India has embarked on an ambitious strategy that integrates reproductive, maternal, newborn, child and adolescent health (RMNCH+A) to address the major causes of mortality among women and children. A leader in implementing the RMNCH+A strategy is Ms. Anuradha Gupta, Additional Secretary and Mission Director, National Rural Health Missions. Recently, Jhpiego’s India Country Director, Dr. Bulbul Sood, sat down with Ms. Gupta to talk about the new strategy, the importance of empowering nurses and the role development partners can play in implementing RMNCH+A.
On the Government of India’s (GoI’s) RMNCH+A strategy
Q: At the London Summit, you made a commitment to launch the RMNCH+A strategy and within a short period of time, it has been released. Please tell us your vision behind this RMNCH+A strategy?
A: As you are aware, the Reproductive and Child Health (RCH) 1 and 2 programs were designed to address the challenge of reproductive, maternal and child health comprehensively. But our experience has been that the three components of maternal, child and reproductive health have actually been quite vertically operated. For instance, reproductive health—which primarily addresses family planning—was being promoted more as a population stabilization strategy and less as a strategy to improve maternal and child health outcomes. Thus, it was implemented as a stand-alone, isolated program without articulating the critical inter-linkages with our interventions in maternal and child health. Similarly, maternal health and child health also operated in silos. While we have made good progress on other fronts, our own experience, as well as the data, told us that reducing under-5 mortality and neonatal mortality remained our Achilles heel. Clearly, there was a crying need to articulate a very strong commitment on newborn health and bring it under much sharper focus.
Secondly, apart from traditional RCH areas, one of the key pillars of this RMNCH+A strategy is the “Adolescents” because until now adolescent health was literally on the backburner and the weakest pillar of our RCH program. To me, this is the most important component of our strategy because in India, like many other countries, the majority of health issues are anchored in poor determinants of health. For instance: early age of marriage, where we see 47 percent of girls (NFHS data) getting married before 18 years of age; early childbearing; lack of access to contraception; and lack of spacing.
I very strongly feel, and there is a substantial body of evidence on this, that unless you start to work with adolescents in a big way, you cannot address those very fundamental and critical issues which impact maternal and child health outcomes. So now we have the RMNCH+A, which primarily denotes two things. First, it is an integrated approach that we need to pursue because of inter-linkages between different life stages and the causal relationships that each stage has with another. We appreciate those inter-linkages and have included high-impact interventions at each stage as a part of a bigger whole. Second, it uses a continuum of care approach under which you look at the household level, the community level, the facility level and the referral linkages between them. This is an extremely critical approach for us, and we have distilled this into the integrated RMNCH+A strategy to help us bend the curve on maternal and child mortality and achieve our goals on maternal and child health.
On challenges in adolescent health and the GoI’s strategy to address adolescent health
Q: What challenges do you foresee, especially in working with the adolescents in this country?
A: We have 243 million adolescents in this country—this could well be a population of a country on its own. Approximately 48 percent of these are girls, and yet we continue to struggle with gender gaps in terms of female access to education, empowerment, agency and autonomy. Girls do not get educated beyond or even up to elementary level; they do not have any control over decisions pertaining to marriage and, therefore, get married early. Parents and families decide their destiny, and after marriage, the husbands take over. These girls are unable to make independent decisions about their own reproductive choices or fertility. Thus we have huge challenges in the sheer number of adolescents and the negative mindsets regarding adolescent issues. We have a huge battle ahead to change societal attitudes and norms towards adolescents, particularly girls, and make sure that age at marriage becomes higher.
