Life-saving Intervention

In mid-2020, an unexpected problem came to light as administration in Meghalaya conducted weekly reviews to monitor the situation of the COVID-19 pandemic in the state: a high number of maternal deaths. In FY 2020-21, the state reported a high MMR (number of maternal deaths per 1,00,000 live births) of 289 against a national average of 97.

There were many factors that caused Meghalaya’s high maternal mortality.

Fear and anxiety about contracting the SARS-Cov-2 virus had led to a decline in pregnant women coming to health facilities to seek necessary antenatal care.

Meghalaya’s geographic challenges further compounded the problem. Around 30 per cent of the state’s nearly 7,000 villages were hard-to-reach. This meant that they were either inaccessible by motorable roads, or were inaccessible during monsoons. GIS mapping of health facilities by the state government showed that residents of 49 per cent of the state’s villages could not reach a health facility within thirty minutes by vehicle. Providing healthcare services to the state’s population became a challenge in such circumstances.

Most importantly, there was a lack of purpose or urgency within the health system for prevention of maternal deaths. High maternal deaths were seen as inevitable, and not as a problem that could be solved.

Faced with such challenges, the state’s leadership realised the importance of taking a systems approach to solve the problem of high maternal mortality.

The late Donella Meadows, in her book ‘Thinking in Systems: A Primer’, highlights that systems are made up of three important aspects: elements; interconnections between the elements; and the system’s purpose or function. For instance, a state’s health system is made up of human resources for health, health infrastructure, medical supplies, etc., which form its elements. The information and finance flow between different decision-making points of the health system form its inter-connections. However, the most important component of a system, according to Meadows, is its purpose and function. When a system loses its purpose, or its purpose is unclear, then the system ceases to function properly. Even when all the elements are present, without a clear purpose, the system can’t achieve its function.

Meghalaya launched the Rescue Mission in November 2020 with express commitment from political leadership. As a first step under the Mission, the senior leadership instilled a sense of purpose and urgency in the health system for preventing maternal deaths. Regular reviews of maternal deaths became the order of the day to foster inter-department collaboration between the Health & Family Welfare (H&FW), Social Welfare (Women & Child Development), and Community & Rural Development departments around the core problem of addressing the preventive, curative, and enabling dimensions of maternal health.

These inter-department reviews also helped strengthen the interconnections between the different levels of the health system. A crucial element that helped facilitate this was the MOTHER APP—a real-time open data platform that tracked each and every pregnant woman who was expected to deliver in the state. This helped in timely tracking of high-risk pregnant women so that they could receive the necessary life-saving care.

To address the geographical challenge, the state leadership conceptualised the Chief Minister's Safe Motherhood Scheme (CM-SMS). Under CM-SMS, Medical Officers (MOs) were given autonomy and agency to use funds in flexible and adaptive ways with the core purpose of saving the lives of pregnant women. The Scheme enabled the MOs to hire vehicles to bring pregnant women to health facilities at least two weeks before delivery, where they could stay in ‘transit homes’—which are halfway homes established under the scheme, often managed by Self-Help Groups (SHGs). But most importantly, CM-SMS gave autonomy and agency to MOs to utilise funds in any manner they saw necessary to ensure the pregnant women received the required life-saving care. This was an important system where the scheme was designed with a system of trust rather than a system of audit as priority.

A crucial element that was identified as a gap in Meghalaya’s health system was the lack of adequately skilled human resources. According to the report ‘Health Dynamics of India (Infrastructure & Human Resources) 2022-23’ by the Ministry of Health & Family Welfare (MoH&FW), Government of India (GoI), Meghalaya had a 96 per cent shortfall of specialists in rural Community Health Centers (CHCs). In addition, the long time taken for recruitment resulted in vacancies in primary care health facilities. This meant that pregnant women often couldn’t receive life-saving emergency obstetric care when required.

The Meghalaya government implemented two interventions to address these human resource challenges.

It constituted the Meghalaya Medical Services Recruitment Board (MMSRB) in October 2022 to streamline the recruitment of both general and specialist doctors. Over 450 doctors have been recruited so far across two rounds, with the recruitment process being completed within a month in both instances.

Secondly, an MoU was signed with the Government of Tamil Nadu for the upskilling of the state’s doctors in emergency life-saving obstetric care. In the spirit of cooperative federalism, over 80 doctors from Meghalaya have been trained and certified in Comprehensive Emergency Maternal Obstetric Care (CeMOC), Life-Saving Anaesthetic Skills (LSAS), and Ultrasound Sonography (USG). The doctors are trained and certified in six months.

The upskilling of doctors also enabled the state to activate First Referral Units (FRUs) at its CHCs, with the purpose of reducing the time-to-care. Since the signing of MoU with Tamil Nadu in 2022, around 10 of the state’s 30 CHCs have been upgraded to FRUs. The establishment of the Meghalayan Medical Drugs and Supplies Limited (MMDSL) in 2022 also helped streamline the supply of essential drugs, diagnostics and equipment that were required by the FRUs, specifically, and health facilities, generally.

At the same time, the state leadership realised the importance of investing in strengthening community institutions to drive demand and action on health care. Meghalaya notified Village Health Councils (VHCs) in 2022. They came to replace the erstwhile Village Health, Sanitation and Nutrition Committees (VHSNCs). VHCs leverage traditional sources of community authority—such as village headmen—as part of their leadership. This helps mobilise community action around health and nutrition issues.

Accordingly, the Rescue Mission helped strengthen Meghalaya’s health system by instilling a sense of purpose and urgency within the system for solving a core problem: maternal deaths. In line with this purpose, the required elements of the system, and the interconnections between different elements of the system, were strengthened.

The achievements of this system strengthening approach were remarkable. There was a 49 per cent reduction in MMR between FY 2020-21 and FY 2023-24.

Crucially, the strengthened health system can now be leveraged by the state to solve other health issues. Meghalaya plans to adopt a similar approach toward tackling the emergent problem of Non-Communicable Diseases (NCDs) with the purpose of increasing the state’s life expectancy to over 75 years.

The approach adopted in ‘Rescue Mission’ under the inspired leadership of Ram Kumar, the then Mission Director, National Health Mission, Meghalaya, and the guidance of Sampath Kumar, Health Secretary of the state, holds promise for other such initiatives in the state and in other states as well. The model can be replicated and scaled in the true spirit of Nexus of Good.

The writer is an author and a former civil servant. Views expressed are personal