SNCU Quality of Care Index (SQCI)

SNCU Quality of Care Index (SQCI)01

Evidence based Performance tracking of Special Newborn Care Units (SNCU)

SNCU Quality of Care Index (SQCI)

Process Document

Enhancing Efficiency of Pneumonia Management02

ContentsAcronyms .................................................................................................................04

executive summAry ................................................................................................05

introDuction ...........................................................................................................06

sncu QuAlity cAre inDex - sQci .............................................................................07

imPlementAtion of sQci in Vriddhi stAtes ...........................................................08

stAte level sQci GuiDeD Actions .......................................................................... 10

cost effectiveness of sQci .................................................................................. 12

HAnDinG over of sQci to tHe Vriddhi stAtes ....................................................... 12

outcomes of tHe initiAtive .................................................................................... 13

cHAllenGes fAceD .................................................................................................. 15

WAy forWArD ............................................................................................................ 16

Annexures ............................................................................................................... 17Annexure 1 - sncu Quality of care index (sQci) ............................................................17

Annexure 2 - letters from state Governments............................................................ 18

Annexure 3 – report on sQci Handing over Process: uttarakhand as sample ............. 24


AD Aspirational DistrictATR Action taken reportAV Audio visualC-PAP continuous Positive Airway PressureDEO Data entry operatorDP Development PartnersFBNC facility Based newborn careFPC family Participatory careFRU first referral unitGoI Government of indiaHR Human resourceKMC Kangaroo mother careLBW low Birth WeightLR labor roomMO MedicalOfficerM&E monitoring & evaluationMoHFW ministry of Health & family WelfareNBSU newborn stabilization unitNHM national Health missionNMR newborn mortality rateNRP neonatal resuscitation ProgramNSSK navjaat shishu suraksha KaryakramSDG sustainable Development GoalsSNCU special newborn care unitsSQCI sncu Quality of care indexSRS sample registration systemWHO World Health organizationUSAID united states Agency for international Development

Acronyms


From the current Neonatal Mortality Rate (NMR) of 23 (SRS 2018), India needs to accelerate its efforts to achieve the SDG Target of ‘single dig-it’ NMR by 2030. Special Newborn Care Units (SNCU) established in several district hospitals across the country have significantly enhanced newborn survival rates - but have scope for im-provement and further impact.

The World Health Organization (WHO) empha-sizes the need for ‘actionable information sys-tem’ in its framework to improve quality of pae-diatric care. Evaluation report on SNCU in India by an international agency also recommends building capacity of the program managers to-wards better utilization of data for quality im-provement. Hence, effective use of ‘data for action’, especially for specialized care in SN-CUs, could enhance performance and further reduce preventable neonatal deaths.

In 2019, as a step to-wards this SDG goal, USAID Vriddhi intro-duced SNCU Quality of Care Index (SQCI) in its six project states i.e. Chhattisgarh, Jharkhand, Uttara-khand, Punjab, Har-yana and Himachal Pradesh. SQCI - a set of 7 composite indi-ces (As detailed in figure 1) tracking key technical and pro-grammatic areas - is a tool approved by Government of India to strengthen use of

SNCU data for action and quality improvement. SQCI was well received in the states and with technical support from Vriddhi National and State teams, was regularly discussed in the state SNCU review meetings and helped strengthen action planning at state, district and SNCU level. With Vriddhi’s focus on im-provement in SNCU quality of care especially in 29 Aspirational Districts (ADs) of six states, SQCI helped ADs to strengthen the SNCUs in term of logistics, Human Resource (HR), equipment purchase and clinical practices.

With an aim to ensure self-sufficiency of the states post Vriddhi, the project teams strate-gized transfer of learning of SQCI generation, analysis and interpretation to the states and fa-cilities. The project provided handholding sup-port to states to sustain these efforts and ad-dress issues related to quality of care in SNCUs.

SQCI is currently be-ing generated by the state and district teams at periodic in-tervals. Vriddhi state teams are providing need based technical support to identify & manage the root cause and bottle-necks. As its tenure ends, Vriddhi has al-ready begun smooth transition of the initi-ative after strength-ening capacity of state and facilities to efficiently utilize SNCU data for action.

