| 4. In which ways is the initiative creative and innovative?
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Basing on the premise that family is the prime in a child’s life and that a parent is the one most concerned about wellbeing of their sick neonate FCC concept is innovative in the following ways:
1. Empowering and involving parent/family (who hitherto forth was only a passive receiver of care in silo) as an active partner in health care delivery for their own hospitalised sick baby.
2. Family-cantered care reflects a shift in traditional focus from only the medical aspects of care of a sick neonate to a wholesome care where a sick newborns developmental needs as well as families’ psychosocial needs too are addressed by their being actively involved.
3. All skill building initiatives in health care systems focus on health care providers.
In family centred care we focus on building capacity of the accompanying parent/family through an operational, culturally sensitive, indigenously developed Audio Visual Training tool’
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Dr. Ram Manohar Lohia Hospital, New Delhi where the concept of “Family Centred Care for sick newborn” FCC was innovated, researched and originally practiced FCC. Now, the institute has been recognized as a National Technical Resource Centre for Family Centred Care of Sick Newborn.
With approval and recommendation of GOI MOHFW, Norway India Partnership Initiative (NIPI) undertook the pilot implementation in 5 districts of 4 states namely {Alwar (Rajasthan), Hoshangabad and Raisen (MadhyaPradesh), Jharsuguda (Odisha), Nalanda (Bihar)}.
An MOU was signed between RML and NIPI with UNDP as implementation partner for this pilot in May 2015. A National Training of Trainers was conducted in August 2015 at Dr R.M.L Hospital to train national trainer pool from these representative districts. Until March 2016, 2,209 mothers/ parents had received FCC sessions in these four state districts. (http://www.nipi.org.in/wp-content/uploads/2016/08/39.pdf)
Thereafter following the success of FCC in these state districts the states of Rajasthan, and Madhya Pradesh and later Odisha upscaled the program to all their state districts (33 and 52 , 30 or so respectively) by early 2016.
Currently the population of these 115 districts and 118 SNCUs is covered under FCC implementation. Recently Government of Andhra Pradesh has expressed keenness to roll out the programme to across its 13 districts. NIPI is supporting the implementation of FCC with IPE Global as implementation partner in their districts and RML hospital continues to be the technical resource centre.
At RML Hospital till date 255 mothers/Parent- attendant and their babies have directly benefitted from the implementation of FCC.
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| 6. How was the strategy implemented and what resources were mobilized?
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1. Since 2015, Dr. R.M.L. Hospital is recognised as a technical resource Centre for “Family Centred Care for sick newborn” (FCC). Through iterative process of implementation research an implementation framework to move this concept into practice and scale up as a replicable model for programmatic implementation in consultation with MOHFW, GOI has been developed.
Necessary training and resource materials have also been developed namely:
o Audio-visual parent training tool
Session 1- Nursery Entry Protocol- https://youtu.be/S2_nvcDSkIY
Session 2- Developmental supportive care- https://youtu.be/ALoGXC6-RQk
Session 3- Kangaroo mother care- https://youtu.be/kKjNbYJ-R9w
Session 4- Care after discharge at home - https://youtu.be/Hbd14bq1iy8
o Training Guide - http://www.nipi.org.in/wp-content/uploads/2016/08/20.pdf
o Operational Guidelines- http://www.nipi.org.in/wp-content/uploads/2016/08/21.pdf
o IEC material on FCC
2. RML Hospital is conducting implementation research to fine tune the implementation framework for the strategy as well as undertaking quality improvement initiatives within ambit of FCC.
Broadly the strategy of implementation involves moving from a predominantly provider centric to a shared model of newborn care, where parents and providers work together to ensure the well-being and survival of the most vulnerable newborns. It builds upon the Kangaroo Mother Care (KMC) and optimal feeding for low birth weight babies which were already existing. The strategy is designed to align with India Newborn Action Plan 2014.
A strategic plan for Scaling up of Family Centered Care in Public Health System is outlined below:
o Sensitization of State and District Managers
o Facility mapping: Identifying sites where FCC can be initiated
o Training of Trainers
o Institutional support for FCC
o Human resources for FCC
o Monitoring and Evaluation
o Linking FCC with community based care
o Budgets for operationalizing FCC
A. FCC was recognized by MOHFW as one of the top 5 Innovative best healthcare practices at the 3rd national summit in August 2016, MOHFW and thereafter GOI have approved the programmatic scale up across all the states. Since health is a state subject and there is approval from MOHFW, GOI and State NHMs are on board for programmatic implementation.
B. A consortium has been formed of Dr. R.M.L. Hospital along with INCLEN and NIPI as implementation partners with approval of MOHFW and GOI.
C. State Health Governments (Madhya Pradesh, Odissa, Rajasthan) have implemented FCC in all their districts. Bihar and Andhra Pradesh are in process of scale up of this intervention across their district-SNCU’s.The budget for FCC is earmarked out of state NHM budget in the respective year’s annual PIP.
USAID-ASSIST is partnering with Dr. R.M.L Hospital in working on Continuous Quality Improvement within framework of FCC.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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Multisectoral collaborations have been integral to the genesis and implementation of the concept of Family Centred Care for Newborn care. Involvement of different stakeholders during stages of development of various activities have been as follows:
1) The concept of Family Centred Care itself rests on the foundation of a collaborative partnership between the conventional care provider (nurse\ doctor) and the family for care of a sick newborn.
