsequently it was included as part of the SaMMaN Health Initiative of the State. As part of the Initiative the State is planning to scale BLISS Model Strategy across all the thirty Blocks in the High Priority Districts. As part of the scale up Process, the project team also supported in developing Program Management Information System (PMIS). This

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

IT based system shall generate information and evidence for guiding future planning and policy decisions and to facilitate performance based recognition. The scale would increase the intervention reach to approximately 40% of the total state population. It is expected that the successful implementation would result in positive pregnancy and post-delivery experience for mothers and their newborns. State Level Workshop on Improving Maternal and Newborn Health Outcomes: State Level workshop was held on March 19, 2017. Participants included District Officials, Gynecologists and Medical Officers from all the thirteen districts. The workshop jointly facilitated by team members from NHM Uttarakhand and Vriddhi Workshop on Collaboration with Medical College in Uttarakhand: SRU co-facilitated a workshop on involving Medical Colleges within the RMNCH+A strategy in collaboration with Government Medical College, Srinagar, Pauri Garhwal on May 23, 2017 in Pauri, Uttarakhand. During the meeting, the participants were briefed about the RMNCH+A strategy and the “Care around Birth” approach. The workshop also provided a platform to discuss the findings of the SS visits undertaken by the Medical College and learnings from the project interventions in Uttarakhand

NATIONAL RMNCH+A UNIT (NRU)

KEY ACHIEVEMENTS OF NRU

National RMNCH+A review meeting: The project team coordinated the National RMNCH+A review meeting held on November 23, 2016 under the chairmanship of Joint Secretary (RMNCH+A) Ms. Vandana Gurnani. The meeting was attended by all the Deputy Commissioners from the MoHFW and representatives from partner agencies and ably facilitated by the project team. The interaction provided a platform for the National RMNCH+A Unit (NRU) and the State Lead Partners (SLPs) to apprise the Ministry on the progress achieved and challenges faced in the implementation of the RMNCH+A strategy in the HPDs and also provided a roadmap for the future. RMNCH+A review for North Eastern states: NRU facilitated GoI teams visit led by Deputy Commissioners in High Priority Districts of North-Eastern states for reviewing the implementation of RMNCH+A interventions from January 19 to 21, 2017. In a review meeting by the Joint Secretary, NRU further participated and presented Supportive Supervision status of North-Eastern states based on reported SSV data during review meeting organized by NE-RRC held at Guwahati on January 23 to 24, 2017. Learnings from the “Community Based Advance Distribution of Misoprostol” program in Himachal Pradesh were presented during the review by the project team. Partners and RMNCH+A Review Meeting: A review Meeting with Lead Partners/ agencies involved in intensification of RMNCH+A activities was held on September 05, 2017. The Additional Secretary and Mission Director chaired the meeting while the Joint Secretary, RCH was the co-chair. Discussions included identifying and finalizing a set of indicators to track progress of RMNCH+A implementation, alignment of development partner’s work with the national level programs and formulating a mechanism for operationalization of health and wellness centres.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Regional training on revised Supportive Supervision Checklist and Web based Supportive Supervision Visit (SSV) software: NRU facilitated regional and state level training workshops on revised Supportive Supervision (SS) checklists (facility and community) and Web based software /data entry tool. These trainings were organized to build the capacities of key stakeholders, State health officials, SRUs and District Level Monitors on the revised checklist and analysis software. Another two days training on RMNCH+A SSV at Guwahati was organized by North East–Regional Resource Centre (NE-RRC) with UNICEF support for RRC & UNICEF Consultants (46) posted in North Eastern States including Assam. User interface of SSV data entry software has been developed and data entry has started in 29 states. Assessment of RMNCHA SSV Mechanism: NRU has developed two assessment formats to assess the implementation status of RMNCH+A SS mechanism in states. These formats capture the basic information and feedback for the assessment of RMNCH+A Supportive Supervision Mechanism and Stewardship Index Data pertaining to state health system. NRU team members visited Bihar, Odisha, Jharkhand, Tamil Nadu and Puducherry to collect data on the new formats and test them. Launch of Swachh Swasth Sarvatra Abhiyan: NRU participated in the launch of Swachh Swasth Sarvatra Abhiyan on December 29, 2016 at New Delhi, which was presided by Union Health Minister with participation from national level officials. Mission Indradhanush: NRU team regularly visited states for Monitoring Mission Indradhanush. Key findings and recommendations to strengthen the implementation of MI rounds were shared with Immunization Technical Support Unit (ITSU). State NHM PIP for the year 2017-18: Representative from NRU participated in NHM meetings along with GoI team facilitate the NHM PIP preparation for year 2017-18 by the state at Raipur, Chhattisgarh. Discussion with Mission Director (MD) NHM & state program officers was around the key priorities of program divisions such as: Roll out of new contraceptives, quality delivery of family planning services as per Supreme Court directives, MCH Wings, new maternity scheme, incentives to private providers for C-Sections, skill labs establishment, budget for Mission Indradhanush and cold chain maintenance in Immunization, RBSK, RKSK and release of 30% extra funds to HPDs based on gap analysis done by UNICEF for the state. NRU coordinated between state NHM and program division for approval of raised funds of RMNCH+A activities. The team also discussed with the state program divisions of Punjab, Jharkhand and Uttarakhand regarding inclusion of scaling up of Care around Birth approach in the proposals. Program monitoring indicators for Prime Minister’s Office (PMO): Based on the requirement of PMO (Niti Aayog) for tracking RMNCH+A progress in 52 identified HPDs, NRU in coordination with UNICEF has developed a robust monitoring framework. This monitoring framework includes a set of critical program indicators under each thematic area of RMNCH+A. This was done after an initial desk review and detailed discussions based on which eleven most critical program indicators from HMIS were finalized and data was collated and compiled for tracking the progress. The project through the NRU also helped to prepare the baseline report on status of 52 high priority districts according to the identified monitoring framework. RMNCH+A Mobile App: NRU under the guidance of Dr. Ajay Khera, DC, Child Health has developed a RMNCH+A Toolkit app for the MoHFW. The app envisages to bring all relevant RMNCH+A data from different sources (like NFHS, DLHS, AHS, Census, SRS, HMIS, SSV) on a single platform for each state and respective districts of the country. After an initial discussion and brain storming sessions by the NRU team, a draft framework and set of indicators corresponding to all the thematic areas were developed. The content, design and layout of the app 26

