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#289 - 🌍 Reducing Neonatal Mortality in India (ft. Dr. Rajesh Mehta)

Writer: Ben CourchiaBen Courchia
13 hours ago32 min read



Hello Friends 👋

In this episode, Dr. Rajesh Mehta  shares his extensive journey in pediatrics, detailing the evolution of newborn care in India, the challenges faced in providing quality healthcare, and the importance of continuous improvement in neonatal care practices. The conversation highlights the significant strides made in reducing neonatal mortality rates while addressing the ongoing challenges in healthcare infrastructure and quality of care. In this conversation, Dr. Mehta also discusses the importance of establishing frameworks for quality care in maternal and newborn health. He emphasizes the need for a national structure to support quality standards and the role of global initiatives in enhancing healthcare systems. The discussion also highlights  Point of Care Quality Improvement (POCQI) strategies that empower healthcare teams to improve care delivery without requiring additional resources. Dr. Mehta also addresses the significance of integrating quality improvement into training programs, the necessity of addressing upstream determinants of newborn mortality and the importance of  collaboration and teamwork in healthcare settings.


Link to episode on Youtube: https://youtu.be/Azfg773hpD4


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Resources mentioned in episode:


POCQI Website : https://www.pocqi.org

POCQI E-Learning course : https://workbook.pocqi.org

POCQI Community of Practice : https://www.nqocncop.org

 

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Bio: Dr Rajesh Mehta is presently adjunct Professor at Public Health Foundation of India and Indian Institutes of Public Health and supports academic programme  and research in the area of maternal. Newborn, child and adolescent health, and public health.

He is the Chair of the International Pediatric Association (IPA) Working Group for Quality Improvement and Patient Safety (2023-2025). He also works as a consultant with WHO headquarter, regional and country office levels for newborn, child and adolescent health. Until 2022 he was the Regional Advisor newborn, child and adolescent health with WHO-SEARO. He provided strategic guidance and support eleven countries of the Region to strengthen the national programmes for newborn, child and adolescent health focusing at coverage, equity and quality of services.


Dr Mehta championed the cause of improving quality of care for MNCAH programmes while at helm at WHO-SEARO. He led and coordinated the point of care quality improvement model (POCQI) across the Region and beyond, that has been acknowledged globally. Before that, Dr Mehta worked in the India Country Office of WHO from 2006 to 2010, where he managed a range of programmes on newborn & child health, adolescent health, maternal & reproductive health, nutrition, gender, and nursing-midwifery. He has been an international and national trainer in IMCI course and assisted in national adaptation of IMCI guidelines in India and other countries. He prepared IMCI guide for private practitioners based on the India IMCI package.  He undertook pioneering work in the area of adolescent health in the country, especially adolescent-friendly health services with a focus on coverage and quality. Later he supported the national adolescent health programme in the country and then in the South-East Asia Region.


He is a Pediatrician by training and earned master’s degree in Pediatrics from Maulana Azad Medical College, New Delhi after which he worked as a Paediatrician in a range of settings from secondary to tertiary care hospitals for about 25 years. Before moving to WHO he was a Faculty at VM Medical College and Safdarjung Hospital, New Delhi where he taught undergraduate and postgraduate medical students.  He has published many scientific papers in medical journals and has contributed chapters in several textbooks and contributed to many national and international training packages for newborn, child and adolescent health, birth defects, programme management, and quality of care.  He is an awarded Fellow of India Academy of Pediatrics and a Salzburg Global Fellow on Early Child Development.



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The transcript of today's episode can be found below 👇


Shelly-Ann Dakarai (00:02.689)

Hello again, and welcome to another episode of the Global Neonatal Podcast. Bozu, how are you doing today?


Mbozu Sipalo (00:10.052)

I'm good, how are you?


Shelly-Ann Dakarai (00:12.981)

I'm good. As always, excited for our interview conversations. We meet such amazing people who do amazing work. I'm very excited about our conversation today.


Mbozu Sipalo (00:23.012)

Yeah, same. I’m super excited to be speaking with Dr. Rajesh, who was on our newborn toolkit webinar recently, talking about leadership in fast-progressing countries. I’m super psyched to hear about his quality improvement work.


Shelly-Ann Dakarai (00:44.745)

Dr. Rajesh, we're so happy to have you on the podcast. In the interest of time, we're going to just give a very brief introduction, and we'll put your more extensive bio on our podcast show notes. Today we are honored to welcome Dr. Rajesh Mehta to the show. Dr. Mehta is currently an adjunct professor at the Public Health Foundation of India and the Indian Institutes of Public Health, where he supports academic programs and research in maternal, newborn, child and adolescent health.

He also chairs the International Pediatric Association's Working Group for Quality Improvement and Patient Safety, and consults with the WHO on global child health initiatives. With decades of experience, including his role as regional advisor for the WHO Southeast Asia Regional Office, Dr. Mehta has been a driving force in improving healthcare quality and equity across nations. We're thrilled to have him today. Dr. Rajesh, welcome to the podcast.