In India, a very peculiar challenge is that 70 percent of our adolescents are in rural areas, scattered in more than 600,000 villages in remote areas across the country. Clearly, a program offering facility-based services is not enough. Our earlier strategy for adolescent health was confined to setting up Adolescent Reproductive and Sexual Health (ARSH) clinics. But uptake of these clinics has been extremely limited; what was needed was a community-based approach reaching out to adolescents in their own spaces. As we all know, adolescence is considered a healthy period; nonetheless, more than 33 percent of the disease burden and almost 60 percent of premature deaths among adults can be associated with behaviors or conditions that began or occurred during adolescence. Thus, we need a huge and very comprehensive bouquet of services so that their attitudes change, they become more aware of issues, and they are better equipped to deal with the physiological, psychological and emotional changes that confront them as they enter adulthood.
Programmatically speaking, what would work in this scenario at the community level is a cadre of well-trained and rationally deployed counselors, but for we are woefully short on counselors since we haven’t really developed a systematic cadre of counselor in India. To me, a very important way forward is to determine how to develop peer educators who are then able to reach out to their own peers, to engage with this huge number of adolescents, and then try and make sure that there are positive changes in attitudes, and that there is appropriate information available to them to equip them to have much better control over their own decisions.
Q: You just mentioned ARSH clinics and how they have not done so well. Is there any strategy right now that the government of India is looking at in working with the adolescents?
A: We have put together a very comprehensive adolescent health strategy which is underpinned by this large army of counselors and peer educators. Accredited Social Health Activists (ASHAs), I feel, are not equipped to be peer educators because a lot of them are not adolescents themselves. They are more focused on reproductive and child health, and simply do not have that orientation or time to engage with adolescents in the way we want. For peer educators, our approach is to look at organized networks of the youth which already exist, like Nehru Yuva Kendra (NYK). As a strategy, I feel those adolescent boys and girls who are in senior classes in the village school can actually be trained to become peer educators. They live in the same community, all the others with whom they need to engage are there, and their own understanding of adolescent issues is so much more experiential. Equipped with certain training and tools, I think they can do a remarkable job.
We also want teachers to be very proactively associated with this whole process of identifying peer educators. We would work in tandem with the Ministry of Youth Affairs and Sports, which has piloted these NYKs and Youth Clubs, in order to ensure that we are off the ground as soon as possible.
On the GoI’s policy shift from focusing on limiting births to spacing births
Q: Would you like to shed some light on the shift in the government’s strategy from limiting to spacing births?
A: We have a very old family planning program. The national family planning program was launched in 1951, and was the world’s first governmental population stabilization program. But it has been completely sterilization-centric. Spacing has been a very important and a huge directional change that we have brought in India.
Data for me is the touchstone; numbers never lie. While analyzing a data set, it showed that 52 percent of our fertility is clustered in the age group of 15–24, and 45 percent of maternal deaths also occur in the same age group. This clearly told us that women are dying because they are getting married at an early age, they are not able to space births, and some of them are bearing a child on a yearly basis—their bodies are not ready for it. It is here that spacing becomes a paradigm shift. We are not looking at family planning just as a population stabilization mechanism but more as a health issue; as a very critical and key intervention to improve maternal and child health. I am very confident that this profound policy and program change will bring about some very remarkable results.
On strengthening and empowering the nursing cadre in India and task shifting from doctors to nurses as well as career progression of nurses
Q: You have been an advocate of strengthening the nursing cadre in the country. Can you share your vision for empowering the nursing profession in this country?
A: When I sat down and tried to analyze the reasons for India not being able to make accelerated progress on some of our key goals, one of the things that I personally felt that came out very strongly was that in India we have historically relied too much on doctors to provide both primary health care and services for mothers and children. Nurses, like our Auxiliary Nurse Midwives (ANMs) and staff nurses, are really not empowered enough, even though they are the service providers actually doing a lot of maternal and child health-related work on the ground. The skill sets that our ANMs and General Nurse Midwives (GNMs) possess leave a lot to be desired; there is room and scope for improving and upgrading these valuable hands. Also, there are many things they can be empowered to do, but the policies to enable them were not in place. A lot of task shifting that could be done, was not being done. Doctors had the powers to administer medicines but this did not apply to ANMs and the GNMs. In addition to strengthening pre-service education (PSE), we need to improve the quality of PSE. One of our huge challenges is to make sure that we have continuing education for our ANMs and GNMs so that their skills are first rate. We also need to ensure they have career opportunities and progression.
