Blended Tele-mentoring Support for Strengthening Antenatal Care by Private Health care Facilities: FOGSI VISTRIT INITIATIVE

Abstract

Introduction

The objective of the present initiative was to build capacity of health care providers in private sector along with standardisation of care during antenatal period for common antenatal problems of GDM and iron deficiency anaemia in private sector.

Methods

A pilot project for all levels of health care providers including doctors, nurses, counsellors and laboratory technicians of 34 private facilities in six districts of Jharkhand was planned. Training modules for GDM and anaemia based on government of India guidelines were developed. End line evaluation included data collection and descriptive analysis of quantitative data quality scores from assessment standards on GDM and anaemia in pregnancy.

Results

Knowledge assessment of health care providers and doctors through baseline and end line knowledge assessment survey questionnaire showed that 100% health care providers who were trained scored 85% or more in knowledge assessment questionnaires as seen by baseline and end line questionnaire results. All project hospitals (n = 34) in Jharkhand achieved quality standards of care in intervention period for gestational diabetes mellitus and anaemia in pregnancy. They achieved total score more than 80% and exceeded target of 80% of the quality standards.

Conclusion

A systematic strengthening of private health care facilities through a blended tele-mentoring and onsite support is possible.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13224-023-01866-5.

Introduction

India contributes to one-fifth of the global burden of absolute maternal deaths. There has been a decline in maternal mortality ratio (MMR) from 122 in 2015–2017 to 113 in 2016–2018 [1]. India has committed itself to the latest the target 3.1 of sustainable development goals (SDG) set by United Nations that aims at reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 [2]. Although the decline in mortality indicators has been encouraging with a current MMR at 113 and infant mortality rate (IMR) 32 infant deaths per thousand live births1, we are still lagging behind the desired targets. Reduction in maternal mortality has therefore been a major area of concern for governments across the nation and time bound targets have been set to achieve. Furthermore, suboptimal performance in empowered action group (EAG) states points to gaps in antenatal care and emergency obstetrical care [3]. This calls for a shift from a system focused on emergency care for a few women to wellness-focused care for all. During the antenatal period, women are encouraged to get themselves screened for high risk factors to avoid poor maternal and child outcomes. Anaemia and gestational diabetes mellitus (GDM) have been two major causes of maternal and neonatal morbidity and mortality and can have grave implications for both the mother and the foetus. Antenatal care (ANC) is one of the priority interventions for reducing maternal and neonatal morbidity and mortality.

Universal ANC provision is not possible without strengthening all ANC providers including private sector.

India has a mixed health care system with public and private health care service providers including health care workers and doctors. There is an increase in utilisation of private providers with a rise in urban monthly per capita expenditure [4]. The private sector contributes to nearly half of all deliveries. Private hospitals are largely unregulated with no standardisation of quality of services. Studies have also shown that providers often fail to adhere to clinical guidelines; for example, in Uttar Pradesh, India, facility-based birth attendants did only 40% of items on the WHO safe childbirth checklist in a typical birth [5]. There is need for private sector to adopt standardised quality checks and increase self-monitoring capabilities.

The objective of the present initiative was to build capacity of health care providers (health care workers and doctors) in private sector along with standardisation of care during antenatal period for common antenatal problems of GDM & iron deficiency anaemia in private sector. The outcomes were targeted towards creating innovative and replicable training modalities with simultaneous strengthening the infrastructure capacities including the equipment and IEC.

Methodology

Safe Motherhood Committee (SMC), Federation of Obstetrics and Gynaecological Society of India (FOGSI), is a cohort of technical experts who engage in initiatives towards making pregnancy and childbirth safer.

There was a felt need to harness the strengths of both the private and development sector to achieve greater impact than either could achieve alone. For putting this into action, FOGSI partnered with USAID under the Private Sector Engagement (PSE) operating model of USAID under the IPE Global implemented project to standardise antenatal care practices by aligning the private sector to public health goals for improved health of mothers.

This projected was implemented from December 2020 to end of April 2021 under the name of project ‘VISTRIT’ as a prospective interventional study. It was conceptualised as a pilot project for the all levels of health care providers including doctors and other health care workers such as nurses, counsellors and laboratory technicians of 34 private facilities in six priority and aspirational districts of Jharkhand (Bokaro, Dhanbad, Giridih, Ramgarh, Ranchi and Jamshedpur) and also included four aspirational districts as depicted in Fig. 1. For this purpose, the focus of this project was on three levels such as facilities (n = 34), health care workers (HCWs) including paramedical staff, laboratory technicians, nurses (n = 227) and doctors who were primarily obstetricians or gynaecologists with an average 10 years of experience (n = 39).