Dr Rajesh Mehta (01:43.64)

Thank you. It's my pleasure to be part of this conversation. I hope we are able to recall and present to the people who may be interested in understanding how newborn care goes in low and middle income countries. And I'm happy to be with you. Thank you.


Shelly-Ann Dakarai (02:04.855)

Great. We always like to start the podcast with origin stories. So we would love to start by hearing a little bit about your journey. What prompted you to do pediatrics? Can you tell us a little bit about how your career unfolded? You've done so many different things across your career. Tell us a little bit about what prompted you to do pediatrics and how your career unfolded over the years.


Dr Rajesh Mehta (02:10.614)

I am of previous generation, as you would imagine. I completed my MBBS, which is the medical degree in India, from Delhi University. I was lucky to get into a prestigious institution called Maulana Azad Medical College, in New Delhi. It’s alumni have made a good name for themselves, as well as for the institution. After completing my graduation, we had to make a choice for post-graduation. There was an All India Entrance Examination, even in those days. This was 1981. In those days, pediatrics was opted by the toppers; those who secured a good rank in MBBS would aim to get into pediatrics. My own personal motivation was that I was fond of children. Many of my peers couldn’t withstand a crying child, whereas I was quite comfortable. I was keeping a good rank, so I thought, let me give a shot to pediatrics. And that's how I entered pediatrics. So in ‘83, I completed my master's program. Pediatrics, at that time, was not a separate subject. It was part of internal medicine. And it wasn't even a subsidiary in examinations. At the best, we would have a spot case in clinical examination in final year, and a short note and written examination of pediatrics. So the specialized skillset which I acquired was through my master's degree of two years.

From there, I continued to work in clinical settings. I was fortunate to experience the pediatrics clinical side from primary level to tertiary level. I had postings in remote small hospitals as well. Finally I landed up in a tertiary hospital, a premier institute in Delhi. Safdarjung Hospital is a 1500 bed public hospital, with a big pediatric department and a neonatology unit. While during our MD pediatrics, neonatology was not a specialty at that time. It was a central part of training, but it had not required subspeciality status. A few years later, people had started doing fellowships. Then postdoctoral program was introduced in India. The Indian Academy of Pediatrics actually was formed in 1968. The National Neonatology Forum of India was formed in 1980. The NNF helped evolve the government, the public program of newborn care with a constant, you know, technical support coming from the professionals.

After 28 years of clinical service, I moved to the WHO, first in the India county office where I spent about 4.5 years, and then 10-11 years in the regional office. The regional office included 11 countries of Southeast Asia. I have watched the evolution of newborn care in India and in the region very closely. Therefore, it gives me an opportunity to rewind and see where we excelled and where we could have done better. So that's my association with the child health and neonatology: 28 years in the clinical side and about 15-16 years in WHO. Now I continue to teach and research a little bit after retirement.


Mbozu Sipalo (07:37.397)

I don't even know where to start from, what to unpack from what you've shared, but it sounds like you have lots of experience and lots of learnings. So I'm sure our listeners will be very happy to hear from you and learn from you. You touched on the evolution of newborn care towards neonatal mortality rate in India at the end of your descriptive story. Could you please share with us your role in WHO linked to the evolution of the newborn care and the neonatal mortality rate in India? How do you think other LMIC countries can learn from fast progressing countries, like India?


Dr Rajesh Mehta (08:20.974)

When neonatology first came to the profession, there was hardly any newborn or maternal-child health programs in the country. India launched a family planning program quite soon after independence, in 1951. Subsequently, the next biggest program was EPI, Expanded Programme of Immunization, in 1971. In all of the public health programming, maternal-child health was receiving attention, but it remained a very rudimentary package of primary health care. But it hadn't been given the priority it deserved. For example, the first neonatal unit actually emerged in a postgraduate institute in north of India in 1968. These are a couple of professionals who had exposure to neonatology because they visited UK and USA. They came back, and then with WHO support, started a two-week training and opened a neonatal unit in a medical school which was postgraduate specialty hospital. After that, it took a while for neonatal care to emerge as important component of MCH programs. For example, the first national program which recognized mother and child issues was Child Survival and Safe Motherhood Program, 1992 to 1997. A lot of dependence at those days was on traditional birth attendants (TBA). There were not many skilled midwives or nurses to deliver women.

The NNF, as I said was established in 1980, and soon after they had recommended a perinatal committee and recommended that essential newborn care should be introduced. But it took the government about a decade. So only in CSSM in 1992 or 10 years later, essential newborn care actually came in as an intervention package. Then training methodology started for medical officers, nurses and TBA’s on essential newborn care and a very rudimentary training on resuscitation.

