Maternal & neonatal mortality rates in India have declined yet fell short of 2015 millennium development goals (MDG). Several maternal and neonatal health indicators show improvement yet inequities in population-wide coverage in certain geographies and gaps in quality and continuity of care remain unresolved.

Reaching scale to ensure coverage of migrant, high-risk women and children in the care-continuum is a visible gap. Ensuring coverage during their antenatal and postnatal periods in a seamless manner with high-quality emergency obstetric & neonatal care requires newer innovative approaches. Meaningful engagement of grass-root structures such as Gram Panchayats (GP) /Village Health Sanitation and Nutrition Committees (VHSNC) needs to reach scale. Integration of technology interfaces to ensure continuity and real-time data-based planning is required.

Our Approach

Our approach focuses on improving availability, accessibility, quality, utilization, and coverage of critical MNCH interventions among the rural poor through Facility, Community, Health Systems, and Technology. It includes strengthening of health care providers’ knowledge and skills to threshold levels to deliver quality MNCH services in district-level public health care facilities. Our focus is on prioritizing the integration of respectful maternity care principles and practices
We also have a community-level focus on vulnerable populations, which includes community participation and accountability through frontline workers, Village Health, Sanitation and Nutrition Committees (VHSNCs), and Arogya Raksha Samitis. We look to building capacities and scaling up the reach of quality community-based services. This will improve functionality, and generate ownership and accountability of Gram Panchayats and VHSNCs.

We also implement health system strengthening activities to improve the availability of drugs and supplies, accessibility for maternal and neonatal complications, a robust referral system that ensures stabilization of complications and effective infection control practices to reduce maternal and neonatal sepsis.

We aim to integrate and expand the use of technology across the continuum of MNCH care from community to facility levels to expand identification and service delivery for vulnerable populations and strengthen the quality of clinical care at facilities.

Our Achievements

• Our tools and processes such as the ASHA diary, nurse mentor case sheets, frontline health workers’ convergence and VHSNC strengthening to improve MNCH were adopted by the Karnataka government and scaled to the state of Uttar Pradesh by the Bill & Melinda Gates Foundation.
• Our Kangaroo Mother Care Model piloted in Koppal district was adopted and scaled to the entire state by the Government of Karnataka in 2018.
• KHPT received the IMPACT award for ‘Deeply impacting communities through innovation in programs’ for MNCH related initiatives in 2017.
• Our women centered empowerment model to improve nutrition levels within disadvantaged households became a national learning initiative in 2016.
• Our work in MNCH resulted in a ten-point reduction in rates of Neonatal Mortality (41 to 30) and Infant Mortality (54 to 44) between 2010 and 2015.
• KHPT conducted a large-scale Mapping at facility and community levels in 25 high priority districts of UP in 2013.
• Our project learnings from Karnataka have been transitioned and scaled to the state of UP, and were being implemented by the University of Manitoba with other partner organizations in 2013

About the project:

KHPT implemented a project of St. Johns Research Institute (SJRI), a home-based study to scientifically evaluate the long-term efficacy (two years) of daily consumption of indigenously developed extruded micronutrient fortified rice in improving iron stores in school going children (6-12 years). The study is funded by the Department of Biotechnology, Government of India.

KHPT aimed to determine the efficacy of micronutrient fortified rice (containing micronized ferric pyrophosphate, vitamin B12 and folic acid) in improving iron stores in school children; in improving the micronutrient status in school children and their mothers; the acceptability of the rice, and the adverse effects, if any, of its long-term consumption.

Geography and duration: KHPT implemented the project in Koppal taluk of Koppal district between September 2019 and October 2022.

Key Activities:

• Baseline screening to identify the children who are iron deficient without anemia
• Randomizing the screened and identified mother-child pair to either receive micronutrient fortified rice or normal rice
• Establishment of rice blender unit to blend fortified rice kernel with natural rice to produce micronutrient fortified rice and storage warehouse
• Provision of rice to identified household on a monthly basis with compliance and adverse events monitoring

About the project:

India has more than 70 million undernourished women of reproductive age. The consequences of pre-conception and maternal undernutrition on fetal growth, birth outcomes, childhood stunting and adulthood chronic diseases has been well established. Dietary habits, anthropometric measurements, and nutrient stores before and during early conception are vital for good pregnancy outcomes.

With a grant from the HCL Foundation, KHPT aims to build an informed and responsive ecosystem within the public health domain to address the pre-conception nutrition needs of Newly Married Women within vulnerable communities in Niti-Aayog designated aspirational districts in Karnataka. KHPT conducted an in-depth situational needs assessment to understand challenges and opportunities and present these findings to state and national-level decision makers through dissemination workshops.

