operational guidelines - undp in india

An enabling intervention for quality maternal and newborn care at the facility level

Operational Guidelines

YASHODA/MAMTAfor

Yashoda Operational Guidelines

2010

Contents

Foreword 1

Yashoda 2

1. Summary 3

2. Rationale and Evidence 7

3. Role of Yashoda 10

4. Scaling up of Yashoda Intervention 14

5. Yashoda Implementation Process 17

5. Capacity Building 29

6. Supervision 35

7. Monitoring 41

8. Institutional Mechanism 44

Annexures 45

DearColleagues

IcongratulateallthecolleaguesfromthefourstatesforimplementingYashodaintervention.Whilestaringtheprocesswasagreatchallenge,itisnowevolvingasacomprehensivematernalandnewborncareinterventionwithinthelargerhospitalprocess.We,inthelast18monthshavelearntagreatdealaboutthepotentialoftheintervention.

InthisperiodYashodashaveassistedapproximatelyover400,000mothersandnewborninthefourstates,enablingYashodastogainexperienceandNIPItolearnandstreamlinesome of the processes. Of the planned 1584 Yashodas to serve in about 100 Districthospitalsand40selectedCHCfromthefourstates,about1200areinplace.60%ofthesehavereceived2or3dayorientationandonedayrefreshertrainingandtherestareinprogress.

TheoperationalguidelineisasynthesisofthelearninginestablishingYashodainterventionintheinitialphaseandregularfeedbackfromthestates.TheNIPISecretariathastakenthelibertytoputtheprocessestogethertofacilitatetheexpansionoftheinterventions.SinceallthefourstatesareinascalingupmodeIhopetheseguidelineswillhelpthemgetasystematicoverviewofthestepsinestablishingtheinterventions.Theseguidelinesareaimedatprovidingaframeworkandarenotprescriptive.Thisisworkinprogressandaprocessforlearningtogether.

TheStatesasalwayswillbedrivingtheprocessandwilldecideifcertainmodificationsarerequiredtobringvalueadditionthatmeetthestatespecificneed.ThisworkwillbetranslatedinHindiandOriyatomakeituserfriendly.

WealsosuggestthatthestateshouldconsidertheYashodaprocesstobeinstitutionalisedatthestatelevelbymakingitpartofthestateASHAcoordinationcell.

Welookforwardtogettingfeedbackontheseguidelines,fromthefieldstaffaswellasfromthemanagers,asitisajointlearningprocess.

IwishyousuccessintakingthisinterventionforwardandbringingvalueadditiontoJSYandMGD4inaconcretemanner.

PrasannaKumarHota

Director Emeritus, NIPI-UNOPS

Foreword

OperationalGuidelinesforYashoda/Mamta2

IampartofYashodaprocess,andanewmemberofthematernitywardteam.Ihaveseveralresponsibilities:

Iwelcomethepregnantwomanheartilyandmakesurethatsherelaxes,andreassurethatsheisinasafeplaceandamongpeople,whocareforher.

IhelphertogetregisteredasJSYbeneficiary.

IgetinformationonherstatusfromaccompanyingASHA/familymember/ANCcardandinformthenurseifsheneedsextracare.

Iprovidemoralsupporttoherinthelabourroom.

Iobservethenurseandlearntoweighthenewborn,wrapherwellandsupportmothertoinitiatebreastfeeding.

Iensurethecleanlinessincludingtoiletsandfunctionalityofthepostnatalwardduringmyshift.

Icounselthemotheronbasichygienepracticestoavoidinfectionforthenewborn.

Iensurethatthebaby’sbedisclean;nooneissittingoreatingnearthebedandnotcrowdingaroundthebed.

Isupportthemotherbyshowingherthecorrectpositioningforbreastfeeding.

Ieducateherontheimportanceofexclusivebreastfeeding,keepingthebabywarm,andseekinghelpofanursewhenthebabyissick.

IalsoensurethatBCGandpoliodoseisgivenbeforethebabyleavesthehospital.Informthemotherabouttheimmunizationschedule,whenandwhereshecangetitdoneinhervillage.

Iinformheronbirthspacingoptionsandwhereshecangettheserviceswhenshegoeshome.

Imaintainrecordsofallthevitalinformationonthebabyandthemother.

Iensurethateachmotherleavesthefacilityasasatisfiedperson,withmoreunderstandingonbasicnewborncareandhappyaboutthecleanlinessandsupportinthehospital.

No work is too small or too big for me as long as it can help the mother and newborn. I am proud of the fact that I can empower each mother with information that can build her confidence to take care of her baby.

Yashoda

OperationalGuidelinesforYashoda/Mamta 3

SincetheinceptionofNRHMin2005,theoverallhealthbudgethasgoneupalmost300%whiletheJSYprogrammeallocationitself,aimingatsafemotherhoodthroughpromotinginstitutionaldeliveryhasincreasedalmost20fold.Howeverduringthisperiodtheinvestment

onnewborncarepersayhasbeenminimalorsubsumedundermaternalcare.VarioussurveysincludingNFHSIIIandtheseriesofsurveysbyUNFPAofJSYrealityinthefocusStateshavebroughtouttheurgentneedforbettercounselingandcarecoordinationinthecrowdedhealthfacilitiesforbothmotherandnewborncohort,toachievegoalsofMDG4and5.

YashodaprocessintroducedunderNIPIsince2008isonesuchspecificpiloteffortasaquickresponsebytheStateHealthSocietiesofMP,Bihar,OrissaandRajasthanforaddressingqualityofnewbornandrelatedmaternalcarestartingwithmaternitywardsofthedistricthospitalswithhighdeliveryload.Sinceinception,thisefforthassupportedover400000mothersinthe12Districthospitalsfromthe4statesforqualitycareforthenewbornthroughcounseling,supportandcarecoordination.

ThenonclinicalsupportandcounselingbyYashodasfocusesonmotivatingmotherstoweighandimmunizethenewborn,initiateexclusiveandimmediatebreastfeeding,spacingofchildbirthandinformationonpostnatalcareservicesaccess.,ThepurposeistoaddvaluetotheJSYinvestmentsatanominaladditionof7-10%.Theexperiencesofarhasshownthatadedicatedsupportatthefacilitylevelcansignificantlycontributetothequalityofcareandachievingtheoptimumadvantageofdeliveringinafacility.Thoughtheinitialresultsareencouraging,thisinterventionneedsnurturinginordertogetsustainedresultsoveraperiodof5-7years.

ItisstronglyrecommendedthatscalingupoftheinterventionshouldbelimitedtotheDistricthospitalsandCHCsthatareFRUsandhavehighdeliveryload.Approximately5-7yearsmustbethelearningcycletogettheinterventionfunctionaltotheexpectedstandardsandgetsolidevidencestodemonstratethevalueadditionthatitbringstoJSY.Priortothat,expandingtocovertheCHCsandPHCwithlowdeliveryloadwillundulyburdentheexistingsystem,.Thoughallthemotherswouldbenefitfromcounseling,thosefacilitieswithlowdeliveryloadmayfindmethodstotrainthenurse/evenASHAwhobringsthemotherstocounselduringtheirstayatthefacility.

Summary 1


1.1 Learning from the NIPI States and rationale for revised guidelinesTheexperienceof implementingtheinterventionhasresultedinseveralcritical lessonsinmanagingandscalingupapilot.Themanagementstructureoftheinterventionwasvisualizedasasimpleonethatwouldputminimumburdenontheexistingsystembutwoulddrawheavily on their experience andexpertise to embed the interventionwithin thehospitalsystemsubsequently.SincethereisnosimilarexperiencewithinthehospitalsystemintheNIPIStates,asetofoperationalguidelineswerepreparedandsharedwiththestateteamsforsuggestionsin2008.Theguidelinesarerevisitedduetothefollowing:

l TheStateHealthsocietiesandthestateNIPIprogramteamshavepointedouta few ambiguities in the Yashoda selection criteria, which allow interpretations resultingindelay/non standardization (Example: calculationof requirednumberofYashodas,modeofengagement,incentivepaymentetc).Clarificationswereprovidedonspecificaspectsperiodically.(e.g:Decisioninthe7thJSC,regardingbasisofcalculationofYashodarequirementbasedontotaldeliveryinoneyearinthefacilityandnotonthenumberofavailablebeds).

l Bythelastquarterof2008,thestateofRajasthanandOrissabeganscalingupoftheinterventiontocovermorethantheoriginal3DistrictsHospitals,includingselectCHCs(inRajasthan),whileGovernmentofBiharscaleduptocovertheentirestatefromthestart.MPhasdecidedtoincludeoneadditionaldistricthospitaland7CHCsfromtheexistingfocusdistricts.Theoriginalguidelinesdidnotcoverseveraloftheaspectsrelevantforscalingupoftheintervention.

l AprocessdocumentationofYashodainterventionconductedinMP,RajasthanandOrissainSeptember2009indicatedapositiveacceptanceoftheinterventionbythedistrictandhospitaladministrationbuthighlightedanumberofmanagementgaps.

l AcapacitybuildingtrainingconductedbytheIndianInstituteofManagement(IIM)AhmedabadinDecember2009,fortheStatehealthsystemfunctionariesandNIPIStateprogramteamfromthethreestateshighlightedtheneedforimprovedmanagementoftheYashodainterventionforscalingupandsustainability

Thisrevisedguidelineisaresultofcontinueddialogueatthestatelevelandhandholdingatthedistrictlevel.Thisisexpectedtohelptheprogrammanagerstoimprovetheirperformance.


1.2 Key issues highlighted in the revised guidelines include:

1.2.1YashodaispartofaprocessanddoesnotdenoteapersonTheobjectiveoftheprocessistoenhanceajointownershipforcarecoordinationatthefacilitywith‘Yashoda’aspartofthelargersystem,wherethepregnantwomenfeelswelcomeassheentersthefacilityandleaveswithafeelingofbeing cared for and looked after with her newborn baby. The value additionthattheYashodaprocessbringsisthedemandgenerationofservicesforcarefor newborn and improved accountability at the facility level.While Yashodafillsacriticalgap forcounselingthemotheronnewborncareandcoordinateserviceswithinthematernityward,YashodaisNOTasubstituteforthenurses.Hersuccessdependsalotonthesupport,ownershipandleadershipgivenbythehospitalteamincludingthematron,nurses,hospitalmanagerandhospitaladministrators.

1.2.2OwnershipanddecisionmakingmechanismTheRKShastheoverallmanagerialresponsibilityforalldecisionsrelatedtotheintervention.However,acommitteewithinthehospitalneedtobeformedtohaveaformaldecisionmakingprocesstomanagetheinterventionefficiently.ThiscommitteewillalsoensurethattheYashodasandtheChildHealthSupervisors(CHS)aretreatedasteammembersofthematernitywardandsupportedintheirdailyefforts.(seedetailsunder4.2Establishmentofdecisionmakingmechanismwithinthehospital.)

1.2.3Yashodaengagementl Thetotalannual delivery averaged out to a daily/monthly load will be the basis for calculation ofYashodarequirement.ThismaybedifferentfromthesituationatBlockHospitalwhereaseparateapproachhasbeensuggested.

l Yashodashouldbeclearlyinformedofthetemporaryandvoluntarynatureoftheengagementwithoutanyambiguity

l Each Yashoda will get an incentive of around Rupees 3000 - 3500for23-24shiftsofworkinamonth.ThiscouldbelowerinaBlockhospitalwithpartialdeliveryload.

l Inordertoimproveperformanceefficiency,Yashoda will be given every fourth day off after completion of night duty.

l The non clinical support and counseling role of Yashoda must becommunicatedclearlyandcontinuouslytoallthehospitalstaffanddistrictteamincludingthefactthatYashodaisNOTasubstituteforthenurses.

The hospital committeewill ensure that theYashodasandtheChildHealthSupervisors(CHS)are treated as teammembersofthematernityward and supported intheirdailyeffort.


1.2.4Supervisionl AtthedistrictfacilitiesappointmentoftheChildHealthSupervisor/DeputyChildHealthSupervisormustprecedetheengagementofYashodaAttheblockleveleffortmustbetoidentifyasupervisorfromamongtheavailablestaffpriortotheengagementofYashodastomakethe interventionfunctionefficiently.

l A formal linkagemust be established for liaising of the child healthsupervisor and deputy supervisors with the hospital manager/ and hospitaladministrators and the District Project Management Unit/Block ProjectManagementUnit(DPMU/BPMU).

1.2.5Capacitybuildingl Thecapacitybuildingisnotaonetimeeffort.Whileformaltrainingsareprovided,thedistrictsmustbuildtheirin-housecapacitybydevelopingtheANMTCstomeetthecontinuouslearningneedsandonthejobsskillsbuildingrequirementsofYashodas.