By then, professionals said that we need essential care for all babies right from birth. Thereafter, all babies, whether healthy or sick, small or good size, received essential care for all newborns. But they also said that additional care would be required for small babies, low birth weight and preterm. Of course, more care would be required for babies who become sick or have complications. The profession informed the government saying that we need to provide care at home through community approaches, through home-based care, and also in facilities where small babies and sick babies must be managed. Those were the days when most deliveries were happening at home, so even facility-based care at the time of delivery was not followed or not available. Institutional deliveries were very few.

Initially we started with ENC (essential newborn care), then more complex facility-based care for level one, level two, for smaller hospitals in the district settings. Meanwhile, some intensive care units had also started emerging. NNF recommended that we must make intensive care available for 10-15% of babies who need that care. But since the resources are not there, there are not enough facilities or professional expertise, we did a regionalized model where in the region, there is at least one neonatal intensive care unit that is surrounded by several level two units.


When I look back on how other countries or the developed world has progressed, it's been a similar historical trend that initially the lives were saved by the public health approach and community oriented essential care approach. The understanding of newborn care was not much in the first phase. In LMIC like India, that was the situation with which they started. And then technology evolved, level two care emerged, and then level three or intensive care also then continued.

The first district level intervention through facility-based care in India happened in late 1980s in a district in West Bengal. It was more of a model to demonstrate that without very high tech equipment, lives can be saved, newborns who are sick or have complications in the hands of a pediatrician or trained medical officers and some nurses in a level two unit in a district. Proof of principle actually was established and this experience was available.

We had support beginning from the government side, some state governments, with UNICEF and some partners initially. They started with district-level newborn care, level two care, which was labeled as special newborn care units. So the SNCUs, district level two care units, with a standardized model started in the year 2000. So the first was in 80s, but it took about 10 years to actually catch up and start neonatal care units in the district level. 

After initial demonstration that such units can be operationalized, the government then quickly replicated the units and very soon. From 2000 until now, in these two and a half decades, we now have more than 1000 such units. It's a long historical journey.

So that's the story within India. A lot of work was done and we know how it was scaled up. We have studied and documented what the facilitating factors which led this. This model was exported to neighborhood countries and taken by partners to some countries in Africa. It's important to understand that if experiences are shared in time and that some documented success becomes a learning, cross-learning mechanism, countries can benefit from each other. And the South-South dialogue and cooperation was very important. For example, there is this association for a local formation of eight countries in South Asia, which is called SARC (South Asia Association of Regional Cooperation). There is a SARC Foundation Fund, which was made available by Indian Donation. This model of facility-based newborn care district-level SNCUs was actually provided to Afghanistan, Bangladesh, Nepal, Sri Lanka, Maldives. So that's how some of these countries actually got formal application support to undertake district-level newborn care programming.

I think it was USAID with whose help the model was transplanted in some countries in Africa. So that's learning from LMICs: if the government shows leadership and actually provides along with the policy, dedicated budget line, and much of this was government of India money. Partner money was initially useful when we were trying to do a demonstration exercise in one unit. The government was waiting until we could demonstrate in 5-10 units, 5-10 districts, and then they picked up. So technical support continued to come from National Neonatology Forum, but also from WHO, UNICEF and other agencies. But the government led the whole stuff. They had clear budgetary lines. They had clear commitment to hire people. One pediatrician, four doctors, nine nurses or 12 nurses sometimes for each unit. Essential equipment, continuous supplies, then data and information management, close monitoring. So all the health system, know, readiness was demonstrated by this very consistent approach.

But we still have challenges. Adequate infrastructure is still not there. We have more than 1000 units; all districts have at least one unit. And the global target was by 2025 to achieve 80% districts at least have one unit. But we should have CPAP available in such units. India has met the newborn unit target, but CPAP is just being scaled up and not yet available in all units. Even now, many district level SNCUs are very crowded. We could see two or three babies to a cot. This crowding has happened because government of India, alongside this level two unit, the program has been focusing also on level one care in subordinate hospitals. So there has to be a newborn stabilization unit for a district level unit that is five, six in the catchment area, there should be stabilization units. Every birthing unit where deliveries happen should be a newborn care corner. Newborn care corners stabilization units are still to catch up. Since those are not very functional and operational, most of the babies land up in district level hospitals, therefore overcrowding with compromise in quality.


It is unfortunate that our hospitals in India, as much as in other countries, 60% of hospitals do not have adequate water, sanitation and hygiene infrastructure. There are several district hospitals where sometimes there is a challenge even to have basic amenities. So government and the people are struggling in that respect, the infrastructure and the basic amenities. And then HR is always a problem. India has less issues now, because the pipeline has improved a lot. But we have other issues of recruitment for those district and sub-district level facilities and then retaining them. Retention is a huge issue because the life support for a human being is not up to the mark. So many specialists and pediatricians would not want to stay there. There's nothing for their children, their education is not there, the safety issues. We are all in urban facilities and provisions, which they are used to, and these are not easily available in those settings. And the professional satisfaction is also a little less because they can only do limited things, despite having learned a lot. So the retention issues are there. Nurses are always rooted. Nurses are posted, but hospital superintendent is always struggling to take care of other parts of the hospital, the neonatal nurses are then taken away. I can imagine in other countries where even the pipeline is not adequate, this must be much more difficult. Without warm bodies and working hands, newborn care cannot be delivered, even if equipment was there.