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions was reviewed by the NRU team. Accordingly modification and changes were also done before finalizing it. NRU with the knowledge hub team designed the RMNCH+A app brochure and a user manual describing app capabilities and its usage. NHSRC and NRU joint visit for preparation of road map for Maternal and Child Health interventions: With an aim towards improving maternal and child health across the country with special focus on EAG states, National Human System Resource Center (NHSRC) and NRU undertook joint visits to the states of Assam, Jharkhand and Madhya Pradesh. The visit was held to conduct a gap analysis and firm up the implementation strategies for key interventions under maternal and newborn health. The team undertook facility and community visits to two districts of Assam, four districts of Jharkhand and four districts (Jabalpur, Mandla, Sagar and Dindhori) of Madhya Pradesh. Based on field visit, programmatic and systemic issues were identified and subsequently an action plan pertaining to the issues was strategized. Post the visit, high quality strategic reports including a follow up mechanism were prepared and shared with respective state governments. Indicators for FP commodities Software: NRU assisted the family planning division in preparation of Indicators Framework and designing Dashboard for the national Family Planning Logistic Management Information System. NRU also played a vital role in designing the LMIS and also devising a field testing plan. Intensified Diarrhea Control Fortnight (IDCF): During preparatory phase of IDCF, NRU supported child health division in compiling the field findings and key observations of IDCF monitoring visits and sharing the same with Ministry of Health and Family Welfare, Government of India. The team also conducted IDCF monitoring in Vishakhapatnam, Andhra Pradesh. Participation in NPCC Meeting: NRU Members participated in NPCC meetings held in MoHFW for Bihar. Team also shared the key issues and achievements based on SSV data and field observations with Joint Secretary (Reproductive and Child Health). National summit on best practices and replicable innovations in public health at Indore, MP: The team participated and presented at the National Convention on Best Practices in Public Health held in Indore, Madhya Pradesh from July 6-8, 2017. NRU presented on Supportive Supervision mechanism in the summit. The summit was attended by Hon'ble Lok Sabha Chairman Sumitra Mahajan, Hon'ble Union Health Minister and Minister of State (MoS), MP State, MoS Health Minister, Senior Health Officials including PS Health, MD NHM. All state representatives shared their best practices and outcomes in detail. National Deworming Day: NRU team members visited Ranchi, Gumla (Jharkhand) for monitoring and tracking of implementation of NDD in district. Key findings and recommendations to strengthen the implementation of NDD rounds were shared with Child Health division, MoHFW Development of Supportive Supervision Software: A supportive supervision software for Government Officers is being developed by NHSRC in collaboration with JSI, UNICEF and IPE Global. NRU contributed in design, analytical module and eventual pilot testing of the software.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