Geography and duration:

KHPT’s qualitative research was conducted in Surpur taluk of Yadgir district and Devadurga taluk of Raichur district  between April 2021 and March 2022

Key activities:

• Identification of facilitators and barriers that exist within families, community, society, which affect demand (coverage and equity) . Within health programs, the identification of systems and policies that affects supply (accessibility and quality).
• A systematic review and exploring barriers and facilitators of preconception nutrition and RMNCH (evidence, interventions and best practices) in partnership with Department of Life & Allied Health Sciences, Ramaiah University.
• Development of a solution framework for inclusion of newly married women in the “inception” of care to healthy motherhood.
• Orientation of public health officials at the state and national level on the proposed guidance and solutions through state and national-level workshops.

Expected Outcome:

This initiative is intended to catalyze national and state thought leaders to develop nutrition solutions which will help newly-married women to attain optimal nutrition status in the pre-conception stage, and help to achieve a reduction in maternal and neonatal mortality (SDG 3) & zero hunger (SDG-2). It will also help build a community-transformative, gender-inclusive and multisectoral convergence model to enhance gender equality in nutrition access (SDG 2 and 5).

About the project:

Deficiency of micronutrients including Vitamins A, D, iron and folic acid in the diet can result in poor cognitive and learning abilities in children, lower productivity and immune responses, and increase morbidity and mortality. Fortification of staple foods such as oil, milk and wheat flour with these micronutrients, is a safe, cost-effective, evidence-based strategy to ensure that everyone, including the most vulnerable, has access to essential micronutrients.

KHPT worked to assist in the catalysing, coordination and implementation of the scale up of large-scale staple food fortification across 18 states in India according to standards set by the Food Safety and Standards Authority of India, and through effective engagement with the government and food industry representatives. The aim of the project, funded by Global Alliance for Improved Nutrition (GAIN) was to create a favourable policy environment to promote food fortification, build the capacity of industries to adopt fortification of edible oil, milk and wheat flour and increase awareness on the benefits of fortified foods among general population in intervention states.

Geography and duration:

The large scale fortification project was implemented between October 2017 and October 2021 in the states of Andhra Pradesh, Karnataka, Maharashtra, Uttar Pradesh, Andaman and Nicobar, Kerala, Meghalaya, Tamil Nadu, Assam, Gujarat, Odisha, Telangana, Bihar, Haryana, Punjab, Tripura, Himachal Pradesh, Madhya Pradesh, and Rajasthan.

Key activities:

• Providing trainings and building capacity on technical processes of fortification for edible oil, milk and wheat flour industries across intervention states.
• Sensitization of officials and technical support to officials from Food Safety Departments including Commissioners, Assistance Commissioners and Food Safety Officers.
• Analysis of fortified edible oil, Milk and wheat flour samples from production plant and open market to ascertain the level of fortificants available in the products.
• Working with social safety net programs like PDS, MDM and ICDS providing food to vulnerable population to adopt fortification.
• Gap assessment of laboratories of various Government departments including Food Safety Department and Food and Civil Supplies Department across 5 states with respect to analysis of fortificants in the fortified staples and prerequisites to obtain NABL certification for fortificant analysis.

Impact:

• Over 1360 officials from Food Safety Department across 11 states including Commissioner’s, Assistant Commissioner’s, DO’s and FSO’s were sensitized on food fortification.
• 7 round table meetings were conducted in the states of Kerala, Bihar, UP, AP, Telangana, Tamil Nadu and Meghalaya with the senior government officials from Food Safety department and social safety net programs.
• More than 400 edible oil industries (small, medium and large scale) are fortifying their oil with Vitamin A and D in 14 states.
• More than 35 milk dairies are fortifying their products with Vitamin A and D in 6 states.
• With the technical support from KHPT, around 80 metric tons of fortified wheat flour is supplied to Akshaypatra Kitchen Lucknow every month, reaching around 97,366 children in 1354 schools.
• Launch of a training course, with support from the KLE Society, Belgaum, on Analytical Methods for Estimation of Micronutrients in Fortified Wheat Flour and Edible Oil for laboratory analysts/professionals under the guidance of Prof. M.M. Godbole, Padma Shri Awardee and renowned endocrinologist in India.
• Conducting a nation- wide survey to better understand the experience of food companies (edible oil mills, milk dairies and roller flour mills), especially the impact of COVID-19 on production and fortification process during the pandemic. The report can be found here (link to be inserted)
• Creating a resource pool of edible oil fortification experts through technical trainings in collaboration with the Food Fortification Resource Centre (FFRC), FSSAI.
• Process documentation of different types of edible oil fortification processes; the report can be accessed here (link to be inserted)

About the project:

It is widely agreed that communities should take an active part in improving their own health outcomes and that frontline health workers can play a vital role in increasing both access to and utilization of maternal healthcare. The ASHA, ANM and AWW work across the primary health care spectrum to provide health education and promotion, distribute commodities, diagnose and manage illness, and provide referrals.