1.2.6Monitoringl Yashoda daily reporting registers must be monitored regularlybythesupervisorsforquality.

l Formal assessment mechanism must be established formonitoringYashodaperformanceonanongoingbasisalongwithfeedbackmechanism.

l Managers must ensure that a community monitoring process is established as part of social auditing oftheintervention.

l The NIPI State program Unit has a large responsibility to ensuresupportingsystemsareinplaceforthedistrictteamstomonitortheinterventionappropriately.

Thedistrictsmustbuildtheirin-housecapacitybydevelopingtheANMTCstomeetthecontinuouslearningandonthejobsskillsbuildingrequirementsYashodas.


2 Rationale and Evidence

Womenhavecomplexneedsduringchildbirth.Inadditiontothemodernobstetricalcare,womenneedconsistent,continuousreassurance,comfort,encouragementandrespect.

2.1 Why Yashoda intervention – Evidences and Rationale:ThesuddeninfluxofbeneficiariesinpublichealthinstitutionsduetoJSYhasaddedtothechallengetoprovidequalitymaternalandneonatehealthcare.However,itprovidesawindowofopportunitiestoimprovetheRCHservicesatthefacilities.

Women have complex needs during childbirth. The In addition to the modernobstetrical care, womenneed consistent, continuous reassurance, comfort,encouragementandrespect.Theyandtheirnewbornneedindividualizedcareandmoresowhenapoorruralwomenchoosestodeliverinanalienenvironmentlikeadistrictorblockfacility.

ThescientificevidenceforemotionalsupportandhandholdingduringdeliveryandimmediatepostnatalcarecomesfromtheUnitedStates,Drs.JohnKennelandMarshallKlauswhileinvestigatingwaystoenhancematernal-infantbondinginthelateseventies,theyfound,thatintroducinga‘doula’(amother’scompanion)intothelaborroomnotonlyimprovedthebondbetweenmotherandinfant,butalsoseemedtodecreasetheincidenceofcomplications.(Kennel,JHetall)Sincetheiroriginalstudies,publishedin1980and1986,numerousscientifictrialshavebeenconducted inmanycountriescomparingusualcarewithusualcareplusa‘doula’.

Analysis of the numerous scientific trials of labor support led the CochraneCollaboration’sPregnancyandChildbirthGrouptostate:“Giventheclearbenefitsandnoknownrisksassociatedwithintrapartumsupport,everyeffortshouldbemadetoensurethatalllabouringwomenreceivesupport,notonlyfromthosecloseto thembut also from specially trained caregivers. This support should includecontinuous presence, the provision of hands-on comfort, and encouragement.”(McGrath,SKetall)

TamilNaduhassuccessfullydemonstratedtheneedandusefulnessofawomenwho‘holdshands’ andprovides themuchneededemotional supportbesideshelpingthewomentonavigatethroughthecomplexprocessesinthehospitals.Themorerecentexampleof‘Breastfeedingcounselor’inMadhyaPradeshprovidesafurtherexampleofimprovingthequalityofcareforthewomencominginforinstitutionaldeliveries.


SurveysonJSYshowthatmanyofthewomenstayintheinstitutionforlessthan24hoursafterdelivery,regardlessofanormaldeliveryoradifficultdelivery.ConcurrentassessmentofJananiSurakshaYojana(JSY)schemeinselectedstatesofIndia,2008sponsoredbyUNFPAraisedseveralissuesaboutitsbenefitsandprocessesforthewomen.Theseinclude:thedurationofstayatthefacility,thequalityofservices,thefacilitiesavailableatthehospital,thesafetyofmother&child,andtheavailabilityofcounsellingonfollowupvisit,breastfeeding,immunization,familyplanning,newborncareanddiarrhoeamanagement,etc.

Thefirst24-48hoursafterdeliveryofferagoldenopportunityforintegratingneonatalcarewithpostpartumcare.Manyoftheconditionsresponsibleforthemotherand/orneonate’sdeatharerecognizableinthefirst48-72hoursafterdelivery.ThereforethegovernmentofIndianormsrequirethatmothersstayinthehospitalwiththenewbornfor48hoursafterdelivery.

Can a person from within facility be foundtomakethepregnantwomenfeelwelcome, to make her feel comfortable after delivery, initiate exclusive andimmediatebreastfeeding,counselthemotheronbasicnewborncare,andtomotivatethemothertostayatthefacilityforalongerduration?Thehospitals,withincreasingvolumesofdeliveriesperday,havenotbeenabletousethisopportunityfullyduetoashortageofnursesandapoorlymanagedlogisticssystem.WhilethereareprescribedstandardsregardingtheavailabilityofnumberofqualifiednursesbytheMedicalCouncilofIndia,intheMedicalColleges,andpenaltiesfornoncompliancenosuchstandardsareavailableforthematernitywardinaDistricthospital,whicharecronicallyunderstaffed.TheIndianPublicHealthStandardsarenottiedtopenalties.Whiletheselong-termHRprocessesare still debated, theYashodaprocessprovides aquick response tohelp thehospital system to copewith the increasingdemand for quality care for thenewbornbyhavingdedicatedteamtotakeonnonclinicaltasksandfreeupthetimeofthenursestofocusoncurativetasks.

If and when the availability of extra posts of ANMs come up, the Yashodaprocesswillgetevenmorestrengthened.TheadditionaltrainedANMscanevenoperateasDeputyChildHealthSupervisors.InanaverageDist.Hospitalwith25deliveriesperday,thenumberofsupportingpersonsinaYashodaprocesswillbearound16/17.OnecannotvisualizesomanyANM/NursepostsbeingcreatedbyStatesovernight;andevenifthesearecreated,findingqualifiedstaffandhigherbudgetforthemwilltaketime.

Manyoftheconditionsresponsibleforthemotherand/orneonate’sdeatharerecognizableinthefirst48-72hoursafterdelivery.ThereforetheGovernmentofIndianormsrequirethatmothersstayinthehospitalwiththenewbornfor48hoursafterdelivery.


Why Yashoda, and why not ASHA? Ithasbeenobservedthatinalmost30-40

%ofcases,ASHAsdonotaccompanythepregnantwomentothehospital.EventhosewhoaccompanydohaveotherresponsibilitiesunderNRHMandcannotbeawayfromthecommunityforover24hours.IfweassumethatASHAsaccompanypregnantwomentoaDistricthospitalwhere20-30deliveriestakeplaceaday,inthecourseoftwodays,therewillbe40-60ASHAsatthehospital.Thereisnoarrangementfortheirstay,food,orsecurity.Theseadditionalpeopleinanalreadystretchedinfrastructurecouldcreatechaos. Also, it will be difficult for the RCH nurses, doctors etc in a district hospital to relate to 1000 strong ASHA force in a district; while their ability to organize support and counselling through Yashodas who are to become regular features of the maternity ward over a period of time will be considerably smoother. Accountability can be organized much better.

TheNIPIfocusstateshaveengaged‘Yashoda’/’Mamta’forfacilitatingtheinitialcarethatthenewbornandthemotherrequireduringtheirstayatthefacility,therebyaddressingtheabovegapstosomeextent.

Yashodaisnotasubstituteforthenursingstafforparamedicalstaffavailableatthefacility.


Role of Yashoda 3Yashodashavearangeofresponsibilities;Ensuringcleanlinessandfunctionality

oftheward,beafriendtothemother,tocounselthemotheronnutritionforselfandnewborn, immunizationandfamilyplanningchoiceetc. Since

Yashodas, will be on duty 24 hours they will provide a closer watch over the mother and the newborn, and alert the nurse or the doctor immediately for any difficulty faced by the newborn or the mother.Asasupportworkerforimprovingqualityofcare,Yashodasalsohavetheresponsibilitytofacilitatesafety,security,dignity and privacy of the mother and special and dedicated attention to thenewborn.Since each healthy mother and newborn leaving the hospital will be an ambassador for spreading the message of improved care at the institution, Yashoda’s role in building confidence of the mother becomes crucial.

3.1 A congenial environment Yashodamakesthemotherfeelwelcomeandmakesherstaycomfortablebybeingfriendlyandcordial.Shewillfunctionasaninterfacebetweenthehospitalstaff,themotherandherfamily.ShewilllinkwiththeASHAaccompanyingthepregnantwomanandgatherbasicinformationoncompletionofANCcheckup,anyproblemetc,andinformthenursingstafffornecessaryaction.Shewillassistthenursesinbedmakingandavoidcrowdingintheward.

3.2 Newborn and mother careYashodawillmakearrangementtoensurecleanlinessofthearea,preparethebedforthemotherandbaby,managethefoodandotherancillaryrequirementsofthemotherandbaby,andkeepthepaperworkready.

3.3 Assist in pre and post delivery care

Yashodasfunctionasanemotionalsupporttothepregnantwomaninthelabourroom;subsequentlyassistthenurseinreceivingthenewborn,cordcare,puttingidentificationtags,takingtheweightofthenewborn,cleaninganddrapingthenewborninadequatesheetandblanketsaspertheweather.ShewillassistthemothertoinitiateimmediateandexclusivebreastfeedingandensureallZero-doseimmunizationfromtheinstitution.

Asasupportworkerforimprovingqualityofcare,Yashodasalsohavetheresponsibilitytofacilitatesafety,security,dignityandprivacyofthemotherandspecialanddedicatedattentiontothenewborn.


3.4 Counsel the mothers

Motivatethemothertostayatthefacilityfor48hoursaspertheguidanceofthedoctors.DuringthestayatthehealthfacilitytheYashodawillcounselthemotheron:

l Breastfeedingandcomplementary feedingandnutrition requirements formother.

lDetailsaboutfurtherimmunizationrequirements,schedule,availability.

lPreparationstobemadeincaseofillnessofthebabyandmother.

lPreventionofcommoninfectionsincludingReproductiveTract Infection/SexuallyTransmittedInfection(RTIs/STIs).

lFamilyplanningadviceasrequiredincludingspacing,contraception.

lAccessinginstitutionalcareinfuture,iftheneedwouldariseforthebaby/child,whomtocontact,etc.

lPersonalhygiene

3.5 Initiate birth registration / procuring birth certificate:

Yashodawillassistinfillingoftheformsforregistrationofbirthandstillbirthandexplaintherationaleforregistrationtothemotherandfamilymembers.


3.6 Provide information on the follow-up after discharge from the health facilityProvideinformationontheneedforregularweightcheckups,weightgainforthebabyintheensuingmonths,immunization,feedingofthebaby(exclusivebreast feeding till 6 months and introduction of complimentary feedingthereafter);contactpointssuchasANM,AWW,andothersupportsystemsinthecommunity.

3.8 Informing family members present at the health facilities about: l Basiccare formotherandnewbornafter leavingthefacility includingrest,nutrition,basicsanitation&hygienicpractices.

l Existinghealth services, immunizationdays, andothermaternal childhealthcareservices,especiallyforpostnatalcare(providedbyANMandASHA,supplementarynutritionservicesavailableattheAnganwadicentres).

3.9 Record Maintenance Thisinnovationrequiresappropriatefollowupoftheservicesrenderedtoimprovequality.

MonitoringeffectivenessofYashodainterventioncontributingtoincreasingthedurationofthestayofmothers,byinitiationofimmediateandexclusivebreastfeedingandzerodoseimmunizationinadditiontomothersreceivingappropriateinformationoncareforselfandnewbornafterleavingthefacility.Towardsthis,it is suggested that Yashoda capacity is built to maintain appropriate dailyrecords,whichareexpectedtofacilitatethenursingstaffaswellastheChildHealthSupervisorstotakesuitablemeasurestoimprovethequalityofservice.

3.10 Linkage with ASHAAsYashodatakesoverthepregnantwomanfromASHAonarrival,sheneedstolinkwiththeASHAasmuchaspossiblewhenthemotherleavesthefacilitywiththenewborn.Shemustprovideinformationonimmunizationreceived,information that require reiteration, problem if any regarding the health ofthenewbornor themotherthat canfacilitate better counsellingandcarecoordinationtothemotherbytheASHAinthecommunity.

AsYashodatakesoverthepregnantwomanfromASHAonarrival,sheneedstolinkwiththeASHAasmuchaspossiblewhenthemotherleavesthefacilitywiththenewborn.


Yashoda Time Piechart

BasicNewborncarecounseling,immunization&breastfeedingsupport(50%)

MaternalCare(10%)FamilyPlanningCounseling(10%)

PostDischargecounseling(10%)

GeneralSupport*(20%)

l HaveclarityontherationalebehindYashodainterventionunder NRHM

l HaveclarityontheroleofYashodas

l Ensurethatallthehospitalstaff(nurses,doctors,hospitalmanagers andsupportstaff)understandsthevoluntaryandnonclinicalnature ofYashodawork.

l Establishsupervisorymechanismthatwillensurethat:

-Yashodaprovidesonlynonclinicalsupportintheward

-NonclinicalroleofYashodaispostedprominentlyintheward

l Informmothersthattheserviceisfreeandavailableroundthe clock.

