The case of Dr Jayam and sasthinatha trust
Introduction:
The sasthinatha trust is a registered NGO which runs a neo-natology unit in Vijaya
hospital in Chennai. The trust was set up in 1999 with an aim to take the knowledge of
newborn care to the community and render service. The trust also manages six
neonatology ambulances and undertakes teaching and training activities. Dr Jayam retired
as professor of neonatology and director of Kasturba Gandhi hospital in Chennai.
History of neonatology in Tamil nadu:
In the late sixties and early seventies, the prevailing concept was that of separating the
mother from child at child birth and kept out of child survival. The concept of using the
mother to facilitate neonatal survival was an antithesis.
“Right from my post-graduation days, I as clear that the mother has to be involved
if some babies have to be saved. The logic was that the mother has to breastfeed which
increases child’s power of resistance against infections. She also has good nursing skills
which create a bond between her and the child and mother can be clean and take care of
the baby in place of the nurse and can be relied upon to feed the baby, keep it clean and
warm. This led me to implement the concept when I joined medical college in Chennai in
1973.” (Dr Jayam, retired professor of neonatology, chairperson sasthinatha trust).
The first neonatology unit was built in 1973 and was attached to the medical college
Chennai as one of the most modern units with 50 beds. Earlier these were attached to
maternity units. In 1973, under WHO programme, Dr Alan wells undertook a
neonatology unit teaching programme. 4 doctors, including Dr Jayam got trained in this
programme.
In 1977, Dr Jayam joined the institute of child health (ICH) at Egmore. A neonatology
unit was started which was attached initially to the general hospital and later became an
independent unit.
“Dr Kamala did her fellowship training in that unit, shifted out and started a
neonatology unit. Thus, Neonatology as a subject was started in Tamilnadu much before
it took roots in other parts of India.” (Dr Jayam, chair person sasthinatha trust).
The neonatology unit faced problems on account of lack of antibiotics, equipment and
facilities for newborn care.
“We had the problem of getting equipment like warmers etc. Still despite these,
we carried on the work of neonatology. In 1980, I identified 3 engineers and instructed
them what equipment was required for newborn care. Equipment was made on a no profit
no loss basis. This gave me equipment which was cheaper, used locally available material
and could be maintained locally. The other problem we had was shortage of nurses. For
this, I educated the mothers to take regular baths, keep themselves clean, and how to keep
the baby clean and warm. Thus most of the work was done by mothers, while a smaller
number of nurses kept track of baby’s vital events and gave medicines. Breast feeding
was a priority. All baby food and feeding bottles were removed, thus saving money and
reducing chances of infection. Oral feeding was done using a traditional instrument
“Paladi” used in Indian households and which was easy to keep clean and dry. By these
measures, we could reduce the incidence of infection and reduce neonatal mortality from
34% to 12 %”(Dr Jayam, chair person sasthinatha trust).
The success of “use of Paladi for feeding” led to its introduction at PGI Chandigarh at Dr
Jayam’s insistence and it became a part of neonatal care.
In 1980, the national forum for neonatology was started. Till then neonatology was a part
of obstetrics or pediatrics. In 1980, these concepts were introduced at the National forum
for neonatology. The forum was used to advocate a national policy on neonatology and
stress on breast feeding, importance of link between mother and child, need for
indigenous equipment and need for cleanliness. A campaign for breast feeding as the
norm for newborn care was started (www.nnfi.org).
The association with public health system:
The beginning: Kancheepuram model
In 1988, ford foundation was funding equipment and training programme on
neonatology. As part of that programme, the district hospital at Kancheepuram was
chosen for setting up a neonatology unit. The programme also involved training of
doctors to run the unit and traditional Dai’s as support staff. The aim was to identify high
risk infants and refer them to district hospital for care, with an overall aim to reduce
neonatal mortality.
“As part of this, a batch of 15 traditional Dai’s from Kancheepuram district was
introduced as trainee assistants in my neonatology unit at ICH. They were given clean
uniforms and educated about need for cleanliness when handling babies or at the institute
learning. It was a two way learning process. The Dai’s were quick learners and willing to
learn. They would watch how things were done, and keep practicing to gain knowledge,
confidence and skills. Their traditional skills were retained. Some of the traditional skills
like back support during delivery were learnt by my institute staff. This was called the
Kancheepuram experiment.” (Dr Jayam, chair person sasthinatha trust).
Dai’s from 950 villages were trained. The later batches were trained at Kancheepuram
itself. They became the link between community and health institutions. Equipment was
supplied and training on how to use the equipment was also given.
“Because of the training given to doctors and Dai’s and equipment supplied, there
was a tremendous increase in the referrals to the district hospital. This was later
duplicated elsewhere as the “Palasa model”( Dr Jayam, chair person sasthinatha trust).