Executive Summary

Optimal UtilizatiOn Of ServiceS

mOrtalityOUtcOmeS

gapS in clinical

practiceS

Optimal Bed UtiliSatiOn

index

lOw Birth weight

SUrvivalindex

index fOr mOrtality in gOOd weight

BaBieS

index fOr ratiOnal

USe Of antiBiOtic

ratiOnal admiSSiOn

index

SncU qUality Of care index

(Sqci)

lOw Birth weight

admiSSiOn index

inBOrn Birth

aSphyxiaindex

Figure 1. SQCI Indicators and Indices


There has been rapid scale up of SNCUs across the country through Facility Based Newborn Care (FBNC) program to enhance secondary newborn care at district level in India. Cur-rently, more than 1 million newborn babies are treated in more than 700 SNCUs every year.1 The admission and treatment of so many ba-bies generates wealth of data ranging from demographic information, anthropometric and vital statistics, admission criteria, treat-ment profiles, outcome status, bed occupan-cy etc. The data is entered in the SNCU online

Introduction software regularly and is meant to improve quality of care in SNCUs. However, effective use of data to improve quality of care remains a key gap in India’s public healthcare system. In its ‘Standards for improving quality of care for children and young adolescents in health facilities’2, WHO recommends establishment of ‘actionable information systems’ to im-prove health outcomes as depicted in the be-low flowchart (Figure 2). Such an ‘actionable’ information system is found to be a missing link especially in SNCUs.

1 https://www.unicef.org/media/58076/file 2 https://apps.who.int/iris/bitstream/handle/10665/272346/9789241565554-eng.pdf?ua=1 3 LSTM Center for Maternal and Newborn Health. Special Newborn Care Units to help reduce newborn deaths in India 2007-2017

Evaluation of UNICEF’s Support to the SNCU Based Newborn Care (FBNC) Program in India. 2019.

HealtH SyStem

Quality of Care

7. Competent, motivated, empathetic human resource

8. essential child and adolescent-friendly physical resources

individual and facility - level outcomes

Coverage of Key Practices

Health outcomes

Child and family-centered outcomes

Provision of Care

1. evidence based practices for routine care of children and management of illness

2. actionable information systems3. functioning referral systems

4. effective communication and meaningful participation

5. respect, protection and fulfilment of child rights

6. emotional and psychological support

experience of Care

Figure 2: WHO Framework for Improving Quality of Care

This aspect is also emphasised in the evaluation report on FBNC Programme in India by London School of Tropical Medicine (LSTM)3


some of the key highlights of the evaluation report are:• Use of (SNCU online) data for quality im-

provement in the facilities was low• Capacity to use the data was poor• Efforts and resources invested in support-

ing the FBNC program and SNCUs have not translated into the intended results on the ground especially regarding quality of care

• SNCUs are seen as ‘islands of excellence’ in the facilities with no links to other important components of care in the same facilities notably labor room and NBSUs (Newborn Stabilization Units)

• Capacity of program managers at district, state

and facility level should be built to conduct fo-cused examination of SNCU online data to in-form implementation and improvement.

In addition, the data is fragmented across various platforms and absence of consolidated and holis-tic dashboards often limits decision making ca-pacity. To overcome these challenges, a simple, consolidated, and focused Microsoft Excel based tool – the ‘SNCU Quality of Care Index’ - was devel-oped. The SQCI was first piloted in Odisha in 2015 and was subsequently extended to other target-ed states through IPE Global led USAID supported Vriddhi project. SQCI dashboards are being gen-erated since January 2019 in the project states.

SQCI is a GoI recommended decision making tool that makes use of available SNCU online data to generate seven specific indices on key indica-tors to assess mortality outcomes, gaps in clini-cal practices and optimal utilization of services in

SNCU Quality Care Index - SQCI SNCUs. The indices included in SQCI are explained in Table 1. It also generates a Composite Index, which is a geometric mean of all the 7 indices. The indices are color coded for better understanding and ease of tracking the progress, refer Table 2.

Table 1. Indices Included in SQCI

index what it tellS

Low Birth Weight Admission Is the unit serving the purpose for which it was established

Rational Admission Whether unnecessary admissions are taking place

Optimal Bed Utilisation What is extent of service utilization

Inborn Birth Asphyxia Are intra-partum care and newborn resuscitation practices adequate

Rational use of antibiotics Are antimicrobials being overused

Low Birth Weight Survival Are optimal feeding / Kangaroo Mother Care (KMC) / infection prevention practices followed

Mortality in good weight babies Are Standard practices being followed

Table 2. Color Coded Meaning & Performance Grading of Indices

perfOrmance grading range Of index valUeS

Good Performance 0.71 – 1.0

Satisfactory Performance 0.4 – 0.7

Unsatisfactory Performance <0.4

meaning Of Sqci indiceS

perfOrmance grading Of the indiceS

The seven indices of the tool are well explained along with the formulae of calculation in Annexure 1.