Fig. 1.

Coverage area of the Vistrit Project

Content Development

The training modules were developed by the expert panel of Safe Motherhood Committee based on Government of India guidelines on GDM and anaemia and the pilot project was rolled out on 1st December 2020. Six modules for GDM (3 for doctors and 3 for HCWs) and 7 modules for anaemia (3 for doctors and 4 for HCWs) were developed. The key strategies for program implementation at various levels of health care included online training, panel discussions and mentoring visits. The purpose of taking up GDM and anaemia as a part of the pilot intervention were many fold. First these are quite prevalent among the pregnant women with serious implications on the maternal and neonatal outcomes. Secondly, it is relatively easy to diagnosis of both these conditions and yet standardisation is imperative. Thirdly, both these conditions involve dietary and lifestyle measures beyond just pharmacological management. Counselling is a major part of management of these conditions which is usually ignored at all levels. With these in mind, the training modules were planned to address the issues of diagnosis and management.

Training Implementation

The training started in 9th January 2021 and completed by 27th February 2021. The training had both online and offsite components. Online sessions were conducted by senior experts and members of Safe Motherhood Committee, FOGSI for HCWs and doctors on anaemia in pregnancy, which included an overview of anaemia in pregnancy and diagnosis and management of anaemia in pregnancy. Similarly, for GDM, the training sessions covered an overview, diagnosis and management of GDM. Case based discussions and online panel discussions on the same were an integral part of the training sessions and each session lasted for 1.5 to 2 h duration. Mentoring sessions were conducted online regularly to the facilities to support and hand holding of HCW’s in the facilities. During these mentoring sessions, gaps were identified, support to health facilities was provided for maintenance of equipment and maintenance of records and log book was also supervised. For some facilities, onsite mentoring was possible despite the Covid pandemic.

Development and Administration of Assessment Tools

Technical team from Safe Motherhood Committee and IPE Global ‘Vriddhi’ project drafted structured survey tool questionnaires. These were reviewed by all the project team members and pretested in a small number of facilities before being finalised for use. Separate tool was designed to assess the quality of care at different levels; facilities, health care workers and doctors. The questionnaire included structured questions to measure project outcomes, and to measure the present status, knowledge, attitudes and practices on themes relevant to all the objectives and outcomes. Facility questionnaire emphasised on equipment, testing facilities, availability of information, education and counselling (IEC) and record keeping. Health care worker’s tools had questions related with screening, counselling, single step testing, diagnosis and postpartum services for anaemia and GDM. Doctor’s questionnaire focused mainly on diagnosis and management.

In order to standardise care for GDM and anaemia in private sector, ‘Standards’ were designed by safe motherhood committee, FOGSI experts and senior consultants to assess the quality of care at different levels of health care. This included standards related to systematic patient testing, accurate diagnosis, provision of appropriate treatments, and proper patient counselling. Facility standards emphasised on equipment, testing facilities, availability of IEC and record keeping. Scores for screening, counselling, single step testing, diagnosis, management, and postpartum services for anaemia and GDM were given. Quality was also assessed based on availability of emergency drugs, display of appropriate IEC material and record keeping at the facilities (Figs. 2, 3, 4). All these standards were used to assess and obtain scores about effective implementation and quality standards of gestational diabetes management and anaemia. Scores were generated from all the facilities based on the GDM standards and anaemia standards.

Fig. 2.

Documents used under Project VISTRIT (Log-book, Case Records, Record Book)

Fig. 3.

Patient information leaflets developed for anaemia and diabetes

Fig. 4.

Facility standards for a anaemia and performance on the standards and b gestational diabetes mellitus and performance on the standards

The end line evaluation included data collection and descriptive analysis of quantitative data obtained in form of percentage correct responses, from key questionnaire surveys and quality scores from assessment standards on GDM and anaemia in pregnancy. The basic assessment methods used were personal interviews and observations. Table 1 summarises the tools and instrument used in data collection and methods of administration. Table 2 describes the objectivised points for assessment. Point percentage differences were calculated by a comparison in the baseline and end line survey. These scores for quality standards were summarised and compared with the target scores.