The district model:
In 1989, the Kancheepuram model was modified as the district model. In this, at the
district in the neonatal unit there were trained doctors and nurses who manned the unit
and managed it while in the field, there were trained VHNs who would detect high risk
babies and refer them for treatment. This model was up-scaled to 16 districts in the same
year with components of equipment supply, training of doctors and VHNs and
establishment of neonatology units at district hospitals.
Policy incorporation into RCH I:
In 1993, a global task force on neonatology visited Kancheepuram and Kasturba Gandhi
hospitals.
“They were impressed. We recommended that this be incorporated into the RCH
policy matters. It got incorporated and helped later RCH activities. It was at this time Dr
Padmanabhan (then DD saidapet and present DPHS) was keen to get this activity
extended.” (Dr Jayam, chair person sasthinatha trust).
In 1993, Tamil nadu got a world bank (CSSM) aided project which had grants for
neonatology equipment. The aim was to upgrade District hospitals, PHCs and sub-centres
to ensure safe motherhood and neonatal care. The district hospitals were converted to
FRU’s. Six districts were covered under this project. The equipment for this was given by
the neonatology foundation of India. Training of nurses and VHNs was undertaken.
“At the same time, initiatives under DANIDA complimented these trainings for
newborn care which we were undertaking.” (Dr Jayam, chair person sasthinatha trust).
The unit at Kancheepuram was renovated and up graded in 1995.
RCH I activities:
In 2003, under DANIDA, training in new born resuscitation and comprehensive newborn
care was undertaken. It consisted of both theory and skills. In the first instance, a team of
trainers consisting of doctors and staff nurses were trained using hospitals in Chennai as
institutions for training. These trainers then, gave training to staff and doctors at their
respective district hospitals. A CD was given to enable practice of skills after training
session was over. The aim was to identify high risk conditions and emergencies in infants
and neonates and take action including referral. This covered 6 districts.
In 2004 and 2005, a neonatal resuscitation programme for nurses and VHNs was done at
three training institutes of the government.
RCH II activities:
Training of field staff: In 2006 and 2007, with UNICEF support, 800 VHNs and AWW
(anganwadi workers) were trained in 5 tsunami affected districts. The training was
conducted at the government training institute at villipuram. It was a combination of
knowledge and skills. All material was in vernacular language (Tamil) and mannequins
were used to facilitate practice of skills. Hands on training for phototherapy and radiant
warming were given. 5 facilitators were used. It concentrated on neonatal care
immediately after delivery and identification of high risk pregnancies.
“The logic is that 66% neonatal mortality occurs within 28 days of birth and 66%
of these occur within 7 days of birth. 16% of these births occur within first three days.
75% of NMR occurs in the rural areas.”( Dr Venkatesh, pediatrician, Sasthinatha trust)
An evaluation of one district was done.
“On evaluation, it was found that there was increase in knowledge. 80% of VHNs
and AWW were good. Their complaint was that the doctor was not listening to their
suggestions for management of cases, since their knowledge was better than that of
doctors.”( Dr Venkatesh, pediatrician, Sasthinatha trust)
A second phase of similar training was done for VHNs and AWWs of districts other than
covered in the Phase I. The training covered pediatricians and anesthetists also. The aim
was to identify all high risk pregnancies and refer them to district hospitals for better
management so as to reduce NMR (neonatal mortality rate) to 20/1000 live births by
2010. An immediate aim was to train a core group of trainers. The core trainers are being
used to train further staff.
“For last six months, the initiative is under implementation” ( Dr Venkatesh,
pediatrician, Sasthinatha trust)
Training of medical officers: In 2006 and 2007, 1000 doctors were trained in
comprehensive newborn care to improve the knowledge and skills of doctors so as to
bring them in line with what was taught to VHNs and AWWs.
Training of community link volunteers: This training was taken up in the block of Tali in
Dharmapuri district in September 2007. This district has a very high NMBR and IMR.
One volunteer per village got trained. Initially training of trainers was conducted at the
training institute at Hosur. Two batches consisting of MO, staff nurses, VHNs and lady
health supervisor of all the PHCs in the block. These trainers trained all the volunteers at
their respective PHCs. Each trainee was given a CD and a booklet in local vernacular
language. The booklet had pictorial representations of all the key concepts.
An evaluation was done.
“An evaluation using the written record method was done and found high amount
of variation” (Dr Venkatesh, pediatrician, Sasthinatha trust)
A second round of volunteer training was done in a second block of the same district in
December 2007.
Training of senior officers of headquarters: A sensitization lecture on new born care for
all joint directors, district health unit heads, obstetricians and gynecologists was
conducted at the training institute at Egmore.
Training of nurses of urban health units:
Nurses posted in the health units and hospitals of Chennai Corporation were given a one
day training programme on comprehensive new born care, at the unit premises at vijaya
hospital. Till now 200 nurses have been trained.