SQCI was implemented in the six Vriddhi states - Chhattisgarh, Jharkhand, Uttarakhand, Pun-jab, Haryana and Himachal Pradesh. While the focus was on SNCUs in Aspirational Dis-tricts, implementation was carried out in all functional SNCUs irrespective of their dis-trict classification. Gradually, SQCI was used to facilitate discussions at state level SNCU reviews, highlighting key issues and utilizing data for action-planning.

Orientation of State & District OfficialsAs the first step in implementation, state offi-cials were given a detailed orientation on SQCI, its purpose and advantages over conventional SNCU data analytics. The state Na-tional Health Mission (NHM) monitor-ing and evaluation officials were giv-en demonstration on calculating the SQCI at the end of each month and quarter. Vriddhi team members in each state also oriented the district officials on SQCI through state level platforms and/or during mentoring visit to respective facilities. Despite initial resistances from technical experts and development agencies in some states, Vriddhi team could convince them of its utility and effi-cacy through technical discussions. The initiative gradually progressed and gained acceptance by the states and SNCUs.

During initial phase in financial year 2019-20, SQCI was generated by na-tional Vriddhi team and shared with the state Vriddhi teams for further

sharing with government & district counter-parts after thorough analysis and interpretation as depicted in figure 3. Some SQCI related gov-ernment letters/directives released from pro-ject states/districts are attached as Annexure 2.

State level supportState level support through SQCI was provided to all 106 SNCUs in these six states and perfor-mance of all the SNCUs were reviewed using SQCI on periodic basis. Vriddhi also facilitated comparison of SNCU performance over various quarters. Based on the interpretation, neces-sary directives were released from the states to districts and SNCUs to ensure improvement

in services.

Facility Level SupportThe project also provided facility level support for SQCI in all 29 SNCUs of Aspirational Districts (14 SNCUs in Jharkhand, 10 in Chhattisgarh, 2 in Punjab and 1 each in Uttarakhand, Haryana and Himachal Pradesh). Fa-cility and index specific bottlenecks were identified through physical visit to SNCUs by the project team, observation of skills and practices of the staff, interaction with staff and parents of the admitted babies, veri-fication of requisite logistics and re-sources. The issues were discussed with concerned facility and district authorities.

Action Plan & Recommenda-tionsBased on these, an action plan for

Implementation of SQCI in Vriddhi States

Sqci generation by

Vriddhi national team

Sqci analysis &

interpretation by Vriddhi

State team

release of State

directives to SncUs

Figure 3. Implementation Chain of SQCI in Vriddhi States


rectification of the problem was developed and implemented. Haryana Vriddhi team pro-vided technical support to the state to devel-op an annual report based on action taken for 4 quarters using SQCI at SNCUs. They shared this report with recommendations for quality improvement of their SNCUs.

Monitoring and HandholdingThis regular support, monitoring and hand-holding in generating SQCI at district SNCUs helped the Data Entry Operators (DEOs), SNCU staff and district officials understand the im-portance of SQCI for quality monitoring of SN-CUs. Vriddhi district team members shared the analysis during District SNCU review meetings, helping them to interpret SQCI scores of each of the 7 indicators and composite indicators.

Support for Wider Application of SQCI Based on this, state authorities of Himachal Pradesh requested Vriddhi team to generate SQCI for all the district SNCUs and organize training for their DEOs. Similar request came from Chhattisgarh, Haryana, Uttarakhand, Punjab and Jharkhand. The process of gen-

erating SQCI and interpretation continued throughout the project period and was ulti-mately handed over in June 2020. Now the states are generating SQCI independently.

In state of Jharkhand, sharing SQCI regularly with the Child Health (CH) cell of NHM creat-ed a huge impact. For improving the scores, some of the districts even used District Min-eral Fund for recruitment of Doctors and Staff Nurses for SNCUs. Equipment, Inverters were purchased, 24 hour water supply was ensured in various district after the SQCI analysis & recommendations. Figure 4 highlights SQCI support provided by the project to the states which includes generation and interpretation of SQCI, tracking of SNCU performances over consecutive quarters, supporting SNCU state & district level reviews using SQCI, technical support in action planning based on identified gaps and facilitating release of state direc-tives to concerned facilities to address gaps.

The data entry, interpretation and analysis was done regularly in various forums and this was extended to Non-Aspirational Districts as well.

