The COVID-19 outbreak highlighted the gaps in quality of healthcare systems across the globe and countries’ preparedness to handle public health emergencies. In India, nursing professionals were at the frontline in management of the COVID-19 outbreak – first in providing 24x7 care to patients amidst the rising case load of the country and then in administration of 220 crore+ COVID vaccine doses, in one of the biggest inoculation campaigns in the world. Simply put, nurses, moreover credible and quality nurses, are essential for any healthcare system to thrive.

Need for Quality Improvement: The story of Uttar Pradesh

To ensure a robust healthcare system, Uttar Pradesh (UP) needs about 2.25 lakh nurses to cater to its large population and disease load, however only 1.5 lakh are currently registered. While 40 thousand more nurses get registered annually, the real challenge is having high-quality nurses join the workforce. A government recruitment drive for nurses in UP, conducted in Jan 2022, revealed the low quality of nursing education in the state. Out of 1,03,200 applicants for 4,500 vacancies, only 2,823 passed the minimum eligibility criteria.

Asha, a final year student pursuing a diploma in General Nursing & Midwifery (GNM) from an institute in Sitapur, was one of the candidates who had applied for these government vacancies but could not get through. Her uncle’s friend offered her a job in a small nursing home in Lucknow that he runs, 40 km away from her house in Sitapur. Asha was offered a salary of Rs. 8,000 per month which is significantly lower as against the government salary of ~Rs. 20,000 per month that she would have otherwise got if she would have secured the government job.

A main reason for her not being able to clear the government recruitment exam was her lack of understanding or knowledge of the subject matter tested in the exam. This can be directly attributed to lack of quality teaching or examination mechanisms in her institute; hence calling for prompt action.

The Birth of Niramaya

Responding to this trend, the state was geared up for improving and investing in the quality of nurses, to strengthen its healthcare systems. The state was looking for a scalable way to transform the quality of its nursing and paramedical education and the institutions which offered it. This would require the culmination of efforts from the government, multiple technical & administrative partners, and a robust tech platform to enable wide-scale implementation of the reforms.

This led to the birth of Niramaya, on 12th May 2022 (also celebrated as the International Nurses Day), a partnership between the Department of Medical Education & Training (DoME&T), Govt. of UP and Bill and Melinda Gates Foundation (BMGF), with Samagra as the consulting unit. The vision was clear: making nursing students like Asha job-ready and helping them secure high paying nursing jobs (govt or private) both inside and outside of UP, making UP the hub for quality nursing professionals in India.

In the past one-year, Niramaya has been focused on achieving this vision, by working on improving the quality of nursing institutes and the education offered by them in the state. The Government of UP and Samagra are also joined by implementation partners such as UP Technical Support Unit (UPTSU) and Jhpiego (a Johns Hopkins University affiliate organisation) in bringing this vision into reality.

Reforms introduced under Niramaya

A mix of primary and secondary research was conducted to understand journeys of various stakeholders in the medical education ecosystem ranging from nursing students, teachers, institutes, employers / hospitals up to the professionals to identify the major pain points. The Niramaya team at Samagra visited 21 institutes and 5 large employers across 5 districts in UP. Nursing ecosystems of Tamil Nadu, Kerala, New Zealand and the United Kingdom were also studied to cull out some of their best practices which can be adapted in the context of UP.

Solutions coming from the diagnosis and design phase were prioritised based on their replicability, sustainability, scale of impact, and novelty. This resulted in a five-reform framework focusing on enabling UP to become a hub for nursing professionals through:

• Public rating of institutes
• Centralised admissions
• Conducting fair and competency based assessments
• Issuing verifiable eCredentials to all nurses to track their skills and competencies, and
• Making nursing and paramedics an aspirational profession

These reforms are anchored in the U.P. State Medical Faculty (UPSMF), a quasi government body under DoME&T, and houses the UP Medical, Dental and Nursing councils. UPSMF is the registering body for all healthcare professionals practising in UP. It is also the examining body (analogous to C.B.S.E. which is the examining body for class 10th and 12th) for nursing and paramedical diploma courses.

Enablement of Reforms by Leveraging Technology

The above reforms were envisioned to be enabled by a tech platform built as a Digital Public Good (DPG) leveraging and contributing back to the open-source Sunbird community. The key advantages of this tech system were that it would digitise all processes run by the registering body of nurses in UP – UP State Medical Faculty (or UPSMF), bringing transparency and efficiency into the system. Secondly, by virtue of it being a DPG, other states would be able to pick up and adopt this platform, or its relevant modules, and easily deploy them for their use case.

Industry standard planning and monitoring processes are being followed for timely development and delivery of tech modules. A pragmatic Steering Committee with market leaders from the open source community has been formed to guide and monitor the development process at a quarterly level.

System Buy-in for Niramaya Reforms

Stakeholders at all levels are poised to work towards realising Niramaya’s vision to make nursing students like Asha ready for securing high paying nursing jobs both inside and outside of UP. On 8th October 2022, Hon’ble Chief Minister of Uttar Pradesh, Shri Yogi Adityanath, launched Niramaya in mission-mode and several reforms under it. In this event, Hon’ble CM stressed upon the importance of nurses in our society and mentioned how it provides opportunities for seva (service), rozgaar (livelihood), and swabhimaan (self-respect).

Mission Niramaya Team with Hon’ble CM Yogi Adityanath at the launch event

Attendance of 400+ representatives across nurse employers, institute and funder groups (and many more virtually), helped create a lot of buzz around Mission Niramaya on-ground. Every activity in the medical education sphere in UP started aligning itself to Mission Niramaya and its reforms.

Despite ~95% nursing and paramedical institutions belonging to the private sector, reforms under Niramaya were welcomed with open-arms. Institutes were eager to under-go the on-ground assessment exercises for getting or improving their ratings, they also drove participation in drafting of the centralised admissions policy, conducted fair exit-examinations with utmost transparency and probity, all as per UPSMF’s direction.

Celebration and Way Forward

Tightening the examination process means that students who haven’t prepared for exams or rely heavily on cheating will not be able to pass. This also gives confidence to employers that graduating nurses are of higher quality; thus offering them better jobs. Further, an increased focus on generating better placement opportunities will incentivise nurses to focus on their education and secure high paying jobs based on their merit.

Additionally, students of grade 12 are made more aware of various opportunities in nursing, through several career counselling sessions conducted by institutes across the state. They can look up to several role models and their success stories for inspiration. Moreover, prospective students will be able to use the public ratings of institutes to determine their quality and choose which institute they would want to take admission in.

As the program steps into its second year, Niramaya’s focus will be to build an ecosystem of high quality nurses and nursing institutes. This will also act as a blueprint for other states and countries to improve their quality of nursing professionals and build robust healthcare systems. The government is resolved to continue supporting more nurses like Asha in soaring high in their nursing careers & motivate others on the way.