2) Development of training package: A simplified comprehensive audio-visual training tool was prepared with multidisciplinary technical input from a neonatologist, community medicine specialist, psychologist, nurse, and hindi-language expert.
This enabled creation of an operational, culturally sensitive comprehensive audio visual training tool, unique of its kind for skill building of parent/families.
a) Translation to public health (with Dr. R.M.L. Hospital as the technical resource centre) started in December 2014 after GOI approved pilot implementation of FCC in 5 districts of 4 states with the help of UNDP-NIPI newborn project for a well-coordinated effort and to help with the adaptation process in district and sub-district settings.
b) To facilitate the pilot, an MOU was signed early in 2015 with NIPI for the last two years. Currently as RML-NIPI Newborn project.
c) After inclusion in Innovative best healthcare practices at the 3rd national summit in August 2016, MOHFW and GOI have approved the programmatic scale up of FCC across all the states.
d) A consortium has been formed of Dr. R.M.L. Hospital along with INCLEN and NIPI as implementation partners with approval of MOHFW and GOI.
e) State Health Governments (Madhya Pradesh, Andhra Pradesh, Odhisa, Bihar, Rajasthan) have / are in process of scale up of this intervention across all district-SNCU’s.
3) USAID-ASSIST is partnering with Dr R.M.L Hospital in working on Continuous Quality Improvement within framework of FCC.
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| 8. What were the most successful outputs and why was the initiative effective?
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Evidence from a randomised control trial, experience from our site and from pilot implementation in district SNCUs have demonstrated:
A. Feasibility
a. Piloting in 4 states (with NIPI’s support) since 2015 and our own (2010) has demonstrated operational feasibility and a demand for scale up in all districts of the states.
b. Intervention was feasible across demographic, literacy, socio-economic and cultural profiles of parent attendant characteristics. Eg. About 65%-90% - fathers/ mothers & 8-20 % - grandparents; 20-60 % - illiterate, 25% -primary & 34 %- middle pass were engaged.
B. Tangible Benefits have been regarding documenting improvements in processes of care and neonatal outcomes.
As per the randomized control study
a. Improved breast feeding rates before discharge. (80.4 % as compared to 66.7 % in control group (p= 0.007)
b. Shorter duration of hospitalisation.
c. No increased infection rates (Incidence of nosocomial episodes of sepsis was not different between groups [incidence rate difference 1.12, 95 % CI = -5.6 to 8.2, p = 0.71]).
d. No increase in adverse event rate with this intervention between the 2 groups i.e. it is safe.
e. The mortality was 8.8% in control (non FCC) as compared to 6.8% in study (FCC) group (p=0.5).
As per implementation at our center we documented:
f. Improvements in systems (staff sensitization and parent training sessions) at local site of implementation. (June 2016-February 2017)
i. More than 90% of unit staff have been trained and sensitized.
ii. Over 240 induction sessions & 81% daily training sessions were conducted for family members.
iii. Over 255 family members have been trained for essential skills : 69.80% -mothers, 21.56%- fathers and 8.62%- grandparents.
g. Improvements in processes of care (June 2016-February 2017)
i. 240 neonates admitted have been benefitted.
ii. 255 family members were involved in various care processes- nesting, positioning & cleaning their sick babies for more than 3/4th of their babies’ hospital stay.
iii. 58.35% newborns received critical to life all breast milk
iv. All the eligible babies (n=77) received thermoregulation through Kangaroo mother care.
Pilot Implementation results of FCC established in five SNCUs:
h. 2,209 mothers/parents received FCC sessions (Sept 2015-March 2016)
i. Initial assessment showed improved breastfeeding and KMC rates.
C. As per an externally evaluated qualitative study
a. Continued care giving practices post discharge at home by parents.
b. Acceptability of the intervention was documented among providers and receivers (family).
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| 9. What were the main obstacles encountered and how were they overcome?
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• “Family Centred Care (FCC) for sick newborn” as a strategy is seemingly simple and appealing with numerous advantages for all stakeholders involved i.e. the baby, family and the nurse –doctors. FCC is truly much more than just training the parent attendant with certain skills in newborn care through use of an audio-video tool.
• There is a huge component of softer skills to be acquired on part of the conventional health care provider i.e. nurse and doctor, requiring a mindset change in the approach to Newborn care becoming Family Centred, being more permissive to allow responsibility sharing with parent attendants and still providing constant oversight and be accountable for care.
• Challenges during implementation have been to get the health care personnel to accept parent-attendant as a co-partner in care delivery.
• Among them there was a feeling of diminished authority and uneasiness because of being constantly watched.
• Institutionalizing pro-family centric structure/facilities
• Providing consistent supportive supervision imparting care giving competencies were limiting at times.
• Tendency for task shifting to mothers beyond the prescribed scope of activities!!
• They are expected to deliver a standard of care that an empowered parent now is aware of and expects from them!!!
• Hence getting on board health care provider is the most important. This was achieved in the following ways:
• A module for health care provider has been incorporated in the operational guide stating what he should and what he shouldn’t do;
o There is a need of initial and then repeated periodic sensitisation and training of entire heath care team including nurses, doctors and other staff whenever there is a change in staff.
o Monitoring must include parameters to assess nurses’ performance of tasks as well as adverse events and hospital acquired infections must be recorded.
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