3.11 Managing Yashoda intervention: Role of the State program management unit (SPMU)

ThepiechartisanapproximatesuggestedtimedevotedbyYashodaforthevariouscounsellingactivitiesinadayduringhershift.


4 Scaling up of Yashoda Intervention

ThescalingupoftheinterventionfromthreedistricthospitalstocovertheentirestateisachallengefortheStateProgramManagementunits(SPMU)intermsofplanningandorganizingandimplementingtheinterventionwithoutdilutingquality.Institutionalizing

Yashodaprocessatthestatelevelrequiresastrategicapproach.TowardsthattheStateProgramManagementUnitsneedtoestablishsystemsthatwillfacilitatesmoothtransitionfromthepilottoscalingupstage.Simultaneously,enhancingtheownershipofthecommunityandtheirinvolvementintheYashodaprocessthroughcommunitysocialauditprocesswouldbuildthecredibilityoftheintervention.TheSPMUhastheresponsibilitytoprovidetheappropriateguidelinestomakethesocialauditasafunctionalmechanism.

4.1 PlanningThisisthemostcriticalstepsinceitprovidestheframeworkfortheentirescalingupprocess.Planningthescalingupwiththediversestakeholdersisimportanttogettheperspectivesfromdifferentdimensionoftheintervention.Tofacilitatetheinteractionwiththestakeholders,theSPMUrequirestohaveasystematicdocumentationofthe lessons learnedinthepilotphase.Thiswouldhelpthestakeholderstounderstandwithevidenceastowhatworked,whyandthegaps.

Theoutcomeoftheplanningshouldbe:

l Clearlyarticulatedobjectives

Detailedimplementationstrategyincluding:

l Identification of institutionalmechanism and responsible nodal persons at the state,districtandBlocklevels

l ClarityontheroleofthevariousstakeholdersengagedinYashodaprocessatalllevels

l ManagingtheYashodabudgetandfinancesincludingstreamliningtheYashodaincentivepaymentmechanism

l Identificationofnodalpointsatdifferentlevelsformonitoringtheprocess

l Establishingprocessesforcapacitybuilding

l Expectedoutputbyeachquarter,expectedoutcomeattheendoftheyear,andindicatorsofmeasuring,risksthatcouldaffecttheimplementation

l Aplanforsustainabilityoftheintervention


4.2 Preparation of an implementation strategy:Animplementationstrategythatwouldarticulateifthescalingupwouldbesimplereplicationof the previous strategy; or will there be changes in the structure/systems/managementprocesses:andifyes,whicharetheaspectsthatwouldbemodifiedandhow;whowillberesponsible. For example, if the pilot phase included only health facilities from the plainregionsandthescaledupversionincludesmountainousregions/desert/otherhardtoreachareas,thestrategyneedstobemodifiedaccordingly.

l Thestrategywillalsoclearlyidentifyhowthescalingupwillbeimplemented-Willitbeinphasedmanner?Willitbescaledupwithdifferentlevelsofstandardstomeetthelocalneeds(example:Facilitieslocatedintribal/desertareasmayfinditdifficulttogetsupervisorswiththeprescribedqualificationorexperience.Astrategytouseadifferentyardstickforselectionofsupervisorystaffmaybeadoptedforthoseareas)

4.3 Institutional mechanism: Formanagingtheexpansiontocovertheentirestaterequireswellestablishedinstitutionalmechanismthatwouldbeconstantlyassessingtheinterventionandprovidingpolicyandotherrequiredsupport.SPMUmustensurethatthemanagementstructureisclearlyarticulatedandrolesandresponsibilitiesatthevariouslevelsarecommunicatedeffectively.Forexample,InordertostrategicallylinktheYashodaprocesstotheASHAprocessandinstitutionalizetheYashodaprocess,theStateASHACoordinatorcouldbethestatenodeforcoordinatingtheYashodainterventionandre-designatedasASHA–YashodaCoordinator.

TheSPMUhastheadditionalresponsibilityofensuringthattheadministrativeandprogramimplementationguidelinesandofficeordersorganizedanddisseminatedtothefieldwithoutanydelayandprovideclarificationsnecessaryincaseofambiguity.

InadditiontothestatelevelmechanismsuchasStateCoordinationCommittee,appropriateinstitutionalstructuremustbeestablishedatthedistrict/blocklevelandevenatthefacilitylevel.Forexample,thoughCMHOistheoverallsupervisorandRKSisthedecisionmakingbodyatthefacilitylevel,bothhaveinadequatetimetogetinvolvedinthedaytodaymanagementoftheYashodaintervention.FormationofahospitalcommitteeatthedistricthospitalwillenabletheYashodasandsupervisorstoknowtheirfocalpointwithinthehospitalforgrievanceredressalanddaytodayoperationalsupportrelatedtoimplementation.Thecommitteecouldhavethematron/seniornurse,Districtmaternalandchildhealthcoordinator,hospitalmanagerandYashodachildhealthsupervisorasmembers.

Expansiontocoverthestatealsorequiresspecialskillsformanagingthebudgetandleveragingtheresources.Aspecificnodalfinancepersonatthestatelevelmaybeengagedtomanagethe finances including, calculating the overall intervention cost, tracking expenditure,documentingthepaymentofincentiveprofile,useofuntiedfundsandbuildinglocalcapacitytounderstandthemanagementofthefinanceaspects.


4.4 Human Resource Management:ThescalingupresultsininductionoflargenumberofYashodasaswellassupervisorsandinvolvementofpublichealthnurses,counselors,accountants,medicalofficers,nurses,andothersfromtimetotimeforvariouspurposes.

Ahumanresourcemanagementpolicyshouldbeinplacethatwouldarticulatethevariousaspectsofhumanresourcemanagementrelatedtotheinterventionincludingselection,placement,supervision,capacitybuildingamongotherthings.TheHRpolicymustalsoenablethedistrictorblocktoanalyzetheircapacitytoimplementasperstandardssinceoftentheexistingsystemsareillpreparedorinadequateintermsofmanpoweradtechnicalcapacitytomanagethescaledupprocess.HRpolicyshouldhavetheflexibilitytoexplorehiringofexternalagency/iesthatcangiveappropriatesupportforestablishmentofsystemsrelatedtomanagingtheprocesses.

Toremainacatalyticprocess,theYashodainterventionhastobeinnovative.InordertohaveinbuiltselfresurgenceandkeepYashodasalert,itissuggestedthattheHRpolicyshouldconsiderinducting1/5ofnewYashodaseverythirdyearbyreplacingfromtheexistingpool.ThismethodwouldensurecontinuationofexperiencedstaffbutinductionofnewYashodasperiodically.

4.5 Capacity building: ThepilotphasebyandlargefocusedonorientationandinductiontrainingoftheYashodasandthesupervisorcadretoalimitedextent.Capacitybuildinginascaledupmoderequiresaconsistentapproachtocovertheentiregamutofcapacitybuildingincludingtraining,mentoring,counseling,exchangevisits,continuouslearningopportunitiesetc.

It is essential to equip Yashodas with upgraded their skills and counseling abilities to provide quality care tothenewbornandthemothersthroughorientation,inductiontraining,refreshertrainingandcontinuouslearningopportunities. The capacityof the supervisorsmustbe suitably enhanced tomanage the aboveprocesses, keepYashodateamtogether,documentthebestpractices,monitortheimplementation,andliaisewiththehospitalteamsandreport.

Anotherchallengeiscreatingapooloftrainers.Sincetheinterventionisexpandedtocoverfacilitieslocatedatdistrictsandbelow,apoolofdistrictandblockleveltrainersneedtobeidentified,providedwithTrainingoftrainersprogramtomeetthecapacitybuildingrequirements.TheSPMUcapacitybuildingplanningalsomustaddresstheissueofaccessinginnovativelearningmaterialsforYashodas.

Enhancingunderstandingof theYashoda intervention to theDistricthospital andBlockhospital teams,Districthealthsociety,DPMUandRKS isequally important.TheabovestakeholdersmusthaveclearunderstandingtheirownroleinfacilitatingthequalitycareaspectthroughYashodaprocess.PerformanceassessmentisanotherstepincapacitybuildingofYashodas.TheSPMUmustensurethatasuitablydesignedperformanceassessmentsystemisestablishedandconductedbythesupervisors.

4.6 Monitoring and reporting:Astatelevelscalinguprequiresrigorousfollowupoftheimplementationateverylevelandappropriatelytrainedpersonnel at thedistrict andblock level handle themonitoring effectively. While theday todaymonitoring ismanagedbythetrainedmanagers,establishmentofastatelevelstructure(Acell)tomonitortheimplementationfromthepolicyperspectiveisimportant.

AsaprocessofcontinuumofcarethedistrictASAHcoordinatorcouldhavetheleadresponsibilitytomonitortheimplementationatthedistrictlevel,ablysupportedbythechildhealthsupervisor,districtmaternalandchildhealthcoordinator.AttheBlockleveltheBlockmaternalandchildhealthcoordinatorcouldtakeuptheresponsibilitytomonitortheYashodaintervention.


5 5.1 Preparatory activitiesStateProgramManagementUnit(SPMU)hasacrucialroleinthepreparatory

activities.

l Orienting the state and district RCH /NRHM teams:PrepareahandoutwithsalientfeaturesoftheYashodaprogramandorienttheStateNRHMofficersandthedistrictofficials (CDMO,ADMO/MedicalSuperintendent,DPM,DIO,doctors,matron,nurses,HospitalManagers)ontherationale,administrative and financial arrangements, mode of engagement, andtrainingandmonitoringofYashoda.

l Issue appropriate administrative guidelines forengagement, training,incentivedisbursement,supervision,monitoringandreportingofYashodaintervention. Thisprocesswill be facilitatedby theNIPI StateProgramUnits.

l Ensure transfer of funds to the districts fortheimplementationbasedon theprojectedneed. Ensure transfer of funds to thedistricts for theimplementationbasedontheprojectedneed.

5.2 Establishment of a decision making mechanism within the hospital StateHealthSocietyissuesoveralladministrativeguidelinesregardingthe

intervention.However,therewillbesituationswhereinterpretationoftheguidelinestomeetthelocalneedsmayarise.Similarly,theremaybelocalspecific emergency situation calling for immediate decision which maynotbecoveredintheoverallguidelines.(e.g:verylow/veryhighdeliveryload,Yashodagrievance,disciplinaryaction,leave,awardsandrewards,recognitionetc).Toavoidadhocprocessesandfacilitateastreamlineddecisionmaking,itisessentialtohaveformaldecisionmakingcommitteeestablishedwithin thehospital. Suggested representationcould includeHospital Manager, Matron, Child Health Supervisor and District ChildHealthManager.DecisionsmadeshouldberecordedandputuptheCDMO/RKSforinformation/approvalsasappropriate.ThedecisionsmustalsobecommunicatedontimetoYashodas.

Yashoda Implementation Process

StateNRHMwillissueappropriateguidelines

forrecruitment,engagement,training,

incentivedisbursement,supervision,monitoring

andreportingofYashodaintervention.


ThoughYashodas,DCHSandCHShavebeenintroducedwithinthesystem,oftentheyarenotconsideredaspartofthematernitywardteam.Theyalsohavedifficultyfindingtheirfocalpointswithinthehospitaladministration.ThecommitteemustensurethatallconcernedunderstandthepurposeofYashodainterventionandroleoftheinductedmembers,needforfunctioningas a team and treat themwith respect and give the space to dischargetheirfunctionseffectively.NIPIStateProgramUnitmustensurethatthecommitteeiswellorientedonalltheabovementionedaspects.

5.3. Engaging Yashodas.a)Placing Local News Paper Advertisement: Thiswill beplacedbyDistrict

Immunizationofficer(DOI)orChiefMedicalOfficer(CMO)/CivilSurgeon//RCHNodalofficer/DPMwithpermissionfromDistricthealthsociety(DHS).

b)Suggested criterion for Selection:

- Alocalwomanlivingwithinthemunicipallimits.

- Hascompleted8thgradeasaminimum.

- Sheagreestoworkasavolunteer

- Shewillreceiveperformance-linkedincentives.

- Her engagement as volunteer worker does not entitle her to claim theregularpositioninthesystem.

- Free from communicable diseases, subject to clearance by the MedicalOfficer.

- Willingtoworkonrotationalbasisincludingnightshifts.

Decisions on the criteria are to be finalised at the district level by the DHS and / or Rogi Kalyan Samiti (RKS) of the hospital. These agencies must have a process for screening of the applications within a limited time since large numbers may apply for a few positions.

c)Short listed candidates will be invited for interview.

