How did Exemplar lower mortality states implement?

Throughout this section, progress and programming is described in the context of India’s four overarching national health policy periods, shown below in Figure 15. These policy periods are described in detail within the national-level report.

Health infrastructure

India’s health system is described further in the national-level NMR/MMR Exemplars research, with the overall structure of the health care system shown below in Figure 16.

Here, the health systems of Maharashtra and Tamil Nadu are explored in depth, highlighting intermediate and distal health system factors that contributed to the status of each as an Exemplar state within the lower mortality state cluster.

Overall, health systems in the lower mortality state cluster were generally more mature than other regions of India at baseline. Although the lower mortality state cluster has continued to expand and improve its health system over the previous two decades, health infrastructure and human resources for health throughout the cluster were generally more accessible and capacitated to the higher mortality state cluster at baseline. This allowed the health system in the lower mortality state cluster to increasingly focus on reaching the most vulnerable to ensure universal health coverage while also focusing in the last two decades on improving the quality of services utilized by mothers and newborns.

As in other states across India, community health centers (CHCs), primary health centers (PHCs), and health sub-centers (HSCs) serve as a backbone of the public health system, with district, referral, specialty, and medical college hospitals serving as facilities capable of offering more advanced care.

The density of these facilities varied substantially between Maharashtra and Tamil Nadu, as shown below in Figure 17. In Maharashtra, the density of CHCs, PHCs, and HSCs remained fairly constant over the last three decades and is notably lower than the average seen across the lower mortality state cluster. In contrast, Tamil Nadu had the highest facility density of any state in the lower mortality state cluster and in particular saw a surge in CHC density between 2002 and 2012. As a result, in 2018–2019, Maharashtra on average had one CHC per 233,000 residents, whereas Tamil Nadu had on average one CHC per 93,000 residents. Although Maharashtra had a lower density of public health facilities such as CHCs, PHCs, and HSCs, it did have a slightly more active private sector. In 2019, 43.4% of institutional deliveries in Maharashtra took place in private facilities, whereas in Tamil Nadu only 32.2% of births occurred in private facilities.

Maharashtra

Although Maharashtra had a relatively low public health facility density compared to the lower mortality state cluster average, health policy experts in a group discussion for this study reported that the services in existing facilities were substantially strengthened over time. They highlighted that by 2005, lower-level health facilities were able to manage preeclampsia and postpartum hemorrhage, and hospitals were upgraded to provide comprehensive obstetric care thanks to substantial World Bank investment.

The state also conducted targeted needs assessments to allocate funds for strengthening identified weaknesses, particularly in special newborn care units (SNCUs) and labor rooms. The experts communicated that Maharashtra’s focus on enhancing existing facilities made the state particularly effective in upgrading CHCs to first referral units (FRUs). By 2020 the state reported 268 active FRUs capable of providing C-sections and other forms of more advanced care. As noted in the national India research, one initial challenge for FRUs was the capacity to provide timely blood transfusions. However, in Maharashtra, an autonomous State Blood Transfusion Council allowed for coordination with other blood units in the state, making blood transfusion services more accessible throughout the state. This unique approach was noted as a key reason women were able to receive comprehensive obstetric care in areas outside of major cities, with one government health system expert saying:

Tamil Nadu

The high density of existing PHCs and HSCs in Tamil Nadu shown above in Figure 17 allowed the state to focus on improving the quality of these facilities while building more CHCs and other higher-level facilities. In particular, Tamil Nadu focused on upgrading tertiary neonatal care by establishing a neonatal intensive care unit (NICU) in nearly every district hospital and two SNCUs in each district. The state also upgraded all pediatric emergency units to also function as NICUs, with protocols established for receiving vulnerable newborns transferred from delivery care at lower-level facilities like FRUs, CHCs, or PHCs.

Experts noted that Tamili Nadu stands out as a state that considered transportation to health facilities to be a health infrastructure issue to be addressed by policy, as opposed to a patient issue. Both the national “108” ambulance system and Tamil Nadu’s neonatal transportation system are seen as key contributors to improved timely care, and one government official suggested at some flexibility in how these programs have been locally implemented, saying:

The state has also introduced a hearse service to reduce rates of premature discharge. The government identified that relatives were often taking patients home when they appeared close to death because of the high costs for transporting the deceased. The state scaled up a Red Cross Society initiative to provide hearse services in hopes of encouraging families to keep their vulnerable loved ones at facilities, giving providers additional opportunities to perform lifesaving care.

Human resources for health

Both Maharashtra and Tamil Nadu are considered high producers of health workers in India, with each state having a strong network of medical colleges. Also, they emphasize in-service training and programs that foster continued education for health care providers to strengthen various cadres of workers. The states have also each developed unique approaches to ensuring rural areas in vulnerable communities have strong health workforces.

