Child Health in the State PIPs 2008 09 Mapping Technical Assistance Needs Version 1 0-620

8/8/2019 Child Health in the State PIPs 2008 09 Mapping Technical Assistance Needs Version 1 0-620

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National Health Systems Resource CenterNational Rural Health Mission

Ministry of Health & Family Welfare

Government of IndiaNew Delhi

Child Health in the State PIPs

2008-09

Mapping Technical Assistance Needs(Version 1.0)


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Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00

1

Child Health in the Project Implementation Plan 2008-09

&

Mapping technical assistance needs

Version 1.0

Contents:

Section

No.

Topic Page

number

1 Mapping of TA needs for child health: 2 to 6

2 Analysis of the State PIPs- a cross state

appraisal.

7 to 21

3 Matching TA needs assessment from PIP

analysis with JRM recommendations.

22 to 27

4 State Specific PIP appraisals ( first cut) 28 to 99


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Section 1

A preliminary mapping of TA needs for child health:

There are three sources for defining TA needs. The first is the JRM and CRM reports, thesecond is discussions with programme officers and mission directors in each state and the

third is the examination of the state data and the state PIP. This note analyses the PIPsand then compares its findings with the JRM and builds upon the latter to define the TA

requirements.

A brief summary of TA needs is given below in this section. We however recommend a

prior reading of section 2 before reading this summary. .Please note that on school health

and immunization separate notes are being submitted.

TA

Task

Sl. No.

TA task

Description

TA task needs TA task

modality

1 Provide CH division with a tool

kit ( manuals , guidelines,

strategies, equipment list,

enabling orders etc) for

propogating SNCU level 1 of

care in all PHCs and CHCs

within 18 to 24 months. The

training manuals in this tool kit

would be integrated with the

IMNCI module for medical

officers.

As JSY has broughtnewborns to every

PHC, all of them need

to have a clear set ofguidelines and tools

provided with an

orientation programme,while over time they

are trained for this

One agencyselected at

national level

and nodalising aworking group.

2 Agencies could be specifically

recruited for each state who

would work with the state to

help it conduct the training

programmes and support the

state in putting in place SNCU 1

level care in all PHCs and

CHCs.

A tool kit would not

move by itself. A

catalyst agency thatwould the district

health

socieities/directorateshelp introduce this

across the states in a

short period would beneeded. Though CHCsneed higher level, let at

leas this level be put in

place

One support

agency for each

state with a clearTOR the

bottom line of

which is that thetool kit is

available in

every PHC andthe staff therehave been

introduced the

kit.

3 Provide CH division with a tool

kit for reaching SNCU level 2 of

a tool kit has list of

equipment, list ofsupplies, HR skills

One agency

recruited at thenational level


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care in all CHCs eventually but

within three years in all places

able to handle basic or

comprehensive emergency

obstetric care. As part of TA task

3 would also be to provide a tool

kit for reaching SNCU level 3

where required.

required, training

manuals, training

strategy, model MOUsto be signed with PPP

centers for providing

training, copies ofenabling orders,

advocacy brochures,

standard treatmentprotocols, consultation

back up, evaluation

processes etc. Themulti-skilling module

in this is one big part of

this task

working with

UNICEF and CH

division.

4 Assist each state to draw up a

road map to reach SNCU 2 and 3in every FRU and districthospital and walk down that

road. This would include an

advocacy unit for supporting thetask. The aim should be to have

all in place in three years

The tool kit has to be

applied. Central to thisis defining a fewagencies where SNCU

2 and 3 level training

would be provided andplacing them in control

not only of training but

also of post trainingfollow up to ensure that

every center becomes

functional.

Development

partners in eachstate could assistin this work , NE

RRC for the

northeasternstates and for the

others national

coordinatingagency could

recruit one

agency

5 Quality assurance in IMNCI,attend to gaps in IMNCIimplementation that have been

identified. Build up capacity in

SIHFW to supervise and guideoverall functioning across the

training centers of the state.