Figure 4. Photographs Highlighting SQCI Implementation Support to the States


SQCI has enabled the authorities to identify the key quality of care issues and discuss the findings in review meetings and take correc-tive actions. SQCI is also helping districts ad-vocate for their requirements like increased bed allocation, additional drugs, instruments and equipment like Continuous Positive Air-way Pressure (C-PAP) machines. These have all helped strengthen the clinical practices in the SNCUs.

SQCI analysis became a gateway to meaningful actions which would improve quality of new-born care in SNCUs. Some of the outstanding examples of the SQCI guided actions are:

Prioritization of Mentoring VisitsSQCI helped to prioritize mentoring visits by state level mentors such as from the newly formed ‘Maternal & Newborn Health Resource Centre’ (MNHRC) in Jharkhand. They prior-itized their first mentoring visit to the rela-tively weaker Palamu SNCU based on SQCI performance.

Focused Training PlanIn districts like. Chaibasa, Gumla and Bokaro (Jharkhand), specific training programs to re-duce asphyxia cases and proper sepsis man-agement were conducted. In Mewat (Haryana), training program for Staff Nurses of Labor Room (LR) on Neonatal Resuscitation Program (NRP) for reducing asphyxia cases were conducted. KMC and Family Participatory Care (FPC) was also given special attention across the SNCUs.

Strengthening Referral Linkages In implementing states, directives were is-sued by concerned NHMs for mentoring

State Level SQCI Guided Actionsvisits based on SQCI for taking corrective actions and improving referrals4. In Punjab, the districts Ferozepur & Moga showed im-provement in composite score whereas the indicator for Low Birth Weight (LBW) admis-sion has not improved. Districts based on the SQCI analysis, directed all concerned deliv-ery points to send LBW newborns to these SNCUs rather than directly referring to PGI Chandigarh. This enhanced ‘out-born’ admis-sions in SNCUs thus enabling survival of new-borns without unnecessary travel to distant places.

Human Resource RationalizationIn Uttarakhand, Vriddhi team was able to fa-cilitate posting of Staff Nurses to SNCUs. This was achieved by repeatedly commu-nicating SQCI scores to state and district officials. With continuous follow up, SQCI composite score for Haridwar improved from yellow to green and became best per-forming SNCU as per SQCI in Uttarakhand. Similarly in Chhattisgarh, in districts Ma-hasamund and Narayanpur dedicated SNCU nursing staff in-charge were assigned to enhance supervision. Similarly in Harya-na state, the impact of SQCI was visible in terms of posting of Pediatrician and Medical Officers (MOs) in SNCU. In Ferozepur (Pun-jab), repeated SQCI guided discussions on poor performance of SNCU led to posting of a pediatrician in the SNCU.

Steer Procurement Process SQCI helped in identification of resources re-quired in terms of equipment & instruments. It steered purchase of equipment for SNCUs of Haridwar and Rudrapur (Uttarakhand).

4 In district Mewat district, Haryana and Ferozepur and Moga district in Punjab, letters were issued to FRUs to visit the SNCUs and improve referral to district SNCU.


Salient outPutSthe key outputs from the initiative are as below:-Human Resource • Recruitment of pediatricians and nursing

staff in targeted SNCUs of Aspirational Dis-tricts through continued advocacy based on SQCI gaps

• Acceleration of the recruitment process and channelization of alternate funding routes like District Mineral Funds in Jharkhand

Training• Identification of training needs of staff of

particular SNCUs and labor rooms• Capacity development of staff on Navjaat

Shishu Suraksha Karyakram (NSSK) and FBNC by state and Vriddhi teams.

Logistics• Procurement of KMC chairs, television across

SNCUs of all the states to strengthen FPC to improve Low Birth Weight Survival

• Installation of inverter and solar back up in select SNCUs to ensure electricity backup to improve LBW admission and duration of stay

• Procurement of oxygen concentrators and C-PAP machines. Facility wise key issues, their root cause and the actions taken by USAID Vriddhi team is explained in Table 3.