Table 1.

Comparison of facilities level responses percentages; baseline and end line evaluation (for both GDM and anaemia)

Indicator/questions (N = 34)	Correct response percentage (%)		Percentage point difference (%)	P value
	Baseline	End line
Do you have functional glucometer in your hospital				1.000
Yes	100	100	0
Do you maintain the record of screen positive GDM antenatal patients				< 0.001
Yes	52.9	100	47.1
Do you maintain the record of maternal and fetal outcome in GDM patients				< 0.001
Yes	50	100	50
How do you test the blood sugar in antenatal patient				< 0.001
Glucometer	20.6	100	79.4
Who does the counselling of explaining the diet in anaemic and GDM patients				< 0.001
HCW	20.6	97.1	76.5
Do you maintain the record of severe anaemia in antenatal patients				0.062
Yes	85.3	100	14.7
Do you have 24 h lab in your facility				0.031
Yes	76.5	94.1	17.6
Do you have display of information, education and communication material regarding anaemia and GDM management in your hospital				< 0.001
Yes	38	100	62
Do you have emergency tray in your hospital				1.000
Yes	100	100	0
Are the healthcare workers in the facility trained for performing single step test for blood sugar testing in antenatal patient				0.001
Yes	67.6	100	32.4
What do you use for performing single step test for GDM with 75 g glucose				0.001
75 g anhydrous glucose	47.1	100	52.9
Do you advice the antenatal women to sit for 2 h after taking glucose load				0.001
Yes	64.7	100	35.3

Statistically significant P values are shown in bold

Table 2.

Comparison of health care workers correct response percentages in relation to GDM: baseline and end line evaluation

Indicator/questions (N = 227)	Correct response percentage (%)		Percentage point difference (%)	P value
	Baseline	End line
Whom are you testing for blood sugar level				< 0.001
All women	93	100	7
When is the first test for blood sugar done				< 0.001
First visit	91.2	100	8.8
How do you test for blood sugar in pregnancy				< 0.001
2 h after 75 g glucose	43.2	100	56.8
At what blood sugar level would you say that pregnant woman has GDM				< 0.001
140 mg	35.2	100	64.8
Can a non-diabetic become diabetic in pregnancy				< 0.001
Yes	94.7	100	5.3
If first value is normal, do you repeat test for blood sugar in pregnancy				< 0.001
Yes	82.8	100	17.2
When do you repeat test for blood sugar in pregnancy, if first test is normal				< 0.001
24–28 weeks	69.2	100	30.8
Does high blood sugar in mother affect the fetus/baby				< 0.001
Yes	91.6	100	8.4
How do you counsel for managing high blood sugar in pregnancy				< 0.001
Diet/exercise/drugs/insulin	57.7	100	42.3
If blood sugar level is high in pregnancy, do you follow-up these patients after delivery				< 0.001
Yes	93	100	7
How long do you follow after delivery				< 0.001
Yes	10.6	93.5	82.9

GDM, gestational diabetes mellitus

The assessment was carried out by external assessors who were not a part of the development of module and program implementation to avoid bias in assessment.

It was complemented by the qualitative data in form of Focussed Group Discussions (FGDs), to provide descriptive information on the VISTRIT PROJECT impact. Two FDGs were conducted, one for doctors and other for health care workers, with 6 questions for each. There were 8 participants per FGD. Qualitative evaluation data were collected through Focus Group Discussions (FGDs) with a range of stakeholders from the target population. (Annexure 1).

Results

Baseline survey was conducted onsite, but end line evaluation was onsite for Bokaro and Ranchi, and for other districts it was online for doctors while it was onsite for HCW. The end line assessments were done from 15th March to 8th April 2021. Knowledge assessment questionnaires were administered to 227 health care providers and 34 doctors in 34 private hospitals in six districts of Jharkhand in a simple non-experimental pre-and post-test assessment through interviews to all the HCWs, doctors and the facility owners. Scores for quality assessment for standards for GDM and anaemia in pregnancy from all facilities were assessed online by senior team members of SMC and were compared with target value of 80% standards quality. As the assessments were done by video demonstration, each of these components were meticulously assessed. It was feasible to observe counseling drills in places where required. The data collection was augmented by visual feedback. Although slightly restrictive, detailed and meticulous online assessments helped to increase the access and compliance even during the Covid Pandemic. A descriptive analysis was conducted calculating the summary scores and percentages for each facility and questions.