JOHN SNOW INC. (JSI)

HUMAN RESOURCES District Technical Advisors (DTA) for Haridwar and Gumla were recruited and joined their duties in the first week of January 2016. The DTAs underwent induction training in the second quarter of the year and subsequently interacted with district and state health societies to establish rapport and inform them about their role in the district. National and International JSI team members supported the DTAs in this task. State visits for providing specialized technical assistance to Gumla (Jharkhand) and Haridwar (Uttarakhand) were undertaken by JSI national team along with international experts: Dr. Mary Carnell and Dr. Penny Dawson.

ACTIVITIES Developing PSE Strategy for scale up in six USAID states: With the aim of improving the reach of RMNCHA services and reducing out of pocket expenditure to provide affordable health care services, private sector engagement remained a key strategy of this project. JSI adopted a consultative, evidence-based, sequenced approach to developing a private sector engagement strategy. As a first step, JSI in formal partnership with FOGSI/IAP have already convened national and state government and identified effective association with private sector by conducting landscape analysis of private sector providing MNH services in our six project states: Haryana, Jharkhand, Uttarakhand, Punjab, Himachal Pradesh and Delhi. JSI accomplished all planned activities under the PSE strategy development role this year. Advocacy and policy influence: Findings of the landscape analysis were initially shared with a small group of stakeholders from professional associations for validation and buy-in. This was followed by endorsement of JSI’s approach and state specific strategy for increasing private sector engagement by the leadership in Ministry of Health and Family Welfare (MoHFW) through one to one meetings and national advocacy meet in February 2017. After the commitment of MoHFW, JSI successfully Figure 8: Leaders and technocrats from Ministry, facilitated roll-out of PSE strategy in three of the six USAID, professional associations and JSI opening high states- Delhi, Jharkhand and Uttarakhand and level national consultation on Private Sector Engagement successfully reached out to over 7000 health specialists across six states. State meeting were held with MD, SHM in all states with representation from IPEG, professional associations and JSI. Capacity Building: Over 100 private practitioners have been trained on RMNCH guidelines and government endorsed protocols across three states. Master trainers for these trainings include representatives from FOGSI and IAP/NNF and six state lead coordinators, who were oriented to the training content and methodology in July, 2017.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

The major achievements of these workshops were participants’ increased interest in facility accreditation, acceptance to sharing data with the government periodically on a government endorsed format, willingness to participate in PPP dialogue through web based platforms and greater government interaction through monthly meetings. Private providers showed an interest in partaking in all GoI NHM schemes such as JSY, JSSK and RSBY. They were also interested in receiving updated GoI guidelines/ updates periodically, latest versions of which were shared with them during the workshop. Officials from state government participated in these workshops and endorsed need for PPP cell at state level (Director, Family Welfare, Delhi, Dr J P Kapoor; DGHS, Uttarakhand, Dr Rawat and DG, Uttarakhand, Dr Archana Shrivastava). Creating Evidence Pool and Knowledge Sharing: Evidence pool and knowledge sharing platform was developed for dissemination for all the project activities. Findings from the landscaping assessment were disseminated as a technical brief and in MS PowerPoint format. Key outcomes and proceeding from the National consultation held in February, 2017 were published and used for state level meetings with MD, SHM and other stakeholders to advocate for state level PPP cells with dedicated budget and HR and state specific strategic roadmap. A compendium of latest MNCH guidelines have been created and made available to private practitioners attending the state level workshops. All activity updates on PSE consultations and Figure 9: Compendium of GoI MNCH workshops are posted immediately after event on the Practitioners Guidelines shared with private providers. Forum @ www.rmncha.in website. JSI’s blog –The Pump was used to increase awareness about Vriddhi PSE initiative among development partners and like-minded professionals Developing scalable “demonstration models” for implementation of three key newborn health interventions. Advocacy and policy influence: Vriddhi as the lead agency operationalized KMC unit in Chain Rai Hospital in Haridwar district, Uttrakhand and Sadar Hospital in Gumla district, Jharkahnd despite many challenges with respect to patient load, staff limitations and lack of funding through PIP. A Panel discussion and dissemination workshop was conducted in August 2017 to share the success and challenges in implementing KMC in community and facility. JSI is also providing technical inputs to a training manual on KMC for doctors and nurses. Capacity Building: The project offered the first training on KMC to hospital staff nurses, counsellors and medical officers in both districts (Haridwar and Gumla). ANMs and ASHAs from intervention blocks were successfully trained on screening for newborn sickness, administration of injectable gentamycin and KMC. It was seen that over 300 babies have received KMC in the two districts and the numbers are increasing consistently every quarter since inception In the demonstration blocks – Roorkee Block (Uttarakhand) and Basia Block (Jharkhand), ANMs are gaining confidence in identifying sick newborns and administering first dose of Injection Gentamicin and oral

