Innovative practices in Health sector

1. 28thMarch 2014 Innovative practices in Health sector “It’s about the small things that can have a huge impact on patient care” ArulmozhiRamarajan Bangalore

2. What is healthcare innovation? It is a new concept, process or product aimed at improving prevention, treatment, or outreach, that can lead to better outcomes in healthcare. The Innovation Journal: The Public Sector Innovation Journal, Volume 15(1), 2010.

3. Innovative practices that will improve maternal & child health • Anemia eradication • Averting maternal deaths due to PPH • Preventing infectious disease & reducing child mortality • Improving child survival

4. MDG 5: Improve Maternal Health • Anemia eradication - In the newborn - In adolescents - In pregnancy • Averting maternal deaths due to PPH - Medical innovations - Mechanical innovations

5. Anemia eradication

6. What is anemia? Normal red blood cells Anemic red blood cells

7. Normal Hb : 12-13g% Who is anemic? WHO < 11g% ICMR < 10g% Mild 8.0 – 10 g% Moderate 6.5 – 8 g% Severe < 6.5 g% Very severe < 4.0 g% ICMR

8. Anemia & Iron Deficiency Iron deficiency is 4 times more common than Iron deficiency anemia

9. Iron in Hemoglobin carries oxygen to tissues Iron in Myoglobin helps supply oxygen to muscle Iron in Enzymes assist in biochemical reactions Anemia is at least diagnosed, Iron deficiency is undiagnosed

10. Iron is important • Since iron is required to use energy, iron deficiency and anemia reduce the work capacity of individuals and entire populations, bringing serious economic consequences and obstacles to national development. • WHO estimates that successful treatment of iron deficiency can raise national productivity levels by 20%.

11. Anemia a public health problem WHO 2008

12. Anemia – Disease burden ‘NFHS-3 also found a remarkably high prevalence of anemia – 70% in children age 6-59 months. More than half of women in India (55%) are anemic, and anemia among women has increased  slightly in the past seven years.’ National Family Health Survey 3, 2006 Gets worse with each generation!

13. The Anemia cycle Low fetal iron stores Physiological dilution Increased demands Poor diet Infancy 92% Malnutrition, Worm infestation Pregnancy 80% Childhood 74% Adult women 60% Expansion of blood volume Menstruation, Poor diet Adolescence 55 - 95% ICMR Ministry of Health and Family Welfare, 2005

14. How to improve fetal iron stores?

15. How to improve fetal iron stores? Delayed cord clamping

16. Early cord clamping – within 1 minute after birth • Delayed cord clamping – 1 to 3 minutes after the birth or when cord pulsation has ceased

17. Cord clamping for the prevention of iron deficiency anemia in infants: optimal timing • About 30% more blood flows into the baby and adds about 50mg of iron to the baby’s iron stores • Nature intended for babies to get their iron from placental transfusion, because breast milk is not rich in iron It's just a matter of a minute, it makes a huge difference

18. How to improve iron stores in children & adolescents?

19. India is home to nearly 113 million adolescent girls between the ages of 11 and 18 years

20. Adolescent health in India • Adolescents form about 22% of the population • Anemia prevalence 55-95% • 54% are married < 18years • 28 % of women give birth by age 18 ICMR, Ministry of Health and Family Welfare, 2005 FOGSI Adolescent Health Committee

21. Why focus on adolescent girls? • Anemia is a leading cause of maternal deaths. • Pregnancy is too short a period to build up iron stores • Anemic mothers deliver anemic babies • Many of our women are in their teens at first pregnancy

22. The adolescent girls anemia control program GOI + State governments + UNICEF • WIFS: Weekly iron and folic acid supplementation: 100 mg of iron + 500 μg of folic acid • Tab. Albendazole 400mg once in six months • Diet advice and counseling

23. Evidence speaks! • Studies in India have registered a decrease in anemia prevalence over 12 months with WIFS: • 5% decrease in Jharkhand • 43% decrease in Andhra Pradesh • 50% decrease in Uttar Pradesh

24. Cost of WIFS • 52 tablets of IFA and 2 tablets of Albendazole are required for one adolescent for one year • This costs about INR 24 per beneficiary per year • Operational costs are low because existing infrastructure is utilized WIFS regime during adolescence is an investment in future for safe pregnancy

25. Program implementation • The Department of H&FW ensures supply of tablets • The Department of Education led the implementation in schools for school-going girls (70%) • The Department of Women & Child Development led the implementation in anganwadi centers for out-of-school girls (30%)

26. Anemia in pregnancy

27. Sure, safe & swift: • Oral iron is often not tolerated • Response to oral iron may be poor • Iron sucrose • Ferric Carboxy Maltose