ThehospitalcommitteemustensurethatallconcernedunderstandthepurposeofYashodaintervention,theroleoftheinductedmembers,needforfunctioningasateam,treatYashodaswithrespectandgivethespacetodischargetheirfunctionseffectively.


Parameters* Marks*

1 2 3 4 Additional 2

Education 8thGrade 10thGrade 12thGrade Graduate Nurse/ANMdegree/diploma

Age 50+ 45-50 35-45 25-35 -

Workexperience Neverworked Workedinnon–healthsector

Workedasprivatenurse/assistant

Workedinhospitalsetting

-

Communicationskills Poor Average Good Excellent -

Distanceofresidencefromfacility

Willingnesstoworkinrotationandatnight

- - - - -

Suggested evaluation parameters for the candidates during interview

5.4 Mode of engagement of Yashoda: AsYashodaisavoluntarysupportworker,theengagementwillbethrough

RogiKalyanSamitiintherespectivedistricts.

lInordertoavoidanycomplexitiesrelatedtoengagementofYashodainfuture,itissuggestedthatlegalopinionmaybeobtainedfromthecompetentstateauthority.

Any mode of engagement should ensure that the roles and responsibilities, incentives, reporting and notice period etc are stated clearly without ambiguity and the Yashoda understand the voluntary nature of their work, compensation through an incentive system and does not entitle Yashoda for any claim for an adhoc or a permanent position in the health system in future.

*Thedistrictauthoritiesmaymodifytheparameters/weightagekeepinginviewthelocalneeds.


5.5 Determining the required number of Yashoda in a District Hospital

DistrictHospitalswithahighdeliveryloadaretakenforimplementationofYashodaprocesssincetheyhavetheabilitytosupportthementoringandmonitoringoftheYashodaintervention.ThecalculationoftheYashodarequirementshouldbebasedonthetotaldeliveryinayearinthegivenfacility.Observeandrecordifthefluctuationsaremorethan10-15%eitherway.

Itiswellknownthatthedeliverystatusvariesfrommonthtomonthandsomemonthswithveryhighloadandsomewithlowload.Duringthesemonths,thequantumofincentivegeneratedwillvarybutnotthenumberofYashodas.ThefacilityshouldcalculatetheoptimalnumberofYashodasrequiredfunctioningasacorepoolofworkersonwhominvestmentismadeintermsoftraining,uniform,supervision,consumablesetc.

Therefore the following is suggested:

5.5.1ThecalculationofrequirednumberofYashodas CalculationofYashodarequirementshouldbebasedon:

l Totalnumberofdeliveriesoccurringinoneyearinthefacility.

l Arriveatperdayaveragedeliverybydividingthetotalnumberby365.

l Toprovidearoundtheclockservices,Yashodawillworkin8hourlyshifts.

ManagingYashodaengagement:TheroleofStateProgramManagementUnitlOrienttheState,DistrictandHospitaladministrationonthepurposeand

roleofYashoda.

lEnsurethatalltherequiredadministrativeguidelinesaresentfromStateHealthSocietytotheDistrictspriortoorientation.

lGetthedistrictstocalculatenumberofYashodarequiredandprojectabudget.

lEnsurethattherequiredfundisdisbursedbytheStateHealthSocietywithoutanydelay.

lFacilitatethedistricts/RKStoplacetheadvertisementappropriately.

lEnsurethattheYashodaselectioncriteriaprovidesequalopportunitytoallapplicantswithoutdiscrimination.

lEnsurethatthelegaldepartmentisconsultedregardingthemodeofengagementofYashodas,basedonthevoluntarynatureoftheirservices.

lWhateverthemodemaybe,ensurethatthereisnoambiguityregardingthevoluntaryandtemporarynatureofworkanddoesnotentitleYashodaforfullorparttimeworkinthehealthsystem.

ThecalculationoftheYashodarequirementshouldbebasedonthetotaldeliveryinayearinthegivenfacility.


l The calculation of required number of Yashoda must be based on clearunderstandingoftherequiredshiftsofwork,rest,incentivepaymentandothercostsinvolvedinmanagingtheintervention.

l Currently,Yashodasaretakingcareoffivenewbornbabiespershift.Thenewbornandmotherareexpectedtostayforabout48hoursafterdelivery,soeachYashoda take care of about 10newborns in a shift.However in reality eachYashodaoftenmanages5-6motherbabycohortandnotstrictly5babies.

l ThecalculationtoincludethenumberofYashodasrequiredtoensureroundtheclockservicesallowingspaceforleaveandabsencebyYashodas;andtomeetthehighdeliveryloadperiodneeds.Insomecasesthelayoutofthewardsmaybesuchthat,moreYashodasarerequiredtocoverthematernitywards.

Calculation of Yashoda Requirement

CalculationofYashodarequirementshouldbebasedon:

Totaldeliveryperyear 2190

Dailydeliveryload 2190/365

Dailydeliveryloadis 6

NumberofYashodasrequiredpershift

(eachYashodalooksafter6newbornandmothers) 1

Forthreeshifts 3Yashoda

Additional25%tomeettheroundtheclockservice 1extra=total4 Yashodas

Keeping in view that all the mothers and newborns receive the services of Yashoda, it must be ensured that the duty roster is prepared in such a way that work is distributed among all the Yashodas equitably. All Yashodas will be entitled for the same amount of incentives as per the duty roster.

AdditionallyitmustbeensuredthattheYashodaservicesareavailableinthewardall24hrswithoutanybreak.Currently,thethreeshifttimingsare:morningduty(0800hrs-1400hrs)afternoon(1400-2000hrs)andnightshift(2200-0800hrs).

Thesupervisorycadremustensurethattheshifttimingsarereadjustedinsuchawaythatthereisnogapinservice.


5.5.2DutyallotmenttoYashodaIthas beenobserved that varied standards of duty allotment to Yashodas areadoptedbythestates,includinginterdistrictvariation.InRajasthantheshiftissoorganizedtogiveeveryfourthdayofftoYashodas.InOrissaYashodasdo10daysshiftdutyfollowedbynightdutyonrotationbasis.InMPevery6thdayisgivenasoffdaytoYashodasThefacilityaswellasYashodasseemtohavewelladjustedtothisdutyallocationpatternintheirrespectivestates.WhiletheDistrictshavetheirrationaleforfixingtherotationaldutysuitabletotheircontext,caremustbeexercisedtoensurethatallYashodashaveequalworkandequalrest.TheRajasthanmodeloffers274shiftsofworkand91restdaystoYashodasinayear,whileinotherstatesYashodasgettowork313daysofworkand52restdays.TheRajasthanmodelseemto facilitateYashodasto functionoptimally(sincegets restafternightduty)withoutcompromisingthequalityofworkandhelpshertobalanceherpersonal life.Theother threestatesmayexplore thepossibilityof readjustingYashodascheduleinsuchawaythatshegetsoptimalnumberofoffdaysasinthecaseofRajasthan,especiallysincetheydonothaveopportunitytoavailanyotherleave.

Rajasthan duty roaster chart is given as annexure: to demonstrate how the model functions.


5.6 Leave for YashodaThe preceding paragraphs informed the duty load of Yashoda and organization of restdaysinRajasthan,OrissaandMP.SincethispositionisnotaregularNRHMcontractualposition,theNRHMleaverulesforcontractualstaffdoesnotapply.Thefollowingarethecurrentpractice.

InRajasthanallYashodasgettoworkequalnumberofdays(23daysandhave7daysoffinmonthresultinginatotalof91restdaysinayear.Since they get 7days off in each month, there is no additional casual, medical or other leave permitted.

IfanyYashodawantstogoforshortleaveduetoanemergencysituation(2-3days)shemanageswiththoseYashodaswhoareindayoffshift(restshift)withpriorinformationtotheChildhealthSupervisorandwardnurseandapprovalinordertoensurepresenceofYashodasinalltheshifts.TheDCHSandCHSmaintainarecordforsuchleave.

IntherestofthestatesYashoda/Mamtaget52daysoffandworkfor313daysinyear.Theyalsotakeadditionalleaveamaximumof3-4dayswithpriorpermissionfromthewardnurseandChildhealthsupervisor.

l Any absence in addition to those mentioned above result in deduction in the incentive on a prorated basis in all the states.

5.7 Calculating the cost of intervention TheobjectiveofcalculatingthecostistounderstandtheoverallcostoftheinterventionasanadditiontoJSY.

5.7.1DetailedbudgettemplateforYashodainterventionatDistricthospital.Yashoda intervention isnotastandaloneprocess. It ispartof thecontinuumofcareapproach and an aimed at strengthening JSY by enabling mothers to stay for longerdurationatthefacilityandprovidequalitynewborncare.However,therearestatespecificvariationsinthecalculationofYashodacostcurrently.(e.g:OnlycostofYashodaincentiveispostedtoNIPIbudgetandtherestcomesfromNRHM/RCHbudget(Rajasthan)InMPthe Yashoda cost from NIPI budget includes Yashoda incentive, cost of birthing kit,Yashoda consumables and cost of Supervision). The following table is given to helpthestatestocalculatetheoverallcostoftheinterventioninpracticalwayandplanforabsorptionofthecostsbytheongoingNRHMprocessesattheearliest.

Thecostsareoftwotypes.

a) Direct Yashoda cost

b) Support cost


Item Suggested cost RemarksDirect costs

Yashoda honorarium 3000-3500 per month Each Yashoda must get honorarium calculated @ 100 per baby and mother cohort looked after. It is strongly recommended that the incentive does not exceed 300-3500 per month per Yashoda.

In order to standardize the honorarium amount as guided, it is suggested that all the states examine their current level of honorarium and Yashoda requirement and their availability at the facility

Yashoda Materials (Apron, bag, badges, slippers)

Rs.1000 per Yashoda per year.

For two sets to each Yashoda (some states have included washing allowance as well)

Yashoda capacity building Rs.5100 per Yashoda This item has five components: 1.Training of trainers (3 days at state level)

(Though direct costs, Training cost of Yashoda is not stand alone cost. Due to state wide and expansion beyond three focus districts , the cost would be taken up under NRHM RCH training budget) The training cost calculation as per NRHM norms should ensure that: the cost of the venue, food, transport, travel, training aids as required, hiring of AV equipment as required honorarium to resource persons, photocopy requirement if any, flipchart, pen, writing pad to participants, Yashoda **Performance assessment and miscellaneous to meet any unplanned expenditure are included.

1.Training of trainers (3 days at state level)2. Orientation training for 2 days.3. Induction training of Yashodas for 2 days 4.Refresher training after 6 months for 2 days 5.On the job training –continuous learning -2 sessions of 2 hrs each -skill building and counseling training per month ** it is suggested that a sum of Rupees 100 per Yashoda may be allotted towards hiring of external resource persons for conducting Yashoda performance assessment . In some states assessment is conducted twice a year. It is recommended that one assessment must be conducted per year.

Support costs (Existing NRHM Process)Supervision:Two Deputy child health Supervisors (DCHS) @ 7500 PM x2 This position is visualized as temporary one for one year to 18

months till the Yashoda process gets embedded within the hospital system The given costs are indicative only.

One Child health Supervisor (CHS) Rs.10,000 PMMatron honorarium Rs.1000 per month As resource person and mentorTraining of Supervisory cadre Rs.10,000 one time DCHS can be part of Yashoda training as well.

Both DCHS and CHS require training in management of the interventions including mentoring, Yashoda capacity building, team building, budgeting, using untied funds, monitoring, supervision, and reporting. ( 2days)

Rs. 5000 Annual CHS refresher training Untied funds at the disposal of the CHS Rs.3000 per month This untied fund at the disposal of the CHS is meant for meeting

any immediate needs that other wise would affect the quality of counseling and care for the neonate and mother. E.G: consumables for Yashodas

Mother and Baby kit (Also known as ‘Yashoda kit’ or ‘birthing kit’ in the states)

Rs 100-150 per baby This cost is already part of the on going RCH efforts partially in some states. Effort must be to include the entire cost in the NRHM budget at thee earliest.

Community group social audit Rs.3000 per year This fund must be budgeted in order that a group of community members are invited every quarter once by the Hospital committee to have informal discussion with the mothers and Yashodas. The fund may meet the transport, tea and snack expenditure during the visit.


Keyparameterstorememberwhilecalculating

YashodaCost

l Yashoda requirement is calculated based on total delivery per year at thefacility

l EachYashodashouldgetequalandoptimalworkandrest.Thecalculationofshiftsmaybedoneaccordingly.

l EachYashodashouldgetRupees3000-3500incentivepermonth.

l Thedistrictfacilitymusthaveatleast6deliveriesperdaytosupportthis

l TheYashodacostincludes-bothdirectandsupportcosts.(Directcostsinclude:Yashoda incentive, apron, consumables, orientation, on the job training andmaterials). Support costs such as salary to DCHS & CHS, their capacity buildingincentivetomatronasaresourceperson).