Table 3. Specific Actions Taken in Facilities

facility (ad) iSSUe rOOt caUSe actiOn taken

pakur, Jharkhand Low Admissions Non- availability of 24 hour electricity Installation of solar power backup and invertor

ghatshila, Jharkhand Low score in Rational use of antibiotics index

Poor hand washing practices especially in winter due to non-availability of geysers

Installation of geyser

gumla, Jharkhand Low score in LBW admission and survival index

Shortage of nursing staff resulting in poor monitoring of babies

Initiation of recruitment process if nursing staff

chamba, himachal pradesh

Low score in LBW survival index

Antenatal corticosteroid administration to pre-terms inadequate

Orientation of LR staff on Antenatal Corticosteroids

mewat, haryana Low score in Rational use of antibiotics index

Inappropriate understanding of FBNC sepsis management guidelines

Orientation of SNCU staff on FBNC sepsis management guidelines

ferozepur, punjab Low score in LBW admission & Optimal Bed Utilization Index

Lack of space & shortage of HR in SNCU Identification of space and shifting of SNCU in new Maternal & Child Health (MCH) building, recruitment of pediatrician and nursing staff

Dr. Ajit Kumar Prasad (MO, Child Health Cell, NHM, GoJ), addresses participants during Webinar on Improving Clinical Care through SQCI


The SQCI is a cost effective innovation as it did not require any additional resources for implementation. The data for calculating all the indices under SQCI are obtained from the SNCU online software of Government of In-dia. Capacity building of state & district per-sonnel was done through physical and virtual platforms respectively. Due to brief duration

(1-2 hours) of training, it did not have any ad-ditional cost implications for the government or the project. Despite practically nil addition-al expenditure, SQCI has been able to make substantial contribution to SNCU quality im-provement process. An independent evalua-tion would be required to further measure the cost effectiveness of SQCI.

Cost Effectiveness of SQCI

After successful completion of a year of SQCI implementation, it was time to hand over the generation & interpretation of SQCI to the states and districts. Based on Vriddhi team’s advocacy of SQCI’s utility and impact, the state government officials accepted and agreed to internalize it for improving SNCUs. Detailed discussions were held with the state child health and Monitoring and Evaluation (M&E) cell on SQCI handing over processes.

During June – September 2020, capacity of the State Child Health Cell, Monitoring & Eval-uation Cell and District SNCU nodal officers and data managers was developed on all rele-vant aspects of SQCI by Vriddhi to make them self-sufficient in dealing with SQCI and SNCU improvements. The capacity development was carried out using virtual platforms due to travel restrictions amid COVID-19 pandemic.

SQCI generation, interpretation and action planning is being currently conducted by the concerned state and district teams with lim-ited need-based handholding support from

Vriddhi. The processes are standardized with minor state-specific variations. An example of the SQCI Institutionalization Process is de-picted in the flowchart (Figure 5) .

A detailed report of the state Uttarakhand as sample capturing the process of handing over the tool is appended as Annexure 3.

Handing Over of SQCI to the Vriddhi States

Vriddhi team giving orientation on SQCI dashboard to consultant Child Health, NHM Uttarakhand


Composite index of each of the supported SNCU in Aspirational Districts for 4 quarters were taken for analysing the trends in their performance. It is very well evident from the Table No. 4 that out of 29 SNCUs, 16 (55%) SNCUs namely Gumla, Latehar, Pakur, West Singhbhum, Hazaribag, Firozpur, Moga, Haridwar, Jagdalpur, Bijapur, Dantewada, Kanker, Korba, Narayanpur, Rajnandgaon and Sukma have shown improvements in their overall performance, whereas SNCU Godda & Kondagaon has slipped from yel-low to red zone. SNCU at Godda (Jharkhand) & Kondagaon (Chhattisgarh) slipped to red due to several staff including MOs & nursing staff being on leave due to unavoidable cir-cumstances leading to poor supervision. In

Kondagaon there were also couple of cases of HIE (Hypoxic Ischemic Encephalopathy) among good weight newborns who could not be saved despite sincere efforts.

Improvement in the composite index in ma-jority of the SNCUs in a span of just one year underlines the contribution of SQCI in improv-ing the quality of newborn health care servic-es. The regular follow up for SNCU software data resulted in regularisation of data update in software by DEOs of SNCUs. Even if DEO is on leave, the data was entered by alternative arrangements. In Punjab, the state was very happy to see this change after introduction of SQCI in Aspirational Districts and then scaled up to non-Aspirational Districts as well.

