Norway India Partnership Initiative

2007-2012: Gains and Gaps

UNICEF India Country Office,

New Delhi

Norway India Partnership Vision

Scaling-up of quality child health services

• Community based newborn and childcare: Integrated Management of Newborn and Childhood illnesses (IMNCI) – ANMs – ASHAs - AWWs

• Facility based services: Facility based newborn care

• Outreach services: Immunization

Scaling up of community based newborn and child health

0

10000

20000

30000

40000

50000

60000

2005 2006 2007 2008 2009 2010 2011

Numbers of workers trained in IMNCI in NIPI States: 2005-2011

Bihar MP Orissa Rajasthan UP

Scaling up of community based newborn and childcare

0

10

20

30

40

50

60

70

80

2006 2007 2008 2009 2010 2011

Co

vera

ge in

%

3 PNC visits in first 10 days

Non NIPI states

NIPI states

Lessons learnt in community based newborn and childcare (1): Implementation Research

(Bhandari et al, 2012, BMJ)

14% reduction in neonatal and 15% reduction in infant

mortality

Greater reductions in neonatal mortality in the sub-group

of births within the village of residence (20%)

Mortality impact supported by a substantial effect on:

- infant care practices

- prevalence of morbidity

- timely & appropriate care seeking for illness

Lessons learnt in community based newborn and child health (3): Supervision is critical, weak

S

No State

Madhya

Pradesh Chattisgarh Jharkhand Orissa Assam Rajasthan Gujarat

1 TRAINING

1.1 Coverage 2 1 2 2 2 2 2

1.2 Training norms 2 1 2 2 2 2 2

1.3 Recall on training 2 2 1 1 1 1 2

1.4 Knowledge & skills 2 2 1 2 2 2 2

1.5 Coordination of training center &

administration 2 2 0 2 2 2 1

TOTAL FOR TRAINING 10 8 6 9 9 9 9

2 SUPERVISION

2.1 Joint Supervision 2 0 0 0 0 0 0

2.2 Supportive Supervision 2 0 2 1 0 1 0

2.3 Monitoring 0 0 0 0 0 1 0

2.4 Quarterly reviews 2 0 0 1 1 0 0

2.5 District Coordination committee function 0 0 1 0 1 1 1

TOTAL FOR SUPERVISION 6 0 3 2 2 3 1

Lessons Learnt in community based newborn and childcare: Improving supervision is possible!

For achieving improved CCSP skills in trained personnel, there is minimal incremental gain after 3-4 supervisory visits

Optimum IMNCI Program IMNCI

Improve skills of workers - Training in IMNCI – AWW, ASHA, ANMs, - Private providers in formal and informal

sector, government physicians

Community promotion activities - Advertisements of available services - Group meetings - Promotional IMNCI messages - Production of communication material -On the job training by supervisors in conducting group meetings

Health systems strengthening - Supervision visits – ensuring 2 supervisors available per PHC

- Establishing a drugs depot in the village under village level committees, replenish every 3 months

-Performance linked incentives

Lessons learnt in community based newborn and childcare (2): Health System & community promotion missing

Improve skills of workers - Training in IMNCI – AWW, ASHA, ANMs - Private providers in formal and informal

sector, government physicians

Community promotion activities - Advertisements of available services - Group meetings - Promotional IMNCI messages - Production of communication material -On the job training by supervisors in conducting group meetings

Health systems strengthening - Supervision visits – ensuring 2 supervisors available per PHC

- Establishing a drugs depot in the village under village level committees, replenish every 3 months

Opportunities for strengthening community based newborn and childcare

• Large numbers of trained workers

• IMNCI “Plus”:

– Incentives

– Supervisors

• Challenges:

– Numbers

– Quality assurance

– Supportive Supervision

Scaling-up Facility Based Newborn & Childcare

0

5

10

15

20

25

30

35

40

Bihar Madhya Pradesh Orissa Rajasthan Uttar Pradesh

Cumulative numbers of SNCUs in five NIPI states, 2008-2012

2007-08

2008-09

2009-10

2010-11

2011-12

Contribution

• Standards and norms – Toolkit

– Operational guidelines

– Developmental follow-up (in progress)

– Accreditation

• Support structures – Collaborative Centers

– National Neonatology Forum

• Evaluation, mid-course corrections, informing policies

• Regional Dissemination

UNICEF

Key learnings (1): mortality declines except form asphyxia

UNICEF

Key learnings (2): Rapidly increasing needs!