Maharashtra

The state of Maharashtra is home to 52 medical colleges, of which 23 are public. Doctors who graduate from the public colleges are bonded to serve in rural areas for one year, which has contributed to the relatively high density of human resource availability in lower-level facilities such as PHCs.

In-service training has primarily focused on enhancing the skills of auxiliary nurse midwives, nurses, and medical officers. The state specifically developed a training program for medical officers called the Medical Officer Certificate Program (MOCP). The MOCP allowed over 2,000 medical officers working in rural areas to receive one year of fully funded training in pediatrics, medicine, and surgery to become doctors and return to rural service. In-service training for auxiliary nurse midwives and nurses typically took the form of mentorship from faculty based at state government medical colleges who regularly engaged with communities about best practices. Additionally, Maharashtra was one of the first states to adopt a task-shifting strategy that trained providers of ayurveda, yoga and naturopathy, Unani, Siddha, and homeopathy (AYUSH)—the six forms of nonallopathic medicine practiced in India—in basic emergency obstetric care. After 14 days of training, AYUSH providers were able to identify signs of complications and facilitate referrals.

Tamil Nadu

The government of Tamil Nadu has made strong investments in public medical colleges, and there is now at least one in each district in the state. Because public medical colleges do not pose high costs to students like private medical colleges do, Tamil Nadu’s medical schools are primarily merit based and enroll far more middle-class students than most other states in India.

The state also has elevated education requirements for practicing nurses because a bachelor of science is required over a general nursing and midwifery diploma. Postgraduate medical programs also reserve 50% of their seats for candidates who have worked in rural areas, especially PHCs.

Tamil Nadu’s government also consists of a relatively unique division, referred to as the Directorate of Public Health (DPH) and made up of public health management professionals, statisticians, epidemiologists, and health inspectors. The DPH oversees the planning and management of public health services in a way that fosters an integrated approach not only to clinical thinking, but also to systems thinking. Staff in the DPH generally begin their careers in oversight at the PHC level before being promoted to the district or state level, which has ensured that decision-makers have relevant backgrounds essential for informed decision-making.

Community engagement and demand generation

Promoting community involvement in the health care system has been a key factor for success in both Maharashtra and Tamil Nadu. Each state pioneered cash incentives for maternal health care before India’s Janani Suraksha Yojana (JSY) initiative, described in more detail in the national Exemplars narrative, was established in 2005.

A focus on primary health care—for decades in Tamil Nadu and more recently in Maharashtra—has also contributed toward localized influence over the health system to address context-specific needs. In both states, this has contributed to a citizenry aware of its health rights and engaged with the health system.

Maharashtra

Although the influence of village health, sanitation, and nutrition committees (VHSNCs) across India was varied—as noted in the national Exemplars narrative—the VHSNCs in Maharashtra were noted to be an influential platform for local action. In 2008, Maharashtra became one of eight states to institute a “community-based monitoring and planning” process operated by VHSNCs that audited government health services and developed local-level project implementation plans. This process also served as a pathway for identifying violations of health rights in the government sector and advocating for change.

Maharashtra also had a strong network of Accredited Social Health Activists (ASHAs) and viewed them as the main link between communities and health services, especially in villages. Auxiliary nurse midwives were also key as their role shifted from a focus on family planning to a broader role that included providing antenatal care and encouraging institutional delivery. Efforts by these cadres of health workers built on a strong foundation in which Maharashtra also targeted vulnerable or hard-to-reach communities.

Almost a decade before India’s JSY program was established, Maharashtra introduced the Matrutwa Anudan Yojana initiative, which offered cash incentives to encourage pregnant women from marginalized groups to access health care services.

This initiative was soon accompanied by the 2003 Navsanjeevan Yojana initiative that improved access to health services in Maharashtra’s 52 tribal blocks by integrating and improving essential health services. It introduced monitoring to identify villages and households with acute needs and financed squads of health care workers to then visit and treat these needs.

Tamil Nadu

The state of Tamil Nadu was the first in India to introduce a maternity benefit scheme providing cash and goods to pregnant women. In 1987 the Dr. Muthulakshmi Reddy Maternity Benefit Scheme was established and provided financial incentives for women with low income to access government health care. The scheme was later updated to increase incentive amounts, add nutrition support, and even include a basket of goods for the mother and baby. This program was enacted almost two decades before India’s JSY initiative, contributing to the state’s long history of strong demand for services.