Outcomes of the Initiative

SQCi inStitutionalZation ProCeSS

Step 1

Step 2

Step 4

State child health cell

Step 3

State child health cell

State level review with SncUS BaSed On1. most recent

quarterly Sqci (prepared in Step 1)

2. action taken report of previous quarter from next cycle as mentioned in Step 6)

Step 5

cS/dpm

diStric level mOnthly

review Of SncU BaSed On

SqciShare qUarterly Sqci with diStrict

1. State ch cell will share with district

2. dS/mS will share with all SncU staffs

3. deO will share with hm for dqci

preparing qUarterly

actiOn plan BaSed On pOOr indiceS in the

Sqci

SncU incharge support from dS/mS, hod (neonatalogy / paediatrics), mOs, Sns and deO of the SncU

By 10th of following month of each quarter

By 15th of following month of each quarter

By 25th of the month (within 10 days of receiving Sqci from the State)

quarterlymonthly/during monthly review meeting

prepare and Share qUarterly

actiOn taken repOrt (atr)

BaSed On previOUS

qUarterly actiOn plan

cS/dS/mSquarterly (example: atr to be submitted to State ch cell by 30th Sep 2020) for quarter apr-Jun 2020

Step 6

Figure 5. SQCI Institutionalization Process


Table 4: Composite index of improvement in SNCUs in Aspirational Districts for 4 quarters

S n State SncU name/ad apr-JUn 2019 JUl-Sep 2019 Oct-dec 2019 Jan-mar 2020

1 HR GH Mewat 0.655 0.518 0.593 0.656

2 HP RH Chamba 0.651 0.505 0.595 0.535

3 JH DH Bokaro 0.537 0.517 0.575 0.496

4 JH DH Dumka 0.5 0.538 0.513 0.465

5 JH CHC Ghatshila 0.574 0.571 0.252 0.538

6 JH DH Godda 0.63 0.68 0.603 0.278

7 JH DH Giridih 0.509 0.46 0.521 0.449

8 JH DH Gumla 0.477 0.468 0.643 0.709

9 JH DH Hazaribagh 0.527 0.564 0.643 0.577

10 JH DH Latehar 0.318 0.619 0.518 0.559

11 JH DH Pakur 0.592 0.261 0.712 0.693

12 JH DH Palamu 0.474 0.492 0.472 0.412

13 JH RIMS Ranchi 0.673 0.737 0.679 0.672

14 JH DH Sahebganj 0.622 0.646 0.667 0.579

15 JH DH Simdega 0.69 0.649 0.535 0.679

16 JH DH West Singhbhum 0.582 0.349 0.678 0.63

17 PB CH Firozpur 0.382 0.544 0.592 0.573

18 PB CH Moga 0.652 0.723 0.689 0.705

19 UK FH Haridwar 0.681 0.762 0.744 0.766

20 CG MH Jagdalpur 0.557 0.593 0.644 0.573

21 CG DH Bijapur 0.695 0.347 0.727 0.718

22 CG DH Dantewada 0.356 0.614 0.591 0.776

23 CG DH Kanker 0.801 0.828 0.788 0.832

24 CG DH Korba 0.650 0.677 0.643 0.674

25 CG DH Kondagoan 0.683 0.743 0.595 0.376

26 CG DH Mahasamund 0.799 0.676 0.817 0.705

27 CG DH Narayanpur 0.569 0.712

28 CG DH Rajnandgaon 0.611 0.607 0.486 0.707

29 CG DH Sukma 0.720 0.661 0.740 0.746


• There was initial resistance from state techni-cal experts and other development agencies on introduction of SQCI as new SNCU review tool. The state was also not sure of the indi-ces’ usefulness as it was already reviewing the SNCU online data. A series of meetings, advo-cacy efforts and technical discussions with state technical experts, other development agencies in the presence of state officials, were facilitated by Vriddhi to ensure under-standing and importance of using an index, each indicator of the SQCI and how monitor-ing can be improved using this tool.

• Facility level challenges were observed while implementing the recommendations and pro-cess improvement derived from the tool. For example, shortage of space was the biggest challenge for providing quality of care in the Aspirational Districts. Patient preferences for medical colleges and private hospitals was also one of the big reasons cited for poor admis-sions which facilities found difficult to address.

• Change in HR status at state, district and facil-ity level along with slow recruitment process did affect and often slowed down the process of SQCI generation and review mechanism.

• Ownership of SQCI at the SNCU level – Pedi-atricians are more inclined to individual clin-ical case management and less comfortable with general, average data. This disinterest sometimes limits optimal utilization of SQCI during performance reviews. Also high work-load due to severe shortage of MOs and spe-cialists across SNCUs (for ex. There is only 1 pediatrician in 11 districts in Haryana) is a serious barrier to quality of performance re-views and action planning.

