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Key Performance and Quality Indicators for High Impact RMNCH+A Interventions

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Key Performance and Quality Indicators for High Impact RMNCH+A Interventions

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Key Performance and Quality Indicators for High Impact RMNCH+A Interventions

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Introduction
In February 2013, the Ministry of Health and Family Welfare (MoHFW), Government of India (GoI), released a comprehensive Reproductive Maternal New-born Child and Adolescent Health (RMNCH+A) strategy that was developed using a life-cycle and continuum-of-care approach to meet the Millennium Development Goals 4 and 5. In the year that followed, a series of other guidelines and handbooks on RMNCH+A have been developed for better understanding of the strategy and for role clarification among the Development Partners (DPs), state governments and other stakeholders. Apart from these guidelines, the MoHFW also developed a RMNCH+A 5x5 matrix enlisting five high priority interventions under each thematic area. These interventions have been proposed to be closely monitored by program managers and other stakeholders for better performance monitoring. Alongside, a list of essential commodities were enlisted that to ensure their availability among the facilities. In continuation of strengthening implementation of RMNCH+A strategy, there is a need to monitor the performance of high impact interventions identified in the 5x5 matrix. Key performance indicators (KPIs) are ways to periodically assess the performances of organizations, departments, employees, or programmes. Quality indicators (QIs) are statistical measures that give an indication of output quality or process quality. Accordingly, KPIs and QIs need to be defined in a way that is understandable, meaningful, and measurable. This booklet provides a list of KPIs and QIs that the MoHFW has developed to monitor progress of high impact interventions identified in the RMNCH+A 5x5 matrix. These indicators could be uniformly used by program managers at state, district and block level across all over country, with special focus on 184 high priority districts identified by the GoI. It is proposed that the findings from the first round would be considered as the baseline and will be used to monitor the progress in the coming years.

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ABBREVIATION LIST 4Ds AEFI AFHC AFHS AMTSL ANC ANM AWC AWW BCG BEmOC CEmOC CHC DEIC DH DP DPT DQAC EAG ECPs EmOC ESB FRU GoI HBNC HDC HR Defects, development delays, deficiencies, and disease Adverse Events Following Immunization Adolescent Friendly Health Clinics Adolescent Friendly Health Services Active Management of Third Stage Labor Ante-natal Care Auxiliary Nurse Midwife Anganwadi Center Anganwadi Worker Bacillus Calmette Guerrin Basic Emergency Obstetric Care Comprehensive Emergency Obstetric Care Community Health Center District Early Intervention Centres District Hospital Delivery Point Diphtheria, Pertussis, Tetanus District Quality Assurance Committees Empowered Action Group Emergency Contraceptive Pills Emergency Obstetric Care Ensuring Spacing at Birth First Referral Unit Government of India Home-Based Newborn Care Home delivery of Contraceptives Human Resource IFA IUCD LHV MBHT MCH MCP MCTS MDR MoHFW MTP MVA NE NRC NSSK OCPs OPV ORS PHC PPH PPIUCD PTKs RBSK SAM SBA SC SDH SNCU SRH Iron-Folic Acid Intra-uterine contraceptive device Lady Health Visitors Mobile Block Health Team Mother and Child Health Mother Child Protection Mother and Child Tracking System Maternal Death Review Ministry of Health and Family Welfare Medically Terminated Pregnancy Manual Vacuum Aspiration North East Nutritional Rehabilitation Center Navjaat Shishu Suraksha Karyakram Oral Contraceptive Pills Oral Polio Vaccine Oral Rehydration Solution Primary Health Center Post-Partum Haemorrhage Post-partum Intra-uterine Contraceptive Device Pregnancy testing kits Rashtriya Bal Swasthya Karyakram Severe Acute Malnutrition Skilled Birth Attendant Sub-Center Sub District Hospital Sick Newborn Care Unit Sexual and Reproductive Health

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Key Performance and Quality Indicators for High Impact RMNCH+A Interventions
Key RMNCH+A Interventions
1.1 Focus on spacing methods, particularly post-partum intra-uterine contraceptive device (PPIUCD), at high case load facilities