With the support of the Bill & Melinda Gates Foundation, the Bihar Technical Support Program, spearheaded by CARE, focused on supporting the Government of Bihar to improve the performance of frontline workers, specifically to increase the quantity and quality of interactions between the frontline workers and the community to drive critical RMNCH behaviours. KHPT worked with CARE to build the capacity of the ASHAs and ANMs through District Trainers to effectively engage pregnant women, mothers, newborns, their family decision makers and community structures. The model was focused on developing audio-visual online modular training for a team of trainers within CARE, district and block-level health functionaries and  select ASHA Facilitators.

Geography and duration:

The project was implemented from July 2020- March 2021 in 38 districts of Bihar.

Key activities:

KHPT conducted capacity building sessions for the District trainers comprising of Block Coordinators of CARE and Block Community Mobilizers of the Health and Family Welfare department to :

• Deliver effective modular training that covered technical aspects including Family Planning, maternal/neonatal, nutrition, gender and sexuality, as well as communications and soft skills to address inequities, social analysis and resilience.
• To addressing the skill requirement for ASHAs to make effective home visits, use of their data for planning and prioritizing and handhold them during their supportive visits to home and communities.
• To impart effective strategies to ensure ASHAs are able to constructively influence communities to develop their community structures that will periodically address review and support for all pregnant women, mothers and newborns within their communities.

Impact:

• KHPT developed a set of training modules including interactive movie clips to disseminate the training through virtual mode during Covid-19 pandemic. The training process included participatory approaches using Intimate Interactive Movie Capsules (IIMC). A series of interactive movie capsules were using Intimate Interactive Techniques to trigger the participants to actively participate throughout the training.
• KHPT conducted a series of consultations with the Frontline health workers of Bihar state and program officers of CARE to understand the key issues on MNCH. Based on this consultation workshop, team had developed a Behaviour Change Communication matrix. Based on this matrix a series of scripts were developed by involving the script writers and the program implementers. These scripts were converted in to the form of Interactive Movie capsules. These movies were incorporated in to the training modules.
• In view of the SARS-CoV 2 pandemic the package will be disseminated through internet based platforms.
• KHPT trained the 38 District Training Officers of CARE as Master trainers.
• KHPT provided handholding support to the Master Trainers to roll out the district level training for the District Trainers.

About the project: Kangaroo Mother Care (KMC), which is comprised of skin-to-skin contact and exclusive breastfeeding, is proposed as a ‘game-changer’ for improved newborn health among low birth weight newborns. It has also proven to improve bonding between mother and infant, reduce newborn infections, lower stress levels, and many other benefits.

KMC coverage is minimal in India and across the globe due to various barriers at the community, health care workers, and facility level. The World Health Organization awarded funds to St. John’s Research Institute and KHPT for an implementation research initiative for scaling up KMC in Koppal district, Karnataka. The project aimed to develop, implement and evaluate an innovative implementation model designed to attain KMC coverage of 80% among all eligible babies with birth weight <2000gms.

Geography and duration: Koppal was selected since it is a high-priority district of the National Health Mission and because of prior experience of the study teams with MNCH work in Koppal. The project was implemented between 2016-18.

Key activities:

The project had interventions at two levels:

• Facility level, wherein all stable babies weighing under 2000g received KMC as early as possible and families were enabled to continue to provide KMC through a cadre of nurse mentors.
• Post-facility level, families were enabled to continue KMC at home (learn how to support the continuation of KMC during the neonatal period or until the baby no longer accepts it), where ASHAs were trained along with the ASHA facilitators.

Impact

• The Government of Karnataka adopted the learnings and scaled KMC up across the state
• KHPT conducted a state level Training of Trainers for Master trainers
• The Government of Karnataka established of KMC wards in Special Newborn Care Units (SNCUs) across the state.
• Mentoring of SNCU staff by the specialist doctors was included in the state Program Implementation Plan.
• The project showed that KMC initiation was 85% and effective KMC was 60% at the time of  discharge.
• KHPT found that post-discharge, after 7 days at home, 62% were on KMC and 42% were doing effective KMC.

About the project:

In India, while maternal and newborn deaths have been declining over the past two decades, the pace has been slow. In particular, progress among the poorest and most marginalised populations in the country continues to lag, with continued disparities in health outcomes. A combination of complex multi-level factors increase the vulnerability of this segment to poor health outcomes.

The project, funded by the Bill and Melinda Gates Foundation, supported the National Rural Health Mission to improve the functioning of programmes and resources, and was directed primarily at the interactions between health workers and families/ communities at the home, community and first level health facilities (i.e. up to First Referral Units) to provide a focused set of critical interventions during pregnancy, around birth and during the neonatal period.

KHPT partnered with University of Manitoba, Canada, St. John’s Academy of Health Sciences, Karnataka, Karuna Trust, and Intra Health to implement the programme.