• SQCI generation at SNCU level – While SQCI generation at state level has been taken up very well, it’s generation at SNCU level may be a challenge. The capacity and motiva-tion of SNCU DEOs varies across units. To achieve this, they will require adequate train-ing, handholding and regular accountability.

Challenges Faced

Mentor from JSMNHRC, Dr. Kiran hankar, HOD Neonatology at online mentoring of SNCU Latehar, Jharkhand based on SQCI


Vriddhi will continue to provide technical support till the completion of the project. All states and majority of aspirational districts are able to generate, interpret and use SQCI to plan appropriate actions. However, due to engagements in COVID-19 preparedness and response, some facilities still require contin-uous motivation, guidance and support. The project state and district teams would be pro-viding the necessary support to ensure SQCI is appropriately institutionalized in the review mechanism of aspirational districts.

In reference to Haryana state online review of during COVID pandemic was appreciated by NHM officials to see the progress of SNCU Mewat. The state are able to generate SQCI and review independently with minimal sup-port of Vriddhi project from September’20 on-wards. However, Vriddhi team will continue to provide need based technical support to the state in institutionalization of SQCI in Non-As-pirational Districts.

Due to COVID-19 travel restrictions, capacity building and follow up processes would be done virtually through state or by concerned district project representative. Despite the pandemic related limitations, Vriddhi would endeavour to ensure maintenance of the quality during handholding and knowledge transfer.

The project is also working to accommodate certain other parameters (Such as status of human resource availability) in the tool to make it more robust and comprehensive. Vriddhi National team would continue the advocacy with MoHFW for scaling up SQCI to other states.

This sustainable model of SQCI will be dissem-inated with partner states and MoHFW in April 2021, Vriddhi project team is extremely thank-ful to national and state governments for their cordial support and encouragement, without which the initiative would not have achieved the desired results.

Way Forward

Online review of SQCI for the state of Haryana


Annexures Annexure 1 - SNCU Quality of Care Index (SQCI)SQCI is a composite index of 7 indices based on key indicators of assessing the quality of servic-es in SNCUs. The 7 indices included in SQI are as under:

S n index definitiOn nUmeratOr denOminatOr fOrmUla fOr index calcUlatiOn1. Rational

Admission Index

Proportion of newborns discharged within 24 hours

No. of New born discharged in <= 24 hours

Total number of new born discharged

1 – (Number of New born discharged in <= 24 hours / Total number of new born discharged)

2. Index for rational use of antibiotics

Proportion of new-born with sepsis received antibiotics

Number of new-born received antibiotics -Number of new-born diagnosed as sepsis

Total Admissions 1 - [ | (Total number of new-born received antibiotics - Number of new-born diagnosed as sepsis) | / Total Admission]

3. Inborn Birth Asphyxia Index

Proportion of in-born admitted as Birth Asphyxia

Number of In-born admitted to SNCU with Birth Asphyxia

Total number in-born admissions

1 – (Number of in-born admitted with Birth Asphyxia / Total number inborn admissions)

4.

Index for Mortality in normal Weight babies

Proportion of deaths in inborn infants weight 2500 gram or more against total admissions of inborn infants weight 2500 gram or more.

No. of deaths in inborn weight 2500 gram or more

Total admissions of inborn weight 2500 gram or more.

1 – (No. of deaths in inborn weight 2500 gram or more / Total admissions of inborn weight 2500 gram or more)

5. Low Birth Weight admission Index

Proportion of low birth weight newborn (less than 1800) admitted to the unit

No. of newborn with birth weight less than 1800 gms admitted

Total number of admissions

No. of newborn with birth weight less than 1800 gms admitted / Total number of admissions

6. Low Birth Weight survival Index

Proportion of low birth weight babies (Between 1000 to 1800 grams) survived

No. of newborns with birth weight between 1000 to 1800 grams discharged alive

Total number of new born with birth weight between 1000 to 1800 grams admitted

No. of newborns with birth weight between 1000 to 1800 grams discharged alive/ Total number of new born with birth weight between 1000 to 1800 grams admitted.

7. Optimal bed utilisation index

Average number of newborns admitted per bed per month

Total admissions Total number of beds X 6 X No. of Months

1 – | (1 – Average Admission) | Average admission = (Total admissions / Total number of beds X 6 X No. of months)

The outcome indicators are also reviewed in light of the data on total number of beds, % bed utilization, % Out-born Admission, % Referred to higher facilities and % LAMA case, for decision making process.