Key Performance Indicators

% of institutionally delivered women accepting PPIUCD services (in facilities providing PPIUCD insertion services) % of L2 and L3 facilities providing PPIUCD services Number of PPIUCDs inserted per trained provider per month % of trained service providers providing PPIUCD services at L2 and L3 facilities Range of PPIUCDs inserted per district per month % of sub-centres and PHCs providing interval IUCD services on fixed days % of CHC/SDH/DH providing interval IUCD services on demand % of sub-centres having ANMs trained in IUCD insertion % of trained ANMs providing fixed day IUCD services out of total trained and available Number of interval IUCDs inserted per trained provider per month Range of interval IUCDs inserted per district per month % of ASHAs who maintained a line list of eligible couples % of ASHAs who faced stock out of any contraceptive in the quarter

Quality Indicators
% of PPIUCD cases returned for the first follow-up % of PPIUCD cases returned with complications, infections and expulsions % of L2 and L3 facilities reported stock out of IUCDs in the last quarter % of service providers received incentive for PPIUCD insertion in the last quarter % of ASHAs received incentive for PPIUCD insertion in the last quarter % of interval IUCD cases returned for the first follow-up % of interval IUCD cases returned with complications, infections and expulsions % of L1, L2 and L3 facilities reported stock out of interval IUCDs in the last quarter

Intervention brief Insertion of intra-uterine contraceptive device (IUCD) within 48 hours of the delivery of placenta. This service is currently being provided at high case load facilities and subsequently needs to be provided in all facilities that conduct delivery.

1.2 Focus on interval IUCD at all facilities including sub-centres on fixed days Intervention brief Provision of interval IUCD services in a health facility by trained providers posted in the same facility, on fixed days, throughout the year.

1.3 Home delivery of contraceptives (HDC) and ensuring spacing at birth (ESB) through ASHAs Intervention brief

% utilization of condoms, OCPs and ECPs per district during the quarter

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Key RMNCH+A Interventions

HDC: Door to door distribution of contraceptives (condoms, OCPs and EC Pills by ASHAs to the beneficiaries. ASHAs can charge Rs. 1/- for a pack of three condoms, Rs. 1/- for a cycle of OCP, and Rs. 2/- for a pack of one tablet of ECP. ESB: Under the scheme, services of ASHAs will be utilised for counselling newly married couples to ensure delay of two years in birth after marriage and couples with one child to have spacing of three years after the birth of the first child. The scheme is being implemented in 18 states of the country (8 EAG, 8 NE, Gujarat and Haryana). ASHA would be paid following incentives under the scheme: Rs. 500/- for ensuring spacing of two years after marriage Rs. 500/- for ensuring spacing of three years after the birth of the first child Rs. 1000/- in case the couple opts for a permanent limiting method (up to two children only) 1.4 Ensuring access to pregnancy testing kits (Nishchay kits) and strengthening comprehensive abortion care services Intervention brief Pregnancy testing kits (PTKs) are used for detection of pregnancy by testing urine. Each sub-centre (SC) in the country is entitled to receive PTKs based on its projected requirement but not exceeding 150 kits per year. The sub-centres should ensure that 50% of the received stocks of PTKs are distributed equally among the ASHAs attached to the subcentre and replenish their stock strictly on the basis of performance and not on normative basis. The ASHA shall replenish her stock every month from the sub-centre. 1.5 Maintaining quality sterilization services Intervention brief Provision of male (vasectomy) and female sterilization (minilap and

Key Performance Indicators

% of ASHAs who received incentives under ESB scheme

Quality Indicators

% of ASHAs who faced stock out of PTKs in the last quarter % of sub-centres reported stock out of PTKs in the last quarter % of L2 and L3 delivery points (DP) provided safe abortion services % of L2 and L3 DPs faced stock outs of Mifepristone in the last quarter

% utilization of PTKs at SCs % of abortions through MVA out of total abortions % of service providers trained on safe abortion % of trained service providers performing abortions % increase in MTP at L2 and L3 DPs

% of L2 and L3 facilities provided female sterilization services in the district % of L2 and L3 facilities provided male sterilization services in the district

% of trained doctors who provided female sterilization services out of the total doctors trained on female sterilization

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Key RMNCH+A Interventions

laparoscopic) services as per the prescribed norms.