Knowledge assessment of the health care providers and doctors through baseline and end line knowledge assessment survey questionnaire showed that 100% health care providers who were trained scored 85% or more in the knowledge assessment questionnaires as seen by baseline and end line questionnaire results. Tables 2, 3, 4 and 5 depict the results for knowledge assessment questionnaire on baseline and end line survey and a comparison in form of percentage point differences at all levels, i.e. facility, HCWs and doctors for both GDM and anaemia.

Table 3.

Comparison of health care workers correct response percentages in relation to anaemia: baseline and end line evaluation

Indicator/questions (N = 227)	Correct response percentage (%)		Percentage point difference (%)	P value
	Baseline	End line
How are you screening antenatal women for anaemia	52	100	48	< 0.001
Pallor and Hb
At what period of gestation is haemoglobin tested	46.3	94.3	48.1	< 0.001
Once in each trimester
What is the normal value of haemoglobin in pregnancy				< 0.001
11 g%	44.9	100	55.1
At what haemoglobin level is anaemia severe				< 0.001
< 7 g%	82.8	100	17.2
Are you routinely testing for thalassemia and sickle cell anaemia				< 0.001
Yes	52	100	48
Are you deworming pregnant women				< 0.001
Yes	58.6	100	41.4
Which deworming medicine are you using				< 0.001
Albendazole	81.5	100	18.5
Anaemia is caused by deficiency of which nutrient				< 0.001
Iron	86.8	100	13.2
Which of the following improve iron absorption				< 0.001
Vitamin C	41	100	59
Will you give iron supplement to pregnant women if haemoglobin is > 11 g%				< 0.001
Yes	71.4	100	28.6
What are the treatment options for improving haemoglobin levels in pregnancy				< 0.001
Diet/drugs/blood	69.6	100	30.4
Are you aware of any injections which improve the haemoglobin in anaemic pregnant female in your practice				< 0.001
Yes	81.5	100	18.5
What route of injection is preferred to improve haemoglobin in anaemic pregnant female in your practice				< 0.001
IV	53.7	100	46.3
Iron tablets are well absorbed when given				< 0.001
Before meals	33.9	100	66.1
What are the complications of anaemia in pregnancy				< 0.001
Preterm labour, IUD, PPH, Delayed wound healing	73.6	100	26.4
Below what haemoglobin level is blood transfusion advised				< 0.001
< 7 g%	78	100	22
Do you do haemoglobin estimation in postpartum routinely				< 0.001
Yes	69.2	100	30.8

Table 4.

Comparison of Doctors' correct response percentages in relation to GDM: baseline and end line evaluation

Indicator/questions (N = 39)	Correct response percentage (%)		Percentage point difference (%)	P value
	Baseline	End line
When do you first test for GDM				0.031
First visit	82.1	97.6	15.6
How do you screen for GDM at your centre				< 0.001
GTT with 75 g glucose	56.4%	100	43.6
What is the cut-off for blood sugar for diagnosing GDM in pregnancy				0.031
140 mg/dL	84.6	100	15.4
When do you retest for GDM, if first test is normal				0.062
24–28 weeks	87.2	100	12.8
How do you manage GDM in pregnancy				0.125
Diet/drugs/insulin	89.7	100	10.3
What do you understand by MNT				0.031
Medical nutrition therapy	84.6	100	15.4
After how many days of MNT, are you retesting				< 0.001
14 days	66.7	100	33.3
Which test are you doing after MNT				< 0.001
Fasting and postprandial	15.4	100	84.6
At what level should the fasting and 2 h postprandial blood sugar be maintained in GDM patients				< 0.001
90 mg/dL and 120 mg/dL	46.2	100	53.8
If the mother is detected GDM at 10 weeks of gestation, what is your preferred modality of treatment besides MNT and exercise				< 0.001
Insulin	41.0	95.2	54.2
What is your first line of therapy after MNT in 2nd trimester if the blood sugar levels are not controlled				< 0.001
Metformin	20.5	83.3	62.8
Do you monitor GDM patient with HbAlc				< 0.001
No	38.5	100	61.5
How long do you follow GDM patient in postpartum period				< 0.001
6 weeks	20.5	100	79.5

Statistically significant P values are shown in bold

GDM; gestational diabetes mellitus; MNT, medical nutrition therapy

Table 5.