** Though the states have the flexibility to decide which costs of YashodainterventionwouldbemetfromRCH/NRHMbudgetsandwhichfromtheNIPIbudget,thebasicpremisesshouldbethatYashodaprocessisnotastandaloneoneandisacontinuationofJSYeffort.


5.8 Incentive structureTheincentiveforYashodamayvarydependingonthenumberofdeliverieshappeningatthehospitals.

ThenumberofdeliverieswillfluctuatepermonthsotheincentiveforYashodawillvarythroughtheyear.Althoughvariationisexpected,theincentivestructureneedstobedesignedinwaywhichensuresaminimumofRupees

3000permonthandamaximumofRupees3500perYashoda.HoweverthereareinstanceswhereYashodasgetmore than rupees3500permonthbasedon thedelivery load;ButhavelessnumberofYashodas.InsuchcasesthestatesneedtorevisitandexaminethedeliverypatternandcalculationofYashodarequirement.ConverselyifthefacilitieshavelessdeliverybutmoreYashodas,itneedstoberationalized.

InordertoensurequalityeachYashodawouldideallylookafter5-6newbornandmotherco-hortandnotmore.

5.9 Payment Process

1. Incentiveswillbepaidonmonthlybasis.

2. Bank account of each Yashodawill be opened in the same bankwhere account ofInstitution/RKSisoperated.

3. TheChildHealthSupervisorswillpreparemonthlysummaryattendancesheetofeachYashodabasedontheYashodadailyreportingrecord.(see annexure for format)

4. ChildHealthSupervisorwillgetthesummaryattendancesheetverifiedandapprovethepaymentvoucherbytheHeadNurse/matronby3rddayofthefollowingmonth.

To speed up the payment process it is recommended that the head nurse/matron be authorised to approve the voucher for payment of incentives based on the already approved norms.

5. TheChildHealthSupervisorswillforwardthedulyapprovedsummarysheetforpaymenttoDistrict/Blockaccountant/RKSby4thdayofthefollowingmonth.

6. The fundswillbetransferredtothedesignatedbankaccountsofYashodasdirectlylatestbythe10thofthefollowingmonth.

7. TheRKSwillsubmittheutilisationcertificatetoDHSonamonthlybasis.TheutilisationformwillbethesameasprescribedunderNRHM


5.10 Engaging Yashoda at the CHC/PHC MP,RajasthanandBiharhaveexpandedtheinterventiontoincludeCHCsadPHCs.ThereareCHCswhichhavefewerdeliveriesthanthePHCandviceversa.Whilethegeneral framework for implementationof the intervention remains the sameastheDistrictleveloperation,engagingYashodainthesefacilitieswithlowdeliveryloadneedstobeaddressedfromadifferentperspective.SincetheobjectiveoftheYashodaprocessistohelpthemothersandnewbornandcounselmothersonbasicnewborncareduringtheirstayatthefacility,managersneedtouseadifferentyardsticktoengageYashodainaCHC/PHCwheredailydeliveryloadmaybelessthanfive.

Insuchcases,alocaldecisionmaybetakentoengageonly1Yashodaswhocanassistthemotherstounderstandthebasicnewborncaremessagesandcounselherfor8hrsduringtheday.Sinceshedoesnothaveanynightduty,shedoesnotgetanoffdayonaweeklybasisbutwillbegiventwodaysoffinmonth(onedayeveryfortnight).AgainitisalocaldecisiontobemadebytheBlockmedicalofficer/RCHOandtheteam.

5.11 Supervision at the CHCUnlikethedistricthospitalthereisnoseparatesupervisorycadrewithintheCHCstohandholdYashodas.Theseniormostnurseisexpectedtogivethenecessaryadministrative and logistics support and technical guidance to Yashodas. It isexpectedthattheRCHO/Blockmedicalofficerwillbeoverall inchargeoftheintervention.TheBlockMaternalandChildHealthCoordinatorwouldberesponsiblefordaytodaymanagementoftheintervention.

The State Program Management Unit will ensurethattheseniornurse,RCHOand the rest of the hospital team are oriented well on the role of Yashodas,expectations,deliverables,monitoring,reportingandsupportrequiredformakingtheinterventionasuccesswithintheblockcontext.

Infacilitieswherethedeliveryvariationsaresteep,butYashodaservicesisrequired,usealocaldiscretionregardingengagementofYashodas.


Managing Yashoda placement and payment of incentives: Role of SPMU

l HaveclarityontheYashodacalculationmethodandtherationale.

l Ensurethatthedatacollectedonthetotaldeliveryofthefacilityisfromthecorrectsource.

l FacilitatethedistricthospitalsystemtocalculatetherequirednumberofYashoda.

l EnsurethateachYashodagetequitableopportunityforrestandworkload.

l Ensure that the Child Health Supervisors, nurses, RKS accountantandhospitaladministratorsunderstandtheYashodadutyrosterforcalculationofincentive.

l Familiarizeyourselfwith thecostsof runningthe interventionandthecoststhatarebuiltintheongoingNRHMprocesses

l Incentive structure should be such that each Yashoda gets Rupees3000-3500permonth.

l In facilities where the delivery variations are steep, but Yashoda services is required, use a local discretion regarding number of Yashodas.

l Establishasystemtoensureincentivedisbursalbythefirstweekofeverymonth.

l Establish amethod for documenting thepayment process to avoidanyambiguity.

l Orient the Block Medical Officer and the CHC team adequately tosupportYashodainterventionandmonitorprogress.


6.1. Training

CapacitybuildingofYashodaisacontinuousandincrementalprocessthatiscritical toenhancehereffectiveness.Thecapacitybuilding isseenanempowering process, which will enable Yashoda to gain competenciesprogressively.Yashodaswithcertainlevelofcompetencycouldbefurthertrained to become ‘newborn care aide ‘in the Sick Newborn Care Unitsand the StabilizationUnits in the District hospitals and Block hospitalsrespectively.

Induction training upon recruitment, continuous hands on training;refreshers training etc are tobe carefully plannedanddesigned to keepupdatingher knowledgeand skills. Capacitybuilding, in addition to theabovetraining,mustalsoinclude

l Exchangevisits

l Sharingoflessonslearned

l Documentationofbestpractices

l Mentoringandsupportivesupervisionatthefacility

l Accesstocertificationcoursesanddistancelearningcourses

The above will contribute to career progression, motivate Yashodas andlikelytoreducedropoutrates.

6 Capacity Building

Capacitybuilding,inadditiontothe

training,mustalsoincludeexchangevisits,

sharingoflessonslearned,documentation

ofbestpracticesetc.Mentoringand

supportivesupervisionatthefacilitywill

alsocontributetohercapacitybuilding.

Anumber of steps constitutethe capacity building process for Yashodas. To enable Yashodasperformoptimallythefollowingstepsaresuggested:

1. Training2. Supportsystemsandsupervision3. Simpleformatsandreports4. Assessmentandfeedbackprocesses5. Clarityonthereportingandmonitoring processes6. Learning,sharingandcareergrowth opportunity7. Recognitionandrewards.


Continuing Education, skill up gradation and integration: Inthefuture,this critical support mechanism will be integrated into the NRHM processandscaleduptootherpartsof thestateandhealth facilities. In turn, theircapacitybuildingactivitiesneedtobegivenanorganizedstructureunderthestate trainingmechanism such as SIHFWor another appropriate institutionalmechanism.However,thedistrictmustensurethatapooloftrainersareavailablewithinthedistrictbybuildingthecapacityofANMTCs,whocanstrengthenthecontinouslearningprocessesofYashodas.

6.1.1PreparationfortrainingofYashodal Identification of trainers:Thetrainerswillbeidentifiedfromamong themedicalandnursingstaffofthehospital,thenearestnursing college,andANMtrainingschool.

Nursing staff and experienced ANM should be used as core trainers.

Include counsellors, to build counselling skills of Yashodas.

l Holdoneinitialplenarymeetingwiththefacilitators/trainers/resource personsbeforehandsotheyunderstandtheoverallrequirementofthe programandthecontents.

l ProvidethemwithanoverviewofYashodaconceptnoteandexplain theexpectedrolesandresponsibilitiesofYashoda.

l Makedecisionsonvenue,food,andhandoutmaterials,trainingaids andotherlogisticsarrangements.

l Getthenecessarybudgetapprovedandgovernmentlettertoconcerned personforparticipation.

l Havecoretrainerspreparetrainingschedulesfortheirrespective districts.

6.1.2Developmentoftrainer’smanual/facilitator’sguidel Alltherequiredtrainingmaterialshavealreadybeendevelopedduringthepilotphase,undertheguidanceofcompetenttechnicalexpertandotherpartnersattheStatelevel(SIHFW,Medicalcollege/Nursingcollegeanyotherspecializedagencies)fieldtested,translatedinlocallanguagesandavailableforuse.

l Thechildhealthsupervisorsshouldensurethattheavailablematerialsareusedasmuchaspossibleandmakelocaladaptationsasrequired.

CapacitybuildingactivitiesneedtobegivenanorganizedstructureunderthestatetrainingmechanismsuchasSIHFWorotherappropriateinstitutions.ThedistrictsmuststrengthentheANMTCsaspartofresourcepoolwiththedistrict.


6.1.3MakingtrainingpracticalKeepinginmindthatYashodaisanon–clinicalsupportworker,thetrainingmaterialshavebeenprepared.Therefore,themethodologyshouldbepracticumbasedandparticipatory.Thetrainingmethodologyshouldfocusonbothtechnicalcontentofthecounsellingaswellasthecommunicationaspects.Yashodastobetrainedtousetheflipbookappropriatelywhileinteractingwiththemothers

6.1.4Documentationofthetraining/trainingreportThetrainingsmustbewelldocumentedtomakeappropriatechangesinsubsequenttrainings.Thedocumentationshouldclearlymention:Relevanceofcontent,usefulnessofthetraining aids andmethodology, what additional information could be introduced, duration, meeting theexpectationsoftheparticipantsandachievingsessionobjectives.TheChildHealthSupervisorortheseniornursewill prepare an evaluation of the trainings and analyze them as ameans to improve the quality oftraining.

6.1.5TrainingoftrainersTheYashodainterventionhasbeenscaleduptocovertheentirestateinRajasthanandBihar;15ofthe30districtsinOrissaandselectedCHCsinthefocusdistrictsofMP.Thisrequiresthatapoolofdedicatedtrainersareavailableineachdistrict,toensurethatYashodacapacitybuildinghappensinansmoothway.TheStateprogramunitneedtoidentifyteamof3trainersfromeachdistrict,preferablyamedicaldoctor(gynecologist,a nurse, and a counselor). A three day training of trainers program would be essential to bring them tounderstandtherolesofYashodaanddevelopthetrainingmethodologyusingparticipatoryapproaches

6.1.6OrientationtrainingThis isnotenvisagedtoimpartdetailedknowledge,butdesignedtoorientthenewlyrecruitedYashodatobecomeconfidenttoworkinthehospitalcontext.TheorientationshouldbeprovidedwithinthefirsttwoorthreedaysofjoiningoftheYashoda.Thiswillbeforamaximumof2daysandhalfofthesessionsmustbeconductedinthewardforpracticallessons.Theobjectivesinclude:

l To become familiarwith the hospital environment, themedical, nursing and other paramedical staff,labourroom/ward,laboratoriesandotherfacilitieswithinthehospital.

l Toorientthemwithbasicinformationonnewborncare,breastfeeding,supplementalnutrition,postnatalcareofthemothers,counsellingonimmunization,andpossiblebirthspacingoptions.

6.1.7InductiontrainingThepurposeofconductingtheinductiontrainingafter2-3monthsofjoiningtheYashodateamistoprovidethemwithbasicinformationandskillstohandlethejobwell.ExperiencehasshownthatthetwomonthsofworkexposurehelpYashodastounderstandandparticipateinthetraininginamorepracticalway.

6.1.8RefreshertrainingTwodayrefreshertrainingmustbeconductedafter6monthsofworkexperience.ThesupervisorswouldhavegatheredgoodunderstandingoftheskillsandcompetenciesofeachYashodaandwillbebaletoguidethembetterduringtherefreshertraining.TheStateprogramunitneedstoensurethatappropriaterefreshertrainingmaterialsareprocuredandthedistrictleveltrainersareavailabletoconductthetrainings.


6.1.9Onthejobtraining/continuingeducationBuildingskillsofYashodaisacontinuousprocessandnotaonetimeeffort.