Not allowing our nurses to specialize was a huge systemic flaw. Almost every state has a policy under which nurses are routinely rotated, and they did not have opportunities to specialize. The net result of this was that nurses in the labor rooms did not have the required skill sets to do things from A to Z. In newborn care units, which we have set up in large numbers, we’re struggling with the quality of nurses. Another systemic issue was that in most states we did not have directorates of nursing. Therefore, we had huge numbers of nurses, but no structures and systems to ensure that their interests are looked after or really receive priority.
My own vision is that we can do a lot of task shifting. We don’t have enough doctors and specialist to go everywhere and we don’t need them to do so. It’s not so much about shortage of doctors and nurses, but I think it’s really a question of not saddling them with the kind of work which can easily be performed by our nurses and probably be performed better by the nurses because they have a different kind of skill set. That is the vision that has driven our whole agenda on strengthening of nursing in India.
It is a multi-pronged approach and we are trying to make a frontal attack on all those areas I have just listed: focusing attention on PSE; strengthening the nursing cadres in India; giving them much better career opportunities, career progression and new career paths; sprucing up their curricula; making sure that our PSE institutions’ faculty is trained; and, of course, providing in-service training. And also, giving them hands-on training and competency-based certification to ensure that there is quality of nursing education.
Very importantly, we have taken some significant policy decisions, like authorizing our ANMs to give gentamicin injections. This is something that was not being done in India for so many years and is a huge step forward in empowering nurses. We did this because we knew that our children die of sepsis and acute respiratory infection AND that this can be prevented by this simple empowerment process.
Keeping in mind that we have a very large percentage of preterm births, we also empowered our nurses to administer antenatal corticosteroids for preterm labor. After all, it is these nurses who are actually in the labor room, interfacing with pregnant women. We have taken many steps for empowering nurses with the National Nodal Centers for Nursing, and the State Nodal Centers. We have set up skills labs and are making a baseline assessment of their skills to identify gaps so we can develop a training course to close that gap (be it among the faculty or the nursing cadre), and generally are making sure that there is much greater attention to their issues and that they are prioritized by the state governments.
Q: I know that when the postpartum IUCD (PPIUCD) program was started in the country, it was focused only on doctors inserting PPIUCDs and you decided that we should task shift to allow nurses to also insert PPIUCDs. We are seeing that in places where nurses are trained, the uptake has really shot up and they are taking a lot of interest in providing IUCD to women in the postpartum period.
A: This is a paradigm shift. At the national level, there has been a lot of resistance. It wasn’t easy to do it. I reduced the number of doctors to be trained in PPIUCD—after all, there is only a certain capacity that we have of training numbers. My firm belief is—and I have gone to hospitals and seen it—that even if you train a doctor for PPIUCD, which has to be given immediately after delivery, the doctor is not there. Only the nurse is there—the nurses who are in the labor room. And we now have instructions in place and I reiterate them at every given opportunity—don’t rotate your nurses. The nurses who are in the labor rooms and specialize in labor room procedures must also be trained in PPIUCD, so then and there they can provide IUCD services.
Similarly, we have 150,000 sub-centers across the country and about 200,000 ANMs who can insert IUCDs. So then why should an IUCD be inserted by a doctor? Our vision is to train each of these 200,000 ANMs so that they can begin to offer interval IUCD services at the sub-centers. So that in the high case load facilities, staff nurses insert PPIUCDs, but at the 150,000 sub-centers the 200,000 ANMs provide interval IUCD services. These are just some illustrations of work that can be done by nurses and we are progressing very fast on this.
On maintaining quality of service delivery
Q: This brings me to another question. Are there any specific steps that the government is taking to ensure that there is no dilution of quality?