Equipment management and maintenance is a big issue. Still in India, in Bangladesh, in Nepal, we are catching up with biomedical engineering backup, but still, still an issue. So we have done a lot. We have exported the success. We still have challenges to meet and we should be ready to roll out more concrete action. We should be ready to bring in more advanced care because epidemiology is changing.

When we started newborn care, 50% of under-five mortality was newborn causes. And our top three causes were, in this order, infections, asphyxia, and prematurity. Over the years, I have seen the sequence of the first three causes change. Now, newborn mortality is easily 60% of under-five mortality, because other causes of under-five mortality have been controlled through vaccination programs, through diarrhea control. 


But the causes of death also have changed. Prematurity is the top cause. In India, 41% of mortality is coming from preterm complications, followed by asphyxia, and then infection. So infections have gone down.

But the fourth cause is birth defects. Congenital anomalies, birth defects, which can be fatal, is coming up because the other causes of mortality have gone down. So we need to prepare. We have to have surgical facilities. We have to have extreme prematurity care, technologies, surfactant, ventilators, and more. 

Our advice to countries has been that while you are reaching, while you are sustaining the gains, you will need to focus on equity. In many states in India, newborn mortality has shown a good reduction over the period. From 1990, there is a 60-65 % reduction until two years back. So, new mortality has fallen and India will reach SDG target by 2030. But there are 6-8 states where mortality is quite high. In Kerala, mortality is four per thousand, which is as good as Scandinavia. But then we have states where it is 28, 30, 31. So that India has to manage that in equity. And then quality of care. Coverage has been great. The whole MDG (Millennium Development Goal) period was spent on coverage. All countries did well. India did well. Therefore, mortality has reduced. But to accelerate further, quality of care would be great. And then we have to also do some high technology intensive care availability going forward. That's future. But we should be ready.

So what I'm suggesting is that countries have to do basic things right. Essential newborn care for all babies that would start from good care of mother during antenatal period, good quality institutional delivery, essential care at birth for the newborn, then postnatal care, additional care for preterm, additional care for sick babies, with home-based care and newborn care in combination.

India did reasonably well to adopt all the WHO supported evidence based recommendations in time. My role in WHO later on was to bring the evidence from global to the region and help countries to implement. Research was carried out in some of our countries, but largely it is the work of the people in Geneva, our WHO headquarters, and the regional office where I was sitting, we were bringing the evidence to countries and converting research into policy. I remember calling a regional meeting for our high priority countries on KMC (kangaroo mother care, or skin-to-skin). KMC research was being done, immediate KMC, which is keeping mothers right from birth inside the newborn unit. That research was conducted in India, Bangladesh, and three countries in Africa. Results were available but not yet published. So I said, why lose time? I brought six countries and we gave them the evidence that this is emerging. Be ready to implement IKMC in hospitals at home, community initiated, home initiated KMC. The evidence was already there. So that's how we supported countries to adopt the evidence-based practices, which were coming regularly from the global process. And therefore, with all of that, all countries have to take these steps. They have to do home-based care, new-born care, closer to homes, level two care at district level, and also basic care in the subordinate health facilities, but also top up with intensive care as the resources and skill set becomes available. So then this is the progress, this is the trajectory all countries should follow. And then we will talk about quality of care a little bit later.


Shelly-Ann Dakarai (32:15.989)

Yeah. Thank you so much for providing that conceptual and contextual roadmap for improving neonatal mortality rates. You talked earlier in that bit about how just having skilled birth attendance and essential newborn care helps in that first big drop in neonatal mortality. then after that, it goes into the more specialized care, the level two care and scaling that up. And then once you get that, then you start having the concerns with quality and ensuring that you're having high quality care as well. It seems like a good part of the discussion to kind of talk about quality, because I know that’s one of your other areas of interest. And I'm curious as to when did that interest in quality develop? it as you saw, okay, we've scaled up care, we have all these level two NICUs, but now we have overcrowding and now we're still having high mortality, where did that interest come from?


Dr Rajesh Mehta (33:28.91)

This was an observation which was common to many of us that there is a problem with quality of care in the pediatric practice. For example, I remember I was still with the government in my clinical time, and WHO had a regional meeting on pediatric hospital care improvement in 2007 and 2008. There were some remnants of those considerations that pediatric care. IMCI (Integrated Management of Childhood Illness) was launched in 1995. There were at least 120 countries where IMCI was introduced. IMCI was a great instrument to assure good quality, standardized care for common illnesses which are causes of mortality and morbidity for under-five years. Now, IMCI actually would mean that if we did it well, would assure reasonable quality of care for people in the homes. But it wasn't happening that way. There was a realization that we should do more. More tools were emerging. We had a pocketbook of child care in hospitals. That's a famous pocketbook, blue colored, now in third edition, where we have described, WHO has described, how to manage in small hospitals common pediatric illnesses as inpatient treatment. So the standards were getting available. IMCI was standardized, pocketbook was standard. There was a pink book in WHO on managing complications in newborns.