Organizingstructuredtrainingregularlyisexpensiveandtimeconsuming.Forcontinuousperformanceimprovement,alearningenvironmentneedstobecreatedwithintheworkplace.ThesupervisorsmustensurethatonthejobtrainingsarestructuredbasedontheneedsoftheYashodaseverymonthandthecontentarebalancedtoprovidetechnicalinformationalongwiththeskillbuilding.

TheprimaryresponsibilityoftheYashodabeingcounselingthemothersonvariousaspectsofnewborncareandcareforself,thecontinuouslearningsessionsshouldfocusonimprovingcounselingskillsoftheYashodas.

Inadditiontothechildhealthsupervisors,staffnurses/seniornursespostedatthefacility,doctors (paediatrician and gynaecologist), nursing tutor, family planning counsellors, nutritioncouncelors,RCHcounsellorsandpublichealthnursesshouldbe invitedasresourcepersonsforthecontinuouslearningsessionsanddemonstrations.Atleasttwosessionsinamonthforadurationof1,5to2hoursneedtobeorganizedtowardsthis.

Thedoctorsandnursesareexpectedtoprovidecommentsontheprogress/competencyoftheYashodatothesupervisorsduringthewardrounds.

The child health supervisor or the deputy child health supervisor must note down the feedback/comments/suggestionsgivenby thedoctors onperformanceof Yashoda and take action to ensurequalityimprovement.

l The selection of the topics should be based on the feedback given by the gynaecologist/paediatrician and mothers along with supervisors’ observation of the quality of counselling byYashodas.

l Analysisofthefilledpreandposttestformatandinterviewswiththemothersaretheothertoolsthatcouldhelptochoosethetopics.(Seeannexureforpreandposttestformat)

l TheCHSandDCHSshoulddiscusswithYashodasonaregularbasistoidentifyissuesfacedbythemduringtheirinteractionwiththemothers,documentandusetheminthetrainingforpracticalexamples.

l EachsessionhastoberepeatedtwicetoinvolvealltheYashodas,takingintoaccountthedutyshifts.

l TheCHSmustsendtheidentifiedtopicsforthecurrentmonthandproposedforthefollowing month with names of the resource persons in her monthly communication to the Stateprogramunitandseektheirfeedbackandinput.


Managing Yashoda trainings –Role of State Program Unit

l MakeatrainingcalendarforentirerangeoftrainingsfortheyearbrokenintoquartersandsharewiththeSecretariat.

l Developachecklistformonitoringofthetrainingasplannedandidentifylocalresourcesformonitoringthequalityofthetraininginconsultationwiththedistrictadministration.

l Developalistofpooloftrainersfromthedistrictandensuretherightmix of trainers is available for all trainings including counsellors; review thesuitability of the trainers to modify the content and deliver the training asrequired.

l CoordinatewiththeDistrictChildHealthManager/DistrictMaternalandChildHealthCoordinators/DPMforalllogisticsandconductingthetraining.

l Ensurethattheappropriatetrainingmaterialsareavailablewithyouinadvance.

l Establish amechanism to ensure that the trainings are conducted asplannedandassessthequalityoftraining(E.g:externalmonitoring/DCHM)

l EnsurethattheChildHealthSupervisor(CHS)orDeputyCHSdocumenttheprocesses(includingpreparation,trainers,content,schedule,methodology,whatworkedandwhatdidnotwork,shortcomings,learning)andshareitwithNSPU.

l EstablishasystemforreceivingandsendingfeedbacktotheDCHM/CHSregardingthetrainingconductedbyanalyzingthereport.DevelopamethodologyforgettingfeedbackfromtheYashodasontheusefulnessofthematerialsandmethodology

l Assess periodically and update the requirement of training and IECmaterialsrequirementandplantheprocessofprocuring/producingthem

l Basedon the analysis, identify those facilitieswhere Yashodaswouldrequireadditionaltrainingandplanforit.


6.1.7PeriodicInternalAssessmentandfeedbackItisessentialtoassessthetechnicalknowledgeandcounsellingskillsofYashodaevery sixmonths, to gaugewhether shehas acquired the expected standard tofunctioneffectively.Thiswillbeausefulinputfortherefreshertrainingaswell.

Towardsthis,theChildHealthSupervisorneedstocoordinatetheassessmentprocess.ThiscouldbeconductedbythenursematronandtheANMTCtutors,preferablyby thosewhohadprovidedthe inductiontraining.Theassessment toolswillbeprepared in consultation with thenursematronat the facility. Theassessmenttools will target both knowledge and skills related to the various componentsincludingnewborncare,mothercare,andbreastfeedingsupport,counsellingforcareafterdischarge,feedingpractices,familyplanningoptions,immunizationandgeneralsupport.(See annexure for suggested criteria for assessment)

Feedback and recognition: Itiscriticalthataftereachassessment,allYashodasmustbegivenfeedbackontheirperformanceandindicateaspectsofstrengthsandweakness.

StateProgramManagementUnitshouldensurethattheSupervisorsareadequatelytrainedingivingfeedbackappropriately.

It is likely that some Yashodas perform better than the others. A system formonitoringtheperformancemustbeestablishedbythechildhealthsupervisor.

ThepurposeandcriteriamustbeinformedtoYashodaswithtransparency.

Incaseofperformancebelowtheexpectedlevel,Yashodamustbeinformedduringthemonthlymeeting.Additionallyduringtheonthejobtrainingsessions,thosepoorlyperformingYashodasshouldbegivenmoreattentiontobringthemonparwiththebetterperformingYashodas.

In caseof consistentpoorperformance, thehospital competent authoritieswilldecideonstrategiesforretaining/removingtheYashodas.Inthesametoken,wellperformingYashodasshouldberecognizedandorrewardedintheHospitalmonthlymeetingschairedbytheCDMO/CMHOandintheward.Thiswillbeabigmotivatingfactortothevoluntaryworker.

6.1.8Refreshertraining

This training is planned to be held after 3-6months of the induction training,aimed at providing an intensive revision of the technical and practical aspectsrelatedtotheirwork.TheDistrictleveltrainerswillconductthistraining.TheChildHealthSupervisor(CHS)andtheDeputyChildHealthSupervisor(DCHS)willalsobetrainersandcoordinatetheentireprocess.

Itiscriticalthataftereachassessment,allYashodasmustbegivenfeedbackontheirperformanceandindicateaspectsofstrengthsandweaknesses.


7 Supervision

7.1 Overall supervision OverallsupervisionisprovidedbytheADMO/medicalsuperintendentidentifiedbytheCDMO/CMHO/PMOinthedistricthospitalsasthecasemaybeineachstate.InthecaseofCHCs,theRCHOcouldprovidetheoverallleadershiptomanagetheintervention

Thisincludes:

l Yashodaengagement, approvalofpaymentnorms, and incentivedisbursal, purchaseof thesuppliesandconsumables,monthlyprogressreport,regularperformancereview,grievanceredressalandrelatedadministrativematters.

l In the NIPI focus districts, the District Child Health Managers/Maternal and Child HealthCoordinatorswillassisttheADMO/MedicalSuperintendentindischarging/coordinatingalltheabovefunctionsanddaytodayoperations.

IndistrictsotherthantheNIPIfocusdistricts,theHospitalManagersorapersonidentifiedbytheCMHOcouldberesponsiblefortheabove.

7.2 Child Health Supervisor (CHS) and Deputy Child Health Supervisors (DCHS)YashodasaresupervisedandsupportedbytheChildHealthSupervisor(CHS)andtwoDeputyChildHealthSupervisors(DCHS)sothat foreachshiftthereisonesupervisoravailable.TheYashodainterventionisintheinitialstagesandthereforerequiresintensivesupervisorysupport,especiallyinfacilitieswhichhaveshortageofnursingstaff.ThepositionoftheDCHSisatemporaryonetogiveintensivehandholdingfortechnicalissuestotheYashodasinthefirstyear.AstheYashodasgaincompetencyandtheYashodaprocessgetsembeddedinthehospitalsystemthispositionwillbephasedout.TheDCHSareselectedthroughadistrictprocess.

Yashodainterventionrequiresaskillmixthatbringsabalanceinthemanagementandtechnicalsupervisionandsupport.Accordingly, it is suggestedthat theDCHSwillbe fromthe nursingstream,preferablyaretirednurse/ANM/LHV;becauseoftheirunderstandingofthefunctioningofthehealthsystemandcanbegintosupporttheYashodasfromdayone.TheCHSontheotherhandrequiresmoremanagerialskillsandcouldbefromthesocialsciencesbackground.


7.3 Child Health Supervisor

TheChildHealthSupervisorhastheoverallresponsibilitytomanagetheinterventioneffectively.CHS also functions as shift supervisor and need to be located in the ward.WhilesheprovidescertainsupporttotheDCHMandDPM,her primary responsibility is in the wardandprovidingoverallsupervisionfortheintervention.

TheCHSisexpectedtodoatleastoneortwonightshiftsinaweek.TowardsthatincooperationandsupportfromtheDCHSandwardnurse,shewill:l DevelopanactivitycumprogressreportforthequarterandshareitwiththeStateprogramunit.l SendmonthlyprogressreporttotheStateProgramManagementUnit.l PlanwiththeDCHSandwardnurseforthemesforYashodaonthejobtraining,coordinatethetrainingandensurethescheduleiscompleted. l Overseethatthedutyrosters,attendanceandleaveregistersofYashodaaremaintainedproperly.l VerifythedailyrecordsheetfilledbyYashodaandcrosscheckedbytheDCHS.l Preparethemonthlysummaryattendancesheetforpaymentofincentiveandsubmitvia(as applicable in the respective state)theDistrictChildHealthManager/theDistrictAccountsManagerforapprovalofthePrincipalMedicalOfficer/ChiefMedicalOfficerandprocessedbyRogiKalyanSamitiAccountant.l FollowupontimelypaymentofincentivetoYashodaandmatron/nurse. lLiaisewiththehospitalmanagerandotherhospitalauthoritiesforensuringsupportservicesfortheYashodaincludingspaceandtoiletfacilities.l Ensure that Yashodas are not assigned duties by the nurses, , for which they are not trained and in particular, clinical work by the nurses or doctors. In instances where such duties are assigned , CHS must take it up with the Matron and correct the situation.

l EstablishanofficialgrievanceredressalprocesswiththeCDMO/CMHO.l Establishaformalmechanismwiththehospitalmanagerforsortingoutdaytodayissuesinthewardmaintenance.l CollatethedailyreportswithassistancefromtheDCHSandanalysethesameforprogressanddeficienciesforfurthercorrectionandaction.(e.g:Ifyoufindthatthereisconsiderabledifferenceinthenumberofbabiesreceivingzerodoseimmunization(polioandBCG)visavistotalnumberoflivebirths,itrequiresimmediateaction)l InterviewtwomothersonaweeklybasisusingaquestionnairetounderstandthelevelsofclientsatisfactionandensurethattheDCHSconductssimilarinterviewswithtwoothermothers.CollatethereportandusetheinformationinthemonthlyreviewmeetingbytheCDMO/PMOasthecasemaybeandsendcopyofthereporttotheStateProgramManagementUnit.l ParticipateinthemonthlyreviewmeetingheldbytheChiefMedicalOfficer/PMOandhighlighttheimprovementinnewborncareservicesbyYashodasbyusingmonthlyreports.


l Ensurethatthecapacitybuildingeffortsincludingtrainingstakeplaceasplanned.

l EstablishamechanismincooperationwiththeChildHealthManagerandStateProgramManagementUnitforperformanceassessmentoftheYashodasandDCHS.

l MonitorperformanceofYashodainconsultationwithwardnurseandDeputyChildHealthSupervisors.

l OrganisestructuredmeetingswiththeDCHSstogetfeedbackonYashodaperformanceandissuesthataffectthequalityofservice.

l EstablishasysteminconsultationwiththeCDMO,DCHMandNIPIStateProgramUnitforassessingperformanceoftheDCHS.

l Suggestaspectsthatcanbeimprovedusingtheuntiedfundsandsendtheproposalviathehospitalmanagerortheappropriateauthorityforapproval

l Participate in district PIP planning meetings and give input related to newborn careissues

Leave for the CHS:

TheChildHealthSupervisorisrecruitedunderNRHMprocedureandalltheleaveruleapplicableforNRHMcontractualstaffwillbeapplicableintheircaseaswell.WhileCHSinteractsdirectlywithCDMO/CMHO/PMOandgetherleavesanctioned,shemustinformthematronregardingtheleaveandmakeappropriatesupervisoryarrangementswiththeDeputyChidHealthSupervisorsandDCHM.