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Amoxicillin. An informal peer support group has been formed by ANMs of Roorkee block to build each other’s confidence and motivation to care for new-borns. Creating Evidence Pool and Knowledge Sharing: The process of institutionalizing KMC units and strengthening field follow-up of babies discharged from KMC units has been captured through three case studies published in the RMNCH+A resource publication. An impact case study on the field administration of injectable gentamicin in Vriddhi intervention sites has been published in USAIDs bimonthly bulletin. A poster on challenges and achievements in implementing KMC was presented at an international conference organized by Consortium of Universities for Global Health (CUGH) at Washington DC. KMC initiative was also captured in the seventh edition of KMC Foundation bulletin. Two assessments- one on KMC implementation and other on injectable gentamicin have been completed and assessment were disseminated during the national consultation. Report on the proceedings and outcomes from the national consultation on KMC is available as reference for policy and program thinking on KMC implementation in facilities and community settings.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

PLANNED ACTIVITIES VS. ACCOMPLISHMENTS -YEAR 3

No Activity Project inputs Progress against activities Output 1 Availability and quality of RMNCH+A services improved in Government health facilities Vriddhi successfully consolidated the In Y3, the focus of activities was to implementation of Technical consolidate the implementation of TIP Intervention Package 1 by sharing 1 package through learning cycles for Consolidate the the learnings among the states and care around birth with monthly implementation of districts through Experience Sharing mentoring visits and QI meetings at Technical Intervention Platforms (ESPs) and conducting facility level. Regular ESP meetings at Package 1, interventions regular QI meetings and mentoring 1.1 the state and district level to share for every mother and visits. their learnings among intervention newborn, in the VRIDDHI facilities were planned. Training For scaling up CAB in non-HPDs, intervention facilities in packages and job aids were developed Vriddhi conducted ToT and trainings HPDs of 6 focus states to reinforce TIP1 package and of staff nurses from non-HPD of activities for scaling up TIP 1 package Delhi and HP. While the states of in non-HPD was initiated Jharkhand & Uttarakhand received approvals for conducting trainings

The TIP II package is focused on management of complications; i.e. The project team, including SRU and initial management of PPH, severe Pre- DTOs, was trained on the content of Eclampsia / Eclampsia and managing TIP II in two 3 day training of trainers pre-term and low birth weight infants (ToT) and further handheld for the and newborn sepsis. district trainings. Roll out of the TIP Strengthen delivery Vriddhi has developed a TIP II training II package started with training at all points for care around and implementation package in Year 3 facilities in project HPDs. A total of birth roll out Technical (Obstetric Drill Manual, PIN Girl poster, 651 providers have been trained on Intervention Package 2 1.2 Posters on 4 pause points of SCC, Safe TIP II interventions to manage birth Checklist poster, trainer kits This was followed up with onsite complications in Vriddhi which includes observation checklist, mentoring, QI team meetings and supported facilities in information cards for PPH and support to facilities to start HPDs of 6 focus states Eclampsia, and KMC handout book) practicing obstetric drills and improve coverage of LBW newborns The roll out of the TIP II package with KMC and other necessary included a baselines, defining of monitoring indicators and training of The TIP II interventions are being master trainers and staff from monitored and tracked in HPDs implementation facilities

