Partner Spotlight: Five Questions With Piramal Swasthya

The COVID-19 pandemic has jeopardized hard-won gains in women’s, children’s and adolescent health. Though women and children are at less risk from the virus itself, the knock-off effects—such as limited access to vaccines and sexual and reproductive health resources—are projected to do immense harm. Every Woman Every Child believes that women and children must be placed at the center of COVID-19 recovery plans. In that spirit, we have launched a new “Five Questions” feature to feature partners who are working to make sure that no one from these vulnerable groups is left behind. 

1. What is your organization’s primary concern with the global pandemic as it relates to women, children and adolescents?

Piramal Swasthya, through its different projects, aims at making primary healthcare accessible, affordable and available with special focus on preventing maternal and child mortality in line with the Sustainable Development Goals. We believe in reaching those who are unreached either geographically or socially.

Since March 2018, Piramal Swasthya, in partnership with the National Institution for Transforming India (NITI) Aayog, has been working with an objective of transforming maternal and child health and nutrition indicators in 25 of Aspirational Districts across seven states. These 25 Aspirational Districts have major gaps both on the demand side as well as on the supply side. These gaps within the thematic area of health and nutrition include those pertaining to infrastructure (including equipment and drugs), human resource for health and service delivery (limited capacity to effectively deliver services etc…), operations (supply chain management, flow of funds etc…), community awareness, participation, engagement and mobilization and so on. Over and above these challenges, the COVID-19 pandemic has added a new dimension. 

In the face of the COVID-19 pandemic, the health systems in these districts are facing immediate pressure to institute control measures and strengthen COVID-19 response. Given the context of Aspirational Districts, the COVID-19 pandemic adds tremendous pressure to respond to this emergency. The current lack of resources in terms of testing facilities, surveillance mechanism, Personal Protective Equipment (PPE) kits and underprepared health infrastructure, compounded by myths and misconceptions in the community and lack of capacity of the health workforce to respond to the situation, make these districts vulnerable to the evolving issue.

As resources are diverted to tackle the COVID-19 pandemic, the delivery of routine public health and nutrition services have been compromised across the country. Analysis of National Health Mission data from rural India data shows that maternal, child health and NCD services have taken a hit during the current lockdown phase. For example, the percentage of pregnant women opting for institutional deliveries have gone down by 7.7%, the percentage of immunization sessions held have decreased by 5.7% in March 2020 as compared to February 2020.

As the pandemic situation gets prolonged, routine health services will get further disrupted and the health impact due to maternal and child health conditions will start taking their toll. These indirect effects might include increased mortality and morbidity due to childhood diseases such as pneumonia, diarrhea and vaccine-preventable diseases, maternal deaths due to compromised antenatal care and institutional delivery services, increased burden of severe malnutrition etc. 

Keeping this context in mind, the primary concerns of the organization are, firstly, to strengthen the immediate response of the Districts to the COVID-19 pandemic and, secondly, to ensure that the gains made in the area of maternal and child health and nutrition by these Districts are not neutralized.

2. What concrete actions are you taking to advance/safeguard the goals of the EWEC Global Strategy during this time, specifically for ending all preventable deaths among women, children and adolescents by 2030?

As stated above, Piramal Swasthya has been working in 25 Aspirational Districts since March 2018. The team has been providing strategic and operational support to the district administration as well as concerned line departments at district, state and national level to bring about improvement in key indicators related to maternal and child health and nutrition. The strategy to comprehensively address constraints on both demand and supply side of the public health ecosystem includes interventions in four key areas. These four areas are as follows:

1. In order to improve perception towards public health care system and generating demand for health care services, it was envisaged to undertake massive community-based demand generation activities and make health a “People’s Movement” or a ‘Jan Andolan’. 
2. Additionally, it was important to enhance technical skills and leadership capacities and hence capacity building of health personnel emerged as the third theme. To strengthen and re-energize the supervisory cadre of health functionaries a strong supportive supervision program was designed. 
3. Without strengthening the supply side of the system, generating demand would be counterproductive. Therefore, the second thematic area was to address the supply side by strengthening public health facilities, particularly the district hospital and first referral units in each district. 
4. Lastly, multiple government schemes and programs fail to effectively ‘converge’ at the ground level and so the utilization of the scheme benefits at the beneficiary level remains a challenge. Therefore, effective scheme implementation at the grass roots level was the fourth thematic area of work.

Adopting this approach, these 25 districts have been able to show unprecedented improvement over a short span. In the area of maternal health, there has been an increase in the proportion of pregnant women registering for antenatal care from 73% to 94%. More importantly, registration of pregnancy within the first trimester has increased from 64% to 73% and proportion of registered women receiving at least 4 antenatal checkups have increased from 27% to 34%. The proportion of women opting to deliver at health facilities has also improved significantly and institutional deliveries in these districts have gone up from 66% to 82%. There has also been significant improvement in indicators pertaining to child health and nutrition in these districts. Early initiation of breastfeeding within one hour of birth has increased from 33% to 54% and exclusive breastfeeding till 6 months of age has increased from 55% to 59%. Proportion of under-five children suffering from diarrhea who received treatment with ORS increased from 51% to 63% while those who received Zinc treatment increased from 34% to 50.