Supervisionisacoordinatedeffort

l Supervisingtheinterventionisateameffort.CHSandDCHSneedtoenlistthesupportandcooperationofthehospitalmanagerandnursesinastructuredway.

l TheYashodasareatthelowerendofthedecisionmakingchain,anddonothavetheauthoritytomakethesystemwork.Butbycreatingcertainprocesses, Yashodas can be empoweredwhich in turnwill facilitatebetterqualityofcaretothenewbornandmakethemanagementofthematernitywardmoreefficient.

l Developachecklistrelatedtodaytodaymanagementoftheward(e.g:privacyandcleanlinessinlabourroom,ward,visitinghours,garbagecollection timing, disposal facilities, security, functionality of thetoiletandwateravailability).

Train Yashodas to record information related to the above on a printedregister,whichcouldbetakenupfordiscussionwiththehospitalmanagerbyDCHS/CHSforwardimprovement.


7.4. Deputy Child Health SupervisorForensuringsmoothfunctioningandeffectivetechnicalsupervision itisproposedto have two Deputy Child Health Supervisors. They, apart from assisting the CHS foreffectivesupervisionandmentoringoftheYashodas,willalsoensurethatYashodasgetappropriate supportwithin theward.The twoDCHS in turndodayandnight shifts tosupervisetheYashodas.Thispositionisvisualizedasatemporarypositionforaperiodofoneyear.Thestatesmayreviewthevalueadditionanddecideonextentionofthepositionorotherwise.

They have the responsibility to:

DevelopamonthlyworkplanbasedonthequarterlyworkplandevelopedbytheCHS

l BewiththeYashodasinthewardandprovideonthejobsupervision.

l SupportYashodasbothbywayofdemonstrationandteaching,especiallyforsupportingbreastfeeding,takingsicknewborntodoctorornurse,andcounsellingmothers.

l EnsurethattheYashodasaregivingcorrect,gendersensitive,andcompletemessagesto themothers on newborn care and care for self. Also ensure that the Yashodas areobservantthatnodiscriminationtakesplacewithintheward.(e.g:willfullnegligenceoffemalechild,notimmunizing,notbreastfeeding,abandoningthegirlchildetc.)

l DevelopthedailydutyroasterforYashodasandmaintaintheattendanceregister.

l EnsurethateachYashodaunderstandstherationaleforfillingthedailyregisterandtheformatiscompleted.

l AssisttheCHSforcollatingthedailyregisterdataforpreparingthemonthlyreport.

l OrganiseonthejobtrainingasplannedinconsultationwiththeCHSandnurse.

l ReviewperformanceofYashodasonanongoingbasisandgivefeedbacktotheYashodasandCHS.

l Getfeedbackfrommothers/families.

l Ensure the required logistics and administrative support in cooperation with thenurses.

l HelptheYashodastodocumentsomeoftheexperiencesintheward.(e.g:savingtheunderweightnewborn;helpingmotherandfamilymemberstogiveupsomeharmfulnewborncarepractices;advocacywiththemalemembersforkangaroocarefornewborn)

l ProvidesupporttothehospitalforimmunizationofnewbornonSundaysandHolidaysasguidedbytheCDMO/CMHO.

l AnyothersupportrequiredbytheCHS/Yashodas/Wardnurse.


The role of the Deputy Child Health Supervisors may besummarizedasfollows:

Daily Activities

l Supervision of Yashoda work including counselling; attendance andcheckingqualityofdailyrecordfillingbyYashodas.

l Interactionwith thewardnurse for ensuring support services for theYashodas.

l MonitoringthedutyassignmentoftheYashodasarelimitedtothenonclinicalfunctionsonly.

l SkillbuildingofYashodasthroughdemonstration.

l Applicationofposttestformat.

l Supportingthewardnurseasrequired.

l Takingupoperational issueswiththehospitalmanagerandCHSonadailybasisforimprovement.

Weekly Activities

l Interviewingofthemothersonasamplebasis.

l Collatingthedailyreport.

l ChecktheprogressvisavisthemonthlyplananddiscusswiththeCHS.

l OnceintwoweekscollatethepreanposttestformatresultsandshareitwiththeCHSforanalysis.

Monthly Activities

l AssistingtheCHSinmakingthemonthlyreportforreviewbyPMOandsendingittotheStateProgramManagementUnit.

l AssisttheCHSforcollatingtheattendancesheetforincentivepaymentoftheYashodas.

l DiscusswithCHSontheperformancequalityandprogressoftheYashodasandassistinperformanceassessment.

l AssisttheCHSinidentifyingtopicsandresourcepersonsfortheonthejobtrainingoftheYashodas.

l HelpingtheYashodastodocumentsomeoftheexperiences.


Managing Supervisors-Role of State Program ManagementUnit

l Facilitate the development of an annual work plan by the CHS broken intoquarterlyactivities.

l Establishmechanismfortrackingtheactivitiesandprogress.

l FasttracktheappointmentoftheCHSandDCHSbyrigorousfollowupwiththeState/DistrictHealthSocietieswhereitisstillinprogress.

l EnsurethatDCHShavecounsellingskillsandarewillingtodonightduty.

l MakeacomprehensivetourplanforeachfacilitywithdeliverablesduringeachvisitandshareitwiththeCHS.

l Makeatripvisitreportgivingclearobservationpoints,progress,gapsandnextstepsandshareitwiththeCMHOandgivefeedbacktotheCHS.

l EnsurethattheSupervisorstrainingsarescheduledasplanneddocumentedandreported.

l Develop a annual performance assessment process for DCHS and CHS inconsultationwiththeCDMO/CMHO.

l During your visit to the facility have formal interaction with the hospitaladministration, the CHS, hospital managers, DCHM and DPM for sortingadministrativeorlogisticsproblemsforYashodasandsupervisors.

Leave for DCHS: DCHSarecurrentlygettingonedayoffineachweek.BeingahospitalbasedpositionthedecisionregardingadditionalleavemaybemadebytheCHMO/RKS.

Assessment of Performance of supervisory cadre:

TheassessmentoftheDeputyChildhealthSupervisorhastobeundertakeneverysixmonthsandconductedveryobjectively.TheStateProgramManagementUnitneeds to develop the appropriate tools in consultation with the CHS and thehospitalteamforsuchassessmentwiththeinvolvementofexternalmembers.

Performance assessment of the CHS: Thought the CHS appointment is done bythe NRHM, and annual performance review is carried out, programmatically asystemforassessingtheirperformancemustbeestablishedbytheStateProgramManagementUnit(SPMU).Thetoolsmaybedevelopedinconsultationwiththehospitalteam,DHSandSHS.


Monitoring88.1. Record keeping and reporting

A daily record register will be filled and signed by all the Yashodas working in the three shifts to havecontinuityintherecord.ThiswillbecheckedandsignedbytheDeputyChildHealthSupervisoreachday.TheChildHealthSupervisorsmustensurethattherecordisfilledbytheYashodaintheirrespectiveshiftsinadaytohavecompletedataoneachmotherandnewborn.(See annexure for record format).

l Toensurequality,CHSmustmakesurethatYashodasunderstandtherelevanceofeachcolumnfilledandimportanceofrecordingthedata.Thesamewillalsobeusedfortrainingthemandtoinformthemoftheircontributioneachweekduringfeedbacksession.

Pre and post feed back form:

ThistoolapartfromgivinginformationonclientsatisfactionwillalsobeusefultounderstandeffectivenessofthecounselingbyYashodasinimprovingtheknowledgeofthemother.Thiswillhavesetofquestionsdividedintwoparts.Yashodaswilladministerthefirstparttothemotherpriortodeliveryorwithinfourhoursafterdelivery.ThesamequestionsgiveninthesecondpartwillbeaskedbytheDeputyCHSortheCHSpriortothedepartureofthemother,whoisexpectedtohavereceivedcounselingfromYashodas.

Thefeedbackformwillspecificallycollectinformationfromi)mothershavingfirstdeliveryand(ii)mothershavingsubsequentdeliveries.TheChildHealthSupervisorswillcollatetheinformationonfortnightlybasisanda)shareitwiththeDistrictChildhealthmanagerandnursingstaffandb)usetheinformationformentoringtheYashodaandc)seekingsuggestionforimprovementfromtheheadnurse/matrontoimprovequality.(see annexure)

While the above are hospital level processes, a state level scaling up requires rigorous follow up of theimplementationateverylevelandappropriatelytrainedpersonnelatthedistrictandblocklevelhandlethemonitoringeffectively.Whilethedaytodaymonitoringismanagedbythetrainedmanagers,establishmentofastatelevelstructuretomonitortheimplementationfromthepolicyperspectiveisimportant.

AsaprocessofcontinuumofcarethedistrictASAHcoordinatorcouldhavetheleadresponsibilitytomonitortheimplementationatthedistrictlevel,ablysupportedbythechildhealthsupervisor,districtmaternalandchildhealthcoordinator.AttheBlockleveltheBlockmaternalandchildhealthcoordinatorcouldtakeuptheresponsibilitytomonitortheYashodaintervention.


8.2. Informal community monitoring of quality care at the facility-Involving clients: Local Women’s Visiting Group for social auditing

Several potential outcome are expected out of the Yashoda interventions includinglongerdurationofstayofmothers,moremothersinitiatingimmediateandexclusivebreastfeeding,improvedimmunisation,increasednumberofmothersgetinformedonbasicnewborncare,nutritionandfeedingpractices,increasedutilisationofoutreachservicessuchasimmunization,referralservicesetc.inthosevillagesthatutilisetheservicesofthehospital.Theinterventionismonitoredatdifferentlevelsinthehospitalforachievingtheseexpectedoutcomes.

Itisrecommendedthat,involvingthecommunityininformalmonitoringoftheservicesperiodicallywillbringvalueadditiontotheprocessbywayofenhancedownershipandinformalpromotionofthehospitalservices.Thiscouldbefacilitatedbyestablishingaprocess,whichengagesagroupoflocalwomentovisitthehospitalperiodicallyandinteractwiththemothers,Yashodasandthenursesonthevariousissuesrelatedtocaregiventonewbornandthemothers.Thiswillgivethemachancetoseethehospitalsbythemselves,observetheimprovements,maketheirsuggestionsinthevisitor’sregister,thereby contributing to promoting improving quality of services. The first VisitorsCommitteecouldstartwiththeDistrictCollector’spouse/prominentwomanmemberofZillaParishadastheChairperson.

While this group does not have any legal position, they carry the goodwill of thecommunityandcouldcontributetoenhancedcommunityappreciationoftheeffortsofthehospital.TheDistrictHospitalauthoritiescouldexploreestablishingthismechanismby inviting a mix of women Panchayat members/self help groups/village sanitationcommittee, from the villages to visit the hospital periodically. This event could befacilitatedbytheDistrictChildHealthManagerbyprovidingtheappropriatebudgetandlogisticsarrangements.


Managing monitoring processes-role of State ProgramManagementUnit

l Ensurethatthemonitoringmechanism,reportingrelationshipandmethodsarecommunicatedtotheCHS,DCHMandDPMwithoutambiguity.

l Make a schedule for receipt of the various reports related to Yashodainterventionfromthefacilitiesandforforwardingthesametothestate.

l GivefeedbacktotheCHSandDCHSontheprogressandplanthesupportyoucangiveforimprovingperformanceasrequired.

l KeeptheCDMO/ADMO/DPMintheloopforreceivingmonthlyYashodareviewmeetingreportsaswellassharingprogressreports.

l Dialogue with the State Health Society for incorporating the YashodaindicatorsinthestateHMIS.

l Ensurethatasocialauditingoftheprocessesthroughlocalwomen’sgroupisestablishedandappropriatebudgetiskept.


9Institutional mechanism

9. Institutional mechanism: Within the Hospital:

Yashodagetsbothadministrativeandlogisticssupportaswellastechnicalsupportfromthehospitalteam.Ondaytodaybasis,sheissupervisedandmonitoredbytheCHSandmentoredbytheDCHS/thenurse/matron.TheCHSsareresponsibleforalltheadministrativeandlogisticssupportandsupportivesupervisiontotheYashodaandactsasmentor.ThenursesprovidetechnicalguidancetoYashodaduringregularwardrounds,givefeedbackonYashodaperformanceandsupportthesupervisorontheadministrativeaspects.

The medical officers (Paediatrician and Gynaecologist) support Yashoda capacity building through hands ontrainingandfeedbackduringwardroundsonadaytodaybasis.TheMedicalSuperintendentandDPMU(throughthehospitalmanagerandtheDistrictChildHealthManager)togetherprovideoverallsupervisionandmanagementsupporttotheChiefMedialOfficer.

At State level:

Formanaging the expansion to cover the entire state requireswell established institutionalmechanism thatwouldbeconstantlyassessingthe interventionandprovidingpolicyandother requiredsupport. SPMUmustensurethatthemanagementstructureisclearlyarticulatedandrolesandresponsibilitiesatthevariouslevelsarecommunicatedeffectively.Forexample,InordertostrategicallylinktheYashodaprocesstotheASHAprocessandinstitutionalizetheYashodaprocess,theStateASHACoordinatorcouldbethestatenodeforcoordinatingtheYashodainterventionandre-designatedasASHA–Yashodacoordinator.