Maternal Health

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

The project has successfully adapted training module and job aids for scale up of the intervention Scale up of misoprostol distribution is approved in PIP of 17-18 for the 12 blocks in HP and 30 blocks in five districts of Jharkhand. The The major inputs have been Support State procurement of misoprostol tablets, adaptation of the implementation Governments of planning for training and package including training and job aids Jharkhand and Himachal implementation have been initiated. and program processes for scaling up. 1.3 Pradesh (HP) to scale up In Jharkhand after a training of Training trainers and frontline workers community based master trainers block level trainings ANMs and ASHAs / Sahiyas ( in distribution of of frontline workers have been Jharkhand) and supporting the state to Misoprostol completed in 6 blocks of Simdega monitor the scale up sites and one block of Dumka district. 1098 ANMs and Sahiyas have been trained Monthly block and district level monitoring of the intervention by the project team and government has been initiated

A total of 70 master trainers were Vriddhi has developed a training trained in a state level training of module and a handbook on newer trainers. The trainers were District maternal health guidelines as a job technical officers, District program Orientation on New aid for frontline workers. It has managers, representatives of other Maternal Health supported the training of master development partners, District RCH 1.4 Guidelines in Jharkhand trainers, quality assured block level officers and Medical officers. State training of trainers in HPDs and The master trainers conducted block supported the state to track the status level trainings of frontline workers. of dissemination of guidelines in all In the Vriddhi supported HPDs districts of the state. trainings have been completed in 47 out of 55 blocks.

Support Punjab state in developing an Vriddhi support to the state included a Towards achieving this target a draft operational framework review of the various guidelines and operational framework for 1.5 for addressing development of an operational addressing maternal anemia was Prevention and framework for tracking and treating prepared and shared with State of management of maternal anemic pregnant women Punjab anemia (MH)

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

At National level Vriddhi team contributed in developing the protocol and tools for the evaluation of PMSMA. Vriddhi also supported identification of monitoring indicators for PMSMA to be used to help states prepare comprehensive quarterly reports. The monitoring and subsequent Vriddhi has been supporting states to feedback mechanism resulted in Support state and plan and monitor the implementation consistent improvement across the districts to implement of PMSMA and sharing the findings project supported HPDs, specifically 1.6 newer GoI programs/ with MoHFW. It provides Technical the involvement of private providers drives on Maternal assistance at national and state levels has been encouraging in the states Health to further strengthen the of Delhi, Haryana and Punjab and all implementation of PMSMA states have shown a steady improvement in service delivery and record keeping. In addition to this in the states project teams helped to prepare PMSMA register with guidelines and steps to be followed at PMSMA site, PMSMA OPD slip, and process of HRP identification and tracking.

Newborn Health At National level there was continuous technical assistance for the GoI supported programs. Project provided need based support Support state and The Haryana state team supported for the implementation of the districts to implement the development of the Haryana newborn health guidelines and 1.7 newer GoI programs/ newborn action plan and HP helped protocols, It also supported state to drives on Newborn to train SNCU staff. prepare and implement newborn Health action plans 4 batches of training was conducted for SNCU staff of 12 districts of HP. Total 97 SNCU staff nurses trained on newborn TIP 2

Child Health Vriddhi provides ongoing technical In all 6 states the Vriddhi team has Support for expanding assistance at National and state levels been supporting planning and 1.8 coverage of Child health to plan, implement and monitor these monitoring activities for programs interventions programs and drives including Mission

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Indradhanush, National Deworming Day, IDCF and MAA

Provide technical support The HP team of Vriddhi facilitated to the State In this year the state of Himachal the launch of PCV vaccine in June Governments in six focus Pradesh the pneumococcal conjugate and MR campaign in Aug and Sept- 1.9 states for introduction of vaccine (PCV) was launched and a 17 in Himachal Pradesh. Technical drive launched to improve coverage of new and underutilized team monitored Measles Rubella measles – rubella vaccine. vaccines (MR) and IPV, Pneumonia in HP

Adolescent Health A total of 850 AFHC facilities, 234 schools and 107 AWCs were visited. State teams helped to design state specific branding for the AFHC sites, The project teams made regular Strengthen Adolescent logos, and signages were designed. monitoring visits to AFHCs for Friendly Health Clinics Standardized registers, IEC materials 1.10 supportive supervision and to provide (AFHCs) (Adolescent and posters were adapted / Health) on-site mentoring to improve service designed for AFHC sites and delivery provision distributed to them. In HP and Jharkhand the project team facilitated review of adolescent programs at district level.