Key Performance Indicators

Number of doctors trained on minilap services per district Number of doctors trained on laparoscopic sterilization services per district % of facilities having at least one trained provider on male sterilization services

Quality Indicators
% of trained doctors who provided male sterilization services per month out of the total trained on male sterilization Number of clients (disaggregated by sex) reported complication/failure/ death attributable to sterilization % of districts with functioning DQAC as per norms % of mothers/children entered in MCTS portal out of expected beneficiaries at the facility % of registered pregnant women who received full ANC % of registered infants who received full immunization

2.1 Use MCTS to ensure early registration of pregnancy and full ANC Intervention brief Pregnant women and children have been given identification codes to be uniquely identified as an entity so that pregnant women and children, who get registered at one location, may get services from other locations. For this, data related to these pregnant women and children need to be available at respective locations. 2.2 Detect and line list high risk pregnancies, including severely anaemic mothers, and ensure appropriate management

% of women registered in the first trimester out of total registered % of registrations out of total expected pregnancies

% of pregnant women line listed for severe anaemia out of total registered for ANC % of pregnant women diagnosed with hypertension out of total registered for ANC % of pregnant women delivered before 37 weeks

% of pregnant women improved from severe to moderate anaemia out of total severe anaemia cases line listed % of hypertensive pregnant women managed in the district at PHC out of total pregnant women diagnosed with hypertension % of pregnant women who received uterotonic drug post delivery as part of AMTSL % of pregnant women who delivered before 37 weeks received antenatal corticosteroids

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Key RMNCH+A Interventions

2.3 Equip delivery points with highly trained HR and ensure equitable access to emergency obstetric care (EmOC) services through FRUs; add MCH wings as per need Intervention brief Provision of EmOC at FRUs is being done by operationalizing all FRUs in the country. While operationalising, the thrust is on the critical components such as manpower, blood storage units, referral linkages, etc. Availability of trained manpower (skill based training for MBBS doctors) is linked with operationalization of FRUs. 2.4 Review maternal, infant and child deaths for corrective actions Intervention brief Maternal Death Review (MDR) is an important strategy to improve the quality of obstetric care and reduce maternal mortality and morbidity. The importance of MDR lies in the fact that it provides detailed information on various factors at facility, community, district, regional, and national level that are needed to be addressed to reduce maternal deaths.

Key Performance Indicators

% of villages not having access to 24x7 PHCs (BEmOC facilities) within 30 minutes of transport % of villages not having access to FRUs (CEmOC facilities) within one hour of transport % of identified L3 facilities not having full triad of paediatrician, LSAS trained doctor, and OBGY/EmOC trained doctor % of L3 facilities not providing EmoC services % of maternal deaths reported against estimated maternal deaths in the district % of child deaths reported against estimated child deaths in the district % of infant deaths reported against estimated infant deaths in the district % of L3 delivery points conducting Near-Miss Audit and Prescription Audit

Quality Indicators
% of C section out of total deliveries at L3 levels % of women with antenatal and post natal complications managed at L3 facilities out of the total reported % of ambulances in a district, covering more than 100 kms per day (average of the last two quarters)

2.5 Identify villages with low institutional delivery and distribute misoprostol to selected women in 8th month of pregnancy for consumption during third stage of labour; incentivize ANMs for home deliveries Intervention brief The MoHFW, GoI has taken a policy decision for prevention of PPH to permit ASHAs to undertake advance distribution of misoprostol to pregnant women who are likely to deliver at home. Three tablets of

% of home deliveries attended by SBA Number of villages identified with more than 20% home deliveries % of deliveries conducted by ANMs out of the total home deliveries % of women in the above identified villages who received misoprostol at the eight month of pregnancy

% of reported maternal deaths reviewed within two months as per standard protocols % of reported child deaths reviewed within two months as per standard protocols % of reported infant deaths reviewed within two months as per standard protocols % of maternal deaths categorised as others % of villages with less than 80% institutional deliveries showing an increasing trend of institutional deliveries % of PPH cases managed at L2 facility out of total complications received in post-partum period

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Key RMNCH+A Interventions

200g each must be given at the eight month of pregnancy for consumption during third stage of labour. 3.1 Early initiation and exclusive breastfeeding Intervention brief Early initiation (within one hour of birth) and exclusive breastfeeding till six months.

