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Norway India Partnership Initiative
Program Management Group
November 22
2011 Meeting notes for the 12th meeting of the Program Management Group
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Table of Contents Agenda .................................................................................................................................................... 3
For decision ............................................................................................................................................. 4
1.0 Executive Summary ........................................................................................................................... 4
1.1 Background ....................................................................................................................................... 4
2.0 Proposal & budgets for decision at a glance ....................................................................................... 5
2.1 UNICEF .............................................................................................................................................. 5
Social marketing of ORS and Zinc for Diarrhoea Management Program in 44 high focus districts of India– 2011-2012 ................................................................................................................................. 5
2.2 Budget projections for approval ........................................................................................................ 6
UNOPS LFA NIPI Programme ............................................................................................................ 6
UNICEF ............................................................................................................................................ 6
NIPI Secretariat ................................................................................................................................ 7
WHO................................................................................................................................................ 8
3.0 Programme Progress ......................................................................................................................... 8
3.1 WHO ................................................................................................................................................. 8
3.2 UNOPS LFA ..................................................................................................................................... 12
3.3 UNICEF ............................................................................................................................................ 24
3.4 UNICEF Concept Note on Quality of maternal and newborn care ..................................................... 26
4.0 Operational Research ..................................................................................................................... 27
4.1 Results of OR ................................................................................................................................... 27
4.1.1PHFI Study on ASNI ........................................................................................................................ 27
4.1.2 ANSWERS Study on Breastfeed practices in Madhya Pradesh ........................................................ 31
5.1 Progress Report NIPI Secretariat ...................................................................................................... 31
6.1 NATIONAL CHILD HEALTH RESOURCE CENTRE .................................................................................. 38
OPTION I: NCHRC REMAINS WITH NIHFW ....................................................................................... 38
OPTION II: NCHRC SHIFTS TO NHSRC ............................................................................................ 39
OPTION III: NCHRC KNOWLEDGE CENTRE FOR CHILD HEALTH ....................................................... 39
Annexure 1 ............................................................................................................................................ 43
Annexure 2 ............................................................................................................................................ 51
ACRONYMS AND ABBREVIATIONS ............................................................................................... 65
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XII NIPI Programme Management Group (PMG) meeting on 22nd November 2011 at 3.00 pm Venue: India Habitat Centre, Lodhi Road,
Jacaranda Room II, First Floor Gate 3. The NIPI Programme Management Group (PMG) acts as technical advisory board for the Joint Steering Committee of the Norway India Partnership Initiative. The role of the PMG is to review proposals of Partners of NIPI and give its recommendations to the Joint Steering Committee.
Agenda 1. Opening remarks:
Secretary and/or Mission Director, MoHFW, GoI
Director, NIPI Secretariat
2. Programme update by UNICEF ( including progress reports since the last JSC, any new concepts,
proposals and budgets for 2011 requiring JSC decision)
3. Programme update by WHO (including progress reports since the last JSC, any new proposals and
budgets for 2011 requiring JSC decision)
4. Programme update by UNOPS NIPI Programme (including progress reports since the last JSC, any
new proposals and budgets for 2011 requiring JSC decision)
5. Specific update by State Mission Directors on NIPI Programmes from Focus States
a) Bihar
b) Madhya Pradesh
c) Orissa
d) Rajasthan
6. NIPI Secretariat update
7. NCHRC discussion
8. Any other business with permission of the chair.
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For decision
The Program Management Group has one new proposal to be considered from UNICEF on Social marketing of ORS and Zinc for Diarrhoea Management Program in 44 high focus districts if India– 2011-2012
Draft annual work plans with budgets will be presented by WHO, UNOPS LFA , UNICEF and NIPI Secretariat.
For discussion
UNICEF will present a Concept Note on conducting a baseline assessment of quality of maternal-newborn care.
The future of NCHRC along the lines of a number of scenarios .
1.0 Executive Summary
1.1 Background
The 12th NIPI Programme Management Group meeting is being held with a new Union Health
Secretary and previous NRHM Mission Director. This bodes well for the programme where the Secretary already has an in depth knowledge of NIPI and its various components.
Each implementing partner has prepared a draft work plan and budget for 2012 which will be put to JSC for approval.
There is only one new proposal for decision to be taken to the JSC, which is from UNICEF. Here
UNICEF have developed a proposal for social marketing for the management of Diarrhoea.
To be discussed is UNICEFs concept note (Section 3.4) on quality of maternal and new born care.
Up for discussion also is the sustainability of National Child Health Resource Centre (NCHRC)
which has to date been exclusively funded by UNOPS LFA. A number of options for the future of
NCHRC and State Child Health Resource Centre (SCHRC) have been drafted and advice will be sought from government as to the most feasible model to pursue.
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2.0 Proposal & budgets for decision at a glance
2.1 UNICEF
Social marketing of ORS and Zinc for Diarrhoea Management Program in 44 high focus districts of India– 2011-2012 There are two major issues related to management of Diarrhoea among infants and children in the
country: first lack of awareness and use of ORS and Zinc for management of Diarrhoea by health workers
and, second, poor and interrupted supply of ORS and Zinc for Diarrhoea management. When
appropriately addressed, both these problems could lead to avoidable deaths amongst children suffering from Diarrhoea.
It is against this background that a project is proposed to increase availability, awareness and utilization of ORS and Zinc for proper management of Diarrhoea in children in 44 high focus districts of 13 states in
India (Details in Annexure-1), especially through a social marketing concept.
Objectives of proposal:
1. Increase regular availability of ORS + Zinc in public and private sector (traditional and non-
traditional outlets) 2. Increase awareness and knowledge of the rationale and advantages to prescribe ORS and Zinc for
management of childhood Diarrhoea by public and private health workers
3. Change prescribing habits of Frontline and primary care health workers to recommend use of ORS and zinc for management of childhood diarrhoea
4. The proposal seeks to increase the supply and promote the demand and use of ORS & zinc to
prevent deaths due to Diarrhoea among children 2 -59 months. The contracted firm will create
informed demand for ORS and Zinc through a communication campaign targeting families of children 2-59 months, and ensure wide availability of ORS and Zinc tablets (co-package) at
chemists.
5. The specific tasks to be undertaken by the social marketing firm include: a. Training
b. Create a network of depot holders – increasing supply
c. Linkages and Networking
d. Creating awareness e. Monitoring & Reporting
7. Amount budgeted in PBA for the activity
USD 3,710,000
(Detailed Proposal in Annex 1)
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2.2 Budget projections for approval
UNOPS LFA NIPI Programme
Year 2012 Budget Requirement (in USD)
State Budget Requirement 3,984,679
National level office and travel 1,250,000
Grant and others for activities cutting across the states 1,500,000
State offices 500,000
Less expected Unspent amount from current year from national level budget
2,000,000
TOTAL 5,234,679
UNICEF
Year 2012 Budget Requirement (in USD)
Community based newborn and childcare (IMNCI Plus): 2 million USD
– Monitoring & supervision – Quality assurance – Social Marketing of ORS and Zinc
2,000,000
Facility based maternal, newborn and child health (essential care, special care, F IMNCI, operationalisation of FRUs):
– Collaborative centres – States Perinatal Resource Centres – Operationalisation of FRUs – Essential newborn care in focus districts – Baseline assessment of quality of newborn care
• Community and facility (essential and special)
1,500,000
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Immunization: 1 million USD – Technical assistance to measles – Cold chain assessment and strengthening
1,000,000
Strengthened Management: – Capacity Building of State and District Program
Managers – Collaborative centres for District Program
Management Course – PG Diploma in MCH Management
1,500,000
TOTAL 6,000,000
Less expected unspent amount from current year 6,700,000
Balance 700,000
NIPI Secretariat
Year 2012 Budget Requirement (in USD)
NIPI Secretariat budget for the year 2011 (JSC approved)
2,092,056
Funds received for Operational Research on 20 Dec 2010 318,391
Cash Balance remaining from Dec 2010 (incl OR) 1,208,758
2,092,056 - 1,208,758 =
TOTAL Required 2011 883,298
Budget 2012 projected 2,122,000
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WHO
Budget to come
3.0 Programme Progress
3.1 WHO
W H O P R O G R E S S R E P O R T
Update on on-going Activities and note on Proposed Activities
I. Accelerating Child Health Interventions:
a. Strengthening Pre-service IMNCI training:
Expanding Pre-service training in IMNCI for Medical students in the NIPI Focus States:
A Review of operationalisation of pre-service IMNCI training in the NIPI Focus States was
conducted in May 2011 in collaboration with UNICEF and NIPI-UNOPS. Following recommendations, the National Nodal Centre is now updating curriculum as per 2009 revised
IMNCI guidelines and looking into the feasibility of addition of F-IMNCI in the curriculum.
Expanding Pre-service training in IMNCI for Nursing students in the NIPI states: Pre-service
IMNCI for nursing and ANM students is now being given more focus, based on the review in
May.
Further, teaching of IMNCI to nursing students is now being promoted as part of SBA curriculum
– a pilot has been initiated in states of Madhya Pradesh and Orissa (more details in SBA training
under Maternal Health Interventions). Pre-service IMNCI teaching in nursing and ANM schools is going to be initiated in the remaining States of Rajasthan and Uttar Pradesh by the WHO
Country Office (WCO) as in Bihar, NIPI – UNOPS is working on a similar model in
collaboration with JHPIEGO.
b. Capacity building of district level Programme Managers in Child Health programme
review and management A consultation meeting was held on 4
th August, 2011 with representatives of Child Health
division of MOH, UNICEF, UNOPS LFA and PHFI to decide on the framework of the proposed
package on Short Programme Review (SPR) on Reproductive and Child Health (RCH). Discussions led to general unanimity on developing a single Short Programme Review (SPR)
Reproductive & Child Health (RCH) package with focus on simplicity for use by the programme
managers at various (State and District) levels. The module is due for completion in November
2011.
An integrated training package for District level Program Managers is being developed for the
country. A meeting with all stakeholders and partners – including GoI, UNICEF, UNFPA, UNOPS LFA and various academia was held on 5
th September 2011 to finalize modalities. The
development of modules is ongoing and a first draft will be ready by December 2011.
c. Technical Support to Maternal Health Division for enhanced monitoring and review and
quality
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Community monitoring of Maternal & Child Health activities at village level:
Discussions are ongoing with various stakeholders for the initiating same.
d. Strengthening Community based management of Childhood Malnutrition:
a. Determination of appropriate value of MUAC (Mid-Upper Arm Circumference) to
identify SAM (Sub-Acute malnutrition) children with Weight for Height as
reference in Indian population.
The protocol has been revised in line with the recommendations from the XIth JSC – notably: providing a detailed methodology with an increased sample size and also the
recommendations of Expert Group Meeting held from 6th-8th June 2011 in collaboration
with GoI.
i. A cross-sectional study will now be conducted and the participating centres
will utilize uniform protocol, research methodology and survey tools. A
population of 250,000 is proposed to be covered and 900 SAM children are
envisaged to be examined. ii. Further, a Project Advisory Group will be set up which will include
representatives from Child Health division, MOH along with other experts.
All 5 participating centres including the coordinating centre, AIIMS have had their proposals
cleared by their respective ethical committees. The completed proposal along with approvals
has been submitted to NIPI secretariat for funding through Operational Research (OR).
b. Documentation of models of community based management of SAM children in the
country and develop a compendium of the same.
The final modalities for the above activity are being worked out with the collaborative
partner of WHO.
II. Accelerating Maternal Health interventions:
a) Strengthening Accreditation of RCH Service providers – Mapping of Private Health
Care facilities in the states of Madhya Pradesh and Orissa.
Mapping of Private Nursing Homes (PNH) started in the two States in January 2011 and was
completed in May 2011. Mapping was carried out in 3 NIPI focus districts of MP (Raisen,
Hoshangabad, Narsinghpur) and Orissa (Sambalpur, Anugul, Jharsuguda). A total of 121
PNHs were identified of which 83 have been identified for further data analysis as the rest were not found up to the mark due to lack of facility/poor facility or service limitations.
MP had more PNHs in the districts as compared to Orissa, however, in terms of provision of services and the availability of the necessary equipment and the facility, Orissa and MP were
comparable. None of PNHs reported being aware of GoI schemes and program
implementation plans. Approximately 92% of the PNH in all the districts had 2-5 beds, and availability of 24 hours MBBS Doctors & Obstetric and Gynaecologists (Ob Gyn) was in
about 30-40% of them. Approximately 2-3 PNHs who met majority of the key criteria were
available in each district, however they were present mainly in the headquarter town or
neighbouring bigger town. Those PNH that meet the most of the accreditation criteria are noted to be part of the RCH initiatives for providing services, however they were not keen to
participate in the Skilled Birth Attendants (SBA) training initiative.
b) Strengthening Quality Assurance (QA) of RCH trainings under NRHM:
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The Experts’ group meeting had earlier highlighted that better Coordination is required for
training and monitoring between Medical College and District Hospital; operationalisation of FRUs with reference to proper posting of trained doctors, skill practice, number of caesarean
sections performed and other obstetrics emergency handled is required; formation of an
active E- group can be initiated for better experience sharing among expert members and the
contents & duration training both for Life Saving Anaesthetic Skills (LSAS) & Emergency Obstetric Care (EmOC. EmOC requires re-visiting by experts in order to keep pace with
advancement in the field and to make it more practically acceptable. These have been shared
with the Ministry Of Health (MoH) as well as the States. The LSAS curriculum for EmOC training as of now is being considered for revision by the MOH.