Reproductive Health As a result of the Vriddhi’ regular support and mentoring 74,971 clients were counselled on PPFP out of which 23,967 accepted PPFP as the method of contraceptive. Strengthen delivery Vriddhi supported facility level points for 'care around counselors with regular mentoring All State teams were oriented on 1.11 birth' with a focus on visits and supportive supervision and newer contraceptives and they PPFP within the overall updating their knowledge on newer oriented the DTOs in their States. framework of FP 2020 contraceptives. Himachal Pradesh and Jharkhand (RH) conducted training of 18 counselors and 14 service providers respectively on Family Planning especially newer contraceptives. Other states have also initiated the process.

Output 2 Evidence for Scale up RMNCH+A Services Strengthened Monitor VRIDDHI The focus of the monitoring and The project conducted a data activities and evaluation activities was on data validation exercise in 74 facilities 2.1 interventions and quality assurance, regular use of from 23 project districts to review generate reports for and validate the data various target audiences project data in different experience 34

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

sharing platforms to support evidence Monthly MIS data was collected and based decision making by progam feedback was provided to the facility managers. Planning and implementing for action. a third party evaluation of the project The data trends were shared with interventions state and national teams, gaps and errors highlighted, and a plan made to improve data quality An external agency has been hired to conduct a third party evaluation. The methodology, sample size and tools are being finalized The labor room assessment was repeated and findings compared with baseline. An action plan was prepared to facilitate further improvements in the prioritized facilities A total of 715 supportive supervision Analyse and disseminate Vriddhi district technical officers visits were reported from the supportive supervision conducted supportive supervision (SS) project supported HPDs. 2.2 data from HPDs visits according to GoI guidelines, send The state teams and DTOs were data regularly and use the data to oriented on the revised SS checklist, identify gaps, challenges and progress SOP, and SSV web based tool

Vriddhi has submitted a paper on the ‘ Community based distribution of Misoprostol’ , it submitted learnings and experience from ‘Care around birth approach’ for the BMJ awards for the Quality Improvement team of the year and has drafted a paper on newborn immunization for submission to a peer reviewed The key inputs in this section are journal. collating and documenting project Document and Vriddhi organized and participated learnings and disseminating them – disseminate learnings in the USAID partner Consultation 2.3 through submitting papers in journals, from VRIDDHI activities/ on ‘Addressing Key Drivers of preparing status papers, organizing interventions Maternal and Newborn and participating in national Mortality’. VRIDDHI also set up a consultations display stall highlighting all project interventions. Vriddhi developed status papers / articles on: 1. Desk Review on Iron supplementation in pregnancy – alternative regimens & salts 2. Implementation of Community Based Advance Distribution of

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Misoprostol in Himachal Pradesh (India): Lessons and Way Forward 3. Integrating Vitamin A and deworming Towards this target the project team developed audio-visual communication products including a project photo story which documents the project’s journey, and produced two training learning Vriddhi Knowledge and Learning team videos on Kangaroo Mother Care Share learning and collected information and best and feeding of LBW newborns. The 2.4 insights from VRIDDHI's practices from the field and produced knowledge hub initiated activities and a variety of project communication development of communication interventions material material relating to care around birth technical intervention package – II. The team also supported Haryana SRU in designing the Haryana Newborn Action Plan. Translation of the training material to hindi has also been initiated

The website www.rmncha.in was revived, redesigned and launched during the year. It is regularly updated to reflect the project’s Vriddhi has revived and launched the work and achievements. Vriddhi’s website www.rmncha.in, the twitter handle is maintained and Increase project platform helps to keep Vriddhi active kept active. visibility and 2.5 and visible in the digital world. communication with Vriddhi participated in Participation at national and external audiences international and national level international events has improved conferences and presented the project visibility project work during the year. A total of 6 paper presentations and 8 posters were presented in national and international conferences during the year.