Key Performance Indicators

Quality Indicators

% of delivery points that have a breastfeeding counsellor % of health workers trained in SBA

3.2 Home based newborn care through ASHA Intervention brief ASHA will make visits to all newborns according to a specified schedule up to 42 days of life. The proposed incentive is Rs. 50/- per home visit of around one hour duration, amounting to a total of Rs. 250/- for five visits. This would be paid at one time after 45 days of delivery, subjected to the following: recording of weight of the newborn in MCP card ensuring BCG , first dose of OPV and DPT vaccination both the mother and the newborn are safe till 42 days of delivery registration of birth has been done

% of ASHAs fully trained in Module 6 and 7 Number of sick newborn identified % of sick newborns referred to higher facilities Number of ASHAs detecting sick newborns % of low birth weight babies identified by an ASHA during HBNC visits

% of women delivered at public health facilities who initiated breastfeeding within one hour of birth % of infants who were exclusively breastfed for six months % of women who breastfed the child during the last episode of illness in the last quarter % of ASHAs trained in HBNC % of ASHAs who have received incentives for referral to SNCU

3.3 Essential newborn care and resuscitation services at all delivery points Intervention brief Navjaat Shishu Suraksha Karyakram (NSSK) is a programme aimed to train health personnel in basic newborn care and resuscitation. It has been launched to address care-at-birth issues (i.e., prevention of hypothermia, prevention of infection, early initiation of breastfeeding, and basic newborn resuscitation).

% of DPs having functional newborn corner % of DPs having NSSK trained staff

% of asphyxiated newborns who were successfully resuscitated % of trained NSSK staff who provided new born resuscitation services % of new born admission due to asphyxia out of total inborn admissions at SNCU

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Key RMNCH+A Interventions

3.4 Special newborn care units with highly trained human resource and other infrastructure Intervention brief States have been asked to set up at least one SNCU in each district. SNCU is a 12-20bedded unit and requires four trained doctors and 10-12 nurses for round the clock services. 3.5 Community level use of gentamycin by ANM

Key Performance Indicators

% of total SNCUs having an FBNC trained and designated Medical Officer % of total SNCUs having trained and designated staff nurses

Quality Indicators
% of SNCU admissions due to asphyxia Ratio of inborn to outborn referrals to SNCUs Ratio of male to female infants in outborn admissions Mortality rate (asphyxia and sepsis) at SNCU in newborns weighing 2.5 kg or more % of young infants (0-2 months) diagnosed with sepsis by the ANM and given pre-referral dose of injection gentamicin and syrup amoxicillin Mortality rate in children treated by antibiotics % of six months old infants receiving complementary feeding Number of children found underweight at anganwadi centres. % of SAM children who received community based management at anganwadi centre % of SAM children admitted in NRC discharged with more than 15% weight gain

% of ANMs oriented in gentamycin use

4.1 Complementary feeding, IFA supplementation and focus on nutrition Intervention brief Timely complementary feeding after six months with continued breastfeeding till the age of two years. Infants from the age of six months onwards up to the age of five years shall receive iron supplements in liquid formulation in doses of 20mg elemental iron and 100mcg folic acid per day per child for 100 days in a year Children 6-10 years of age shall receive iron in the dosage of 30 mg elemental iron and 250mcg folic acid for 100 days in a year Number of episodes of diarrhoea reported % of children with diarrhoea treated with ORS and zinc % of under-five deaths due to diarrhoea against the total reported under-five deaths % of sub centres reporting adequate stock of IFA syrup (in formulation recommended by GoI with auto dispenser) % of children under five receiving regular IFA biweekly supplementation

4.2 Diarrhoea management at community level using ORS and zinc

% of under-five child deaths due to diarrhoea Community awareness of ORS and zinc

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Key RMNCH+A Interventions

4.3 Management of pneumonia 4.4 Full immunization coverage Intervention brief A child receiving all vaccines under the programme within the first year of life. These vaccines are one dose of BCG, three doses of OPV, three doses of DPT, and one dose of measles. 4.5 Rashtriya Bal Swasthya Karyakram (RBSK): screening of children for 4Ds (birth defects, development delays, deficiencies, and disease) and their management Intervention brief Comprehensive child health care implies assurance of extensive health services for all children from birth to 18 years of age for a set of health conditions. These conditions are diseases, deficiencies, disability, and developmental delays - 4Ds. Universal screening would lead to early detection of medical conditions and timely intervention, ultimately leading to a reduction in mortality, morbidity and lifelong disability. 5.1 Address teenage pregnancy and increase contraceptive prevalence in adolescents Intervention brief Community: Communication with stake holders to create support and influence cultural norms to reduce early marriage Counselling of newly married couples and influencers on the risk of early conception and the importance of spacing