The already established State Quality Monitoring Units have been activated in the States of Bihar, Madhya Pradesh & Orissa. Assessors in the NIPI Focus states have been trained and
field activities have started in Orissa, Rajasthan, Madhya Pradesh, Uttar Pradesh and Bihar.
The State Quality Monitoring has now become part of State NRHM Programme
Implementation Plan in the state of Madhya Pradesh.
c) Strengthening Skilled Birth Attendants (SBA) Training under NRHM:
To address the gaps in the quality of pre-service nursing training, WHO and MoH envisioned
the establishment of National Nodal centres for strengthening Nursing and Midwifery
Education. The identified centres will serve as model teaching institutions and train Master Trainers from State Nodal centres of two States – Madhya Pradesh and Orissa.
The aim is to produce a pool of master tutors/ trainers who are trained in providing skills
based teaching to nursing tutors in States and who can subsequently provide quality education as per norms in ANM and nursing schools in entire spectrum of RCH services The training of
master tutors includes developing their teaching skills, as well as providing skills based and
hands-on training in Maternal, Newborn and Child Health, IMNCI and Family Planning as per the updated GoI guidelines. The national centres will provide two week training for
Master Trainers deputed from State nursing schools to update knowledge, skills and provide
hands on experience in RCH curriculum and also provide training on improving teaching
skills as per adult learning principles. The master trainers from the States will subsequently provide Training Of Trainers (TOTs) to all the nursing tutors from the state in providing high
quality teaching of the RCH curriculum in a cascading manner, and result in a better trained
workforce that can function at the primary care level with minimal hand holding.
The Nodal Centre, besides serving as a model teaching institution, will serve as pedagogic
resource centres for strengthening education at nursing schools with focus on Auxiliary Nurse Midwives Training Centres (ANMTCs), especially in the high focus States of India.
A visit was undertaken in August 2011 to Orissa to evaluate the two centres selected by the
State - School of Nursing in ShriRama Chandra Bhanja (SCB) Medical College and School
of Nursing in ShriRama Chandra Bhanja (SCB) Medical College. Recommendations were to conduct a quality assessment using standard tools, and develop measures to fill gaps before
the training is started.
The assessment was done by a team of WCO representatives and State Training Officer of
Orissa by using a Questionnaire developed by JHPIEGO and USAID. This questionnaire is
based on the Global Nursing and Midwifery standards developed by WHO in 2009. It was based on the assessment, strengthening of the state nodal centres being undertaken.
The National Nodal Centre in LHMC, New Delhi has already initiated activities and
procurement of various teaching aids is underway for strengthening of the same. The Master training is planned to start in November 2011.
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d) Developing Implementation Model for Strengthening Maternal and Newborn health
services:
Further interventions are planned based on review findings. The intervention will focus on
Capacity Building of Program Managers and Health care service providers – including
doctors and nurses and development of a Quality Assurance mechanism for training as well as ensuring Quality of Care provided in the healthcare facilities and beyond. The plan will
also look at strengthening the training capacity of the district and encompass in-service
training – esp. Basic Emergency Obstetric & Newborn Care (BEmONC) and SBA training as well as improvement of pre-service SBA training. In furtherance to this an assessment of
GBNM and ANM training schools is planned in November 2011 and strengthening of pres-
service SBA education on the lines of the model explained above will be initiated in the district.
e) Pilot an Intervention model to delay 1st pregnancy and spacing of second child among
married adolescents and young adults.
For this intervention, WCO will be working in collaboration with PHFI and IIPH, Delhi. A
Baseline study will be carried out in two states. Two districts in each state (total of four districts in two states) will be overall sampling frame where NIPI is providing interventions.
Of these, two districts will serve as intervention districts and two will serve as comparison
districts. A total sample of 400 married adolescents (200 males and 200 females) is envisaged for the current study.
The objectives of the baseline are as given below:
o To determine the existing status of knowledge, perceptions and practices related to sexual and reproductive health including adolescent pregnancy amongst married adolescents.
To assess the existing practices amongst married adolescents to delay pregnancy.
To know about health seeking behaviour in married adolescents for meeting their sexual and reproductive needs.
To ascertain through perceptions of married adolescents about their unmet sexual and reproductive needs
o To assess in context to adolescent pregnancy the knowledge, perceptions and readiness to provide services of field level functionaries like ASHAs.
o To understand the desired characteristics of an intervention through perceptions of
married adolescents.
The Baseline is starting in November 2011 and preliminary results are expected by end
December 2011.
Presentation on progress will be made at PMG meeting.
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3.2 UNOPS LFA
U N O P S L F A P R O G R E S S R E P O R T
M A Y – O C T O B E R 2 0 1 1
UNOPS LFA concentrated its efforts in accelerating and consolidating the gains made out of
implementation of comprehensive newborn care package and addresses the quality issues in implementing both community and facility based interventions. UNOPS LFA developed this package
with the technical support from National Neonatology Forum (NNF), India and Institute of Post Graduate
Medical Education and Research (IPGMER) Kolkata, India. This package works on the principal of strengthening local institutional capacity and adding quality to implementation of community newborn
care through ASHAs and facility based newborn care by way of Yashodas and chain of sick newborn care
units. The facilitation of the State Health Societies for implementing JSC approved interventions such as Yashodas, Home Based Post Natal Care (HBPNC), SNCU, Techno Managerial, Mobile money transfer
and Routine Immunization continues.
Current efforts are focusing on intensification of HBPNC trainings, sharpening the skills of Yashodas to work as better maternal aides, increasing local institutional capacity for facility based newborn care
through SNCU Training and treatment centres, expansion of Mobile Money Transfer, strengthening
supportive supervision of ASHAs , monitoring Village Health Sanitation & Nutrition Days (VHSNC) sessions and staffs working in newborn facilities and developing newer video footages to add quality to
the trainings.
Presentation on progress will be made by States and UNOPS LFA Programme at the PMG meeting.
I) Home Based Post Natal Care through ASHAs
HBPNC intervention was started in the four states with training of ASHAs and almost fifteen thousand ASHAs were trained. A phased training approach was adopted including an initial orientation of two days
that helped ASHAs start visiting homes. The home visit experience enabled them to assimilate the more
intensive five days skills training that followed subsequently.
Progress in intensive HBPNC training of ASHA As follow up to the orientation given to ASHAs a year ago, intensive five days ASHA training
has been rolled out. The newer package has been developed with the leadership of Department of
Paediatrics, All India Institute of Medical Sciences and with technical support from National
Neonatology Forum, National Institute of Health and Family Welfare and other Professional
Organizations. This module builds on established versions in the Country including IMNCI, SBA
training and WHO-UNICEF Package for Care of Newborns at Home with strengthening of hands
on training component, using simple to use pictorial job aids and incorporating supportive
supervision. The package combines postnatal care of mother and baby and has been developed
with support from NNF. In addition to support the field functionaries for quality implementation
of HBPNC an implementation guidelines have been finalized.
Current Status of role out of 5 day package:
Rajasthan trainings have completed - from June to Aug 2011 (5215 ASHA trained)
Orissa trainings have also completed – from June to Sep 2011 (2756 ASHA trained)
Bihar – to be completed by January/Feb 2012
MP –training to start on Module 6 & 7 in the state
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NIPI-UNOPS as per the request from the State will support in all steps of
implementation of HBPNC – Monitoring of training, verification of home visits,
on- job capacity building, Supportive supervision and Data capture & analysis.
Monitoring of Training Quality was done through external agencies in all three states where
intensive training is being done using the tools developed earlier. To add quality to the trainings
and remove transmission loss, a set of new training videos are being prepared focusing on
developing better communication skills and better grasp of understanding danger signs and essential skills needed for performing quality home visits such as recording temperature,
weighing a baby etc. Scripts have been finalized and shooting is scheduled for this year end.
Supportive Supervision to ASHA on the job. As emphasized repeatedly supportive supervision
has been one of the weakest links in newborn and child health services in India. Towards this to
provide hand holding of newly trained staff for better assimilation of skills a package for
supervisors as to how to provide supportive supervision has been developed. This 2 day package
was developed with support from NNF and has been rolled out in 3 States. The trained
supervisors have started providing the support to ASHAs.
o Coverage: Over 122 thousand new born have provided 6 home visits by ASHA
within 42 days of birth, in the last six month ( Jan- June 2011)
o Referrals are being intensely tracked for those ASHAs who have completed the 5
days trainings.
II) Yashoda (Mother’s aide in public health facilities)
Yashodas have been placed in select facilities of the 4 NIPI Focus States to address supply side issues consequent to increase in institutional deliveries. Based on feedbacks from State visits, draft ASNI report
and JRM reports where it was highlighted that although the post delivery stay time of mothers have
increased in facilities they are still not being provided adequate counselling for detection of danger signs in newborn and counselling on family planning, strategy for maintaining and developing the performance
of Yashoda has been developed and thematic trainings packages have been developed on:
Identification of signs of illness in Newborns and Mothers (with support of NNF) and
Family planning methods (Supported by UNFPA)
Draft package is available and will be rolled out in the form of 3 days training. The package dwells on the
feedback that currently danger signs in sick newborns in the postnatal wards are not adequately assessed
and counselling of mothers on detection of danger signs is weak link (ASNI report and feedback from
State Visits). This package developed with support from NNF will focus on providing hands on training to sharpen the skills of Yashodas in identification of danger signs and will have half a day for
strengthening post partum family planning.
Intensive Counselling of Mothers on Breast Feeding (Support of BPNI)
Based on the feedback that while Yashodas have started providing support for early initiation of breast feeding their skills need improvement in solving breast feeding problems especially for
LBW neonates and expression of breast milk for solving maternal problems such as engorgement.
This package has been developed with support from BPNI and will be rolled out soon.
Current Status
1454 Yashodas are functional in 148 facilities
Selected Outcomes in 13 NIPI focus districts
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Indicator*
Time Period:____
%
Percent mothers staying at least 24 hours at the health facility after
birth 72
Percent mothers initiating breastfeeding within 1st
hour of birth 89
Percent neonates immunized for BCG and 0 dose Polio 90
Yashoda programme is adding quality to care at birth (keeping the newborn warm, initiation of breastfeeding and immunization) as per draft ASNI report and has in addition shown that that benefit of
Yashoda program was most evident for initiation of breastfeeding among women who had a caesarean
delivery. In addition Yashodas had an impact on receipt of postnatal checks at the intervention facilities (BP checks, Temperature Checks, Stitches and Perinneum check).
Initiation of Breast Feeding within 1 hour of delivery (%)
III) Facility Based Newborn Care through SNCU
8 SNCUs have been made functional since ??/, additional 5 SNCUs will be functional in 2011. The
currently functional SNCUs are in Alwar, Bharatpur and Dausa in Rajasthan, Hoshangabad and Raisen in
Madhya Pradesh and Anugul, Sambalpur and Burla Medical College in Orissa. In Bihar - SNCUs under construction are in 3 NIPI focus districts and are to be operational soon.
Equipment procurement, posting of manpower and skills building are in advanced stage of planning.
Various challenges and needs for improvements were initially identified while establishing SNCUs. 1)
The need for a bigger capacity SNCU to respond to the potential needs of a District. 2) Designing a triage based SNCU complex with core SNCU complex, neonatal ward and a step down unit to optimize on
appropriate utilization of the SNCU complex. 3) Lack of human resource for clinical care of newborns
and need for capacity building of available manpower. 3) Strategy for infection prevention. 4) Data collection and monitoring.
A National Newborn Resource Centre established at IPGMER provided continuous technical support, capacity building support and quality assurance. While availability of manpower depended on the
contractual mechanisms of NRHM and the overall availability of doctors and nurses in the state, UNOPS-
NIPI in partnership with IPGMER ensured skills development, designed for doctors, nurses and
paramedical personnel.
13.1
35.5
64
35.7
82 93 88 91
0
20
40
60
80
100
Bihar MP Odissa Rajasthan NIPI Baseline 2009 Jan-June 2011
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Designing of the facility with earmarked areas served as the guiding principle for construction.
Innovations made in these SNCUs included constructing the newborn emergency treatment and triage area, stabilizing unit and neonatal ward. Typically SNCU complex of 25 beds addresses the needs of an
average size district. Here the stabilized newborn stays with the mother for the completion of treatment.
Through this mechanism the core SNCU facility remains available for the sickest cases while the step-
down and neonatal ward provide opportunity for specialist and infection-prevention care at much less cost. To minimize infection spread some special features included 1) Use of duct air conditioners for
ensuring cross ventilation and air flow 2) Bleaching overhead tanks; 3) Separate sluice room and
standardize hygiene maintenance processes.
5247 neonates admitted to SNCUs in the last 6 months with approx 10% mortality.
Strategy for follow up of newborns discharged from SNCU is being developed.
IV) District SNCU treatment and training resource centres
For the existing SNCU to be designated as SNCU
Treatment and Training Centre, the unit should itself meet
quality criteria in terms of infrastructure and treatment
protocols as per the prescribed standard from IPGMER or operational guidelines of GOI. The SNCU can be
strengthened with HR, equipments and travel support
costs to meet the challenge of providing technical support to the SNCUs in the focus districts. Apart from serving the
SNCU level-II along with the existing doctors and nurses
and as the training faculties, the team can also extend its capacity building support to newborn care units of the
district through supportive supervision visits. Moreover,
the team will also have further support from the DTC.