Annexure 2 - Letters from State Governments

SQCI Punjab 1st Quarter Directive

Scanned by CamScanner


SQCI Punjab 2nd Quarter Directive



MD Improving Clinical Services in SNCUs through SQCI in Jharkhand Letter No. 950 (MD)



State Government of Chhattisgarh


Letter of SQCI preparation for Mewat, Haryana


State Government Uttarakhand Letter


Towards the end of Quarter 4 (Jan – March): 2018-19, USAID supported Vriddhi project team in Uttarakhand began analyzing the per-formance of SNCUs using the SQCI Tool. The rationale behind starting this exercise was to improve quality of care for Sick and small for age newborns admitted in SNCUs. Prior to the start of this exercise there was no mechanism to analyze the SNCU admissions data for guid-ing necessary improvement steps.

This exercise was repeated every quarter for all the five functional SNCUs in Uttarakhand. The process involved exporting the SNCU On-line portal data into the SQCI tool. The gener-ated index was later discussed with the State and District Officials, Program Managers &

Annexure 3 – Report on SQCI Handing Over Process: Uttarakhand as Sample

BackgroundSNCU Incharges for necessary improvements. SQCI based presentations were also made from time to time during review meetings at State & District level. Over time the State re-alized the importance of the tool and the find-ings were also included for discussions and guiding actions at the highest levels.

As Vriddhi Project entered into its last year, the need to build capacity of State & facility teams to self- generate SQCI was felt. It was decided in discussion with the State RMNCH+A Officials that handover process should start early to en-sure smooth transfer of knowledge related to SQCI generation. A series of activities and tasks were planned with the objective to achieve proper handover of SQCI tool to the state.

1. Handholding of State Program Officer & State Data Manager for Child Health Cell, NHM for generating SQCI Dashboard.

2. Webinar Training of DEO’s posted at SNCUs for orientation on Generation of SQCI

3. One to one facility wise hand-holding of DEOs posted at SNCU for generating SQCI for their facilities

4. Lean Support and necessary hand to State and Facilities for generating SQCI on their own

Key Handover Activities & Timelines in Uttarakhand23-24 July 2020

27 July 2020

August 2020

September to December 2020


Highlights: Webinar Training Session & Follow-Up Vriddhi Project teams facilitated the Webinar Session for initiating the SQCI tool Handover process in Uttarakhand. An official letter was sent to all the SNCUs Officer Incharge for en-suring active participation during the Webinar scheduled on 27th July, 2020.

The introductory session discussing the im-portance of SQCI tool and its use was delivered by Officer Incharge RMNCH+A, NHM-UK. It was followed by a step by step presentation which was made by Vriddhi Team. This helped the participants build understanding on the key steps used to generate the SQCI dashboard.

In the later half discussions relating to report-ing Human Resource availability and ensuring timely generation, sharing and use of SQCI Dashboard were held. All queries raised by the participants were also adequately replied by the State Teams in the end. The facility wise individual follow-up plan was also discussed with the participants. Around 25 people in-cluding State & District Program Officers and Consultants along with SNCU Incharges and DEOs attended the webinar.

As part of the follow-up each DEO of all SNCU are being oriented on SQCI as was decided dur-ing the webinar training. These online trainings are being facilitated by VRIDDHI team and Child

Health Consultant. In August, 2020 staff from SNCU Haldwani and SNCU Dehradun were ori-ented separately on SQCI generation. By the end of September, 2020 all the remaining facil-ity staff will be oriented. The aim is to build the capacity of each SNCU facility for developing SQCI dashboard along with understanding on its use for improving quality of Newborn care being provided at SNCU level.

Sustainability & ScalabilityState has institutionalized the regular use of SQCI for improving quality of care being pro-vided at SNCUs by successfully conducting the training webinar for generating SQCI. As on end of Quarter 1 (April – June): 2020-21 there are five functional SNCUs in Uttarakhand against a total sanction of seven SNCUs. The State has prioritized to make the remaining two SNCUs operational during the 2020-21 period.

Additionally four NBSUs which received ap-proval to be upgraded to SNCUs will also be operationalized as SNCUs in this period. State has made plans to introduce the SQCI across all the new and upgraded SNCUs as and when they become functional. Staff from these new units were also invited to attend the Webinar Training conducted by the State on 27th July, 2020. Vriddhi Project has planned to continue providing necessary hand holding support to all the existing and new SNCUs till the end of December 2020.


Official Letter for Webinar Training


SQCI Dashboard: Uttarakhand; Q1 (2020-21)

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SNCU Quality of Care Index (SQCI)

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