Building on the gains of the National Health Mission, India’s Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Strategy, launched in 2013, was a milestone in the country’s health planning. The strategy recognised the interdependence of RMNCH+A Interventions across the life stages and adopted a comprehensive approach to address inequitable distribution of healthcare services for the vulnerable population groups and in poor-performing geographies of the country. Based on innovative approaches and management reforms, like selection of poor-performing districts, prioritisation of high-impact RMNCH+A healthcare interventions, engagement of development partners and institutionalising a concurrent monitoring system the strategy strived to improve efficiency and effectiveness within the public healthcare delivery system of the country. 184 High Priority Districts were identified across the country on a defined set of indicators for implementation of critical RMNCH+A Interventions and a dedicated institutional framework comprising National and State RMNCH+A Units and District Level Monitors supported by the development partners was established to provide technical support to the state and district health departments. Health facilities based on case load and available services across the High Priority Districts were prioritised for strengthening and were monitored by an RMNCH+A Supportive Supervision mechanism to track progress and generate evidence to facilitate actions for strengthening ongoing interventions. The strategy helped develop an integrated systems-based approach to address public health challenges through a comprehensive framework, defined priorities and robust partnerships with the partner agencies. However, lack of a robust monitoring and evaluation framework and sub-optimal focus on social determinants of health possibly limited its overall impact and ability to sustain improvements. Guided by the learnings and limitations, the Government of India has now designed the ‘Aspirational Districts Program’ to holistically address health challenges in poor-performing districts within the overall sociocultural domain to ensure inclusive and sustained improvements.

BackgroundIndia’s Mother and Child Tracking System (MCTS)1 is an information system for tracking maternal and child health beneficiaries in India’s public health system, and improving service delivery planning and outcomes. This ambitious project was launched in 2009 and currently covers all states in India, but no in-depth assessment of the system has been conducted. This study by the Public Health Foundation of India (PHFI) evaluated the performance of MCTS and identified implementation challenges in areas in Rajasthan and Uttar Pradesh (UP) in December 2012.MethodsTwo assessment methods were employed: a Data Quality Assessment (DQA) to evaluate data quality and an assessment survey to identify implementation challenges. The survey comprised semi-structured questionnaires for health staff in the sampled districts, observation checklists and survey investigator notes. Purposive sampling was used for selecting two districts in each state and two blocks in each district. For the DQA, 45 mothers who became pregnant and 84 children born within the stipulated timeframes were randomly sampled.ResultsDQA overall performance numbers were 34 % for pregnant women and 33 % for children in the Rajasthan study areas, while UP’s performance numbers were 18 % for pregnant women and 25 % for children. Weaknesses in the MCTS' data completeness accounted for much of this performance shortfall. The beneficiary profiles for Rajasthan were largely incomplete, and the MCTS in UP struggled to register beneficiaries. Shared challenges in both states were the absence of clear processes and guidelines governing data processes, and the lack of systematic monitoring and supervision frameworks for MCTS implementation. As a result, Front Line Health Workers (FHWs) were overburdened with data documentation work, and there were long delays in data capturing. FHWs and block level health officials were not adequately trained in using the MCTS. UP staff reported unreliable internet and electricity availability, lack of dedicated data entry personnel, and a shortage of consumables such as MCTS registers.ConclusionsThere is an urgent need to create data processes and supervision guidelines that complement existing workflows and service delivery priorities. Health staff should be trained to implement these guidelines. MCTS outputs, such as service delivery planning tools, should replace existing tools once data quality improves.

Adopting an integrated implementation framework that combined training, mentoring, and quality improvement processes to improve the quality, equity, and dignity of care during the intrapartum and immediate postpartum periods, the Care Around Birth approach addressed key drivers of maternal and newborn mortality. nThe approach refocused energy on facility-based quality processes that are currently central to efforts in reducing mortality and achieving Sustainable Development Goal targets.

Information on population health indicators in India come from a number of surveys that vary in periodicity, scope and detail. In the case of immunization, the most recent coverage indicators are derived from the first round of Annual Health Survey (AHS-1, 2010-11), but these were conducted only in 9 of 35 states and union territories. The most recent national surveys of immunization coverage were conducted in 2009 (Coverage Evaluation Survey) by UNICEF. Therefore, reliable immunization coverage data for the entire country since 2009 is lacking. We used an established approach of small area estimation to predict coverage rates of several vaccinations for the remaining 26 states (not covered by AHS-1) in 2011. In our method, we considered a linear mixed model that combines data from five cross sectional surveys representing five different time points. Our model encompasses sampling error of the survey estimates, area specific random effects, autocorrelated area by time random effects and hence, borrows strength across areas and time points both. Model-based estimates for 2011 are almost identical to the AHS-1 estimates for the nine states, suggesting that our model provides reliable prediction of vaccination coverage as AHS-1 estimates are highly precise because of their large sample size. Results indicate that coverage inequality between rural and urban areas has been reduced significantly for most states in India. The National Rural Health Mission has had both supply side and demand side effects on the immunization programme in rural India. In combination, these effects may have contributed to the reduction of vaccination coverage gaps between urban and rural areas.

BackgroundPostpartum Hemorrhage remains the leading cause of maternal mortality. To prevent PPH, Misoprostol tablet in a dose of 600 micrograms is recommended for use immediately after childbirth in home deliveries wherein the use of oxytocin is difficult. The current article describes an implementation of “community based advance distribution of Misoprostol program” in India which aimed to design an operational framework for implementing this program.MethodsThe intervention was carried out in Janjheli block in Mandi district of the state of Himachal Pradesh which is a mountainous terrain with limited geographical access and reported 90% home deliveries in the year 2014–15. An operational framework to implement program activities was designed which was based on WHO HSS building blocks. Key implementing steps included- Ensuring local ownership through program leadership, forecasting and procurement of 600 mcg misoprostol tablets, training, branding and communication, community engagement and counselling, recording and reporting, monitoring, supportive supervision and feedback mechanisms.ResultsOver the one year of implementation, 512 home deliveries were reported, out of which 89% received the tablets and 84% consumed the tablet within one minute of delivery. No incidence of PPH in tablet consuming mothers was reported. On account of periodic counselling and effective community engagement the intervention also contributed to better tracking of pregnancies till delivery and institutional delivery rates which increased to 93% from 45% and 57% from 11% respectively as compared to the preceding year.ConclusionsThe model has successfully shown the use of single misoprostol tablets of 600 mcg, first time in this program. We also demonstrated a HSS based operational framework, based on which the program is being scaled to additional blocks in Himachal Pradesh as well as to other states of India.Electronic supplementary materialThe online version of this article (10.1186/s12884-018-2036-2) contains supplementary material, which is available to authorized users.