The SPMUhas the additional responsibility of ensuring that the administrative and program implementationguidelinesandofficeordersorganizedanddisseminatedtothefieldwithoutanydelayandprovideclarificationsnecessaryincaseofambiguity.

InadditiontothestatelevelmechanismsuchasStateCoordinationCommittee,appropriateinstitutionalstructuremustbeestablishedatthedistrict/blocklevelandevenatthefacilitylevel.Forexample,thoughCMHOistheoverallsupervisorandRKSisthedecisionmakingbodyatthefacilitylevel,bothhaveinadequatetimetogetinvolvedinthedaytodaymanagementoftheYashodaintervention.Formationofahospitalcommitteeatthedistricthospitalwiththematron/seniornurse,Districtmaternalandchildhealthcoordinator,hospitalmanagerandYashodachildhealthsupervisorwillenabletheYashodasandsupervisorstoknowtheirfocalpointwithinthehospitalforgrievanceredressalanddaytodayoperationalsupportrelatedtoimplementation.

Expansiontocoverthestatealsorequiresspecialskillsformanagingthebudgetandleveragingtheresources.Aspecificnodalfinancepersonatthestatelevelmaybeengagedtomanagethefinancesincluding,calculatingtheoverallinterventioncost,trackingexpenditure,documentingthepaymentofincentiveprofile,useofuntiedfundsandbuildinglocalcapacitytounderstandthemanagementofthefinanceaspects.


Annexures

Annexure:Yasoda Daily Reporting Format

SlNoName&Address Age Parity BPL(Y/N)

Date&TimeofAdmission(tohospital)

Date&TimeofDelivery

Livebirth/Stillbirth

SexofBaby

WeightofBaby

Typeofdelivery(NormalorCeasarian)

1 2 3 4 5 6 7 8 9 10 11

SignatureofYasoda

AnyproblematBirth

Date&TimeofinitiationofBreastFeeding

Vaccination(PolioorBCGorBoth)

Date&TimeofDischargefromhospital

Counsellingtomother(Y/N)

Durationofstay(Hours)

AnyproblemwithBaby

AnyProblemwithMother

SignatureofDYCHS SigofCHS

Remark(Referral/returned/Death/others)

12 13 14 15 16 17 18 19 20 21 22

SignatureofYasoda

YasodaDailyReportingFormat


Annexure: Yashoda duty roster /work schedule - Rajasthan model

Date Days Shifts of YashodaMorning Evening Night Rest

1 Monday Yashoda1 Yashoda2 Yashoda3 Yashoda4

2 Tuesday Yashoda4 Yashoda1 Yashoda2 Yashoda3

3 Wednesday Yashoda3 Yashoda4 Yashoda1 Yashoda2

4 Thursday Yashoda2 Yashoda3 Yashoda4 Yashoda1

5 Friday Yashoda1 Yashoda2 Yashoda3 Yashoda4

6 Saturday Yashoda4 Yashoda1 Yashoda2 Yashoda3

7 Sunday Yashoda3 Yashoda4 Yashoda1 Yashoda2

























Thischartshowshowtheworkdistributionisequalforallandadequate rest is given to allYashodas.

Note: On day one a set ofYashodas will get rest eventhough theyhavenot startedthework.Itwillgetadjustedasthedaysgoby.

On day 2, the morning shiftpersonwilldoeveningandtheevening person will do nightand the night person getsrest. The cycle gets repeatedin the same sequence for theremainingdaysofthemonth.


Annexure:Suggested Criteria for Assessing the Performance of Yashoda1. General

l Attendance,punctuality,personalcleanliness

l Alertnessintheward

l Abilitytomanagethecrowdinthewards

l Ensuringcleanlinessinthewardincludingthetoilets

2. Behaviour

l Groupdynamics–workingwithYashoda/Peers

l Friendlinessandinteractionwiththewomenadmittedinthewardandtheirfamily

l Interactionwiththenursesandotherhospitalstaff

3. Technical knowledge

l Postpartumcareofmother

l Assistinginbreastfeeding

l Basiccareofthenewbornanddangersigns

l Immunization

4.Skills acquired

l Wrappingthebaby,temperaturereading,cordcare

l Assistinginbreastfeeding

l Counselingskills

5. Communication Skills

l Abilitytocommunicateverballytothemotherandherfamily

l CommunicationwithotherYashodas,supervisorsandnurses.

l AbilitytoclarifydoubtstomotherandappropriateuseoftheBCC/IECmaterialswhilecommunicatingwiththemother

6.Reporting

l Regularity,clarityofreportingandcomprehensiveness


Annexure:

Pre and Post Evaluation of Yashoda's Role Rajasthan Model


Annexure:Yashoda Tasks Frequency Activities

Every2-4hourlyduringtheshift

l Checkandassistinstartingbreastfeedingwithin30minuteafterdelivery

l Assistthemothertokeepthebabyclean,dryandwellcovered

l Checkthatthewardisnotcrowded

l Checkifanynewpregnantwomanisadmittedandassistinregistrationandbedpreparation

l Checkbreastfeedingofeverynewbornandassistmotherforsuccessfulbreastfeeding

l Checkthetemperatureofthebabyandrecord

l Ensurethatthenewbornisnotgivenanyfeedotherthanthebreastmilk

l Checkthepadofmotherforbleeding

l Checkthetemperatureandgeneralstatusofmother

l Recordtheparametersformother

Dailyroutineactivities

l Takeoverfromtheearliershift

l InteractwiththeCHSabouttheprogressandproblems

l Accompanythedoctor/nurseduringclinicalrounds

l Followtheinstructionsgivenbynurse/doctor

l Checkthecleanlinessofthewardandtoiletandtakenecessarystepstoensurecleanliness

l Completethereportingsheetwithinformationoneachdeliveryincludingstillbirthandverifywiththenurse’sregisterforaccuracy

l HandovertotheYashodacominginnextshiftabouteachofthebabiesandmothers

l Checkiftheformforbirthregistrationisfilledproperlyforeachlivebirth

l Ensureimmunizationofthebabiesbeforedischarge

l Checkbreastfeedingstatusofeachnewborn

l Basicassessmentofthenewbornandinformifanyproblemnoticed

l Counselmothersonbreastfeedingandbasicnewborncare

l Ensuremothersandtheirfamilymembersarecounseledaboutmother’sdiet,rest,andcontraception

l Basicassessmentofthemotherforproblems

l AssistmothersingettingtheJSYentitlement

Incaseofemergency

l Informthenurse/doctor

l InformCHS

l Takenecessarybasicstepsasdemonstratedduringtraining

l Followtheinstructionsofthenurse/doctor

Foradministrative/incentive/logisticsrelatedissues

l InformCHSandfollowtheinstructions

l MaycontacttheMedicalSuperintendent,HospitalManagerorDCHSdependingonthematter


Annexure:Incremental Technical Input for Yashoda

After a week At the end of the first month

By the third month At the end of six months

l Hospitalstaffandservices,andfacilitiesincludingwards,laborroom,OT,Laboratory&admissionprocedure

l Understandabouttheirrolesandresponsibilities

l Befamiliarwiththerulesandregulationsofthehospital

l Befamiliarwithsomeoftheessentialaspectsofnewborncareaspertheinitialorientation

l Howtoassistthemotherinadmission,registration,andbedpreparation

l Basicpreparationofthepregnantwomanbeforeshegoesintothelaborroom

l Basicnewborncare: -Temperature

maintenanceandwrappingthebabyappropriately

-Cordcare -Keepingthebabydry,

cleanandwarm

l Basiccareofthemother

-Changethepads -Diet

l Checkingtemperatureofthebabyandmother

l Countingrespiratoryrate

l Supportthemothertostartbreastfeeding

l Whentocallthenurseordoctorforassistance

l Acquirecompetencyinassistingandcounselingforbreastfeeding

l Addressbreastfeedingproblems

l Identifydangersignsinthenewborn

-HypothermiaIdentificationandcare

-Respiratorydistress -Jaundice

l Careofthelowbirthweightbaby

-Feedinglowbirthweightbabies

-Kangaroomothercare

l Counselthemother -Aboutcareduring

immediatepostdeliveryperiod

-Diet,rest,contraception

l Adviceatdischarge -Informationon

contactpersonforfollowupandinemergency

-Immunization,exclusivebreastfeeding,supplementaryfeeding

Gainskillsinaddressingalltheaspectsmentionedsofarandadditionally:

l Identifyneonatalsepsis

l Careofsicknewborn

l Measurepulserateofthemother

ekfld izfrosnu ¼;'kksnk ;kst

uk½

ftys dk uke ----------------------------------------------

;'kksnk LohÑ

r-----------------------

;'kksnk izf'kf{kr -----------------------

laLFkku dk uke---------

o"kZ------------ ekg---------

;'kksnk dk;Zjr---------------

¼vkeq[khdj.k@

izf'k{k.k@

fjÝs'kj½

#

fooj.k

efgyk uotkr

iq:"k uotkr

dqy

la[;k

izfr'kr

la[;k

izfr'kr

la[;k

izfr'kr

1

uotkr f'k'kq dk

ot+u

thfor tUe

otu fd

;s x;s thfor tUe

2 fd

yks ls de ds thfor tUe

2 ls 2-5 fd

yks ds chp thfor tUe

2-5 fd

yks ;k vf/kd

ds thfor tUe

2

Lruiku dh

'kq:

vkr

1 ?k.Vs ds Hkhrj Lruiku djk;s x;s uotkr

1 ?k.Vs ckn Lruiku djk;s x;s uotkr

3

Vhd

kdj.k

vLirky

NksM+us ls igys iksfy;ks dh 0 [kqjkd

fiyk;s x;s uotkr

vLirky

NksM+us ls igys ch-lh-th- dk Vhd

k yxk;s x;s uotkr

4

izlo i'pkr~

Bgjko dh vof/k

ekg esa izloksa dh la[;k

24 ?k.Vs ls de Bgjko ¼izlwrkv

ksa dh la[;k½

24&48 ?k.Vs ds chp Bgjko ¼izlwrkv

ksa dh la[;k½

48 ?k.Vs ls vf/kd

Bgjko ¼izlwrkv

ksa dh la[;k½

5

chekj uotkr f'k'kq bdkbZ esa HkrhZ ds fy

, Hksts x, f'k'kqv

ksa dh la[;k

6

uotkr f'k'kq e`R;

q dh la[;k

7

ekrkv

ksa dh la[;k ft

Ugsa izlo i'pkr tfVyrk gqbZ

8

laLFkk ij ekr` e`R;

q dh la[;k

;'kksnk dk nSfud fjiksfVax izi=

ftys dk uke

ekg

vLirky

dk uke

;'kksnk lqijokbZtj% 1- 2-

dze la-

ekrk uke o irk

vk;q

cPPkksa dh la[;k

Js.kh (SC/ST/OBC/Min./Gen)

ch-ih-,y-

HkrhZ dh frfFk o le;

izlo dh frfFk o le;

cPps dk fyax

cPps dk otu

tUe ds le; dksbZ leL;k

Lruiku dk izkjEHk

Vhd

s

NqV~Vh dh frfFk o le;

:dus dh vof/k ¼/k.Vs esa½

cPps ds lkFk dksbzZ leL;k

ekrk ds lkFk dksbZz leL;k

;'kksnk dh fVIi.kh

;'kksnk ds gLrk{kj

i;Zos{kd ds gLrk{kj

ch-lh-th-

vks-ih-oh-

1

frfFk

frfFk

frfFk

1

2

3

le;

le;

le;

2

frfFk

frfFk

frfFk

le;

le;

le;

3

4

NIPI State OfficesState NIPI Office Address

Rajasthan Room No.213, Directorate of Medical Health, Swasthya Bhawan, C-Scheme, Tilak Marg, Jaipur-302006Ph: 0141-2222589

Madhya Pradesh 1250, J. P. Hospital Campus, IEC Bureau Building, Bhopal – 462 011 Ph: 09229834004

Orissa SIHFW Annexe Building,Nayapalli,Bhubaneswar-751 012Ph: 0674-2392489

Bihar B-1, SIHFW Campus,Sheikhpura, Patna-800 014Ph: 0612-2285638, 0-9386570086

An enabling intervention for quality maternal and newborn care at the facility level

Operational Guidelines

YASHODA/MAMTAfor

NIPI – A Child Health Program to Achieve MDG 4NIPI Secretariat, 11, Golf Links, New Delhi-110003

Phone: 91-11-30417500, 30417402Fax: 91-11-43518587

operational guidelines - undp in india

Documents