Tasks of SNCU treatment and training centre:
1. To guide the newer units in implementing clinical SOP
2. To provide supportive supervision for problem solving
3. To provide capacity building for newer recruited staffs.
4. To provide hands on training for the staff trained at NCRC at IPGMER
5. As the training hub for facility based newborn care trainings for district SNCUs and sub-district
SNSUs facilities in other NIPI focus districts
6. To provide post training follow ups through regular monitoring visits and provide supervisory
support to newborn care units
Hoshangabad SNCU has already been designated as SNCU-Training and treatment centre and has been
strengthened with Video conference facilities and posting of additional doctor and a nurse. It has already
conducted a mentoring exercise for improving the skills of nurses. A similar centre is being
operationalised in Alwar.
V) Post Natal Follow up of SNCU discharged newborns
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Neonatal mortality contributes a major proportion of the infant and under-five mortality in India. Majority
of the neonatal mortality is contributed by the sick newborns, including those with low birth weight. Care of the sick newborns is the key to avert neonatal mortality. Post discharge follow up of newborns from
facilities is generally decided by treating doctor based on the clinical condition. Compliance with the
follow up is a complex issue and determined by several factors including the initial experiences of the
family in the facility.
Objectives of the follow up: The main objective of the follow up is to increase survivals and reduce
morbidity in this vulnerable group and track survivals.
Towards this the following tasks needs to be performed.
1. To track survivals till 6week of age 2. Promoting Kangaroo Mother Care (KMC) and Exclusive Breast feeding/Special feeding for Low
Birth Weight (LBW)
3. Prevention of infection
4. Growth Monitoring 5. Counselling for danger signs
6. Referral of sick infants
7. Check for immunization drop out and counsel for immunization 8. Ensuring compliance with follow up visit if any suggested by the admitting SNCU
Current status: A draft concept note has been developed and institutional mechanisms are being finalised. Discussions have been initiated with the State government of Rajasthan and after the State
Government approval it will be rolled out soon in Rajasthan.
VI) New Born Care Centre at IPGMER, Kolkata
IPGMER pioneered the first SNCU level II in the country also popularly known as the ‘Purulia Model’;
the country now has several such units based on this model. During the first contract that IPGMER had
with NIPI, a situational analysis of the proposed sites was performed in the four NIPI focus states; a road
map for setting up SNCU along with Structural layout, Equipment specification and Manpower requirement was developed; and a draft training module for doctors and nurses was developed.
In the second contract it was envisioned that IPGMER will provide expertise and the urgent support
needed in the States for quality of care through SNCUs. Referred to as the Newborn Care Resource
Centre (NCRC), it is responsible for bringing in innovations in the field of newborn care; one such
innovation could be developing a one month certificate course for nurses in newborn care; others would
include developing quality assessment system for the SNCUs. NCRC will provide more intensive support
to the four NIPI Focus states in establishing SNCUs. Towards this a grant support agreement for Rs
13,730,500 was signed between UNOPS and IPGMER to support the States from November 2010 till 30th
November 2012. The support to these states will extend beyond the NIPI focus districts. This support
would include:
Standardization and guiding in setting up of the infrastructure, equipment procurement and
maintenance, training of health personnel, intense hand holding support;
Setting up of a patient reporting system;
Establishment of a quality assurance system;
Establishment of the knowledge centre for newborn care
Development and conducting of Certificate training program for nurses and doctors in newborn
care.
Major activities accomplished so for includes:
Training of 7 batches of doctors and nurses from Rajasthan and MP conducted this year where 70 participants were trained.
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Technical support visits to Rajasthan and MP undertaken 7 times this year
Initiation of development of various treatment guidelines.
Draft Training package developed for ANM/Nurses at Stabilizing Units and will be finalized
soon. 1st batch of master trainers from MP planned for this year
Developed videoconference facility and supported establishment of same at Hoshangabad in
October 2011.
Assisted Hoshangabad to start working as SNCU-Training and Treatment centre for providing
support to facilities in MP. Hoshangabad conducted mentoring first batch of nurses in October
2011
Establishment of web site and online technical helpdesk. Linked to NCHRC
Draft software for collection of information and quality assurance for treatments at SNCU
available. To be field tested and finalized soon.
Tools being developed (Manual and DVD)for resuscitation guidelines based on latest AHA
recommendations
VII) Improving immunization coverage and quality at implementation Evidence from Observations made during field visits in select districts and study through
IIHMR Rajasthan outlined that program management processes became weaker as one
moved towards the periphery and the day-to-day management at the PHC was the weakest.
Essential management activities like logistics management, supportive supervision, use of
data for action and effective social mobilization were found to be inadequate.
An in depth analysis of these findings revealed that while resources for immunization program
were largely available in terms of Finances, human resource, guidelines, strategies, logistics,
there was a need for program management support at implementation levels to improve immunization coverage and quality. Various options to the possibility of managerial persons at
block level fulfilling this role were considered and zeroed in on to Block Program Managers
(EAG states), Block ASHA facilitators (Rajasthan), Block Community Mobilisers (Bihar), Block Maternal and child health managers (NIPI districts).
This inference was drawn because of the fact that:
Lack of managerial oversight especially at block and below.
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Majority of day-to-day problems can be solved below block level.
Roles are more managerial than technical.
Modules for capacity building of non-clinical managers were developed and trainings were provided to these BCHM.
Results: Narsinghpur in MP showed the results of 1 year efforts of Child health managers in
program quality improvement • Improvement in supervisory visits
• From 16% to 94% at cold chain store in last 1 month.
• From 50% to 100% of session site in last 3 months.
• Improvement of cold chain and logistics management at peripheral vaccine stores and
user point
• Equipment maintenance from 60% to over 94% (period needs to be defined)
• Stock maintenance above buffer levels in 80% of stores (period needs to be
defined)
• All vaccines at immunization site from 94% to 100% (period needs to be
defined)
• Improvement in data management;
• Correct vaccine stock records: from 11% to 83% (period needs to be defined)
• Regular coverage monitoring 5% to 67% (period needs to be defined)
• Immunization discussed in block meetings 11% to 44% (period needs to be
defined)
• Improvement in social mobilization
• Known pregnancy and births added to ANM register 56% to 93% (period needs
to be defined)
• Active tracking for drop-outs using due-lists from 44% to 86% (period needs to
be defined)
VIII) Mobile Money Transfer (MMT) for ASHAs
Initial reports after the role out of MMT shows that ASHAs in Sheikpura have been receiving payment through MMT for the past 10 months and more than 50 Lakhs INR has been paid through MMT. District
and block personnel have shown satisfaction with reduced workload related to ASHA payments and the
ability to easily monitor the activity levels of ASHAs. ASHAs are feeling empowered by the use of technology and are satisfied with the improvements in the payment situation.
State Health Society (SHS) has recognized the need to improve the ASHA payments in other districts and has approved scale up of the intervention in other districts; Nalanda (NIPI Focus District) and Rohtas,
Vaishali, Samastipur and Bhagalpur where CSPs facilitated by EKO are already present. (Non NIPI
Districts with NIPI Supported District Child Health Managers). MMT is likely to be operational in
Nalanda by year-end, and in the other districts in 6 months.
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Payment of incentives to ASHAs through MMT is expected to solve some of the challenges faced by State
Health Society to ensure timely incentive payments to ASHAs by way of:
1. Removing extra burden on SHS, District Health Society (DHS) personnel for the payroll function for
ASHAs
2. Improving the overall efficiency and transparency in the system
3. Empowering ASHAs by including them in the financial system
Current status: The intervention has since been expanded to Nalanda, and is currently under
discussion with the State Government to be expanded to 4 Non-NIPI Districts in Bihar namely Samastipur, Rohtas, Vaishali and Bhagalpur which already have the presence of CSPs facilitated by
EKO.
Towards implementing this orders have already been placed for developing advocacy video and Implementation manual for managers and trainings will be rolled out soon.
IX) Techno-Managerial Support in Child Health
This intervention is a key enabling mechanism aimed at providing support to make NRHM child health investments efficient, by accelerating expenditure, fast tracking implementation and tracking the progress
effectively. The support includes:
Facilitation in setting up of SNCUs in 8 districts of Rajasthan, MP and Orissa
Oversight on performance of ASHAs in HBPNC
Maternal and child health facility planning for focus district approach completed in all 13 NIPI
districts
Undertake supportive supervision and monitoring of Immunization sessions and other VHND
outreach activities in all NIPI districts
Have ensured micro planning for Immunization sessions in Orissa and MP
Oversee Logistics management of Immunization related supplies in MP and Orissa
Facilitated immunization training and IMNCI trainings of health workers
Participating in review meetings at block and district levels
Support in management of technical and financial component of RCH programs
Contributed to preparation of Child health component of District health action plans
X) HBPNC Software and feedback mechanism
To make the data management system quick and accurate customized software has been developed for HBPNC. IPGMER clinical software is being developed to record the clinical information for HBPNC.
Once the card is deposited by ASHA at the Block, the data entry operator (or any agency identified by the
authorities) enter the column and row wise data into the software. This software has multilingual support
and can be added more language in the future if required. Under this one day training will be provided to data entry operators and it is recommended that local programme manager should also attend this training,
as it will help them to ensure the quality of data entry and understand the existing data management
system. It is expected that once the ASHA submitted PNC card to the block level, then data entry operator should immediately enter information in to the software. Regular and consistently data entry will avoid
the back log at block level.
A separate training is being provided to the monitoring team besides regular one day HBPNC software
orientation.
XI) Strengthening Pre Service Education for Nursing and Midwifery
Cadre in Bihar – Supported by NIPI
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(report from 1st March’2011 to 31st September 2011)
A. Formation of a state level “Technical Advisory Group" on pre-service nursing and midwifery education
As an integral part of this endeavour, the Government of Bihar (GoB) with technical assistance from Jhpiego and supported by Norway India Partnership Initiative (NIPI) has formed a Technical Advisory Group (TAG). .
B. Completion of Standard Based Management and Recognition (SBM-R) orientation and standards sharing workshop for state officials and state nodal centres
A four day Standards Based Management & Recognition (SBM-R) and Performance Standards setting workshop for improving Pre Service Education (PSE) through of General Nurse Midwives (GNM) schools in Bihar was conducted from 24-27 August 2011. The Principals and Senior Tutors from the Six General Nursing Midwife (GNM) schools of Bihar and Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, which is proposed to be developed as State Nodal Centre along with the Head of Departments (HODs) of Obstetrics and Gynaecology (OBG) Department from respective medical colleges / teaching hospitals, where students are sent to acquire clinical skills , participated in the workshop. All the clinical and educational standards were thoroughly reviewed by the participants and modifications were suggested as per the state’s scenario. An action plan for on-site orientation of staff and baseline assessment was also developed by the participants for their respective sites.
C. Rapid Assessment of GNM and ANM Schools in Bihar A rapid assessment of the 6 GNM schools and 10 ANMTCs Schools was conducted in Bihar from 17-28 June, 2011 by Jhpiego staff. The aim of this exercise was to evaluate the status of ANMTCs and GNM schools with regard to certain parameters like infrastructure, teaching, library facilities and clinical training so that the feasibility of further project interventions to strengthen the quality of Pre Service Education (PSE) in Bihar can be estimated. Infrastructure in terms of building, number of classrooms, Hostel, library, computer lab, skill lab etc. was found to be inadequate in most of the schools. Human resources at all the facilities was found to be inadequate, teacher student ratio at most of the places do not meet the standard of 1:10. Guidelines / manuals developed by GoI/ GoB were not available at almost 90% of the schools. Most of the students (90%) were not found to be confident in performing midwifery skills.
D. Completion of baseline assessment at the IGIMS (proposed state nodal centre): Baseline assessment was conducted at the proposed Nodal Centre i.e. Indira Gandhi Institute of Medical sciences (IGIMS), Patna and it’s clinical site at Patna Medical college & Hospital from 27- 29 September, 2011. This baseline assessment was done on the basis of 60 educational and 20 clinical INC Standards, which were further modified and adapted by the Govt. of Bihar during the SBMR workshop. It was found that out of the 60 Educational Standards only 17 standards (i.e. 28%) were existing at the IGIMS while the clinical training site could not achieve any of the set standards.
XII) Government Contracting to Improve Child Survival Government
Contracting to Improve Child Survival Objectives
To create, test and validate healthcare delivery models providing primary, secondary and tertiary institution-based care to infants through public private partnerships.
To examine and recommend mechanisms to strengthen the state government’s Health Department’s contract management structures and systems.
Geography & Time frame Jehanabad, Nalanda and Sheikhpura districts of Bihar and Angul, Jharsuguda and Sambalpur districts of Orissa, from April 2011- September 2011. The progress till date includes:
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Meetings with Executive Director, State Health Society, Bihar and Orissa, Government Program Managers, donor partners to brief on the project goals and the overall objectives of the Phase-3 of the project and understand current work, programs and plans related to infant health care in the state and identify potential synergies/collaboration
Created state-specific reference books based on secondary data –Orissa and Bihar
Detailed interviews and discussions with private, public providers and users and other key functionaries at the district and sub district level by the State Program Managers
Literature Review – Global Experiences and Scientific documents
Conducted task force meetings with following experts at all six districts (three each in Bihar).