Key Performance Indicators

% of children with pneumonia given antibiotics % of frontline workers trained in IMNCI % of ANMs who know about effective case management of pneumonia % of newborn given BCG and zero dose of polio at birth % infants received the first dose of measles

Quality Indicators
% of under-five child deaths due to pneumonia % of community aware of consequence of pneumonia and diarrhoea % of AEFI reported Drop-out rate of the third dose of DPT out of the first dose of DPT

% of blocks saturated with requisite mobile block health team (MBHT) % of service providers under MBHT trained under RBSK % of children screened for 4Ds out of total children in the age group of 0-18 years % of children accessing services at secondary/tertiary/District Early Intervention Centres (DEIC) Marriage prevalence rate among adolescents % of adolescent pregnancies among total pregnancies % of high risk pregnancy detected among adolescents Couple protection rate among married adolescents

% of children detected with 4Ds out of the total screened % of districts reported less than expected incidences of 4Ds % of screened children supported through DEIC % of children referred with 4Ds out of the total screened

% of pregnant adolescents who undertook four ANC visits

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Key RMNCH+A Interventions

Availability of non-clinical contraceptives through social marketing Facility based: Counselling Provision of clinical and non- clinical contraceptives, and pregnancy testing kits 5.2 Introduce community based services through peer educators Intervention brief This intervention envisages beyond-health-facility-based service provision. Peer educators (both boys and girls) are selected, trained and supported by teachers in the institutional setting and by ASHAs and ANMs in the community setting. They will serve as the first point of contact for reaching out to adolescents in their spaces. 5.3 Strengthen Adolescent Friendly Health Clinics (AFHC) Intervention brief The AFHCs are dedicated spaces for adolescents in the existing health system. These clinics will ensure availability of counselling, commodities, medical, para-medical and specialised services to adolescents, with emphasis on privacy and confidentiality. 5.4 Roll out National Iron plus Initiative including weekly IFA supplementation Intervention brief The intervention includes the following: administration of supervised WIFS; screening of target groups for moderate/severe anaemia and referring these cases to an appropriate health facility; biannual deworming, six months apart, for control of helminthes infestation; information and counselling for improving dietary intake and for taking actions to prevent intestinal worm infestation.

Key Performance Indicators

Quality Indicators

% of peer educators selected against planned % of peer educators trained against planned

Number of sessions held by peer educators against sessions planned Number of adolescents reached through peer educators per month % of peer-led sessions supervised by ASHA/ANM

% of facilities having fully operational AFHCs as per norms Number of MO/ANMs/LHVs providing services at AFHCs trained on Adolescent Friendly Health Services (AFHS) against planned % of counsellors selected against planned % of counsellors trained against planned % of caregivers (teachers, AWWs) who have been trained on implementation of the WIFS % of schools/AWCs reported adequate stock of IFA and albendazole tablets % of schools and AWCs provided with IFA and albendazole tablets

Number of adolescents accessing AFHCs for SRH, nutrition, mental health, substance misuse, injuries, violence, and non-communicable disease related problems Number of adolescents counselled at AFHCs

% of adolescents (in-school and outof-school girls) given 4 or 5 IFA tablets in the reporting month % of adolescents (in-school and outof- school girls) given biannual albendazole tablets

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Key RMNCH+A Interventions

5.5 Promote menstrual hygiene Intervention brief This programme aims at ensuring that girls in the age group of 10-19 years in the rural areas have adequate knowledge and information about menstrual hygiene and have access to high quality sanitary napkins along with safe disposal mechanisms. The scheme envisages providing a pack of six sanitary napkins under the NRHMs brand Freedays. These napkins are sold to the adolescent girls at Rs. 6/- for a pack of six napkins in the village by ASHA. On sale of each pack, the ASHA gets an incentive of Rs. 1/- per pack, besides a free pack of sanitary napkins per month.

Key Performance Indicators

% of ASHAs who have sanitary napkins with them Number of ASHAs who faced stock out of sanitary napkins in the last quarter

Quality Indicators
% of adolescent girls who received counselling on menstrual hygiene % utilization of sanitary napkins stock Number of adolescent girls who were provided with sanitary packs Freedays Number of repeated users out of regular users

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