Table 6. Challenges faced during the implementation of the project.
| Challenges | Steps taken | Outcome |
|---|---|---|
| • HBNC Training had been given to ASHA only at the time of appointment. | • Re-orientation of ASHAs on above aspects was a regular agenda during cluster meetings with success story sharing. | • Number of PSBI identification recorded an increase from 1.6% (of live births) in quarter 1 of establishment phase to 9.9% in quarter 1 of implementation phase. |
| • ASHAs were only weighing the baby and doing verbal inquiry from mothers about the health of the baby. They were not able to carry out all the recommended HBNC activities. | ||
| • Training and continuous re-orientation of ASHA with hands-on training in field and cluster meetings for: | ||
| • Number fast breathing cases identification increased from zero in quarter 1 establishment phase to 14.9% PSBI cases in quarter 1 of implementation phase duration. (Table 3) | ||
| ➢ Counting respiratory rate | ||
| ➢ Correct method to record temperature and weight | ||
| • HBNC recording form did not have space to record weight, temperature and respiratory rate. | • ASHA were requested to document the recordings on the HBNC forms. | |
| • ANMs, medical officers (excluding pediatricians) and staff nurses were “hesitant” to administer inj. gentamicin to infants due to fear of adverse events. | • Medical Superintendent motivated them for administration of inj. gentamicin through: | • Actual number of cases administered simplified treatment at SC/PHC/CHC increased to even though the proportion remained almost the same. (Table 3) |
| ➢ Revision of existing government guidelines and role of ANM in simplified treatment of PSBI | ||
| • Pre-referral drug was administered to 2/8 cases of PSBI in establishment phase which increased to 14/25 cases in implementation phase (Table 3). Out of these, 02 pre-referral drugs were given by ANM. | ||
| • ANMs also perceived that the community may not be willing for their newborns treated by them, especially administration of injection gentamicin. | ||
| ➢ Addressing safety concerns over administration of gentamicin. | ||
| ➢ Sharing success stories of administration of simplified treatment and pre-referral dose by ANMs. | ||
| • Certificate of appreciation was awarded to ANMs who gave simplified treatment or administered pre-referral dose. | ||
| • A “job aid” was provided to ANMs and Medical Officers depicting guidelines to classify and manage a case of PSBI. | ||
| • No provision for providing oral amoxicillin dispersible tablets and inj. gentamicin to ANMs even though it was available in government supply. One ml syringe was not available in government supply | • Oral amoxicillin dispersible tablets and injection gentamicin and 1 ml syringe with 26-gauge needle were provided through the research funds at the health facilities and ANMs in the establishment phase. | • Injection gentamicin was issued to ANMs by government pharmacists |
| • In Implementation phase government supplied oral amoxicillin dispersible tablets and injection gentamicin and 1 ml syringe with 26-gauge needle. | ||
| • Stock out of the HBNC visit recording forms hampered the documentation of the home visits by the ASHAs | • Government authorities were encouraged to regularize the supply of recording forms. | • HBNC forms were supplied to ASHA. |
| • Low awareness among mothers about neonatal danger signs. | • "Mother card" with information about signs of sepsis in newborns was developed and distributed by ASHAs to educate caregivers in village and mothers at the time of discharge after delivery from CHC/ PHC. | • Mother and family were able to identify signs of infection. Most families who identified sickness in their young infants did so in the implementation phase of the program. |
| • Low acceptance among the community for a referral to the government health facilities | ||
| • There was loss of critical time in transport between facilities, resulting in delay in treatment. | • The issue was discussed with State Government planners and policy makers to develop a mechanism to obtain information about the availability of a bed at the sick newborn care unit or referral hospitals | • Government endorsed simplified treatment to reduce the burden of cases at tertiary care facilities. |
| • Issue not completely resolved yet and the policy makers are in process of developing information system about availability of beds in NICU to cut short delay during transport | ||
| • ASHAs were not able to use the digital watch provided in the HBNC kit. On many occasions they were found non-functional. | • One to one training to each ASHA was given for counting of the respiratory rate by using their mobile phones. | Identification of cases of fast breathing cases by ASHA increased from establishment to implementation phase. |
| • Posts of ASHA were vacant in some villages. | • Responsibilities of HBNC visits in such areas were assigned to the ASHAs of the adjacent villages by health administrators. | • Number of first week visit after birth increased from 74.1% in quarter 1of establishment phase to 83.3% in quarter 1of implementation phase. |
| • There are some villages where ASHA are inactive. | ||
| • ASHAs had to participate in other government campaigns such as for immunization, non-communicable disease etc. | • During Cluster meetings, ASHA were reminded to continue the HBNC program follow-up. TSU staff was directly contacted by ASHAs telephonically when a sick infant was identified. | • There was continuous increase in 1st week visit by ASHA and PSBI case identification despite involvement in multiple programs. |
| • Supportive supervision and hand holding assisted ASHAs to develop multi-tasking abilities. |
Abbreviations:
ASHA Accredited Social Health activist
HBNC Home based Newborn Care
TSU Technical Support unit