Comparison of Doctors' correct response percentages in relation to anaemia: baseline and end line evaluation

Indicator/questions (N = 39)	Correct response percentage (%)		Percentage point difference (%)	P values
	Baseline	End line
How are you screening all antenatal women for anaemia	100	100	0	1.000
Clinical and lab
Which investigation are you doing	64.1	100	35.9	< 0.001
Hb, CBC, peripheral smear
Do you perform routine thalassemia screening for all ANCs	79.5	92.9	13.4	0.062
Yes
If haemoglobin > 11 g%, will you supplement oral iron	84.6	100	15.4	0.031
Yes
How do you manage moderate anaemia in 1st trimester	30.8	42.9	12.1	0.062
Oral iron
A 32 weeks pregnant woman and a diagnosed case of iron deficiency anaemia, on her 2nd visit has the constant Hb of 8gm%. What would you do next	59	100	41	< 0.001
Injectable iron
Which composition of injectable iron do you prefer, in antenatal period	66.7	100	33.3	< 0.001
Sucrose
What do you prefer to prescribe it alone or iron combination	53.8	100	46.2	< 0.001
Combination
What composition of elemental iron you prefer while prescribing iron	89.7	100	10.3	0.125
Vitamin C
What investigations do you do before using injectable iron	46.2	100	53.8	< 0.001
HPLC
Do you deworm routinely in pregnancy	64.1	100	35.9	< 0.001
Yes
In which trimester do you do deworming	89.7	100	10.3	0.125
Second
Which drug you use for deworming	76.9	100	23.1	0.004
Albendazole
When do you reassess haemoglobin after injectable iron therapy in anaemic antenatal patient	28.2	100	71.8	< 0.001
2 weeks
Do you do haemoglobin estimation in postpartum routinely	69.2	97.6	28.4	0.001
Yes
How long do you continue iron tablets postpartum	59	100	41	< 0.001
6 months

Statistically significant P values are shown in bold

Facility Level

Marked difference was seen in maintaining records of gestational diabetes patients, single step blood sugar testing methods at the facilities. Earlier all the facilities were sending samples to laboratory but now all started doing it at the facility itself. Health workers started counselling for anaemia and diet in pregnancy in the facilities. Change was seen about the knowledge about display of IEC material at facility (Table 1).

Health Care Workers

Statistically significant difference was seen in the percentage point differences in baselines and end line values of knowledge assessment questionnaires of health care workers. Methods of testing for blood sugar, cut-off values of blood sugar, counselling for GDM and postpartum follow-up in GDM cases were the important questions which showed considerable improvement in their knowledge. For anaemia, testing for haemoglobin (Hb), concepts of facilitators for iron absorption, symptoms of mild to moderate anaemia showed more than 50% difference. Besides these, knowledge of other questions also improved that reflected in percentage difference in the correct answers (Tables 2, 3).

Doctors

Knowledge assessment revealed a considerable difference from the baseline in their knowledge about the tests to perform after MNT, fasting and postprandial blood sugar levels to be maintained in GDM, preferred first line of therapies after MNT, use of HB1Ac, postpartum follow-up in GDM, required investigations after injectable iron and re-assessment after injectable iron (Tables 4, 5).

Standards and Scoring System to Assess Quality in Facilities

All project hospitals (n = 34) in Jharkhand achieved quality standards of care in intervention period for gestational diabetes mellitus and anaemia in pregnancy. They achieved total percentage scores more than 80% and exceeded the target of 80% of the quality standards. The number of standards scored for assessing quality in GDM, anaemia, emergency tray availability and updating, IEC display at the facility and maintenance of record books at the facilities are specified in supplementary (Fig. 3). The facility preparedness including skill and knowledge of doctors and health care workers of all the facilities increased; exceeding the program target of 80% as measured by the end line values in form of scores obtained in assessment of quality standards.

Impact Assessment and Programmatic Implementation

The views of the participants on various aspects of the course elicited an in depth understanding of the strengths and limitations of the project.

Course Material

All the participants felt the training and the courses provided were excellent. They appreciated both the GDM and Anaemia courses, as the new learning changed their practice of detecting GDM and anaemia.

Training Schedule

While three of the respondents felt the timing and frequency of training were appropriate, two reported that it was a problem. For one, it was because of her small clinic with a low staff strength.