So with that in hand, in 2013 WHO held a regional meeting on quality of care for reproductive maternal newborn child and adolescent. We started working on a framework of quality of care for RMNCH (Reproductive, Maternal, Newborn, and Child Health). And finally, with the help of member states and the experts from the region, we were able to publish a regional framework for quality of care for RMNCH in 2015.

We also had access to some facility assessment tools, quality of care assessment. We had the benefit of applying those WHO hospital care assessment tools for pediatric and maternal care in several countries in the region. And we had reports to say that there were gaps in quality. We had an assessment tool also finalized. The framework suggested seven steps in two blocks, that we should start with the national policy on quality of care and a national strategy and a national in a unit. Since we were from RMNCH community, we were focusing on our area of work, not on surgical care or orthopedic care, but RMNCH. So therefore, we said there should be a national structure to support quality of care. And there should be adoption of standards of care for material.


Mbozu Sipalo (38:06.728)

Sorry, Dr. Rajesh, could you please explain RMNCH for our listeners? They may not know what that means.


Dr Rajesh Mehta (38:14.99)

Reproductive, Maternal, Newborn, Child, and Adolescent Health. So that, know, although our focus was, has been until now on maternal newborn health within RMNCH, but the system readiness was to be there. So we said the community moves forward. This was 2013, 2015, we had the framework and the assessment tool. where the framework was saying you do some national level scene setting that there should be structure and mechanism to improve quality of care. But it also said that there should be simultaneous action on adopting the standards, doing some assessments and immediately starting quality improvement at hospital level.

So basically two buckets of work, system level strengthening, right from national and sub-national level, and then hospital level strengthening and improving the quality of care at the cutting edge where the service is delivered.

Fortunately for us, the global quality equity dignity (QED) network started in 2017-18. While we already had published our framework and started some inroads into our member states policies of quality of care, QED was a big push, the global framework. There were seven countries from Africa and two from Asia (India and Bangladesh). That gave us a little bit more thrust to present to the countries in the region. By then, in 2018, we had a Lancet high level commission on high performing systems. They clearly analyzed and said that more lives are being lost because of poor quality of care compared to excess of care. So that clearly suggested that people were able to come to the hospital, were coming to the hospital, but we could not make them survive because quality was bad. So there was twofold problem there: we are not saving lives, we are not reducing morbidity, but also the trust of community is reducing. So they would bypass government hospitals and go to private hospitals, in the hope that there is better quality there, although it was never sure whether they will get good quality even in private hospitals. Private hospital may be clean, maybe a little bit better equipped, but nobody knows whether quality of care actually delivered is as per the standards. 

My job was in WHO at that time to actually convince countries that while you are setting up the system, let us start moving at the quality improvement at the cutting edge, at the point of care. So therefore, we coined this point of care quality improvement strategy in the region, that healthcare teams can actually come together and should consider that quality improvement, or providing good quality of care, should be their business. It's nobody else's business. It's the healthcare teams who have to improve the quality. The problem is when you do lot of quality assurance work, we start accreditation, for example, or certification. For example, if people come to hospital, they assess you, they assess you and then give you some ranking and then go back.


So, it looks like that quality is somebody else's business and they will take care of this. But we realized all health workers want to do their best. It's not that they don't want to do this. Many times it's the system which is not allowing them or is not promoting them to actually provide their best to the patients. So it's not about the people in the system, somehow they have to be mindful of how system is helping them or not helping them. So we picked up some of the models which had a history. IHI, which is based in US, they have been doing this quality improvement stuff for 30, 40 years. In Africa, for example, we have models of the drivers of quality, the change ideas. So all of that is well known. The Japanese methodology, which came from industry to healthcare, five sigma, six sigma, total quality management. All that jargon was available, tools were available. But our contribution in the region was that we simplified it. We simplified it to be able to be used by the frontline healthcare teams in resource-poor settings. Our premise was that all health workers want to do good things. Secondly, by now when we started, 60 or 80 % hospitals were reasonably well provided. Infrastructure was there, health staff was there, shortages will happen. In LMIC countries, there will not be a day pretty soon that everything is available everywhere. So some restrictions would be there, but they are reasonably provided. And without asking for additional resources, health care teams should be able to make some improvement. So our premise was they want to do good in life. The infrastructure is reasonably well provided. And the only thing is they have to be mindful about the process of care. They have been trained, they know what to do, but they are stuck somewhere that they are not able to practice that evidence-based care. 

