CARE India(Member of CARE International)

CARE’s Work in Bihar, India

Innovating at the frontlines of a resource constrained health system to improve the quality of RMNCH care

2

Context of Bihar and Overview of CARE’s work

114 Million PopulationPopulation Density: 1106/sq.km.

Per Capita Income :Bihar – $360 p.a.India - $983 p.a.

Rural Population Bihar - 89% India - 61%

Innovation Districts (2011)Scale-up Districts (2013)

Ambitious goals to reduce:

• MMR• NMR• IMR• U5MR• Malnutrition• TFR• VL Elimination

INDIA

INDIA

BIHAR

BIHAR

Bihar

Integrated Family Health Initiative led by CARE as a part of broader Ananya

consortium started in 2010 with support from BMGF and scaled up to form a Technical Support Unit in 2013 end.

Saving Newborn

Lives

GoB

Donor Government

Lead Partner

Technical Partners and Sub‐Grantees

Bihar Development Partners

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Overview of CARE’s work in Bihar: Trajectory & Timeline

To test and scale‐up innovative and high impact interventions / solutions

Objective of Integrated Family Health Initiative

INNOVATIONS 

CORE

Solutions implemented (2010‐2013)At scale (in 8 districts) for CORE | as pilot for INNOVATIONS

Robust Outcomes / Results Measurementconcurrent outcome measurement for CORE | rigorous assessments for INNOVATIONS

Scale‐up of Solutions (Nov 2013 onwards)Technical Support Unit – catalytic support to GoB at state and ground‐level

Health System Strengthening for sustainable implementation of solutions (2013…)

Implementation Design (2010‐2011)Included frontline health worker and facility level interventions 

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Technical Support Unit: Theory of Change and Structure

#1 Develop leadership & build management capabilities

#2 Focus on outcomes, promote data use & accountability mechanisms

#4 Build technical and program skills

#3 Overcome health system and policy-level barriers

State RMNCH+A UnitLed by CARE/BMGF to work with the health department at state‐level

Nutrition Strategy Unit To work with child welfare department at the state level

Program Performance SupportGround‐level catalytic support to both departments at district and block‐level

Concurrent Monitoring & LearningTracking progress in outcomes and processes; assess solutions; build evidence

CARE India(Member of CARE International)

Successful Solutions & Interventions 

Description and Evidence

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FLW Interventions: Sub‐center Platform MeetingsReview, Planning & Supportive Supervision

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Scenario: Before 

Unstructured reviews in large groups Cumbersome record management

Scenario: After

Sub‐centre level structured & regular reviews and planning 

Improved, interactive & quality home visits

CORECORE

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IFHI Innovation: Team Based Goals and IncentivesConcept and Results of Randomized Control TrialCONCEPT: Strengthen teamwork and motivation among FLWs by providing non‐monetary incentives to groups of FLWs for reaching pre‐set RMNCH+A targets on multiple indicators.

INNOVATIONSINNOVATIONS

Results of RCT show highly positive change in health outcomes

55 54 37 3918 30

79

14

65 6143 50

2954

86

18

At lest 2 homevisits duringpregnancy **

3 home visitswithin 1 week of

delivery **

Advice onmaternal

danger sign **

Advice onEsclusive

Breastfeeding **

Advice onComplementary

Feeding **

ExclusiveBreast Feeding

**

Received DPT3 *

Use of modernmethod of FP *

Control Mean Adjusted Treatment Mean

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A comprehensive end‐to‐end mHealth solution for digitizing entire job of frontline health workers. 

Results of RCT show highly positive change in health outcomes. 

Continuum of Care Services: an mHealth solutionConcept and Results of Randomized Control Trial

INNOVATIONSINNOVATIONS

4260

29

62 5832

77

3252

7350

76 6541

78

43

2 home visitsduring

pregnancy **

3 home visitswithin 1 week of

delivery **

At lest 3antenatal care

visits **

ImmediateBreast feeding

**

Skin to skincare *

Initiation ofComplementary

Feeding **

Received DPT3

Use of modernmethod of FP **

9

29

6

62

29

Feb-14Nov-11

Per

cent

age

Per

cent

age

Per

cent

age

Interventions with FLWs yielded significant resultsImproved overall outcomes in 8 districts

At least 2 home visits by FLWs during last trimester of pregnancy1

At least 3 home visits by FLWs in the first week after delivery1

5582

1437

Per

cent

age

Advice on emergency preparedness during pregnancy1

Advice on extra care for preterm / LBW babies1

14 24

5939

1129

10 17

Early Initiation of Breastfeeding1

Skin-to-skin care1 Couples counselled for FP within 6-8 months of delivery1

Modern contraceptive use, 6-8 months postpartum1

Increased and timely FLW interaction with community

Mothers able to recall specific communication more often

Mothers adopting new practices Contraceptive counseling and use are inching up

Source:1. Concurrent Household Health and Nutrition Surveys (LQAS)

CORECORE

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Quality Improvement in Public Health FacilitiesCORECORE

BEFOREBEFORE AFTERAFTER

• Overall facility transformation– infrastructure, supply, cleanliness & hygiene • Preparedness for more sophisticated clinical interventions• Facility staff ownership of process & sense of pride improved • Clients now feel welcomed & respected

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• On‐the‐job training for BEmONC services

• Use of mannequins & simulation of clinical scenarios

• Continued supportive supervision & mentoring

• Government support for statewide scale up

Mobile Nurse Mentoring & TrainingCORECORE

12Feb-14Nov-11

Per

cent

age

Sorce: Direct Observation of DeliveryDoD R1 and R2 with MNTT and QI

Impact of Quality Improvement Interventions

97

7578

9

Oxytocin correctly administered for AMTSL2

Fundal pressure not applied2

9179

2314

8271

Per

cent

age

Attendant washed hands2

Correct steps followedin hand washing2

% deliveries where attendant wore gloves2

Basic antisepsis practices are going up in facilities

Clinical practices improved in facilities

54

33

11

10083

59

Per

cent

age

% deliveries where ambubag was available

% deliveries where delivery tray was available

% deliveries where episiotomy tray was avl.

Availability of supplies and equipment improved

23

5644

74

Per

cent

age

Immediate STSC after birth

EIBF in labour room within 1 hour of delivery

Improvement in New-born care practices at facilities

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Other interventions…

HR Rationalization  GoB Dashboard 

Mobile IUCD Van

Supply Chain Management 

Mapping  & enumeration

And Many More…

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Thank You