A project transition plan was drafted The planning for transition has begun, and shared with USAID. A scale up Initiate transition and 2.6 and discussions are being held in all the cum transition plan for the Care sustainability processes states around birth approach has been prepared for Delhi State.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

The state governments in the 6 project states have been informed of Vriddhi timelines and discussions are going on for smooth transition of Vriddhi supported interventions to the state

National RMNCH+A Unit ( NRU) The project shared monthly SS findings, feedback and recommendations based on the original SS checklist with all states till February 2017 and from March 2017 onwards on the new revised checklists. Year 3 focused on promoting the use The revised checklist has become of SS data to take actions to improve operational in 184 HPDs in 30 states. RMNCH+A service availability and Eight regional level trainings were delivery and to leverage funds for organized by the NRU to orient RMNCH+A services. Efforts were SRUs, DLMs and state govt. nodal directed to ensure a smooth transition RMNCH+A officers and 283 Strengthen national of SS activities to the revised checklist. participants in all were trained on 2.7 supportive supervision Trainings were organized, coordinated processes the revised checklists. and facilitated.

The revised checklist was scaled up Vriddhi has developed a mobile app to in non-HPDs in UP and Punjab. facilitate use of SS data as well as to access and compare data from various A web based RMNCH+A tool for sources such as National surveys, online data entry of each visit has HMIS, Supportive Supervision etc also been developed and online data entry has initiated in 29 states.

A Mobile based RMNCH+A App has been developed. Official launch is awaited.

Two national reviews were facilitated

The project team provided Support SRUs and State There is a large body of evidence comments on ROPs to NHM cell, governments to use available to the MoHFW from SS and MoHFW and also tracked status on supportive supervision other monitoring activities that are 2.8 release of ROPs for all 6 USAID and monitoring data supported by NRU. Efforts will be states. while preparing annual directed to using the data to guide PIP PIP planning processes in states The project has conducted an exercise for 9 EAG states to assess 37

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

the implementation of RMNCH+A SSV mechanism and state health system based on Stewardship Index. The project team also supported MoHFW in PIP finalization and comments for the states Jharkhand, Bihar, Kerala, Madhya Pradesh, Punjab, Delhi, UP.

NRU supported MoHFW for National NRU has supported monitoring of level campaigns: Mission campaigns and drives such as Mission Indradhanush, IDCF, PMSMA, NDD Indradhanush, Intensified diarrhea Respond to MoHFW etc., National level roll out of MDSR, control fortnight (IDCF) and National emerging needs and MNMR strategies and intervention 2.9 Deworming Day (NDD), Mothers support newer National and FP-LMIS. Joint Visit was absolute affection (MAA) etc and programs conducted by NHSRC & NRU to EAG giving feedback to GoI and states states for preparation of road map regarding the status of towards improving the MCH implementation indicators.

Output 3 RMNCH+A good practices incubated for scale up VRIDDHI supported Uttarakhand state Strengthen block level to develop BLISS model to improve the implementation of coverage and quality of ANC services in The project team prepared a scale RMNCH+A services with the state. Following the success of the up plan & shared it with the 3.1 a focus on coverage and pilot initiative in one block in Haridwar government. Approval received quality of ANC services in district the project worked on from GOI to scale to 30 Blocks Uttarakhand(UK) developing a scale up plan for the state.

Vriddhi supported the Delhi State Vriddhi continued to support the government to introduce a systematic state in outreach strengthening at approach for conducting UHNDs. North West district, it focused on Inputs included - defining the package availability of equipment and of services, microplanning and consumables at the UHND sites such Strengthen outreach monitoring of the intervention. The as weighing machines, functional BP 3.2 services in urban slums in UHND strengthening plan was initiated apparatus etc. through the offices of NW Delhi (Delhi) in the slum areas of Sultanpuri and the medical officer in-charge. SRU Mangolpuri of North West District also supported in fund planning in covering a population of 6 lacs. In year state. More than 300 UHNDs are 3 the focus has been on improving the held wherein > 600 PW were quality parameters of UHND registered with 40 % first trimester registration.

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

KMC unit in Chain Rai Hospital in Haridwar, Uttrakhand and Sadar Hospital in Gumla, Jharkahnd are JSI assisted the states of Uttarakhand now operational. Over 300 LBW and Jharkhand to set up a babies have received KMC at these Strengthen services for demonstration model in one units and the numbers are Kangaroo Mother Care government health facility in each of 3.3 increasing and feeding of low districts Haridwar and Gumla birthweight infants (intervention areas). the learning of A Panel discussion and the pilot were disseminated in a dissemination workshop was national stakeholders consultation conducted in August 2017 to share the success and challenges in implementing KMC in community and facility.