So the point of care quality improvement is basically a problem-solving approach, which is four steps. Now if you compare with other models, there are seven steps, there are eight steps, there are 10. But this was simplified. It's not a proficiency course in quality improvement. It's a primer. For people to start, use their hands, achieve early success, a little bit of leadership emerges. The healthcare teams get formed. They start using local data to identify the problem, then monitor that data to document the improvement, and then sustain the improvement. So what do we suggest to them? Come together, try to see if there are any issues of quality. If there are multiple issues, try to prioritize, and we provide them some tools to do that. And then we say, you please analyze what is causing this problem.

For root cause analysis, other set of tools are there – five-way inquiry, fishbone analysis, Pareto principle. Small skills based on management science, quality-improvement science, problem solving. Identify one problem, use the root cause analysis, then as a team decide what solutions could be there to address that issue and start with one solution. The training is that start with one, although you could do two or three. You could also do two or three quality problems at once, but for training purpose, we said you start with one problem, do one solution, complete a rapid implementation cycle, decide the indicator, monitor if it is working or not, then change the solution. Complete a PDSA cycle and then try to see if it works, sustain it. 

In my regional training, we invited the hospital director, a midwife, a pediatrician and an obstetrician. Because we were starting from maternal newborn care at the time of birth. Because maximum lives, we were told by evidence, are saved if you improve quality around the time of birth. Therefore we started there. Therefore the obstetrician, pediatrician, midwife or a nurse is important.

But the medical superintendent or the director of the hospital is the one who is accountable for overall quality. They should all be trained together. We also made a strategic choice that we will start with the clinical leadership and nursing leadership. We could have started from the field, but we thought clinical leaders must be converted. And once they are convinced, will just this knowledge will percolate down. So we started with medical schools, then we shifted to district hospital. And in some places, we actually went down up to community health worker level to test this four-step model.

So we have success stories from medical school setting on maternal care in labor room, in newborn care in newborn units. And then in many hospitals, it diffused outside the MNH care area. Some of the surgical teams picked up. We have seen projects using point of care quality improvement. We call it POCQI, P-O-C-Q-I, to reduce pressure sores in surgical ward, for example.

In obstetrics, they reduced surgical infections and IV line infections. Cardiology department improved the time period between arrival in the emergency room with chest pain and when the ECG was done. So the time taken initially was 40 minutes, but after the POCQI was introduced, it reduced to 12 to 16 minutes. They could cut down the time by improving the process of care. Waiting time in pharmacy reduced. Waiting time in operation theater reduced. Previously, newborn babies with ROP had to be screened and brought to OT (operating theater) in big hospitals where they received general anesthesia, detailed examination, and treatment. They changed the process of care and they could reduce the crowding and also reduce the waiting time in the OT using this problem solving approach. So we demonstrated that it works at the frontline, it works at the top line, and it promotes local leadership, teamwork, and use of data for improvement.

It can be done without additional resources in the beginning. Our advice was do something, show the improvement, take that improvement data and show a visual run chart. KMC duration improved, mothers’ own milk use improved, oxygen use has decreased, antibiotic use has decreased – we have done all of those projects using POCQI. Now you take this data to the district collector or the district CEO and tell them, without additional resources, we have improved the situation from this to this. Breastfeeding in one hour has improved from 30% to 80%. If you give me a counselor now, additional working hands, I will make it even less. The district management readily agrees. These workers been doing pretty hard and they have already shown improvement. Why not give them some additional hands? If I had gone there the first time and said give me more nurses, give me more, nobody agrees. If you show improvement, you will get more resources.

Point of care quality improvement has three sets of packages. One is for training the healthcare teams. The second is to provide post training handholding support, and coaching in quality improvement. And the third document is how to run this in a district as a program, not just as a training activity. It's not just POCQI training. They have to do training, post training, monitoring, and then collect the data and then start doing collaboratives on improvement that we have common problem in these five hospitals. Why don't you come together, learn from each other, and do a common quality improvement project? Then it becomes a part of our culture in the district. If district system starts engaging and supporting this. 

So that's the vision. This was quite useful in our countries in the region. UNICEF helped us to take it to China. They translated it into one province. It went to Kazakhstan because we had partners. POCQI was supported by WHO, UNICEF, UNFPA, and USAID. It was taken through QED network to the global toolkit. In Africa, I think they have also used it, and maybe they have done a French translation also.

Quality of care for me became a second life. We were able to demonstrate that a simplified approach is possible and we don't have to endlessly wait for the system to get ready. Governments are already investing. They will take time to reach the bottom. Why not start from the bottom? There is a top-down approach, there is a bottoms-up approach. And the system would then strengthen around it. Without wasting time, let's do some action at the point of care.