A: One thing that I want to say is that quality is not synonymous with doctors. Quality can never be the prerogative or monopoly of a single cadre of service providers. Quality is something which has to be observed by each and every cadre. It is not a onetime act, it’s a habit. Even doctors can be shoddy. So that is something I really want to say at the outset. But, as I said, it is important when nurses are empowered to render certain services, that they should also be trained optimally. The skill sets are very important. Therefore, focus is needed on pre-service and in-service training, their quality, skills labs, training of trainers, faculty development and, most importantly, the process of competency-based certification, which is based on certain core competency requirements. The nurses are certified based on these core competencies, and baseline and periodic assessments are conducted of the skills that have been introduced.
Apart from that, the nurses also need an enabling environment to provide high-quality services. We have made huge investments under the National Rural Health Mission to make sure that all high case load facilities—where you have the maximum footfalls, with women and children coming in large numbers—have quality infrastructure.
If your sub-center or Primary Health Center is dilapidated and lacks basic amenities, then even a highly skilled nurse-midwife won’t be able to provide quality services. We have identified 16,000 facilities as delivery points. These have been prioritized for strengthening to assure quality. At the same time we are prioritizing training the nurses for these delivery points.
On the nurse-midwifery practitioner course
Q: The Indian Nursing Council (INC) had started nurse-midwifery practitioner courses in a couple of states. The plan was that at additional Primary Health Centers or other places where doctors are not available, these nurse practitioners would be there to conduct deliveries and also perform functions of basic emergency obstetric care. What’s happening with this?
A: As a part of the roadmap for strengthening of nurses, we have said that nurse practitioners have to be encouraged and positions have to be created. We are now supporting the states under the National Rural Health Mission to create positions of nurse practitioners. We have even introduced an incentive. If states are actually able to strengthen nurses and promote nurse practitioners, then they receive additional allocations over and above what they are entitled to under the National Rural Health Mission. I am certain that with this increased attention on the nursing cadre—their strengthening and empowerment—we will be able to see a lot of progress very soon.
On the role of the private sector in GoI’s RMNCH+A strategy
Q: What role do you see the private providers playing in the RMNCH+A strategy?
A: There are many areas in which the private sector can add a lot of value, either by filling a critical gap or supplementing efforts of the government. Even when we talk of having more nurses, for instance, the private sector can add a lot of value. In some states, there are a large number of private nursing institutions and medical colleges. But my one caveat there is that they have to focus on quality—it is non-negotiable. A lot of these institutions, which we have seen, have very strong mercenary tendencies; nonetheless, there is a huge potential for the private sector to add value by setting up high-quality institutions that produce health workers for India.
On technical strategies, there are several areas where the private sector can step forward and fill gaps—for instance, family planning and safe abortion services. The provision of these services in the public health sector is not enough to meet the demand, so the private sector can add lots of value by providing family planning and safe abortion services. In urban areas, the presence of the private sector is overwhelming, and there is scope for the state government to start enlisting the support of the private sector and think of various strategies for contracting, accrediting or empaneling them. That is something that has just started and our framework actively supports and encourages that.
On the role of development partners in executing the GoI’s RMNCH+A strategy
Q: What role do you see of development partners and organizations like Jhpiego in the RMNCH+A strategy?
A: What is extremely important is technical support. The global expertise, experience and learning that the development partners bring to the table are extremely important to us. Every state has certain pockets, certain districts, certain blocks and certain populations where you still have very huge challenges of maternal mortality, child mortality and morbidity. We have asked the development partners to harmonize their technical assistance, work with the state governments to improve outcomes in these 184 high priority districts, and make sure that the entire set of essential interventions under RMNCH+A is actually implemented in a seamless manner. Because if you can demonstrate that it can be implemented with great success in these districts, then you can do so anywhere. We are very glad that development partners have aligned their approaches to our approach and are on board with us. They are now working with the state governments as a consortium led by a partner and we have assigned different states to different partners so that together we can get move forward with this shared vision of RMNCH+A and make sure that it is implemented in earnest. I am certain this will give us some wonderful results.