In one block each in Haridwar ANMs and ASHAs from intervention (Uttarakhand) and Gumla (Jharkhand) blocks were trained on screening for Strengthen Home based districts an implementation model has newborn sickness, 3.4 New-born Care (HBNC) been set up, Learnings are being services documented and scale up models are being developed.

3.5 Promote use of ANMs and ASHAs from gentamycin and oral intervention blocks were amoxicillin successfully trained on administration of injectable gentamycin

In one block each in Haridwar In the demonstration blocks – (Uttarakhand) and Gumla ( Jharkhand) Roorkee Block (Uttarakhand) and districts an implementation model has Basia Block (Jharkhand), ANMs are been set up, Learnings are being gaining confidence in documented and scale up models are administering first dose of being developed Injection Gentamicin and oral Amoxicillin. An informal peer support group has been formed by ANMs of Roorkee block to build each other’s confidence and motivation to care for newborns.

Output 4 Multiple stakeholders (including private sector professionals) involved in delivery of RMNCH+A services

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

Findings of the Landscape analysis of the private sector in the 6 USAID states were shared in a National advocacy planning meeting chaired by the Joint Secretary of MoHFW State meetings on private sector engagement (PSE) were held in all the 6 states and the strategy has been rolled out in three states – Delhi, Jharkhand and Uttarakhand The main activities in the year were Over 100 private practitioners have dissemination of the report of been trained on RMNCH guidelines Strengthen linkages with Landscape analysis, partnering with and government endorsed protocols the private sector for professional bodies, engaging with 4.1 across three states. Master trainers increasing coverage of state governments and orientation & for these trainings include RMNCH+A services sensitization of private practitioners representatives from FOGSI and on MNCH high impact interventions (as IAP/NNF and six lead coordinators per the recent GoI guidelines). A compendium has been created of the latest MNCH guidelines and made available to private practitioners attending the state level workshops. All activity updates on PSE consultations and workshops are posted immediately after event on the Practitioners Forum @ the website www.rmncha.in

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions

PROJECT CONTACTS

NAME NAME OF DESIGNATION CONTACT DETAILS ADDRESS OF UNIT HEAD UNIT NTSU Dr. Rajeev Project Director 9810703515 IPE Global House Gera [email protected] B-84, Defence Colony, New Delhi-110024 NTSU Dr. Gunjan National Technical 9234002970 IPE Global House Taneja Lead [email protected] B-84, Defence Colony, New Delhi-110024

SRU Dr. Anil State Technical Team 9971828730 Room No. 108, State Institute Gupta Lead [email protected] of Health & Family Welfare, Parimahal, Kasumpti, Shimla, Himachal Pradesh - 171009 SRU Dr. Chitra State Technical Team 8750099998 6 Floor , DSHM, Vikas Bhawan Rathi Lead [email protected] , Civil Lines , New Delhi 110054 SRU Dr. Nidhi State Technical Team 7508618482 Bays 59-62, Institute of Town Chaudhary Lead [email protected] Planners Building, Sector 2, Panchkula-134109, Haryana SRU Dr. Anurag State Technical Team 8872343444 Room No. 325, Fifth floor, Joshi Lead [email protected] Directorate of Health Services, Parivar Kalyan Bhawan, Sector 34A, Chandigarh- 160022 SRU Dr. Jaya State Technical Team 9031056672 State RCH Campus Swarup Lead [email protected] G.V.I., Namkum Mohanty Ranchi- 834010 Jharkhand SRU Dr. Nitin State Technical Team 7457007286 2nd Floor, RMNCH+A Unit, Bisht Lead [email protected] Office of the Director General Medical Health and Family Welfare, Shasheradhara Road, Dehradun-248001, Uttarakhand NRU Dr. Neelesh Team Leader National 9560130303 IPE Global House Kapoor RMNCH+A Unit [email protected] B-84, Defence Colony, New Delhi-110024 JSI Dr. Sudhir Project Director, JSI +919717874646 B6-7/19, DDA commercial Maknikar India [email protected] complex, Safdarjung Enclave, New Delhi-110029

Annual Project report VRIDDHI: Scaling up RMNCH+A Interventions