Adoption of PHCs as model PHCs: This initiative, supported by UNICEF, is aimed to
create model centres where all staff and doctors are trained in the use of equipment and
theory of new born care and are able to manage all cases of high risk pregnancies and
new born infants, especially low birth weight babies. The ultimate aim is to reduce NMR
in those blocks. The PHCs adopted are block PHCs with specialist posted, all facilities
including operation theatre to manage MTP cases and puerperal sepsis. A neonatal ICU is
also made functional at these PHCs. The PHCs adopted are those which have high
number of deliveries. A level II NICU has equipment to tackle all emergencies except
ventilation equipment.
Positioning of Neonatal ambulances: Six neonatal ambulances having all equipment of
NICU level II are positioned at three points in three districts. They are used to render first
aid to neonates and transport them to district hospitals for management, from PHCs. The
staffs of the ambulances, doctors, staff nurses and drivers, are all trained. The trust has
been using similar ambulances from the year 2000 and has considerable expertise in
management of these vehicles and equipment. The aim is to improve skills of staff in
PHCs in the usage of such equipment.
Evolution of the concepts in MCH:
The programmes involving MCH activities have evolved over time and with them the
components of each programme. The CSSM programme was essentially a field
programme. Under RCH I there was the addition of the hospital component (FRU’s). In
RCH II, the gaps between the field and hospital component is filled up with the
strengthening of the hospital component (CeMONC and BeMONC centres).
Similar has been the evolution of the concept of new born care. IMNCI is a field
perspective of newborn care. This is being introduced in RCH II. It has no hospital
component. In new born care, there are two components, essential care and emergency
care.
“In Tamil nadu, we have covered the IMNCI under new born care. New
born care requires higher degree of skill and equipment.” (Dr Jayam, chair person
sasthinatha trust).
Role of medical colleges in transfer of skills to public health officials:
“Medical colleges are the places where advances in knowledge and skills are
learnt and practiced. Here significant inputs come from various sources voluntarily and in
piecemeal form. There is a requirement for transfer of these skills to professionals at the
government level. Government PHC doctors must be guided and given practice oriented
skills which require strict monitoring and a mechanism to ensure transfer. This training
and monitoring is required for a length of time, as time is required to become a good
doctor. Thus medical college professionals should actually give inputs on a regular basis
and voluntarily to government doctors and staff so that they learn practice oriented skills
which translates advances in knowledge and skills into service at the public level.” (Dr
Jayam, chair person sasthinatha trust).
Evolution of training and transfer of skills in new born care in Tamil nadu:
“The Kancheepuram experiment was the first time we attempted to translate
knowledge into practice oriented skills. We attempted to translate knowledge into skills
for the front end field staff which are the traditional dais and VHNs. It was a success. In
1982, we took up training of field workers under DANIDA, in Ramnathapuram district.
We looked at the concept of attitude orientation and self role realization to approach
families for giving health education. This as a method of training was evaluated.
Then in 1986-89, we had the district action programme under ford foundation; in 1993-96
under world bank aided programme; in 1999-2000 programme on neonatal care under
DANIDA funding; in 2004-05 neonatal resuscitation programme for nurses as part of
IMNCI training; in 2006-07 UNICEF supported training of village level workers in 5
tsunami affected districts on neonatal care; in 2007 , volunteer training on newborn care
to act as link between community and referral centres and in 2007 ( continuing
programme) comprehensive newborn care for all staff and doctors.
In all these training programmes, we have transferred knowledge and skills on new born
care to village level volunteers, VHNs, staff nurses and doctors, thus covering all levels
of people between the community and medical college professionals.
The logic behind, all these activities is that we must be able to link skills at each level and
amongst all levels, so that they get interlinked for effective service delivery.” (Dr Jayam,
chair person sasthinatha trust).
Role of government in transfer of skills:
“The role of the government is to be proactive in ensuring the transfer and
interlinking of skills at all levels. Luckily in Tamil nadu, there has been traditions of
interaction between government professionals and medical college professionals and
government officers have always been helpful” (Dr Jayam, chair person sasthinatha
trust).
Role of medical college professionals:
“Our role as medical college professionals is to ensure that we continue to keep
pace with technological advances and integrate them with our training mechanisms, so
that these skills are functionally transferred to middle level facilitators. The middle level
facilitators are basically trainers in government institutions. We need to have younger
people as part of the transfer process so as to continue transfer of skills. This process
needs to go on for a long period of time. One way to ensure continuous transfer of skills
is to post specialists at PHCs or PHCs are attached to medical colleges. In Tamil nadu, on
a trial basis, post graduate students are being posted to PHCs from branches of pediatrics,
obstetrics and Chest medicine.”(Dr Jayam, chair person sasthinatha trust).