Next steps will include broadly : Pilot Implementation and Proof of Concept
Documentation, analysis and dissemination of learning
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UNOPS LFA Financial Report and Budget
Certified Expenditure of 4 NIPI Focus States
States
Total Amount Released/expected to released by Nov. 2011, to the States
Total Expected Fund Utilization by end of Dec 2011
Expected unspent Fund at state level by end of Dec 2011
Budget for the Year 2012 (Jan-Dec)
Additional Budget for 2013 Jan-Mar (buffer for 3 months)
Additional Fund Required for the period of Jan 2012 - Mar 2013
Additional Fund Required for the period of Jan 2012 - Mar 2013 (USD)
Rajasthan 176,000,000 116,896,123
59,103,877
103,090,000
25,772,500
69,758,623 1,550,192
M.P. 156,500,000 110,669,440
45,830,560
77,702,178
19,425,545
51,297,163
1,139,937
Orissa 148,500,000 97,809,389
50,690,611
55,760,600
13,940,150
19,010,139
422,448
Bihar 230,015,536 205,015,536
25,000,000
51,395,700
12,848,925
39,244,625
872,103
Total 711,015,536 530,390,488 180,625,048 287,948,478 1,987,120 179,310,549 3,984,679
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Year 2012 Budget Requirement (in USD)
State Budget Requirement 3,984,679
National level office and travel 1,250,000
Grant and others for activities cutting across the states 1,500,000
State offices 500,000
Less expected Unspent amount from current year from national level budget 2,000,000
TOTAL 5,234,679
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3.3 UNICEF
U N I C E F P R O G R E S S R E P O R T
May 2011-November 2011 Key outputs for UNICEF in the reporting period above were
Four Regional Collaborative centres set up and functional for supporting scale-up of Facility Based Newborn Care in India
Trained more than 50 staff (doctors and nurses) from SCNUs of the NIPI Focus States
Operational Guidelines for Facility Based Newborn Care finalized, disseminated
Cost-effectiveness assessment of IMNCI completed
IMNCI Self-learning Multi-media package developed
“One-stop-shop” model for setting up Perinatal Care Units in progress, 2 agencies contracted
Communication strategy developed for
o Routine Immunization o Measles second dose
o Introduction of pentavalent
Inventory and guidelines for use of BCC material on newborn and child health developed
Program on capacity development of mid-level mangers on management of child health programs finalized, with WHO
Training of Trainers proposed from November 14 to expand the pool of trainers and institutions
National MIS for Cold Chain developed
100 combo solar freezers installed and functional in inaccessible sites of 15 districts
EVM / VMAT conducted in Assam and West Bengal
Key outputs for UNICEF Publications
Introduction strategy for second dose measles in India. Indian Paediatrics, 48 (5): 379-382
Scaling up facility based newborn care in India. Journal of Health, Population and Nutrition (JHPN)
Community Based Newborn Care: A Systematic Review and Meta-analysis of Evidence: UNICEF-PHFI Series on Newborn and Child Health, India. Indian paediatrics, 48 (7): 537-546
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Acute Respiratory Infection and Pneumonia in India: A Systematic Review of Literature for Advocacy and Action: UNICEF-PHFI Series on Newborn and Child Health, India: Indian Paediatrics, 48 (3): 191-218
UNICEF Financial report and Budget
Opening Balance as of 1 Jan 2011 : $ 3,489,319
Additional funds received in August 2011 : $ 1,225,407
Unallocated balance in 2011 : $ 730,243
Estimates of Required Funds (activities in red are new proposed activities)
• Community based newborn and childcare (IMNCI Plus): 2 million USD
• Monitoring & supervision • Quality assurance
• Social Marketing of ORS and Zinc
• Facility based maternal, newborn and child health (essential care, special care, F IMNCI,
operationalisation of FRUs): 1.5 million USD
• Collaborative centres
• States Perinatal Resource Centres
• Operationalisation of FRUs
• Essential newborn care in focus districts • Baseline assessment of quality of newborn care
• Community and facility (essential and special)
• Immunization: 1 million USD
• Technical assistance to measles
• Cold chain assessment and strengthening
• Strengthened Management: 1.5 million USD
• Capacity Building of State and District Program Managers
• Collaborative centres for District Program Management Course
• PG Diploma in MCH Management
TOTAL: 6 million USD; balance 0.7 million
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3.4 UNICEF Concept Note on Quality of maternal and newborn care
Note on baseline assessment of quality of maternal-newborn care
Monitoring and evaluation mechanisms currently capture only quantitative outputs. The quality
of care is not assessed by current mechanisms. RCH-II has led to significant improvements in
coverage of several maternal and newborn interventions such as institutional deliveries, special
care for sick newborns, home visits to all newborns etc. The coverage is likely to further increase
in coming years. However, the increase in coverage of these interventions will result in impact
on mortality outcomes only if the quality of care is high. It is becoming increasingly clear that
further substantial improvements in maternal and child survival will not be possible unless there
are substantial improvements in quality of care.
At the moment, there are no quantitative estimates for quality of maternal, newborn and
childcare. For example, while there is information on what proportion of newborns are visited at
home in the first week of life, there is no information on what proportion of newborns receive
quality assured care during the home visits. Similarly, while the proportion of deliveries by
“skilled birth attendants” is known, there is limited information on what proportion of deliveries
receives “skilled birth attendance”. Part of the reason for not having this information is that it is
more difficult to collect information on quality of care.
It is proposed that in the year 2012, UNICEF will work with NIPI partners (WHO and UNOPS)
to generate estimates of key indicators on quality of care across NIPI states. These estimates
would serve as baselines against which subsequent efforts to improve quality by different
partners could be measured.
This would be done by a mix of methods: observation of quality of care, analysis of the
secondary information, estimation of UN indicators etc. A detailed methodology will be prepared
and shared on receiving the in-principle approval. A summary matrix of suggested methodology
is placed below:
Purpose Method
Assessment of quality of
newborn care by front-line
workers
Structured observations of Home Visits
Review of case records
Assessment of quality of
essential newborn care Structured observations of delivery at health facilities
Surveillance of stillbirth rates in health facilities
Assessment of quality of
special newborn care Structured assessment using quality checklists
Monitoring of case fatality rates
Surveillance of one month and one year survival
Assessment of quality of
maternal care Structured assessment using checklists
Monitoring of UN Indicators (case fatality rates,
perinatal mortality rates, numbers of complications
treated)
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4.0 Operational Research NIPI Operational Research was carried out in a highly consultative manner, first by defining priority areas of research. This was done through conducting a prioritisation workshop with all stakeholders in the last month of 2010. The resulting topics were then further refined in a series of meetings held by the operational research subcommittee. Five research themes with associated questions were then finalised. The process by which the 5 operational research topics would be managed was undertaken by the secretariat and approved by the OR subcommittee. Expressions of interest were drafted as the first step to soliciting proposals, in a phased approach to rolling out the operational research of NIPI. One research proposal put forward by Breast Feeding Partnership (BPNI) of India was not supported by the OR Subcommittee on the grounds it was duplicating existing research in the same NIPI supported District. BPNI was subsequently referred to UNOPS NIPI Programme for collaboration in training of Yashodas in Rajasthan in optimal breast feeding practices. A review panel was assembled from eminent researchers and academics from around India, and the first phase of the operational research proposals was assessed first on the technical quality and then scored accordingly. The process is still ongoing for finalisation of research agencies. The process for requesting for proposals Phase II of NIPI Operational research will be completed by the end of 2011. NIPI Secretariat conducted a desk review on the issue of stillbirths, following and series of articles in the
Lancet and interest has been shown by FAFO to initiate a project to have a more systematic analysis of
data related to still births in India.
4.1 Results of OR
4.1.1PHFI Study on ASNI
The Norway - India Partnership Initiative (NIPI) is an outcome of a commitment by the Prime Ministers of Norway and India to reduce child mortality and improve child health with a view to attaining the
Millennium Development Goal (MDG) 4 by 2015. Assessing and Supporting NIPI Interventions (ASNI)
is an implementation research project, taken up by the Public Health Foundation of India (PHFI) and the
Centre for International Health, Faculty of Medicine (IASAM) and Centre for Development and the Environment (SUM, University of Oslo). This research aims to assess NIPI activities within a continuum
of care approach focusing on both the demand as well as the supply side, and to strengthen NIPI to
achieve MDG 4 and NRHM goals.
Objectives The main objectives of the study were to:
Understand perspectives of communities that are being targeted under the NIPI interventions on
childcare and birthing practices.
Assess the facility based Yashoda program—a cadre of volunteer workers who assist mothers
during delivery and help with newborn care at the facility.
Assess community level intervention of Home Based Newborn Care (HBNC) provided by
ASHAs trained by NIPI that focus on newborn care during the postnatal period.
Assess the roles, responsibilities and the value addition of NIPI techno-managerial personnel who
provide support to NRHM.
Identify bottlenecks if any and suggest recommendations for augmenting and scaling up existing
NIPI initiatives to improve child and related maternal health.
Methods This study was conducted (from November 2009 to September 2011) in Rajasthan and Orissa, two of the NIPI focus states in India. At the start of this study, NIPI was functional in three of the districts in each of
these states. Thus, for the study, one intervention district where NIPI was functional and a comparable
non-NIPI district in the same state was chosen (through discussions with NIPI and use of DLHS data).
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The intervention districts were Alwar in Rajasthan and Anugul in Orissa; non NIPI control districts
were Sawai Madhopur, Rajasthan and Bargarh, Orissa. As part of the quasi-experimental design, mixed methods of data collection--qualitative and quantitative --were used to collect relevant data from both the
supply side (health care providers and administrators) and the demand side (community). Data was
collected in two phases, first phase focused mainly on understanding the supply side perspective of
Yashoda and HBNC program through in-depth interviews, observation studies of providers and administrators including the techno managerial staff placed by NIPI. Interviews of the Yashodas, ASHAs,
and a facility based survey of mothers were also conducted. An ethnographic study that focused on
understanding community norms, perspectives, patterns and beliefs in birthing and child care practices was done during this phase. In addition, a resource analysis was conducted to understand the fund flow
mechanisms and integration with NRHM funding mechanisms.
To understand the benefits of the Yashoda and HBNC program, a community survey of women who had
delivered in two months preceding the survey was done between March to May 2011 (Phase II). The
sample size required to show a minimum of 25% difference in new born care indicators (60% prevalence,
80% power and α=0.05) between intervention and control groups was estimated to be 432 mothers in each of these groups for a total of 1728 mothers. The valid sample size was 1652 mothers. The
questionnaire collected information on indicators specific to Yashoda and HBNC program (counselling
and practice indicators) in addition to socio-demographic information. The analysis focused on comparison of important maternal and newborn care indicators between intervention and control groups
and included univariate analyses and logistic regression of important maternal and newborn care
indicators adjusted for socio-demographic variables (age, parity, income). Further analysis to estimate the combined effects of Yashoda and HBNC programs were also done by comparing relevant indicators for
mothers who were exposed to both Yashoda and ASHA with those who were exposed to just ASHAs and
those who had no exposure to either the Yashoda or NIPI trained ASHAs.
Yashoda Program The study showed that the Yashoda program is functional at the district hospital (DH) and community
health centres (CHC) in Alwar (intervention district of Rajasthan) and at the DH in Anugul, the intervention district of Orissa. The profile of Yashodas (in terms of age and educational status) at the two
study districts matched the NIPI guidelines. Yashodas were positioned in the health facilities to be a
mother’s aide; however, there seemed to be push for Yashodas to become a nurse’s aide. The current
training also seemed to orient them more as a nurse’s aide than a mother’s aide in the facility. Yashodas spent majority of their time in the postnatal care (PNC) ward providing support to mother and
newborn. Limited interactions with ASHAs were reported. Yashodas also highlighted the need for more
frequent trainings. In terms of remuneration, Yashodas reported preference for a mixed system of remuneration (fixed amount plus incentive). Supervision systems in Rajasthan compared to Orissa were
found to be weak especially at the CHC level where no supervisors were available.
The community survey findings focused on the community perspective and supported some of findings from phase 1. The median age of sample mothers in intervention (control) was 23 years (24 years); most
had primary school education; median household income was `7000 in Rajasthan and `4000 in Orissa.
Women in the sample had a median parity of two; 60% to 70% of respondents in Rajasthan and 83% to
86% in Orissa reported receipt of three antenatal care (ANC) visits; expenditures on ANC was highest followed by delivery costs. Sex ratio was 891 female newborns for 1000 male (lesser than 926 per 1000
for Rajasthan as per 2011 census). However, no discrimination by gender was reported for length of stay
in facility, initiation of breastfeeding, immunization at the facility and referral.
The survey findings showed that the maximum interaction of mothers with Yashodas happened in the
PNC ward --81 percent of mothers in Alwar DH; 41% in Alwar CHCs; and 93 percent in Anugul
DH reported being attended by Yashoda in the PNC ward. Very little interaction took place during
registration and during discharge from facilities The study showed that a significantly higher proportion
of mothers in the intervention districts (55% to 97% in Alwar; 87% to 94% in Anugul) reported receiving
counselling on immunization, breastfeeding, family planning and nutrition than those in control districts (34% to 66% in Sawai Madhopur; 49% to 94% in Bargarh). Yashodas seemed to have an impact
on receipt of postnatal checks at the intervention facilities—mothers in Alwar DH (Anugul DH) were
four to five times (1.4 to 1.5 times) more likely to receive temperature and blood pressure check than
29
mothers in Sawai Madhopur (Bargarh). However, the absolute proportion who received basic postnatal
checks was still low.
Some of the neonatal care indicators (keeping the newborn warm, initiation of breast feeding and
immunization), were reported by more than 90% of mothers in both intervention and control districts and
thus did not show significant differences between the districts. This perhaps reflects the impact of the National Rural Health Mission program in all districts of these states. However, the benefit of Yashoda
program was most evident for initiation of breastfeeding among women who had a caesarean section-
- 76 percent of these respondents in the intervention districts reported that they initiated breast feeding within 5 hours compared to 44 percent in the control districts.
