In an Essay, Blake Angell and colleagues discuss ambitious reforms planned to expand coverage of the health system in India.

BackgroundPostpartum Hemorrhage remains the leading cause of maternal mortality. To prevent PPH, Misoprostol tablet in a dose of 600 micrograms is recommended for use immediately after childbirth in home deliveries wherein the use of oxytocin is difficult. The current article describes an implementation of “community based advance distribution of Misoprostol program” in India which aimed to design an operational framework for implementing this program.MethodsThe intervention was carried out in Janjheli block in Mandi district of the state of Himachal Pradesh which is a mountainous terrain with limited geographical access and reported 90% home deliveries in the year 2014–15. An operational framework to implement program activities was designed which was based on WHO HSS building blocks. Key implementing steps included- Ensuring local ownership through program leadership, forecasting and procurement of 600 mcg misoprostol tablets, training, branding and communication, community engagement and counselling, recording and reporting, monitoring, supportive supervision and feedback mechanisms.ResultsOver the one year of implementation, 512 home deliveries were reported, out of which 89% received the tablets and 84% consumed the tablet within one minute of delivery. No incidence of PPH in tablet consuming mothers was reported. On account of periodic counselling and effective community engagement the intervention also contributed to better tracking of pregnancies till delivery and institutional delivery rates which increased to 93% from 45% and 57% from 11% respectively as compared to the preceding year.ConclusionsThe model has successfully shown the use of single misoprostol tablets of 600 mcg, first time in this program. We also demonstrated a HSS based operational framework, based on which the program is being scaled to additional blocks in Himachal Pradesh as well as to other states of India.Electronic supplementary materialThe online version of this article (10.1186/s12884-018-2036-2) contains supplementary material, which is available to authorized users.

IntroductionHealth insurance schemes, like Rashtriya Swasthya Bima Yojana (RSBY), should provide financial protection against catastrophic health costs by reducing out of pocket expenditure (OOPE) for hospitalizations. We estimated and compared the proportion and extent of OOPE among below poverty line (BPL) families beneficiaries and not beneficiaries by RSBY during hospitalizations in district Solan, H.P., India, 2013.MethodsWe conducted a cross sectional survey among hospitalized BPL families in the beneficiaries and non-beneficiaries groups. We compared proportion incurring OOPE and its extent during hospitalization, pre/post-hospitalization periods in different domains.ResultsOverall, proportion of non-beneficiaries who incurred OOPE was higher than the beneficiaries but it was not statistically significant (87.2% vs. 80.9%). The median overall OOPE was $39 (Rs 2567) in the non-beneficiaries group as compared to $ 11 (Rs 713) in the beneficiaries group (p<0.01). Median expenditure on in house and out house drugs and consumables was $ 23 (Rs 1500) in the non beneficiaries group as compared to nil in the beneficiaries group (p<0.01). Non-beneficiary status was significantly associated [OR: 2.4 (1.3–4.3)] with OOPE above median independently and also after adjusting for various covariates.ConclusionRSBY has decreased the extent of OOPE among the beneficiaries; however OOPE was incurred mainly due to purchase of drugs from outside the health facility. The treatment seeking behaviour in beneficiaries group has improved among comparatively older group with chronic conditions. RSBY has enabled beneficiaries to get more facilities such as drugs, consumables and diagnostics from the health facility.

Background: High-risk pregnancy (HRP) puts current pregnancy at an increased risk of complications. In the absence of pre-existing HRP implementation model of the country, in collaboration with the Government of Himachal Pradesh, a new digital HRP model called the 'SEWA—A System E-approach for Women at risk' was developed. The current article demonstrates a model for the early identification and line listing of high-risk pregnant women (PW) with appropriate referrals and increased engagement with the healthcare workers using a digital tool in the form of the Android App. Methods: SEWA was implemented as a pilot intervention in two community development blocks of the Chamba district. The key implementation steps included finalizing protocols for the identification of HRPs, defining processes and roles, mapping health facilities, setting up the communication loop, and developing of digital solutions. The digital app, used by the auxiliary nurse midwife (ANM) and program officers, tracked PW for a year from October 19 to October 20 and recorded the ANC visits, referrals, and birth outcomes. A qualitative assessment was conducted among the health workers to find out their level of acceptance. Results: A total of 1,340 high-risk PW were identified. The intervention year saw a rise in the identification of HRP to 27.9% from 3.5% in the previous year. A total of 2,559 conditions were tagged to the identified 1,340 women categorized into current pregnancy (81%), previous pregnancy (16%), and any existing chronic illness (3%). A majority of the women who required urgent referrals were provided referrals. The application recorded 53% of the delivered HRP with a digital birth preparedness plan, prepared and shared with the PW and Accredited Social Health Activists (ASHA), by text message for compliance. Conclusion: The SEWA application is a feasible and sustainable solution to complement the competency of the care providers for early identification of the high-risk conditions and reduce the burden of preventable unprecedented deaths around the time of birth.

Exploring the implementation blackbox from a perspective that considers embedded practices of power is critical to understand the policy process. However, the literature is scarce on this subject. To address the paucity of explicit analyses of everyday politics and power in health policy implementation, this article presents the experience of implementing a flagship health policy in India. Janani Shishu Suraksha Karyakram (JSSK), launched in the year 2011, has not been able to fully deliver its promises of providing free maternal and child health services in public hospitals. To examine how power practices, influence implementation, we undertook a qualitative analysis of JSSK implementation in one state of India. We drew on an actor-oriented perspective of development and used ‘actor interface analysis’ to guide the study design and analysis. Data collection included in-depth interviews of implementing actors and JSSK service recipients, document review and observations of actor interactions. A framework analysis method was used for analysing data, and the framework used was founded on the constructs of actor lifeworlds, which help understand the often neglected and lived realities of policy actors. The findings illustrate that implementation was both strengthened and constrained by practices of power at various interface encounters. The implementation decisions and actions were influenced by power struggles such as domination, control, resistance, contestation, facilitation and collaboration. Such practices were rooted in: Social and organizational power relationships like organizational hierarchies and social positions; personal concerns or characteristics like interests, attitudes and previous experiences and the worldviews of actors constructed by social and ideological paradigms like their values and beliefs. Application of ‘actor interface analysis’ and further nuancing of the concept of ‘actor lifeworlds’ to understand the origin of practices of power can be useful for understanding the influence of everyday power and politics on the policy process.