The respondents also felt that the online form of the training helped HCW to connect from their home on their mobile which as another advantage.

Methodology

All the respondents appreciated the online form of training as it was the only option available during Covid time. A major advantage was that many participants could join in at the same moment. It reduced travel cost and other logistics.

Changes in Practice

Changes occurred at 3 levels: GDM diagnosis, anaemia detection and in counseling.

Before the training, only cursory attention was paid to pregnant women with high blood sugar level. They also often failed to detect the cases as they were not aware of the proper method. The introduction of the DIPSI method changed their practice.

The diagnosis of anaemia was also strengthened by reiterating on the cut-off which led to an improved counselling and management. The content of counselling was now better with discussion on diet and also regarding the intake of iron tablets. More time was devoted to counselling.

Impact on HCW

HCW expressed an increased “zeal” and “drive” to do their job as they felt more confident of their scientific knowledge and could translate them into clinical practice.

Assessments

According to some of the respondents, during the assessments, questions were directed to a few and all could not get an opportunity to answer. Another respondent had a different experience in her hospital as it was better planned and they worked as a team to answer the questions.

Discussion

This project was designed to achieve a comprehensive goal to improve knowledge, upgrade skills and build competencies of private sector health care providers on key antenatal care practices in anaemia and gestational diabetes mellitus. In order to build capacity of health care providers, expert consultants in the project developed a complete training package on gestational diabetes mellitus and anaemia in pregnancy for health care providers and doctors. Training modules, knowledge assessment questionnaires, record books, log books and IEC material were developed by FOGSI Safe motherhood Committee members, senior gynaecologists, and experts based on the standard operational guidelines. For strengthening care practices of health care providers, training programs were planned and conducted for 100% health care providers. In addition, after the training, onsite and online mentoring was done in the facilities. The online training yielded adequate results as assessed by baseline and end line knowledge and assessment of quality of care through standards, thus, highlighting that the innovative model worked well for the providers. Moreover, these results suggest that there is interest on the part of HCW to adopt these practices for which they were trained; however, there is continued need for promoting the messages to large numbers of HCWs in the future.

The improved activities adopted by some facilities were higher than the other facilities; as the program officer could mentor these facilities onsite specifically and other facilities were mostly mentored online. This could also be the reason that a few facilities could obtain the overall target score of barely 80% and were lagging behind in the individual standards of GDM, anaemia or both and also in maintenance of emergency trays and records that needs to be further strengthened.

India’s health care system is dominated by a highly fragmented and diverse health care sector.

The 75th round on Health conducted by the National Sample Survey Office4 during 2017–2018 showed that among ailments, which were treated, 69.9% were treated by the private sector [6].

It may be a consequence of underfunded and over stretched public health system, but it still is a matter of grave concern as this sector is largely unregulated. Most of the government initiatives on ensuring and improving health care service delivery are focussed on the public health facilities. In such a scenario, it is a huge paradox that the facilities catering to a larger population do not come under the spectrum of interventions.

The FOGSI VISTRIT project is a unique initiative to assess and improve the quality of service care delivery across various private health care facilities. Being a pilot study, it is limited in the scope of the facilities recruited and the interventions planned but the success of the project reflects upon the feasibility and scalability of such an intervention.

There were some key factors which played pivotal role in successful implementation of this project. Firstly, it was uniquely initiated and executed by a professional organisation which has a vast network of experts to handhold the staff as subject experts. Secondly, the project looked at capacity building of not just the doctors but the other cadres health care workers which meant that all levels were equipped simultaneously. Thirdly, two focussed topics of prime importance, anaemia and GDM were taken up with the understanding of the prevalence and impact of these problems. A standard module for targeted intervention had been developed which can be utilised on a wider scale. Fourthly, inclusion of counselling points within the necessary standards was a unique initiative to not just improve the scientific content of care but also to improve the quality and experience of care. Lastly, this study brings to fore the potential possibilities of a public private partnership where the government can liaison with the huge network of experts through organisations like these to bring the private sector under the broad umbrella of regulations for health care service delivery.

The effectiveness of onsite mentoring for improvement of maternal child health have been previously reported. A study in 2016 assessed the effectiveness of a nurse-led onsite mentoring program in improving quality of care of institutional births in 24/7 primary health centres (PHCs that are open 24 h a day, 7 days a week) of two high priority districts in Karnataka state, South India [6]. A higher number of facilities in the intervention arm had all appropriate drugs, equipment and supplies to deal with complications during childbirth. The mentoring program successfully improved provider preparedness and facility readiness to deal with institutional births and associated complications.