Given the low delivery load at CHCs and the lack of NIPI supervisors, the benefits of Yashodas at the
CHCs were unclear. The community survey showed that mothers at CHCs who had exposure to
Yashodas reported lower levels of care than those at DH. However, the levels of counselling and postnatal
checkups in CHCs of intervention districts were significantly higher as compared to CHCs in the
control district.
Thus, the study found that Yashodas both at the DH and CHC levels in Rajasthan and at the DH level in
Orissa provided significant support to mothers and newborns during the postnatal period at the facilities-- mothers/families felt that the presence of Yashodas was beneficial to them and that they were more
comfortable within the hospital environment in the presence of Yashoda than without a Yashoda. The
support in terms of counselling, facilitating postnatal checks and support for initiation of breast feeding among women who had a caesarean section were evident and resulted in significantly higher levels of
these outcomes.
NIPI supported Home Based Newborn Care (HBNC) Program The NIPI supported HBNC program is functional in both the study districts. However, during the study
period, ASHAs had received two-day training on HBNC; the five-day skill based training had only begun
on the first quarter of 2011.
Review of the training materials and interviews with ASHAs showed that NIPI supported training had
improved ASHA’s performance in enhancing maternal, newborn and child survival. The training method,
content, and supportive supervision including the field level follow-up perhaps were the main reasons for the differences in new born outcomes observed between the intervention and control districts. The
data from the community survey clearly showed improvement in key areas of new born care outcomes in
the intervention districts: mothers in Alwar (Anugul) were twice (four times) as likely to register their
newborn compared to mothers in Sawai Madhopur (Bargarh); and twice (16 times) likely to have their
babies weighed at home. Rates of zero dose immunization were above 90% in both the intervention and
control districts. The proportion of mothers who reported receipt of counselling messages specific to newborn care (breastfeeding, birth registration, immunization) from ASHAs during their postnatal home
visits were significantly higher in the intervention districts in Rajasthan and Orissa compared to control
districts. The identification of danger signs and subsequent referrals including use of referral funds
although higher in intervention districts than in the control, the actual proportions reporting these were still low and has potential for significant improvement.
The structure of the training program of NIPI with emphasis on field visit and skill based approach thus holds promise and can play a critical role to make HBNC trainings more consistent, effective and result
oriented.
Yashoda and ASHA: combined benefits The analysis done to understand the incremental and combined benefits of Yashoda and ASHA on
newborn care showed that the dual exposure of mothers to both Yashoda and NIPI trained ASHA had an
incremental effect on newborn care indicators (both counselling and practice). The odds ratios comparing the control sample with full intervention (Yashoda and ASHA) showed (figure below) significant benefits
of the two NIPI interventions on both counselling and practice indicators. For example, mothers in Alwar
(Anugul) were almost four (three) times (OR 3.79, CI 2.57, 5.57; 2.96, CI 1.77, 4.96) more likely to have
30
received counselling on keeping the baby warm compared to mothers in the control district. Similarly,
birth registration was 2.5 (1.37) times higher among mothers who had dual exposure to Yashoda and ASHA in Alwar (Anugul) compared to mothers in control districts. These would suggest that NIPI
interventions on the whole have resulted in improved information among mothers and better outcomes for
the newborn. Further study may be undertaken to understand the impact of these two programs on
neonatal mortality. Combined Effect of Yashoda and ASHA (Odds ratios with 95% confidence intervals) Rajasthan and
Orissa
Techno managerial support The techno managerial support envisaged by NIPI of coordinating and providing technical support for all
maternal and child health issues in the district and block levels remains unfulfilled. The recruitment process planned through government channels faced major bottlenecks; retention of staff also remained
challenging. However, the support provided in managing the Yashoda and HBNC programs through
techno managerial staff in their respective districts has been significant. Another important achievement
has been the on-the-ground post-training support provided by child health managers to ASHAs on HBNC.
Fund utilization NIPI funds contributed to about six percent of total NRHM district allocation for 2010-11. The utilization of these funds has been around 40 percent in both Anugul and Alwar, a significant improvement from
utilizations in the initial program year. Across both Rajasthan and Orissa, maximum funds utilization
was for Yashoda and HBNC components. Frequent revisions of financial guidelines, financial monitoring, follow-up, and coordination were some of the reasons for low fund utilization especially the
ASHA referral and untied funds. These have implications on program activities. Some of the biggest
challenges faced in the implementation of NIPI programs seem to be intrinsically linked to procedures in
the NRHM such as recruitment, fund-flow, retention of staff, and procedures in procurement.
Limitations Some of the main limitations of this study include: 1. Implementation research design does not enable collection of baseline information on the selected
indicators. This affects the selection of a true control sample and thus potentially resulting in biased
findings. However, this was partially addressed through the use of DLHS data to compare maternal and
newborn care indicators across all districts of the study states and selecting a control that most matched the intervention district.
2. Final sample size was slightly less than the estimated required sample size for the study; The analysis
on mothers who caesarean section was limited due to small sample size, unlike expected, the number of c-section were not very high at district hospitals. Thus benefits of Yashoda for this subgroup could not be
analyzed completely.
3. This was not an evaluation study, therefore did not measure impact of NIPI interventions on neonatal mortality outcomes. Interpretation of the findings from this study thus should be limited to impact on
counselling and practice indicators and not on neonatal mortality outcomes.
Recommendations There is need for Yashoda’s role as a mother’s aide to be made specific and clear and to keep her identity
distinct from that of nurses or other staff. This may require more appropriate branding of identity both at the facility and at the community level and careful selection of Yashodas.
Weak supervision of Yashodas has serious implications on discharge of duties by them, and therefore
supervisions needs to be strengthened, especially at the CHC levels.
To improve continuum of care, the presence of ASHAs at registration provides an excellent opportunity for Yashodas to interact with them and take over the mother’s care (through sharing of the ANC card
information) at the facility. Similarly, at discharge, Yashodas could provide similar information about the
mother to the ASHAs to continue care through postnatal visits at home. Although the presence of Yashoda has improved the level of care, there is still scope for improvement.
Counselling on danger signs, facilitation of PNC checks, and use of supplementary feed could receive
further focus and attention. Customized, field based, and frequent training should be considered.
31
With regards to ASHAs, continued focus on supportive supervision, regular refresher trainings,
performance monitoring and feedback are integral part of ASHA trainings and should be emphasized. HBNC training should be customized further in terms of local content, imparted through more field level
demonstrations. ASHAs should be provided further information and training on identification danger
signs for mother and new born and appropriate referral should be strengthened.
Better strategy is urgently needed in terms utilization of referral funds that are to be provided to ASHA/ ANM. Monitoring and supervision along with clear guidelines for fund usage is to be provided.
NIPI should develop appropriate system of authorization, where District Child Health Coordinator and the
District Accounts Manager should be authorized to release the honorarium for Yashodas, referral and untied funds.
Guidelines for utilizing untied funds should suggest a list of possible and permissible activities. Program
managers should be adequately sensitized about the guidelines. NIPI program should attempt to implement uniform system of financial reporting based on activity-wise
resource allocation and expenditure, and reporting of efficiency in incurring of expenses by blocks.
Performance grading of blocks and districts in terms of utilization of funds, can help improve fund
utilisation.
The assessment thus showed that the Yashoda and HBNC programs supported by NIPI in
Rajasthan and Orissa have resulted in significant improvements in knowledge and practice of
important maternal and new born indicators. These could have an impact on both maternal and
neonatal outcomes. The two NIPI programs--Yashodas at the District hospital and CHCs with high
delivery load and the NIPI style training and support of ASHAs for home based new born care--
could be scaled up in rest of the districts in the state and perhaps in the country in a phased manner
with due considerations to various recommendations provided above.
4.1.2 ANSWERS Study on Breastfeed practices in Madhya Pradesh The primary objective of the project was to investigate critical influences regarding mothers’ breast feeding and complementary feeding practices for the first 12 months after birth. Conclusions:
Majority of the respondents were aware of the new health care provider during childbirth in the
hospital - Yashoda.
The study also reveals that the Yashoda stressed and promoted the immediate initiation of breast
feeding but did not give priority to other aspects of breast feeding and new born care.
Clear gaps exist in the clarity of role functions and utilization of the services of the Yashoda
during childbirth in the hospital.
The dai is the key assistant during childbirth at community level – nurse was present only during
the birth and for critical care in emergencies.
5.1 Progress Report NIPI Secretariat
N I P I S E C R E T A R I A T R E P O R T
Programme Assurance
The NIPI Secretariat has in 2011 established its independence from its UNOPS hosts. The Secretariat has
consciously been advancing its role as a provider of Programme Assurance to the NIPI programme and its
implementing partners. The key role of programme assurance needs to be defined carefully, and not be confused with ‘quality
assurance’. In no way would the secretariat be engaged in assessing the quality of various NIPI
interventions which are all implemented through the NRHM. In such a case the Secretariat would be at risk of assessing the quality of government (NRHM) activities which is definitely not its mandate.
Moreover each implementing partner (UNICEF, UNOPS LFA and WHO) have their own quality
32
assurance mechanisms which the Secretariat would defer to. Programme assurance can therefore be
defined as objectively tracking the progress of implementing partners’ NIPI related activities using agreed indicators to measure any development change by evaluating outcomes.
Through strong monitoring and evaluation of current NIPI interventions, the Secretariat assures the
programme by providing Government and stakeholders with objective and independent research and
reporting. Compliance to reporting requirements has always been a problem for NIPI. With an independent secretariat representing the interests only of JSC (Government & Donor) it became clearer to
whom the implementing partners would be reporting to viz. government and donor, rather than another
UN agency. Reporting for 2011 therefore became more regularised. For reporting to be relevant it needed to be consistent across all the partners, measuring common
outcomes. These were defined as Enabling Mechanisms, Quality of Health Services and Learning &
Sharing. Therefore a standardised reporting format was developed, in close consultation with each implementing partner, to be able to equitably compare programme progress and financial status of NIPI
interventions. Research also entails targeting specific activities for study. This can be made through one-
off research as the need arises, or a more systematic operational research which is more structured and is
supervised by a committee. A NIPI annual report was produced for the 2010 period which was demonstrably more results oriented
than previous annual reports from the programme.
Support to union government has been another approach the Secretariat has taken throughout 2011,
especially since during the JSC on 3 May it was pointed out that NIPI has to date supported state health
systems very well, but there was scope for support to National Government also. A concerted effort from
the Secretariat to network with key NRHM and MoHFW figures has been undertaken. Techno managerial
support in the form of 2 consultants to assist in the implementation of the PCPNDT Act, and a further consultant was requested by MoHFW to coordinate the up-scaling of SNCUs. 2 PCPNDT consultants are
now deployed to the Ministry while the recruitment for the SNCU national coordinator is ongoing.
Support to government also extended to developing a video production to generate awareness among the intended audience on issues related to newborn health care with a special focus on sick newborn care
units and home based post natal care. Radio jingles are being developed to raise awareness of the
PCPDNT Act.
Perhaps the most comprehensive and ambitious initiative to assist government in its health planning,
while at the same time strengthening the Secretariat’s functional M&E role, is the development of an
integrated Data Management Information System (DMIS). Along the lines of Government of India requirements, Phase 1 shall focus on conceptualising, developing and implementing the NIPI DMIS
focusing on indicators at three levels viz., NRHM, Overall Partnership and Partner Specific. In the second
year, Phase 2 shall focus on integration of NIPI DMIS within NRHM Health Management Information System (HMIS). Steps taken to date in phase 1 have been identification of which NIPI indicators will be
used over time, categorisation of selected indicators using results chain monitoring, measurement of
different categories of indicators on a periodic basis.
Existing health software packages have been reviewed and where possible be integrated to DMIS. SNCU
software has been developed by IPGMER in Kolkata, and UNICEF which are excellent packages and
orientated for clinicians. These are standardised and used in many SNCU facilities around the country as a clinical tools. However, where DMIS differs is to have major interventions in one on-line web
application which gives the opportunity to analyse cross cutting indicators and measure the progress of
the entire programme. This is envisaged to be an integrated system. Such an initiative shall enable strengthening the DHIS of Government as a monitoring and planning tool for MoHFW. Lessons learned
from the NIPI DMIS pilot can be incorporated in Phase 2 when the existing DMIS shall be integrated into
Government’s DHIS. Online and real time information is what the DMIS aims at giving the Donor and
Partners an opportunity to know the status of the interventions at a given point of time. This is being developed in line with Government’s priorities.
Monitoring & Evaluation is a key component of the NIPI Secretariat’s functions. As part of the agreed
M&E strategy, the NIPI programme is being tracked at three levels. These are at the specific partners,
33
overall partnership and National Rural Health Mission levels. In terms of the specific partners’ level, the
Data Management Information System when in place shall enable a more systematic and rigorous reporting of the progress of the programme. However, currently, the 3 implementing Partners are
providing semi annual reports in the agreed upon format. These reports provide a good indication of
output and process indicators as a result of the specific implementing Partners’ activities. But there is a
need to improve reporting more on the intermediate outcomes.
In terms of the overall partnership indicators, the NIPI Secretariat duly acknowledges that working within
the National Rural Health Mission is like a drop in the ocean. But as it is also believed that every drop matters. Therefore, as a Development Partner, NIPI has its contribution to make as is evident from the
data analysis undertaken for key indicators over the years (cf annexure 2). There is a definite
improvement in indicators such as ‘institutional births’ and ‘early initiation of Breastfeeding’. But what requires further reviewing is ‘mother neonate cohorts checked within 10 days of birth’ (cf Annexure 2).