So what has happened? The government in India have introduced POCQI as a principle in the training package of SNCU training. Now, when they are revising the SNCU training package, POCQI is already sitting there. You train them, but also train them in quality improvement: clinical training plus quality improvement training integrated, so they though you don't have to bring them back for QI subsequently. Tell them to go back, you have learned this new thing and check whether you can actually put that into practice. You will find how to you know put into practice what you learned. In the global midwifery educator program, they have included POCQI already. The global ENCC (essential newborn care course) have also included point of care quality improvement as a component of each module. So going forward, when they do small sick newborn care training package, I think they will use quality improvement. Integration is happening, that clinical training plus quality improvement training and plus supportive supervision later on, which I am saying QI coaching, but that's largely countries that are used to supportive supervision. That should happen after each clinical training. Clinical mentoring should happen. After QI, QI coaching should happen. But it's essentially supportive supervision through which mentoring is offered in post-training phase so that health workers can actually start practicing what they learn in training.

So newborn survival, some of the achievements are there. Next improvement in mortality will happen because of quality improvement. Third, I think we will still need technology-based solutions for two reasons. One is to reduce inequity, but also be ready to higher level, even level four level of care when more extreme prematurity will be the cause of death, when birth defects will be the cause of death. Perinatal heart disease would be killing newborns. So we have to get ready for that. I'm not saying today. We have taken two decades in India to scale up SNCUs from one to 1000. Countries will have to follow their own contextual progress. They will run into problems of infrastructural readiness. They will run into problems of human resources. They will have to be careful about the budgets. They will have to be careful about the essential equipment and supplies and a constant quality improvement and monitoring. 

India also went a little bit ahead and started addressing the upstream determinants of newborn mortality. When we found 10 % of pregnancies were adolescents, and newborn mortality was 1.5 times higher there, the government of India actually paid attention to address the health and nutrition of adolescents, preconception care, health and nutrition of women, etc. before they got pregnant. And family planning, of course, such a huge advantage for child survival. We found in a study in Bangladesh 53% reduction in maternal mortality coming from family planning.

So countries have done well. They have done hardcore newborn care, but they have also not forgotten maternal care component, because half of the newborn deaths happen because of maternal causes. Education and employment in Bangladesh, for example, has postponed pregnancy, postponed marriage. So child marriages have reduced. Adolescent pregnancy has reduced. Adolescent birth rate is going down. We have done well. So countries in our situation in the global south have to learn from each other. Maybe start small, gain incrementally, look at the overall big picture and learn from each other. We can do it. India is poised for newborn SDG. So are eight or nine more countries in my region. Only one country, two countries might miss it out of 11 countries in my region, Southeast Asia. 25 % of world population lives here, although there are just 11 countries and we have little bit disproportionately higher burden of poverty and disease. So I think if I do global calculation, 25% population, but we are responsible for 28% of burden of disease. So we are a difficult population. A lot of inequities are there. I think countries will do better if we learn from each other. That's my ringside view. I have contributed a bit, but I have been there in the journey. And we must admire the commitment of the governments and the partners who have delivered this.


Mbozu Sipalo (01:00:51.506)

Just while Dr. Rajesh, you touched on so many interesting things, and I don't even know where to start from in terms of like what's on path from what you said, but I just want to say, I really do appreciate you saying that we can start from just asking the questions. I think that's something that clinicians from LMICs tend to forget, that just ask the questions and start with the low hanging fruit. You don't need big funding to just start from the quality improvement, POCQI interventions. I really do appreciate that insight. You have thoroughly explained what POCQI is, how POCQI can help and what POCQI can do, but I don't think you've touched on how people can actually access this material and also get linked to the trainers and the champions like yourself. So could you please give us a little roadmap on how someone from Lesotho or Ethiopia can get hold of this information and start doing some POCQI projects in their hospital?


Dr Rajesh Mehta (01:01:58.2)

We have a digital version of POCQI also available. There is an initial four-hour self-learning workbook introductory course available in WHO Collaborating Center for Newborns in Delhi. On their website, the WHO supported that course is available. Now I am helping IPA (International Pediatric Association) to do a similar course available at their platform. Indian International Pediatric Association has more than 150 national associations as their members. And all pediatric associations will have access to POCQI. I don't know whether they will use the same name, but an equal QI introductory course.

The actual POCQI materials are available on the WHO website, in the Southeast Asia Regional Office website, but also in the QED toolkit, the Global Quality Equity Dignity Network, which I think may have stopped by now because of funding issues. But Healthy Newborn Network website, I think they also carried that. And I'm not sure Nest 360 also would have this, because I had shared with them. I will certainly in follow up send you the links where these materials are available. The POCQI training manuals, the QI coaching guide, the district implementation guide, and all of this is also supported by globally developed tools. We should use all of that. If there is a national policy, quality, strategy document from WHO headquarters, that’s the overall national, we have a regional framework from Southeast Asia regional office. Similarly, other regional offices have different approaches. So quality improvement, POCQI is just one small piece. There are other approaches; for example, we ourselves have followed MPDSR (maternal perinatal death surveillance and response system) beautifully to identify what led to the death of a newborn and a mother, and what are the quality improvement triggers in that diagnosis. And then POCQI can come in and improve the situation so that we don't have a next death because of same problem.

