• Global Health
• Healthcare quality improvement
• Quality improvement

Nearly one million neonatal deaths occur annually, and almost two-thirds of these neonates are born in health facilities.1 In low and middle-income settings, sub-optimal quality health systems contribute to these preventable deaths.

Nearly 26 million babies are born annually in India.2 In 2019, India’s neonatal mortality rate (NMR) was 22 per 1000 live births3 and had one of the largest cohorts of preterm and low birth-weight neonates globally. One-quarter of global newborn deaths occur in the Indian subcontinent.4 Every newborn action plan (ENAP) launched in 2014 has set a global target of fewer than 12 newborn deaths per 1000 live births and fewer than 12 stillbirths per 1000 total births by 2030.5 The sustainable development goals (SDG) newborn targets for NMR reduction are like ENAP targets.6 India has set a more stringent target for itself by committing to reduce its NMR and stillbirth rates to a single digit by 2030.7 As a step in this direction, India launched its newborn action plan (India newborn action plan; INAP) in September 2014 and has made concerted efforts to improve access and improve the quality of care.

India’s performance in reducing child mortality is better than global performance. It has achieved a decrease of 64%, 70%, 74% in NMR, IMR and under-five mortality rate, respectively, compared with a global decline of 54%, 58% and 61% in the earlier indicators during the period 1990–2020.8 India has also achieved three out of the four ENAP coverage targets set for countries by 2025.9 However, as per a recent Lancet report based on 2000–2017 data, nearly 50% of the districts in the country would miss the National Health Policy’s NHP-2025 goals and SDG-2030 targets if a higher NMR annual rate of reduction is not achieved.10

As is now well known, structural reforms are more likely to improve service quality at scale than isolated microlevel efforts. Effective governance, leadership, optimisation of service delivery and empowering the community to demand quality from the health system can be efficient modalities to ensure high-quality health systems in low and middle income country (LMIC) settings.1 With this background, the ministry of health, and family welfare, Government of India, has embarked on a mission to prepare an INAP 2021–2030 review roadmap to accelerate the rate of NMR decline across the country. India has worked towards specifically addressing the five intervention pillars of ENAP5 and included an additional sixth pillar of care beyond survival under INAP with the agenda of thriving and transforming.

To achieve the global SDG/ENAP targets in sync with the INAP 2030 goals, India has launched various national programmes explicitly focusing on the six preidentified intervention pillars. To provide high-quality accessible preconception and antenatal care free of cost, assured quality antenatal care to all pregnant women has been offered on a fixed day since 2016.11 Strengthening of mechanisms to tackle intergenerational anaemia,12 improving adolescent sexual reproductive health by providing weekly iron and folic acid supplementation13 and maternity benefits scheme with conditional cash transfer for first pregnancy14 are being implemented on the ground. Care during labour and childbirth is addressed by a programme to improve the quality of care in labour rooms and maternity operation theatres aptly called the LaQshya.15

The country has recently launched national midwifery training institutes with a vision to establish midwifery-led care units at all high caseload points.16 Free transport, drugs, diagnostics or tests for mothers and sick infants are now assured under surakshit matritva aashwasan (SUMAN).17 Immediate newborn care and care of healthy and sick newborns is provided by a network of nearly 21 000 newborn care corners, along with the capacity building of frontline healthcare workers in basic neonatal resuscitation and the provision of free universal immunisation programme is also ensured.18 19 Programmes like home-based newborn care, mother’s absolute affection, newborn stabilisation units (NBSUs) (2600) and special newborn care units (>900) provide a framework for comprehensive care for all categories of newborns.20 Recently, ministry has also released a training package for the staff of NBSUs to provide immediate care to sick and small newborns at subdistrict level facilities.21 The rashtriya bal swasthya karyakram22 includes newborn screening, early childhood development, focusing on the first 1000 days, management of deficiencies, developmental delays and congenital disabilities. Recently, a new initiative called MusQan23 has been launched for all children 0–12 years using the existing national quality assurance standards.

Quality of care, a guiding principle for the INAP, will be the key across all six intervention pillars to achieve INAP, where every child survives and thrives to their maximum potential. The Lancet Global Health Commission report on high-quality health systems in the SDG era24 mentions that the universal health coverage strategy, without quality, is not sufficient to improve health in LMICs. The scale and scope of the aforementioned national programmes addressing the continuum of care around birth reveal a shift towards effective macrolevel interventions with a strong focus on strengthening other social systems and effective governance. This shift is essential for ensuring a better quality of care for the communities in LMIC settings.1

This brief aims to introduce the readers to the policy instruments, the range of high-impact life course, multisectoral interventions and the role of quality of care in achieving the ENAP/SDG 2030 goals as implemented in India.

We sincerely hope that the readers will enjoy the second issue of the South Asia Supplement, which focuses on showcasing improvement stories from LMIC settings, which are often lost due to lack of adequate documentation. This issue has been supported by a generous grant from UNICEF India Country Office. Special thanks to Dr Vivek Singh, Dr Priyanka Singh and their team for helping. The editorial team and the peer reviewers of the South Asian edition deserve congratulations for bringing out this issue amidst sequential waves of the COVID-19 pandemic and highly challenging situations across South Asia during this period. The current issue contains articles focusing on preventing medication errors, improving the duration of Kangaroo mother care, improving the quality of antenatal services and improving participatory family care, using a simple point of care quality improvement approach. This issue will continue to publish articles on a revolving basis and will be followed up by the third edition of the South Asia supplement in 2023. We invite teams from the South Asia region to use this opportunity and share their improvement stories and examples with the broader global community.