Indicators that need to be revised are:
Average retention period of stay at health facilities- HMIS collects this as ‘discharged within 48 hours;
Referral done for mothers for illness & complications during pregnancy- HMIS does not collect
this; Labour rooms with a newborn corner matching existing standards.
There is a noted increase in State wise expenditure on RCH related activities from 2005-06 to 2010-11 across the 5 NIPI Focus States (cf Annexure 2).
Promoting innovation is another role the secretariat has taken on, as part of its programme assurance
mandate. NIPI has always intended to be a catalytic programme, seeking opportunities to provide
technical assistance and new ways of working to what is now a well resourced health sector. The Secretariat is in the position of researching and highlighting potential innovations to strengthen maternal
and neonatal health within NIPI supported states, and even beyond. An example of such potential
innovation has been ‘Save the Baby Girl’ (STBG). This was initiated with the objective to improve Child Sex Ratio through curtailing the rate of termination of the female foetus due to sex determination. With
the introduction of the software and the installation of a device known as ‘active tracker’, there has been
measurable change in Kolhapur district, Maharashtra where it was pioneered. Following the success of
Kolhapur as a pilot District, ‘Save the Baby Girl’ project is further being replicated in a few other districts of Maharashtra such as Nanded and Sangli. The key objectives of this project include:
a) Reduction in under and false reporting of MTPs in the mandated ‘F’ Forms. b) Step towards
effective implementation of healthcare schemes & Pre Conception and Pre Natal Diagnostic
Techniques Act (PCPNDT Act) by engaging innovative technological solutions. c) Reducing
pregnant female and infant mortality. d) Processing data and automatically generating reports
required for implementing various schemes and PCPNDT Act. e) Monitoring, tracking key
indicators such as females in the 35 and above age group, self referral cases etc. f) A tool to
support the administration.
Sex ratio 0-6 years in select states from 2001 till 2011 (Census of India - provisional results
2011)
Sex ratio: Females per 1000 males
States Total population Child Population in the age of
0-6 years
Population aged 7 and
above
1 2 3 4 5 6 7
Years 2001 2011 2001 2011 2001 2011
India 933 940 927 914 934 944
34
1 Rajasthan 921 926 909 883 923 935
2 Bihar 919 916 942 933 914 912
MP 919 930 932 912 916 933
Orissa 972 978 953 934 976 985
Punjab 876 893 798 846 888 899
NCT Delhi 821 866 868 866 813 866
Gujarat 920 918 883 886 927 923
Maharashtra3 922 925 913 883 924 931
NIPI Secretariat’s STBG proposal (a technological intervention) was presented to the JSC on May 3rd
2011, in order to get provisional approval and engagement of the partners. The Joint Secretary, GoI
reiterated the need to address all the dimensions related to the issue of declining sex ratio and improving
compliance to PCPNDT Act in a proactive way. Accordingly, the Secretariat proposed to bring the
various perspectives on one platform and identify the needs of the states to address the issue through a one day consultation which was eventually taken up under an UNFPA inter-agency forum on sex
selection.
Gender / equity mainstreaming under NIPI takes a three pronged approach
• Working with the partners- based on the demand raised by them
• Working with the government- placing consultants and facilitation for larger national efforts
• Working with other UN Agencies – participation with all UN agencies to arrive at a common
agenda to be presented to the government.
With UNOPS LFA, NIPI Secretariat responded to the demand from Rajasthan for the development of a
gender primer for the grassroots level workers for understanding gender issues that affect their maternal and child health services and utilization. LFA requested to give input for Yashoda training in all the States
for promoting gender equity. There was a request from Bihar for input on capacity building of managers
(pending for more info).
NIPI Secretariat contributed as a member of a core group coordinated by UNICEF and with
representation from AIIMS, ICMR, Safdarjung Hospital, several private hospitals, medical colleges from
Bhopal and Surat and consultants to develop minimum standards for Mother and Baby Friendly Services and Perinatal Care during Transport. The aim is to use existing protocols and guidelines for the
development of a simplified checklist for ensuring such standards. Standards promoting mother and baby
friendly services include ensuring privacy, confidentiality and dignity of the clients, and infrastructure, service protocols, skills audit, grievance redressal, infection prevention, breast feeding promotion and
linkage with referral transport .
Through promoting results based gender mainstreaming reporting NIPI Partners agreed to report gender
mainstreaming efforts through the semi-annual reports include sex disaggregated data related to SNCU,
HBPNC, IMNCI and Yashoda. Qualitative analysis of the data is missing however.
NIPI Partners also requested to provide analysis to reflect results of the gender mainstreaming efforts in concrete terms against agreed indicators.
Assistance to Government included providing a Legal Associate and Monitoring Associate to the PNDT
division of MoHFW. NIPI Secretariat coordinated with UNFPA to provide a one day orientation to the two associates.
The PNDT division sought NIPI facilitation for a national campaign using radio jingles and video spots
for awareness among young people via a brand ambassador – discussions are in progress. NIPI Secretariat is to identify an agency to assess the available efforts related to use of technology for
arresting the declining sex ratio.
1 Of the five NIPI Focus states, Rajasthan has the worst record
2 Bihar has improved over the national figure 3 Punjab, Delhi, Gujarat, Maharashtra and Rajasthan are the states with worst record.
35
Linking with other UN agencies NIPI Secretariat has engaged with UN Women, linking NIPI partners
with their governance program. Nalanda and Alwar shall be districts included for participation and discussion with UNOPS LFA Rajasthan are in progress.
An all UN forum on declining sex ratio was lead by UNFPA. Other members included NIPI Secretariat,
UNDP, UNDAF, UNICEF, UN Women, WHO, and UNOPS. The goal is to develop a common UN
approach to address declining child sex ratio via communications strategy research and advocacy. Other such gender innovations have included NIPI Secretariat’s collaboration with partners in the
respective state governments to facilitate building the capacity of the managers and health functionaries to
look at the planning, budgeting, implementation and monitoring processes with a gender lens. The challenge is not to duplicate and create separate gender manuals and materials but to incorporate the
gender lens into the ongoing training curriculum. For example, to help the grass roots level functionaries
such as ASHA, ANM, AWW, and other community bodies like the PRI, VHSC etc, there is no demystified simple, pictorial material that will explain the gender issues and application in her work
context.
The government of Rajasthan requested assistance from the Secretariat to develop such a gender manual for grassroots health workers, in the form of low literacy easy to comprehend cartoons. The Secretariat
has held several consultations and focus group discussions with various cadres of health workers to gain
clear perspectives on what local gender issues are and recorded these results. The information was then used to develop the training material through a gender lens. This have been translated into pictorial
images using appropriate images for the region where gender training is to be delivered.
36
BUDGET 2012
Award ID 00045792
Project Title- NIPI Secretariat
Project
#
Key
Activities
Accounts Budget Description Approximate budget
2011
USD @45.00
00054184
61100 Salary NP Staff 12,000.00
Act
ivit
y 1
NIP
I S
ecre
tari
at
61200 Salaries GS Staff 58,104.67
61300 Salaries IP staff 258,075.00
62000 Recurrent payroll cost- NP Staff 25,659.00
62200 Recurrent payroll cost- GS Staff
16,661.00
62300 Recurrent Payroll cost- IP Staff 33,300.00
63400 Learning Costs 20,000.00
63500 Insurance and Security Cost 41,510.00
64300 Staff Mgmr Cost IP 25,000.00
71300 Local Consultants 339,133.33
71600 Travel 162,222.22
72100 Contractual Services- Companies 71,843.23
72200 Equipment & Furniture 63,333.33
72400 Communication and audio Visual
Equipment 13,361.11
72500 Supplies 4,500.00
72600 Grants 227,355.56
72700 Hospitality 8,333.33
72800 Information technology Equipment 35,555.56
73100 Rental & maintenance- premises 161,888.89
73200 Premises Alterations 22,222.22
73300 Rental & Maintenance of IT Equipments 50,000.00
73400 Rental & Maintenance of other
Equipments 5,555.56
74200 Audio Visual & Print Products 50,000.00
74500 Miscellaneous Expenses 8,888.89
75100 Facilities and Administration 85,725.15
SUB-TOTAL 1,800,228.05
Act
ivit
y 2
OP
ER
AT
ION
AL
RE
SE
AR
CH
72100 Contractual Services- Companies 306,450.00
75100 Facilities and Administration 15,322.50
SUB-TOTAL 321,772.50
GRAND TOTAL 2,122,000.55
37
NIPI Secretariat
54184
FINANCIAL SUMMARY : 2011 in USD
Activity ID Total Budget
Obligations
Accrued
Fees
Current
Expenditure
(Actual &
Projected)
ACTIVITY1
1,770,284.36 376,348.38 50,980.14 1,067,813.05
ACTIVITY2
0 0 2,163.88 45,441.65
ACTIVITY4
321,772.50 0 0 0
2,092,056.86 376,348.38 53,144.02
1,113,254.70
NIPI Secretariat have spent about 53% of the actual budget till end of October but without the OR expenditure.
38
6.1 NATIONAL CHILD HEALTH RESOURCE CENTRE NCHRC Sustainability NCHRC has been an intervention unique to NIPI. Since 2008 it has been exclusively funded by UNOPS
NIPI Programme (LFA) and is housed at NIHFW. Main activities of NCHRC to date have been: Support in Operational Research e.g. coordinated OR
prioritisation workshop, facilitating development of State Child Health Resource Centre, developing
database on HBPNC, development of ‘Repository On Child Health’ and development of IEC/BCC
gallery, developing CH publications, advocacy and networking e.g. supporting the ‘Child Health
Thematic Group.’
The current functions undertaken by NCHRC are a departure from its original mandate. There has also
been a disconnect between NCHRC and SCHRCs which has contributed to the State level centres’
underperformance. Another concern on SCHRCs establishment is that they may be functioning in parallel to the better
performing SHSRCs.
The exclusive association to UNOPS NIPI Programme has not encouraged other NIPI partners to take ownership of the centre to date.
Following discussion among the NIPI Partners pre PMG, 3 general options with some SWOT analysis,
have been developed to facilitate an open discussion with government about the NCHRC’s sustainability,
SCHRCs have been dealt with separately and have also been analysed using SWOT.
OPTION I: NCHRC REMAINS WITH NIHFW Institutional arrangement and linkages with state/other agencies:
- Continues present institutional arrangement within NIHFW as part of the proposed Child Health
Resource Network
- Strengthen links with the State Child Health Resource Centres (at SIHFWs) and other MCH units
in the States to feed data to NCHRC
Activities:
Continue present work (SNCU data analysis, Repository, HBNC data analysis) and further expand work to include
- Data analysis and Technical report for all Child Health activities
- Documentation of best practices (with feedback from states)
- Conduct CH Trainings on technical and managerial aspects
HR requirements:
- Strengthen existing technical team with documentation and statistical skills (4-5 members)
- Support staff (Data entry operator, Library cum IT person)
SWOT Analysis:
Strength: established institutional presence of NIHFW, No change required in infrastructure &
administration
Weaknesses: weak support from the SIHFWs responsible for hand-holding SCHRCs, existing HR at NCHRC inadequate to take more technical work
Opportunity: provide support to MoHFW, strengthen NIHFW per se
Threat: Weak SIHFWs may not provide adequate support to SCHRCs, future support/vision in NIHFW with change in leadership, duplication of work already being done by NHSRC
39
Funding:
NIPI/other partners to fund for 6 months/1 year till NIHFW take over as proposed in their 12th Five-Year
plan
OPTION II: NCHRC SHIFTS TO NHSRC Institutional arrangement and linkages with state/other agencies:
- Shifts to work as a unit under the National Health Systems Resource Centre
- Develop links with the State Health Systems Resource Centres (SHSRCs) and other MCH units
in the States to feed data to NCHRC
Activities:
Continue present work (SNCU data analysis, Repository, HBNC data analysis) and further expand work
to include
- Data analysis and Technical report for all Child Health activities
- Documentation of best practices (with feedback from states)
- Conduct CH Trainings on technical and managerial aspects
HR requirements:
- Strengthen existing technical team with documentation and statistical skills (4-5 members)
- Support staff (Data entry operator, Library cum IT person)
SWOT Analysis: Strength: growing presence of NHSRC as technical support unit of MoHFW, existing support structures
in States/SHSRC, similar objectives of both organizations
Weaknesses: limited infrastructure/space at NHSRC, attention to a new unit?? because of existing workload at NHSRC
Opportunity: technical support to NRHM on Child Health
Threat: change of institutional arrangement and administration, life-span dependant on program Funding:
NIPI/other partners to fund for 6 months/1 year till relocation of NCHRC completed (to NHSRC under
MoHFW)
OPTION III: NCHRC KNOWLEDGE CENTRE FOR CHILD HEALTH Institutional arrangement and linkages with state/other agencies:
- Continues present institutional arrangement within NIHFW OR shifts under the National Health
Systems Resource Centre OR function as an independent organization
- Depending upon the institutional arrangement
Activities:
Broaden existing work portfolio to include
- Identify operational issues of existing CH programmes, develop evidence-based interventions and
healthcare solutions
- Regular monitoring and evaluation of programmes, regular feedback on interventions
- Focus on data analysis, Technical report writing, Documentation of best practices, and secondary
research
- Development of guidelines, protocols, information leaflets for parents/carers
- Platform for PH & CH professionals to work together
HR requirements:
- Strong technical team with documentation and statistical skills (5-7 technical members with 2-3
experts)
40
- Support staff (as required)
SWOT Analysis:
Strength & Weaknesses: depending upon the institutional arrangement & host organization
Opportunity: technical support to NRHM for Evidence-based planning & implementation on Child Health
Threat: leadership & support for initial part as it is a new initiative, support by stakeholders
Funding: NIPI/other partners to fund for 6 months/1 year till institutional arrangement & linkages established
41
State Child Health
Resource Centres.