Geography and duration:  

The Sukshema project was implemented from 2009 – 2015 in eight priority districts in north Karnataka – Bagalkot, Bellary, Bijapur, Gulbarga, Koppal, Raichur and Yadgir.

Key Activities:

• The development of the ASHA Diary, a simple enumeration and tracking tool to assist ASHAs in population level planning and tracking of beneficiaries across MNCH care continuum
• Development of a home-based maternal and newborn care tool to provide high quality service during home visits, including screening and referral of complications
• Family-focused communication to facilitate behaviour change within the families
• On-site mentoring, using a new cadre of nurse mentors, to improve the quality of institutional deliveries in the primary health centres
• Development of a simplified case sheet and other tools and aids to help providers adhere to clinical standards, assist in screening, manage and refer complications, and provide for monitor quality.
• Creating a skills and drills intervention to improve quality of emergency obstetric and newborn care at the first referral units
• Creating supportive community monitoring tools and processes to strengthen community accountability at the grass-root level

Impact:

• The project resulted in considerable improvement in quality of maternal and newborn care at the facility level.
• Arogya Mantapas, formed at the community level, promoted collaborative action at the sub centre level among all front line health workers, Anganwadi workers, junior health assistants as well as community representatives from the Village Sanitation Health and Nutrition Committees
• The antenatal care check-up rates increased substantially in all project districts
• The proportion of women who stayed for 48 hours after delivery and proportion of women who received all services across continuum gradually improved

Outcomes:

An external evaluation through baseline (2013) and end-line surveys (2016) indicated one of the fastest decline in mortality rates.

• Neonatal mortality rate reduced from 40.8 to 30.4
• Infant mortality rate reduced from 53.5 to 43.5
• Institutional delivery rates moved up from 69% to 78%
• FHR monitoring (on arrival) increased from 39% to 67%
• Maternal BP monitoring (post-delivery) increased from 34% to 64%
• Weighing of the newborn inreased from 33% to 70%
• Clean cord care increased from 30% to 63%

About the project:

KHPT’s intervention research project chose four First Referral Units (FRUs) facilities as intervention and control facilities to evaluate the diagnosis and management of select maternal and newborn complications. The Bill & Melinda Gates Foundation funded the project, and KHPT implemented it with support from IECS, Argentina and the University of Manitoba, Canada.

Geography and duration:

The project was implemented  at two First Referral Units each in Bagalkot and Koppal districtsin northern Karnataka, from 2013-2014.

Key activities:

The intervention focused on strengthening providers’ skills and team work, along with documentation. A formative research study collected information related to the facility infrastructure, human resource and supplies. This was followed by visits by experts to ensure adherence to some basic infection control practices at all study facilities. The intervention was a composite of:

• Skills building through refresher training for medical providers
• Emergency drills to strengthen team and system preparedness in handling select obstetric and newborn emergencies
• Supportive supervision provided by obstetric and paediatric specialists, along with drills improvement of referral networks.

Impact:

• A study, based on a mixed methods approach, evaluated the effectiveness and impact of ‘skills and drills’ intervention on such complications. It showed that the ‘skills and drills’ intervention, a relatively new mode of facility-based intervention was well accepted and appreciated by the providers, especially by the nursing staff of these facilities.
• The delivery record, a new documentation format was highly valued, and used for almost all deliveries in both intervention and control facilities.

About the project:

The NRHM and Karnataka Health System Development Project (KHSDRP) included a Public Health Competitive Fund (PHCF) in their project design, recognizing the need to strengthen the capacities of Village Health Sanitation and Nutrition Committees (VSHNCs) and Arogya Raksha Samitis (ARSs) to achieve their active participation in health activities. This fund was granted to KHPT and Swami Vivekananda Youth Movement (SVYM).

The objectives were to clarify the roles and responsibilities of the members of various committees to enable them to achieve their corresponding monitoring and implementation goals; to strengthen community involvement to better public and individual health by creating awareness on health related issues; to create a sense of ownership of healthcare facilities among the community, making healthcare service staff more accountable, responsible, competent and efficient. The project also aimed to

inform the community about the various healthcare facilities and services they could avail, and empower them to coordinate the convergence of various healthcare facilities provided by various organisations and relevant departments

Geography and duration:

The capacity-building project was implemented in the  districts of Bagalkot and Koppal in Karnataka from April 2010-March 2012.

Key Activities:

• Capacity building of VHSNC/ARS in all villages and PHCs
• Kala Jathas at PHC and taluk levels
• Jana Samwada at PHC and taluk levels
• Handholding exercises

                     Impact:

• Improvement in VHSNC/ARS constitution and functionality
• Successful documentation of VHSNC/ARS meetings and activities
• Effective utilization of untied funds
• Awareness among the community about committees like the VHSNC/ARS