As a result, citizens have continued to seek not only health services, but also more from their government. One government official spoke to Tamil Nadu’s success as a state that has focused on reaching all citizens through its public sector, saying:

Process reviews and quality improvement

In both Maharashtra and Tamil Nadu, data-driven decision-making has been crucial in reducing NMR and MMR. In particular, in-depth reviews of factors that contributed to maternal deaths have led to targeted solutioning in both states’ health systems. Cultures of accountability that have focused on continuous improvement underlie these processes, yielding innovative approaches for addressing issues.

Maharashtra

The state of Maharashtra employs an escalation-based accountability system that advances issues from the community level to the district level, and ultimately the directorate level if necessary. Monthly community meetings among ASHAs and auxiliary nurse midwives identify strengths and weaknesses at the local level, providing a forum for issues to be passed up this chain of command. Maternal and child death reviews occur at the district level and have been strongly emphasized, especially since 2010, with strong district ownership of the process. Whereas other states typically include death reviews as one component of broader district health meetings, in Maharashtra, the monthly death review meeting stands alone as its own meeting. These meetings involve thorough examinations of the causes of death—whether that be clinical or on the part of the system itself—with a focus on preventing future events rather than laying blame. Uniquely, in Maharashtra, family members or representatives of the deceased are welcome to participate in the meetings. The state has also expanded this process recently to include audits of “near-misses” for maternal death, with continually improved insights made possible by an innovative digital health management information system that allows for reviews to consider a vast array of indicators.

Experts noted that these reviews have contributed to the state strongly prioritizing and enforcing national-level maternal health guidelines such as the Indian Public Health Standards. The state also partnered with the private sector to ensure that similar standards were being enforced in private facilities. When the 2017 Labor Room Quality Improvement Initiative (LaQshya) was established to promote patient-centered care during delivery, Maharashtra collaborated with the private sector to also advance quality of care in private facilities. The private-sector quality improvement initiative—called Manyata—was combined with the government’s to create the unique “LaQshya-Manyata” initiative, adding credibility to the accreditation process for private facilities.

Tamil Nadu

In Tamil Nadu, an approach of “no penalization” maternal death surveillance and response has proven effective, focusing on problem-solving rather than placing blame. The state has also begun to review “near-misses” in addition to its routinized audits of ambulance services, SNCU data, and financial records—all leveraging databases from the state’s health monitoring information system.

These audits were credited by experts as having contributed to the development of key innovations, including revised blood bank placement, the hearse service, maternity waiting homes, high-risk pregnancy tracking, and a birth companionship program. One government health system expert spoke to the nature of data-driven decision-making in Tamil Nadu by saying:

The state of Tamil Nadu also responded to the issue of drug and device availability in a unique way by forming the Tamil Nadu Medical Service Corporation. Facilities were able to fill procurement gaps and ensure a continuous supply of medicines by purchasing drugs from local vendors. A “passbook system” shared details on the facility’s funding and gave suppliers confidence that they would be reimbursed timely. This system also ensured the functionality of medical equipment by assigning each item to a biomedical engineer who was then personally responsible for its maintenance.

Strong governance and political will

Leadership in both Maharashtra and Tamil Nadu have long focused on maternal and newborn health, with high-ranking officials frequently involved in processes such as maternal death reviews and often visiting local communities to learn about issues on the ground. The citizens and media also often helped to apply pressure that fueled a continuous drive to improve health and reduce mortality.

Maharashtra

Experts noted that the government of Maharashtra is adaptive to issues experienced by frontline workers and genuinely listens, to adjust programming appropriately. Village governments were often able to escalate issues to district governments, and ultimately up to state governments in a system that worked cohesively with a united goal. Maharashtra also sent health officials to other states to learn about best practices they might be able to adapt. From this, Maharashtra specifically incorporated data-monitoring and ASHA protocols implemented in the state of Gujarat. Civil society activists and NGOs such as SEARCH Gadchiroli also played an important role in pushing progress and ensuring accountability, especially for care of isolated and vulnerable communities.

With a citizenry that focused on health so strongly, these figures could call for improvement in a way that garnered much attention, as one state government official said:

Tamil Nadu

In Tamil Nadu, a culture of constant improvement created an environment in which government officials quickly responded to issues and continuously innovated to build on success. Considering the relatively small role of the private sector in Tamil Nadu, experts noted there was a desire to prove that mortality could decline rapidly in a system that relied predominantly on the public sector. Tamil Nadu strove to set a higher standard, evidenced by the fact that the state was the first in India to form a Federation of Obstetricians and Gynecologists—which went on to set elevated standards of care.

Commitments to high-quality public health care in Tamil Nadu are frequently championed by political figures, considering the priority the public affords to health care in the state. The state has also seen a uniquely stable set of political leaders, directors, and health secretaries that have remained in their positions for long periods, which has allowed for program continuity and fostered strong relationships between clinical sectors and public health sectors—including the unique Directorate of Public Health.