Bihar Orissa Madhya Pradesh Rajasthan
Institutional arrangement
In SIHFW
In SIHFW
State NRHM office (new office in IEC Bureau)
SIHFW SHSRC
HR availability (in place/sanctioned)
4/8
6/8
2/8 1/8
SWOT analysis Strength Weaknesses Opportunity Threat
Infrastructure in place No work output Lack of leadership & technical support ?? Technical support unit for CH to State Govt Weak support system (from SIHFW) Linkages/support from other stakeholders
Infrastructure in place Support from SIHFW Visible outputs in last 1 yr Hard working, enthusiastic team Lack of guidance for last 6 months (freq change in SIHFW leadership) Networking with other state stakeholders Strategic location (SIHFW & NRHM) Positive feedback from State Govt Duplication of work (existing MCH cell) Sustainability
Infrastructure in place Supporting NRHM for activities other than their mandate Limited output as per mandate Team sitting separately, reporting to diff officials Leadership & guidance New location – strategic New role can be defined?? ?? Support from State Govt & other stakeholders
Established institutional presence of SIHFW (recently shifted back) HR shortage from start No visible output Can be developed as CH support unit for NRHM (no existing cell) Leadership from SIHFW Sustainability
42
Program Management Group November 9, 2011
ANNEXURES
43
Annexure 1
UNICEF Social marketing of ORS and Zinc for
Diarrhoea Management Program in 44 high focus districts if India– 2011-2012
1. Background Diarrhoea remains one of the major causes of childhood mortality in the country. It is estimated that each child in India suffers an average of 1.6 episodes of diarrhoea per year for first five years4. Most deaths due to diarrhoea can be avoided by appropriate and adequate use of combined ORS and Zinc (Zn) supplementation5. Even though ORT has reduced child mortality in India from 1.9% to 0.6%, more needs to be done to reduce this further. Estimations of the burden of diarrhoeal diseases in India by the National Institute of Cholera and Enteric Diseases (NICED) indicate that diarrhoeal diseases contribute to about 9.1% of deaths in the age group of 0– 6 years. If this is extrapolated, an estimated 158,209 children die each year in India due to diarrhoea6 . SRS report on causes of death: 2001-2003 by RGI, reported diarrhoeal diseases to account for 14% of deaths among children aged 0-4 years. Government of India has included Low osmolar ORS and Zinc in the Revised National Guidelines on Management of Childhood Diarrhoea, 2007. The utilization of ORS remains very low and that of Zn almost inexistent. In the DLHS-III survey conducted in 2007-8, the percentage of children with diarrhoea (in the two weeks preceding the survey) who received ORS was only 17.3%. This is despite the fact that 75% of the community members received some treatment or the other for diarrhoea management. This indicates that health care providers are likely prescribing other treatments, such as antibiotics, rather than recommending ORS and Zn. CES 2009 reveals ORS use rate of 42.8% among children 0-2 years suffering from diarrhoea. There are two major issues related to management of diarrhoea among infants and children in the country: first lack of awareness and use of ORS and Zn for management of diarrhoea by health workers and, second, poor and interrupted supply of ORS and Zinc for diarrhoea management. When appropriately addressed, both these problems could lead to avoidable deaths amongst children suffering from diarrhoea. It is against this background that a project is proposed to increase availability, awareness and utilization of ORS and Zn for proper management of diarrhoea in children in the 44 high
4 (Viswanathan H. Rohde J. Diarrhoea in rural India. A nationwide study of mothers and Practitioners, All India Summary, Vision Books). 5 Effect of zinc supplementation started during diarrhoea on morbidity and mortality in Bangladeshi children:
community randomised trial: Baqui AH, Black RE, El Arifeen S, Yunus M, Chakraborty J, Ahmed S, Vaughan JP.BMJ. 2002 Nov 9;325(7372):1059. 6 NCMH Background Papers·Burden of Disease in India
Program Management Group November 9, 2011
ANNEXURES
44
focus districts of 13 states in India (Details in Annexure-1), especially through a social marketing concept.
Geographic Area: Delhi and 44 high focus districts in 13 selected states
2. Purpose and rationale
Objectives:
6. Increase regular availability of ORS + Zinc in public and private sector (traditional and
non-traditional outlets)
Indicators:
i. % of retail outlets and health facilities reporting stock out of ORS and Zinc at provider
level in each district
ii. % of ASHA workers stocked with ORS and Zinc for distribution at community level
7. Increase awareness and knowledge of the rationale and advantages to prescribe ORS
and Zinc for management of childhood diarrhoea by public and private health workers Indicators:
i. % of physicians surveyed able to describe the advantages of prescribing ORS and
Zinc for childhood diarrhoea
ii. % of ASHA/AWW/ANM workers having correct knowledge of preparing ORS and use
of zinc tablets
8. Change prescribing habits of Frontline and primary care health workers to recommend
use of ORS and zinc for management of childhood diarrhoea
Indicators:
i. % of physicians surveyed prescribing ORS and Zinc for childhood diarrhoea
ii. % of ASHA/AWW/ANM workers having correct knowledge of preparing ORS and use
of zinc tablets
iii. % of children 2-59 months with diarrhoea received ORS and zinc Low- osmolar ORS and Zinc are the two key interventions for management of childhood diarrhoea. Two major issues linked to the low use rates are – insufficient availability of ORS and Zn at the levels of health system, community and household and secondly the limited awareness about the importance of use of ORS and Zn at the community level. There is enough evidence to suggest that use of zinc during acute diarrhoea reduces the duration and severity of diarrhoea and risk of acute respiratory infections subsequently. Based on this evidence, GOI has issued new guidelines, allowing for use of zinc for acute diarrhoea, for a total duration of 14 days. Zinc not only reduces the duration and severity of the treated episode of acute diarrhoea but also reduces subsequent episodes. But the awareness regarding the availability and use of Zn in the community is very low.
Program Management Group November 9, 2011
ANNEXURES
45
The UNICEF 2008, 10 districts survey revealed only two percent of the mothers whose child had diarrhoea in the last two weeks prior to the survey reported to have heard of zinc and 70% had knowledge about ORS. Of these mothers who sought care only 47% and 1% were prescribed ORS and Zinc respectively. Research on appropriate treatment for acute diarrhoea has also found that continuous feeding (breast feeding and complementary feeding) reduces stool output and duration of diarrhoea episodes. In fact, cessation of normal feeding has been found to prolong diarrhoea episodes. Continuous feeding in conjunction with ORS/zinc has the potential to significantly reduce the duration and severity of acute diarrhoea in children. But, the UNICEF 2008 survey reports that only 9 percent of the mothers, who took their child to some health provider for treatment of diarrhoea, were advised to continue or increase frequency of breast feeding or complementary feeding to their child during diarrhoea, while only 15 percent were advised to give more fluids than usual to the child during diarrhoea. There is a felt need to increase the awareness and availability of ORS and Zn and educate the healthcare providers and influence their prescription practices. This initiative, we hope, would also serve as an example for the states to scale up in other districts, to increase the use of ORS and Zn. Since the states are receiving ORS and Zinc as part of Kit A from the centre and are also procuring Zn and ORS at local level, this initiative – if scaled up – would serve as a complement to the initiative taken by the state government towards effectively managing diarrhoea in the state. Strategy for promoting appropriate management of diarrhoea through Social Marketing
Traditionally, governments have sought to ensure availability of the above products through its own supply system: products are procured by the state or district administration, and then are supplied to the health centres. However, several evaluations (including CRM, JRM and validation exercise in border and other districts) have suggested that there are frequent stock-outs of these products at the health centres due to several reasons. Besides, even when they are available the health staff is not aware of the use of Zinc in childhood diarrhoea. Social marketing is the process of using different marketing strategies for promoting use of products that are socially relevant, in order to improve health or well-being of the community. Using the market principles, the strategies also aim towards developing self-sustainable demand-supply equations in the community. Thus, through this intervention, it is possible to develop an alternate channel of delivery of ORS and Zn and also increase awareness regarding the use of these by the community i.e. addressing both the demand and supply issues simultaneously. Thus, introducing Zn and ORS through the social marketing channels would not only increase the availability and utilization of these services, it would also ensure sustainability of the initiative subsequent to the conclusion of UNICEF’s direct support. 3. Details of work:
The contract seeks to increase the supply and promote the demand and use of ORS & zinc to prevent deaths due to diarrhoea among children 2 -59 months. The SM firm will create informed demand for ORS and Zn through a communication campaign targeting families of
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children 2-59 months, and ensure wide availability of ORS and zinc tablets (co-package) at chemists. PDS/NGO/CBO/other shopkeepers than local chemist shops should be trained and incentivized for supplying ORS and zinc tablets (co-package) with other health products as non-traditional retail outlets in these 44 districts. The ORS would be Low-osmolarity WHO Formula procured from GMP certified manufacturers. Zn dispersible tablets (20 mg Zinc Sulphate) would be procured by the SM firm through GMP certified manufacturers. The intent is that the SM firm procures good-quality supplies themselves or motivates the private entrepreneurs to procure such supplies and sell them at acceptable profit through the additional outlets/ depot-holders. This will ensure that even if there are no government supplies available, the community still gets ORS/Zn at affordable prices, at a depot near their home. The specific tasks to be undertaken by the social marketing firm include: A. Training: Task 1: Collect available training and IEC material including the latest Government of India guidelines on Diarrhoea management and amalgamate in a set for the purpose of training:
Public and private healthcare providers
Depot holders (ASHA/AWW/Local chemist/SHG members/NGO etc.) Task 2: Orient cum train
All Health-care providers (Public and Private Sector)
Depot holders B. Create a network of depot holders – increasing supply
Frequent stock outs of ORS and Zinc occur in health facilities due to weak functioning of health system. To address this issue a networking approach needs to be evolved so that community or localized depot holders are part of the supply chain management to avoid shortage of the product. A networking of the depot holders at multiple levels is important to create a linkage with the main stockiest and supplier. Task 1: Develop the network of depot holders
Identify & engage Field Agents/ Depot holders7
Engage the retail points, in rural and in urban areas of districts8 Task 2: Increase the availability of ORS and Zn through the network
Build linkages between chemists/ private manufacturers of ORS and Zn tablets and the depot holders for stocking adequate supplies of ORS and Zinc
Arrange for procurement of ORS and Zinc to maintain stocks
Monitor of sales in private outlets
Monitor availability in government outlets- Subcenters, PHCs, CHCs ,District hospital and with frontline health workers
Ensure regular contact with the outlets and suppliers
7 The intent is to involve a locally active member of the community as depot holder, which may include ASHA, local chemist, AWW, SHG members etc - who is keen to take forward the activity 8 The supplies would have to be stocked/ procured out of private chemists/ pharmaceutical companies (only
GMP certified manufacturers) by the SM firm.
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C. Linkages and Networking Task 1: Strengthen networking and advocate
Strengthen networking with the CBOs, NGOs and PRIs to increase their
involvement
Include diarrhoea management as one of the agenda in VHNDs and VHSCC
meetings
Advocate with NRHM officials to include ORS and Zinc supplies and use rates in
the monthly reporting system Task 2: Demonstrate use of ORs & zinc
Model in some blocks household demonstration on use of ORS and zinc by
ASHA/AWW workers D. Creating awareness Task 1: Adapt available IEC materials for local use:
Fliers, posters, prototypes of wall-paintings Task 2: Information-Education-Communication Campaign:
Interpersonal: Families, Group meetings through frontline workers and the depot holders
Coloured wall-paintings: at all prominent places (at least one per village, 6’X3’ size)
Distribution of fliers, pamphlets to families
Other channels: SMS messages, community radio, local television, street shows, rural melas etc.
E. Monitoring & Reporting Task 1: Evaluate the project
Baseline and End-line evaluation report by an independent agency
Task 2: Document progress of implementation
Develop MIS and monthly progress reports
Implementation Plan in Phase Manner:
1. Preparatory Phase: 0-2 months
The major tasks will be to do rapid baseline assessment by an independent agency chosen in consultation and approval from UNICEF, setting project infrastructure and personnel in place, development of training materials, development of point of purchase, linkages with traditional, non- traditional outlets and health , ICDS and education departments ,health training of health service providers and depot holders, development of an extensive distribution channel, pre-testing of IEC materials and printing, identification of agencies for local media implementation, streamlining process of reporting and data compliance by developing MIS software
2. Implementation Phase: 2- 9 months
The project activities will reach their peak during this period. Distribution system will be in place, promotion and IEC campaign fully operational and MIS system fully functional
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3. Sustainability Phase: 9 to 12 months
The project will focus on consolidation and recording of data. An end term evaluation by an independent agency will be done. The learning and cost of the intervention will be shared with stakeholders on building strategies for sustainability of the intervention. State governments will be assisted in introducing the concept in their plans for other districts.