You can do death reviews, you could do clinical audits. Of course, quality assurance accreditation program is helping to set up the infrastructure to ensure that quality standards are met in terms of infrastructure and processes. But improved clinical performance, many accreditation programs don't have that component. Improving quality of clinical care, which happens through POCQI by the healthcare teams, could be one additional element, even if accreditation has happened. We have to bring those pieces together. Healthcare workers should actually start something which is within their hands to actually start improving. The POCQI materials would be available readily. Online training course is available. We have facilitated a asynchronous and synchronous digital program converted two days training into a digital format that also is available in another network which we had supported from WHO. So it is easy. One could self-learn but also access some community of practices. We have one in operated from India, that community of practice can be useful for providing facilitators also to do the training. I will send you all the details. There is a publication in regional office from WHO which gives the history of implementation of POCQI of first five years. That goes through how did it start, how did it expand, and what were the gains and what are the common projects which people have delivered through POCQI. So that document also is available, I will send you the links.


Shelly-Ann Dakarai (01:06:55.287)

Great. Thank you so much, Dr. Rajesh. We certainly learned quite a bit about how we can start improving neonatal care wherever we are with whatever we have. Starting simply and moving forward and getting more complex as the situation requires it, but we don't necessarily need to start with the complex. We can start simply and move from there. Thank you so much for that.

Thank you for also highlighting the changes that happen as you improve neonatal care. Sometimes I feel like we forget that we see neonatal mortality getting better, but then we start seeing different causes of mortality. Sometimes it's easy to think we're not doing enough, when it's just par for the course that as you get better at infection, then something else becomes the leader that may not have been counted because those babies died before. So it's not that the care isn't improving, it's just that we're changing the landscape. You talked about that early on, and I just wanted to highlight that because that is so easy to sometimes forget. You miss the wins that you're making when you see these changes, and it's just part of improving efforts. As we wrap up today, can you share some words of advice? 


Dr Rajesh Mehta (01:08:27.31)

We are all trained to do good things in saving lives. All of us have received some basic training and we should never give up. It's our job to do the best. If I keep myself a little bit motivated, internally I should decide that I will do my best, which many health workers already have. Keep your local leaders with you. When you start quality improvement, your next in line supervisor, you keep her or him with you. Secondly, form a team. In our healthcare systems in many countries, the hierarchy is very strong. In the medical profession, medical doctors consider himself the top. They don't give a damn about midwives, nurses, ward boys, janitors. But we should realize in a complex business of saving lives, we have to manage a complex health system and where each one has a role and all of us are equal. So consider an advice or a suggestion or a change idea from a security guard or a sweeper whose job is to clean on daily basis to improve the part of the care where their role is direct. A leader can be from the nursing side in the healthcare team who are doing quality improvement. And I have seen nurse leaderships actually perform much better, even better than medical profession. You must empower nurses and midwives proactively. Don't discount the value of a janitor or a person who cleans because they know what can improve the situation much better than the nurse or the doctor when it comes to hygiene.

So my request is, don't give up. We can make a change. Keep the local leadership involved and perform like a team, always. And last, patient and the family are equal partners in healthcare. Many programs are pretty weak in involving community or patient groups. In our day-to-day practice, I think we are reaching the third approach of quality, which is co-production of health. You know, we as a profession and the patients and their families are together responsible for making health and maintaining health. Therefore, healthcare service also depends on equally on the patient and the community, patient themselves, they have grown up and the healthcare teams.

So those are my advice for sticking to basics. And many of these things we actually learned in our medical schools and nursing schools. But during the practice, because of the system issues, because of the several constraints under which we work, we have not been able to practice. We learned many of these things in our schools.


Shelly-Ann Dakarai (01:12:52.545)

Thank you. And I know that there are some folks who are listening who would want to connect with you. What's the best way? Is it through email? Are you on social media? What's the best way for someone to possibly collaborate or even just learn a little bit more about what you do?


Dr Rajesh Mehta (01:13:11.214)

So email is the best of course. I have social media appearance but I don't usually frequently use that. But of course email we could share and people can reach out.


Shelly-Ann Dakarai (01:13:12.939)

Perfect. We'll put those in the show notes as well as the links to the POCQI resources that you'll send us and anything else that you feel like we should share with those listening with us. Thank you again for your time. We certainly learned a lot.


Dr Rajesh Mehta (01:13:34.2)

Yes. Thank you. I didn't realize it's been a long one hour.


Mbozu Sipalo (01:13:45.48)

It's been a very insightful one. Thank you so much for sharing your wisdom and your learnings. I'm sure many people will leave this chat very inspired to do something in their settings.


Dr Rajesh Mehta (01:14:02.754)

Thank you so much. It has been a pleasure. I also was able to recall with pleasure what we have achieved. Thank you.


Shelly-Ann Dakarai (01:14:07.799)

Thank you. To everyone else listening, we will see you next time on another episode of the Global Neonatal Podcast.

 
 
 

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