28. Intravenous iron Response to IV Iron is not greater or faster, but is MORE CERTAIN • Oral iron is the mainstay of anemia management • But if Iron is not reaching its destination? • Intravenous iron sucrose can save lives

29. IV iron has helped reduce MMR • Introducing IV iron sucrose into the anemia management protocol has helped Tamil Nadu reach an MMR of 90 • Karnataka followed suit and is at 144 • Jharkhand introduced IV iron sucrose a last year, and is now at 219

30. Post partum options • Oral iron therapy for 3 months • IV iron sucrose 600mg in three divided doses on alternate days • Intravenous FCM 1000mg single dose • Corrects iron deficiency • Improves general health • Gives her a better start for the next pregnancy!

31. Innovative techniques to save mothers’ lives Post-partum hemorrhage (PPH) accounts for over 130,000 maternal deaths per year.

32. Active Management of Third Stage of Labor Postpartum hemorrhage Prendiville et al 1988; Rogers et al 1998 AMTSL is a simple, low-cost, life-saving intervention

33. Preventing PPH • Medical innovations: • Misoprostol • Oxytocin in Uniject • Mechanical innovations: • Uterine tamponade • NASG (‘Life Wrap’)

34. Misoprostol

35. Misoprostol • It can prevent PPH • It is safe • It requires no injection supplies • It requires no skilled provider for administration • Self administration also possible • It does not need refrigeration and can therefore be stored and provided where there is no electricity

36. Evidence supports use of Misoprostol “The finding that the distribution of oral Misoprostol through frontline health workers is effective in reducing the incidence of PPH could be a significant step forwards in reducing maternal deaths in low-resource countries” BJOG. Feb 2013 The 2012 WHO guidelines for the prevention and management of PPH have included a recommendation for the administration of Misoprostol by CHWs for the prevention of PPH.

37. Oral Misoprostol In home births without a skilled attendant, Misoprostol may be the only technology available to control PPH & save lives Cost: Just about INR 20 per tablet.

38. Oxytocin • WHO recommends 10 units of Oxytocin as part of AMTSL for prevention of PPH • In home births, an injection of oxytocin has to be simple enough for administration by a village health worker or midwife outside of hospital facilities.

39. Problems with Oxytocin? • Availability • Needs to be given as injection • Training of personnel required • Syringe & needle required: single use syringes generally reused / sterilization for reusable syringes unsatisfactory • Oxytocin is not heat stable – needs a cold chain to be maintained • Loses potency if not stored appropriately

40. Oxytocin is not heat stable • Recommended storage: 4 – 80C • At 250C: A 5% loss of potency in 12 months • At 400C: An 80% loss of potency in 12 months 100% 95% 20% 250C 400C 4 – 80C

41. The Oxytocin Initiative Project at PATH • Gorakhpur, Agra, Hassan, Bagalkot • Use of Methylergometrine postpartum is common, the norm in Agra and Gorakhpur, and is predominantly used after delivery of the placenta

42. Drug Quality: Potency of Oxytocin and Methylergometrine Attempt to purchase uterotonic drugs and test the chemical potency of all samples collected in the field. * Within specifications = 90-110% active ingredient

43. Uniject • In 1987, PATH developed the Uniject* injection system in response to WHO’s call for improved injection safety  • Uniject is a pre-filled, single-dose, non-reusable injection technology Program for Appropriate Technology in Health

44. Uniject Components Blister Valve Needle Cap

45. Time-Temperature Indicators (TTIs) The problem • No easy way to track exposure to heat during transport or storage. • Health workers may either use spoiled drugs or discard good drugs. The solution • TTI permanently changes color with cumulative exposure to heat. • Allows more flexible transport and storage options. • Minimizes use of spoiled product or waste of good product.

46. Oxytocin in Uniject is effective, safe • The Uniject system is ideal for administering oxytocin during the third stage of labor. • Oxytocin is also a heat sensitive medication. OIU is equipped with a time temperature indicator (TTI) that monitors heat exposure of the medication during transportation and storage. • The TTI is a tool that helps health providers know if the drug has been affected by high temperatures and if it is still usable. 

47. Uterine tamponade

48. Tamponade in PPH • Simple, low cost method • Minimal training needed • No anesthesia required • No complications reported

49. How does it work? • A balloon distends the uterine cavity and occupies the entire space, thereby creating an intrauterine pressure that is greater than the systemic arterial pressure The globally recommended balloon “Bakri balloon” Expensive, not freely available

50. Glove tamponade Low cost options Condom tamponade