Piramal Swasthya’s key interventions such as strengthening of Village Health Sanitation and Nutrition Days, First Referral Units and Engagement with Faith Leaders and community influencers members have contributed heavily to the aforementioned improvements, however sustaining the progress was a natural challenge considering nationwide lockdown, reverse migration and limited mobility in the wake of the COVID-19 pandemic.

With an aim to sustain the progress while simultaneously responding to COVID-19, the following key health and nutrition platforms were resumed and operationalized in April and May 2020 with necessary tweaks and precautionary measures.

Before the advent of the pandemic and subsequent lockdown, Piramal Swasthya was facilitating over 7000 Village Health Sanitation and Nutrition Days (VHSND) per month. These VHSNDs provide services related to antenatal care, immunization, growth monitoring among others and had completely stopped as India entered into a country wide lockdown. In May 2020, Piramal Swasthya was able to successfully re-initiate over 4,400 VHSNDs. In these VHSNDs over 80,000 pregnant women, lactating mothers and under-two children attended the session and availed services. Alongside, over 950 Auxiliary Nurse Midwives (ANMs) in the state of Uttar Pradesh have been trained so far on strengthening quality of VHSNDs. 

Uncertainties related to COVID-19 also impacted implementation of schemes such as Pradhan Mantri Matru Vandana Yojana (PMMVY). PMMVY, the Maternity Benefit Programme was launched in 2017. Under PMMVY, a cash incentive of `5000/- is provided directly to the account of Pregnant Women and Lactating Mothers (PW&LM) for first living child of the family subject to fulfilling specific conditions relating to Maternal and Child Health. Piramal Swasthya has been working on strengthening PMMVY since September 2019 in the 25 Aspirational Districts. We have been attempting to identify bottlenecks and strengthen the implementation of the scheme. The primary objective of this intervention is increase the number of registered beneficiaries under PMMVY and improving the disbursal rate of the installments. As of May 2020, Piramal Swasthya has facilitated resumption of PMMVY and registration of 52% beneficiaries.

3. How are you supporting national COVID-19 response and recovery efforts, particularly in ensuring that women, children and adolescents remain at the center of such efforts?

Piramal Swasthya has its transformation team present till the sub-district (block) level in all 25 Aspirational Districts which provided it with the foothold to dive straight into supporting response and recovery efforts of the government. In the initial stages of the epidemic, concerted efforts were made for prevention and control of COVID-19 infections hence the team began with supporting the district administration in preparing and operationalizing quarantine centers across the 25 Aspirational Districts along with ensuring adequate COVID-19 supplies (PPE Kits, Sanitizers, masks). The efforts were not limited to preparing quarantine centers. The quality team of Piramal Swasthya which works on strengthening first referral units and district hospitals, also started strengthening Intensive Care Units and Isolation Wards. 

While the quarantine centres were being set up, migration from metropolitan cities had also begun in these Aspirational Districts. It was crucial to identify, track and test the returning migrant workers to ensure their safety along with preventing community transmission. The second support that Piramal Swasthya provided to the district administration was with door-to-door screening of the returning migrant workers and their families. Piramal Swasthya staff also telephonically followed up with people in home quarantine to gauge if they were having any symptoms and prepare for its management. If there were any symptoms detected, the cases were escalated to the medical officers so that adequate care could be provided. As of June 2020, over 100,000 suspected cases have been tracked and followed up by Piramal Swasthya team. 

Piramal Swasthya has always been of the belief that supply and demand side of the health services should be strengthened at the same time. COVID-19 is a new disease which comes with its own myths and misconceptions within the communities. With an aim to generate awareness and dispel myths and misconceptions, Piramal Swasthya re-approached its work with community influencers including faith leaders and Panchayati Raj Institution (PRI) members.

 Around the world, community influencers have significantly contributed to sustainable development, promotion and protection of human rights, and conflict mitigation. Throughout India, religious and community leaders are respected and trusted in their communities. Additionally, faith and PRI leaders have a social standing that strategically places them in a position to influence behaviors of community at large. Piramal Swasthya started re-orienting the community influencers in April. Earlier these community influencers have played the role of advocates for maternal and child health practices and were now being oriented to dispel COVID-19 myths and misconceptions. Given the lockdown restrictions and physical distancing guidelines, telephonic and online sensitizations were identified as they key ways to orient the community leaders. In the last three months, the team has sensitized over 950 faith leaders and over 22,000 PRI members to further spread awareness in the community.

4. What impact will your organization have on the lives of women, children and adolescents, and how are you measuring this?

Through our work, we aim to reduce the morbidity and mortality from COVID-19 and high risk maternal and child conditions in 25 Aspirational districts. The programme activities are aligned towards the following primary outcomes:

1. Preventing new COVID-19 cases
2. Improving detection and management of COVID-19 and high risk cases
3. Improving the coverage of immunization and antenatal care services (including management of high risk pregnancies)

We expect to reach over 1.8 million children and 0.5 million pregnant women annually through our interventions in these districts. 

The organization has a mechanism for routine monitoring of interventions in place. The team reports the progress of the interventions which are reviewed on a periodic basis using analytical dashboards. In addition, as part of the Aspirational Districts programme, concurrent evaluation is conducted at an interval of every 6 months by a third party agency.

5. Who (partner organizations) are you working with to achieve this?

Piramal Swasthya has partnered with Bill and Melinda Gates Foundation to work in 15 out of the 25 Aspirational Districts with the aim of making these Districts resilient to COVID-19 by strengthening outbreak response and mitigating indirect impact on routine health and nutrition services.