Existing number of beds Required Number of Beds

Tonk 12 20

Dibrugarh 17 23

Mayurbhanj 12 25

Purulia 14 32

Lalitpur 12 25

Vaishali 13 32

Guna 20 32

Port Blair 14 10

UNICEF

Key learnings (3): Maintenance of Equipment

Name of the unit Reported time for repair of essential equipment (warners, phototherapy units)

Tonk 6 months

Dibrugarh 1.5 months

Mayurbhanj 6 months

Purulia 1.5 months

Lalitpur 3 months

Vaishali 1.5 months

Guna 0.5 month

Port Blair 6 months

UNICEF

Key learnings (4): Nurses are central to improving outcomes

Key learnings (5): Follow-up care is critical

Facility Follow-up of SNCU discharge

Community Follow-up of SNCU discharge

SCNUs Innovations to address problems

• Equipment: power audit, training of refrigerator mechanics, untied funds

• Human resources (MP): higher remuneration, improved working conditions

• Collaborative Institutions • Survival and Developmental follow-up • One stop shop • Data capturing, management and use for

planning M&E and supportive supervision • Accreditation

Opportunities for Expanding and Consolidating Facility Based Newborn Care

• Large numbers of SCNUs already in place – Large unmet need – Disparities – Quality assurance & Accreditation

• Norms & Standards exist • High political commitment

– Commitment in XII plan – JSY + JSSK – RSBY

• Collaborative Institutions • Expertise and early Experience in Developmental follow-up

– Draft Guidelines

Scaling up immunization (1): Strengthening Cold Chain

• SHTO Pune re-started in 2007 as national cold chain training institute for repair and maintenance of: – ILRs/DFs, – WICs/WIFs, – voltage stabilizers – solar refrigerators

• Almost all refrigerator mechanics in the country trained • More than 14000 (43%) cold chain handlers trained • First National Cold Chain Assessment (with costing) carried out in

2008 (VMAT) and 9 States have followed with VMAT or EVM • Guidance for expansion of cold chain and introduction of new

vaccines in the country • Development of National Cold chain MIS (www.nccvmtc.org) for

real time monitoring

• Vaccine Wastage Assessment carried out in 5 states:

Vaccine wastage range 34% (DPT) to 63% (BCG) at session site

Campaign results: Reported coverage vs. RCA monitoring

0

10

20

30

40

50

60

70

80

90

100

Aru

nachal

Pra

desh

Assa

m

Bih

ar

Chhat

tisgar

h

Guja

rat

Hary

ana

Jhar

khan

dM

P

Man

ipur

Meg

halay

a

Nagal

and

Raja

sthan

Tripura U

P

% Reported coverage % area with >90% chidren vaccinated

Activity ongoing in AP, Assam, Gujarat, Rajasthan & Tripura

RCA areas checked < 100 in AP, Manipur and Tripura

68 of 137 districts achieved

>= 90% administrative coverage (50%)

Data as of 14 March 2012:

Number of areas visited for RCA monitoring = 33,212

Number of children verified = 638,660

Reasons for partial or no immunization (source: CES 2009)

• Demand side issues far outweigh supply

• Lack of Knowledge and felt need contributes to majority of left out and drop outs

• Allaying fear of adverse reactions is also important (8%)

1. Communication guidelines for immunization developed

2. IEC prototypes prepared for print, mid and mass media

3. Routine Immunization Guide with FAQs for capacity building of ANM/ AWW/ ASHAs

4. IPC training videos for frontline health workers

5. Media sensitization (national/ state)

Scaling up Immunization (3): Improve Demand

Scaling up enabling mechanisms

• National, State and district:

– “Enabling “ Child Health Division

– Child Survival Cells in Orissa, MP, Bihar and Rajasthan

– Divisional MCH Coordinators in Rajasthan, UP

– District MCH coordinator in Orissa, Bihar

• Hand over: Progressively these cells/structures are jointly supported and owned by partners and state government:

– Bihar

– Rajasthan

– Orissa

• Capacity building programs (techno-managerial) for mid-level managers developed:

– Short course (WHO, UNICEF, PHFI, PGIMER): more than 100 MLMs from NIPI states trained so far

– One year diploma (PHFI, in progress)

Scaling up enabling mechanisms Key learnings

• Fragmentation at state: – NRHM versus RCH

– Line staff versus consultants

• No clear lines of responsibility for RCH at state and district – DIO for immunization, DLO for Leprosy, DTO for

TB, DPMU for “NRHM”, who for RCH?

• Suggest a District RCH Unit, headed by DRCHO, supported by District RCH Consultants

Catalytic and/or Strategic?

• Progress in NIPI states vis-à-vis others

• Progressively models have been implemented and scaled up

• Assessments

• Corrective actions

• Guidelines and standards

• Partnerships developed, their capacity enhanced

• Enabling mechanisms identified and built

• Innovations ongoing