Another study from Nepal [7] described an onsite clinical mentoring program aimed at improving emergency obstetrical and new-born care (EmONC) in Nepal and assess its effectiveness on nurses’ knowledge and skills. Using updated national training manuals and teaching aids, these clinical mentors assessed and taught 12 core EmONC clinical skills to their nurse-mentees. They reported that mentees had better knowledge of maternal and new-born care and were better able to perform the 12 core clinical skills throughout the program.

All these programs, however, were reported in the public sector with active initiation and involvement of the government agencies.

One limitation in the end line evaluation was the availability of time of hospital staff at that time while administering the surveys questionnaire at baseline and end line evaluation; sometimes HCWs and doctors were engaged and occupied in emergency surgeries. COVID-19 pandemic itself posed lots of challenges in terms of difficult travel due to lockdowns, disease associated morbidities in facilities’ as well as project staff. Due to many such limitations, assessments were conducted online. Knowledge assessment questionnaire also had to be administered online. In addition, HCWs were sometimes not technically sound and were hesitant to speak in front of camera and could not operate different controls required during Zoom meetings. While many of the project objectives and outcome indicators improved dramatically over the duration of the project, however, clear attribution of positive program effects is difficult while there may be other programs, services, and messages being delivered in the same geographic areas. Despite the above limitations, the outcome results at each the site indicate the success of online training and easy replicability of these modules. The success could also be attributed to the fact that project messages have been widely diffused, supplemented with the regular mentoring and hand holding visits to the facilities throughout the project implementation area.

Conclusion

This project presents a proof of concept for the health system intervention for systematic strengthening of private health care facilities through a blended tele-mentoring and onsite support.

In a vast country like India, interventions are required at multiple to reach out to the grass root levels. Private sector in India contributes to a large chunk of health care service delivery. However, there are no organised training programs targeted for covering the smaller health care facilities which are essentially run by individual practitioners supported by trained or semi trained HCWs. This project shows the potential for organised training initiated by a professional organisations and supported by partner agencies. The sustainability of the improvements needs to be ensured through setting up of mentor mentee relationships between the facilities and the experts who would provide continued hand holding for a pre-determined period. Also, there is a scope for cross-mentoring where the facilities in a cluster can look into each other’s practices.

There is an urgent need to scale-up the models of blended learning which utilise the power of virtual platforms along with onsite mentoring for hand holding. Since it was just a pilot project, further full-fledged project with systematic and robust M&E designs should include an integrated final project evaluation design that should include both qualitative and quantitative components. Ideally, monitoring and evaluation design of the next round of programming would incorporate testable hypotheses and a representative comparison groups to evaluate the effectiveness of project activities for beneficiaries vs. non-beneficiaries. Quality assurance and improvement models can be further incorporated and strengthened.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Annexure 1: Focused Group Discussion

Focused Group Discussion (FGD) for Doctors

1. Share your experiences regarding course material, schedule, and methodology of training.

2. How did this project bring change in your routine practice?

3. Would you like such projects to expand in future to improve the quality of care in pregnant women and share your experiences in further improving the training methodology?

4. Share your experiences regarding the impact of this project on your Health care workers?

5. Did you find any shortcomings in the VISTRIT Project, if any and how could we have improved it?

6. Do you think that the assessments of the facilities were done optimally and all the health care workers in your facility were given equal opportunity to express or demonstrate himself/herself?

Focused Group Discussion (FGD) for HCWs

1. Share your experiences regarding course material, schedule, and methodology of training.

2. How did you find the IEC Material and Logbook additionally useful for your routine practice?

3. What Changes do you find in yourself in knowledge, attitude, and practices in the management of Anaemia and GDM after participating in this project.

4. Share your thoughts on online training and onsite mentoring, which do you think have helped you more and why?

5. Did you find any shortcomings in the VISTRIT Project, if any and how could we have improved it?

6. What do you think about the final assessments done by experts on Anaemia and GDM? Do you think that the health care workers were given good opportunity to respond and demonstrate the required drill or procedure?

Funding

The funding for logistic support was provided by USAID.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

Ethical clearance was obtained from Tulsi Hospital Ethics Committee.