5. Deliverables
The broad objective of the program would be to increase the ORS and Zinc use rate by 30%( baseline DLHS-3) in around 16 million household covering 8 million population in 44 high focused districts. As a result of the activities undertaken under this contract, the following deliverables are expected: a. In terms of training: 100% training of healthcare service providers in public and
private sector and depot holders for appropriate management of diarrhoea and use of ORS, and use of zinc tablets
b. In terms of creating network of depot holders: At-least one in each village retail
depots and outlets stocked with ORS and Zinc tablets in the district9 c. In terms of distribution of ORS and zinc: At-least 10% of ORS sachets meeting
GMP certification and courses of zinc tablets of expected demand procured and distributed by the Social Marketing firm using its own funds.
d. In terms of awareness generation: The depot holders would be mandated to create
awareness and thereby increase demand for use of ORS and Zn in the community. The locally-adapted IEC material would be developed and at-least 150,000 distributed to households having children under-five.
e. In terms of IEC materials produced: IEC materials (posters, pamphlets, skits) developed by UNICEF will be adapted and translated in local language for promoting use of ORS and Zn, to be developed within 2 months of the project initiation.
f. In terms of monitoring and evaluation: The consultancy firm will develop an
integrated management information system (MIS). They will submit comprehensive progress reports documenting implementing processes; a monthly progress report on availability of ORS and Zinc in public and private sector, and; a final report at the end of the project period including unit costing of the intervention. Baseline and Endline (at the end of the project) evaluation (quantitative and qualitative) on use of ORS and Zn in the community to document the success of the project by an independent agency chosen and approved by UNICEF.
8. Amount budgeted in PBA for the activity
USD 3,710,000 ______________________________________________________________________
9. Qualifications/specialized knowledge/experience required
Qualifications and experience
Qualifying submissions MUST have direct experience from India in planning and implementation of social marketing projects. This aspect should be supported by letter of recommendations from the client / government.
9 While a minimum of one new depots are proposed, the SM firm would have the freedom to develop and
maintain more depots/ outlets out of its own resources, if they wish.
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Qualifying submissions should have presence of office/technical staff in all regions of India.
Financial performance of business entity MUST show profitability in each of the last 5 years of operation and must not show accumulated losses.
Firm should be qualified to enter into MOU with UNICEF and State governments and should have all permissions from government authorities (central/state/local) to carry out this business or activities
Name of the State Focussed districts
Uttar Pradesh Balrampur
Sonbhadra
Agra
Aligarh
Lalitpur Bihar Bhagalpur
Darbhanga
Purnia
Gaya
Vaishali JHARKHAND Deogarh
Gumla
Hazaribagh
Pakaur
Palamu Chattisgarh Bilaspur
Kanker
Dantewada
Rajnandgaon Madhya Pradesh Katni
Mandla
Guna
Ratlam
Shivpuri Rajasthan Barmer
Dungarpur
Swai Madhopur
Baran Orissa Mayurbhanj
Kandhamal
Koraput
Malkangiri
Nabarangpur
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Andhra Pradesh Warangal Assam Gwalpara Nalbari Gujarat Dangs
Valsad
Karnataka Raichur
Maharashtra Nandurbar
Gondiya
Gadchiroli West Bengal Dakshin Dinajpur
Purulia
TOTAL : 44
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Annexure 2 BIHAR: ANNUAL HEALTH SURVEY 2010-11
MADHYA PRADESH: ANNUAL HEALTH SURVEY 2010-11
55 35
77
305
53 31
67
331
52 27
80
258
58
31
76
295
0
50
100
150
200
250
300
350
IMR NNMR U5MR MMR
Nu
mb
ers
MCH Indicators
Bihar Jehanabad Nalanda Sheikhpura
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ORISSA: ANNUAL HEALTH SURVEY 2010-11
67 44
89
310
68 48
79
296
68 47
77
310
68 47
77
310
78 54
99
281
0
50
100
150
200
250
300
350
IMR NNMR U5MR MMR
Nu
mb
ers
MCH Indicators
Madhya Pradesh Betul Hoshangabad Narsimhapur Raisen
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RAJASTHAN: ANNUAL HEALTH SURVEY 2010-11
62 40
82
277
50 31
60
253
51 41
58
253
56 35
73
253
0
50
100
150
200
250
300
IMR NNMR U5MR MMR
Nu
mb
ers
MCH Indicators
Orissa Anugul Jharsugudha Sambalpur
60 40
79
331
59 35
82
319
55 42
75
292
57 33
87
319
0
50
100
150
200
250
300
350
IMR NNMR U5MR MMR
Nu
mb
ers
MCH Indicators
Rajasthan Alwar Bharatpur Dausa
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UTTAR PRADESH: ANNUAL HEALTH SURVEY 2010-11
NIPI FOCUS STATES: CHILDREN (12-23 MONTHS) FULLY IMMUNIZED
71 50
94
345
0
50
100
150
200
250
300
350
400
IMR NNMR U5MR MMR
Nu
mb
ers
MCH Indicators
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INDICATOR Institutional Births Bihar
74.8
47.8
37.7
55.9
37.2
62.4
48.8
41.4 36.2
30.3
77
53.8 49
42.9 40.9
0
10
20
30
40
50
60
70
80
90
Orissa Rajasthan Bihar Madhya Pradesh Uttar Pradesh
Per
cen
tage
Children (12-23 months) fully immunized
Coverage Evaluation Survey 2006 District Level Household Survey (2007-08)
Coverage Evaluation Survey 2009
42.5 39.3 41.6
66.10
58.60 60.50
98.90
73.70
87.40
0
10
20
30
40
50
60
70
80
90
100
Jehanabad Nalanda Sheikhpura
Per
cen
tage
Institutional Births
DLHS 2007-08 Baseline 2009 HMIS 2010-11
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Orissa
Rajasthan
40.7
56.6
65.1 65.50
78.20 76.50
85.70 93.00
88.90
0
10
20
30
40
50
60
70
80
90
100
Anugul Sambalpur Jharsuguda
Per
cen
tage
Institutional Births
DLHS 2007-08 Baseline 2009 HMIS 2010-11
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Madhya Pradesh
45.9 43.9
60.3
46.00 53.00
71.00
83.00 83.00 88.00
0
10
20
30
40
50
60
70
80
90
100
Alwar Bharatpur Dausa
Per
cen
tage
Institutional Births
DLHS 2007-08 Baseline 2009 HMIS 2010-11
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INDICATOR-Neonates checked within 10 days of birth Bihar
65.6
47.7
36.1 40.4
84.50
71.10 73.30
81.10
92.70
85.00
77.20 77.50
0
10
20
30
40
50
60
70
80
90
100
Hoshangabad Narsimhapur Raisen Betul
Pe
rce
nta
ge
Institutional Births
DLHS 2007-08 Baseline 2009 Baseline 2010-11 HMIS 2010-11
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Rajasthan
31 28
41.3
17.20 15.80
34.40
3.20
37.20
24.90
0
10
20
30
40
50
60
70
80
90
100
Jehanabad Nalanda Sheikhpura
Per
cen
tage
Neonates checked within 10 days after birth
DLHS 2007-08 Baseline 2009 HMIS 2010-11
27.9 25.1
44.5
54.90
64.70 64.70
47.60
60.60
40.00
0
10
20
30
40
50
60
70
80
90
100
Alwar Bharatpur Dausa
Per
cen
tage
Neonates checked within 10 days of birth
DLHS 2007-08 Baseline 2009 HMIS 2010-11
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Orissa
Madhya Pradesh
21.7
45 48
37.30
68.30
37.50
64.00 63.00 65.00
0
10
20
30
40
50
60
70
80
90
100
Anugul Sambalpur Jharsuguda
Per
cen
tage
Neonates checked within 10 days after birth
DLHS 2007-08 Baseline 2009 HMIS 2010-11
63.5
53.1
22.9
36.1
63.40
35.10
52.40
38.85 38.00 33.00 32.90
29.50
0
10
20
30
40
50
60
70
80
90
100
Hoshangabad Narsimhapur Raisen Betul
Per
cen
tage
Neonates checked within 10 days after birth
DLHS 2007-08 Baseline 2009 Baseline 2010-11 HMIS 2010-11
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INDICATOR- Neonates Breastfed Within 1 Hour of Birth Bihar
47.5 49.9 48
59.20
67.90 65.20 67.00
51.00
66.00
0
10
20
30
40
50
60
70
80
90
100
Anugul Sambalpur Jharsuguda
Per
cen
tage
Neonates Breastfed Within 1 Hour of Birth
DLHS 2007-08 Baseline 2009 HMIS 2010-11
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Rajasthan
Bihar
35.8 35.8 40
20.80
31.90
54.40
73.30
94.30
60.20
0
10
20
30
40
50
60
70
80
90
100
Alwar Bharatpur Dausa
Pe
rce
nta
ge
Neonates Breastfed Within 1 Hour of Birth
DLHS 2007-08 Baseline 2009 HMIS 2010-11
18.6
30.2
10.5
20.20
8.50 10.60
56.20
75.50
87.00
0
10
20
30
40
50
60
70
80
90
100
Jehanabad Nalanda Sheikhpura
Per
cen
tage
Neonates Breastfed Within 1 Hour of Birth
DLHS 2007-08 Baseline 2009 HMIS 2010-11
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Madhya Pradesh
RCH 2 STATE LEVEL EXPENDITURES
Expenditures under NRHM- RCH 2 Flexi Pool (including JSY) (In INR)
Year Bihar Madhya Pradesh Orissa Rajasthan Uttar Pradesh
2005-06 6.55 26.77 25.16 20.50 39.24
2006-07 29.94 112.61 42.39 86.24 112.72
2007-08 190.99 337.81 98.90 192.07 273.43
2008-09 274.58 363.76 132.97 292.85 502.85
2009-10 345.01 357.06 170.51 289.87 603.00
2010-11 425.95 375.84 190.96 286.9 655.9
Total 1273.02 1573.85 660.89 1168.43 2187.14
Source: NRHM, MoHFW
47
32.7
49.7
67.9
35.50 30.50
40.60
55.50
92.20
76.00
88.60 82.9
0
10
20
30
40
50
60
70
80
90
100
Hoshangabad Narsimhapur Raisen Betul
Pe
rce
nta
ge
Neonates Breastfed Within 1 Hour of Birth
DLHS 2007-08 Baseline 2009 Baseline 2010-11 HMIS 2010-11
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APPROVED BUDGET VS REPORTED EXPENDITURE: RCH 2
FY 2008-09 FY 2009-10 FY 2010-11
State Approved Budget
(` Lakhs)
Reported Expenditure
(` Lakhs)
Approved Budget
(` Lakhs)
Reported Expenditure
(` Lakhs)
Approved Budget
(` Lakhs)
Reported Expenditure (`Lakhs) till Sept.
Orissa 22101.09 11974.13 20375.14 16157.991 25837.48 7261.64
Rajasthan 22101.09 11974.13 20375.14 16157.99 25837.48 7261.64
Madhya Pradesh 31374.12 34486.90 38665.86 31934.95 39202.54 14542.66
Uttar Pradesh 53475.21 46461.03 66993.15 56223.84 76149.13 24675.02
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ACRONYMS AND ABBREVIATIONS
ADS Auto Disable Syringe AEFI Adverse Effects Following Immunisation
ANM Auxiliary Nurse Midwife
ANMTC Auxiliary Nurse Midwife Training Centre
ASHA Accredited Social Health Activist AWW Angawadi Worker
AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy
BPHC Block Primary Health Care Centre CES Coverage Evaluation Survey
CHRN Child Health Resource Network
CMO Chief Medical Officer DBT Department of BioTechnology
DHFW Department of Health and Family Welfare
EmOC Emergency Obstetric Care
ENBC Essential New Born Care EPI Expanded Programme on Immunisation
FP Family Planning
FRU First Referral Unit GAVI Global Alliance for Vaccines and Immunisation
GNM General Nursing and Midwifery
GoI Government of India
HBPNC Home Based Post Natal Care HIV/AIDS Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome
ICDS Integrated Child Development Services
IGIMS Indira Gandhi Institute of Medical Sciences IMNCI Integrated Management Of Neonatal And Childhood Illness
IMR Infant Mortality Rate
IPMGER Institute of Post Graduate Medical Education & Research INC Indian Nursing Council
IPHS Indian Public Health Standards
JSY Janani Suraksha Yojana
LSAS Life Saving Anaesthetic Skills M&E Monitoring and Evaluation
MCH Maternal and Child Health
MMR Maternal Mortality Ratio MNH Maternal and Neonatal Health
MNCH Maternal and Neonatal child health
MO Medical Officer MoHFW Ministry of Health and Family Welfare
NCHRC National Child Health Resource Centre
NFHS National Family Health Survey
NIHFW National Institute of Health and Family Welfare NIPI Norway India Partnership Initiative
NRHM National Rural Health Mission
PHC Primary Health Centre PHFI Public Health Foundation of India
PHN Public Health Nurse
PIP Program Implementation Plan
PSE Pre Service Education
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RCH Reproductive and Child Health
SCHRC State Child Health Resource Centre
SCNU Special Care Newborn Unit SIA Supplementary Immunisation Activity
SMO Surveillance Medical Officer
SNCU Sick New Born Care Unit
SBA Skilled Birth Attendant SBM-R Standard Based Management and Recognition
SS Supportive supervision
TA Technical Assistance UP Uttar Pradesh
UNFPA United Nations’ Population Fund
UNICEF United Nations’ Children Fund UNOPS /LFA United Nations Office for Project Services Local Funding Agent
VPD Vaccine Preventable Disease
WHO World Health Organization