The scale and qualityand comprehensivenessof IMNCI roll out

needs to improve. For

this the TA shouldevolve state specific

guidelines which the

state mission directors

would issue inconsultation with the

CH division.

Same consultantteam asidentified for TA

task 2 would be

put in place. Inaddition

consultants may

be recruited and

placed with theagency/SIHFW.

6 Help each state draw up orimprove on their plans for

provision of home based newborn care through ASHAs. This

cannot be done at a national

level, but only in a state specificformat. This would include ways

of strategising and simplifying

The Child healthconcern has to be

woven into the thedesign of the support

structure, the mentoring

and monitoring processfor ASHAs and its

training programme,

Select agencieswho are part of

ASHA nationalmentoring group

could undertake

this.


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the Search model and integrating

it with learnings from IMNCI

and making it more costeffective and applicable to

ASHA.

material and training

strategy, into the

ASHA drug kit andinto the ASHA

payment schedule

7 Develop monitoring andfacilitatory systems where

EMRC type ambulance services

are established to ensure that we

can track usage by sick children

and we can facilitate this.

Appraisal of current pattern of

use

Need to have a quickappraisal of the issues

in sick childuse ofambulance services

where they are in place

For other places theneed is to develop such

ambulance services and

this is discussedelsewhere.

One agency tostudy use across

ambulanceservices.

8 Evaluate existing NRCs, and

based on it build guidelines sothat the large numbers of NRCs

starting up can do so well. Seek

to integrate training for NRCs

with SNCU- 2 and a simpler set

of protocols with SNCU-1

training. ( TA task 8)

NRCs are working and

expanding but needappraisal not to see

whether it works-(because wasting

childen have rights to

care) but how to

optimize this strategy.

One team to be

set to appraiseand develop a

tool kit whichother states could

use to start up

and manage

NRCs.

9 Handhold states starting up

Nutrition Rehabilitation Centers

to do so. Build up linkages of the

NRC with ICDS and preventive

aspects too so that each reinforce

the other.

Many states haveproposed NRCs, but

have been unable to

start it up. They neednot have to discover

how to for

themselves

Could be donethrough a team

of consultants for

three to fourstates.

10 Develop and implement an

action research programme in

about 100 blocks or about 10

districts for a significant time

bound reduction in childhood

malnutrition. Convergent district

planning and implementation is

taken as the key principle.

Global best practices

have shown that a 50%reduction in 5 years is

possible. Need

5 to 10 agencies

may be involved.Choose

community

action NGOs for

this and a fewdistricts with

special qualitygovt .leadership.

11 Develop and implement anaction research programme in

about 100 blocks or about 10

districts for achieving asignificant reduction in

Childhood anemia ishigh and increasing and

too little work on its

determinants , effectsand workable solutions.

May becombined with

above TA in a

few districts butthere is some


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childhood anemia, epidemiological

work also that is

indicated.

12 Study to quantify the malariaattributable maternal and child

mortalities and morbidities withcorrespondience to API levels

and to recommend ways ofaddressing this effectively and

efficiently- and with integration

as a central principle.

Malaria is fourth mostcommon cause of death

globally and nationally.In endemic areas it

may be most commoncause. Need to assess

what is happening

today and what needsto happen

Suggest agencylike VCRC

nodalise a taskforce on this

issue.

13 Build up a BCC hub in eachstate SIHFW which can plan for

integrated BCC and as part of

SIHFW work. Includes capacity

to do formative research and tohelp develop district specific

BCC plans and hand holddistricts for one year to

implement and evaluate these

plans.

BCC programmedesign is a critical

bottleneck. ( see

discussion in PIP

analysis) Few SIHFWsare in position to do

this today.

Contract in oneagency for each

state . Agency to

work with

SIHFW and afew or all

districts.

14 Helping state health society todraw up a state specific school

health plan and building capacity

in SIHFW to do so for the futureas well

This is described ndetail in separate

accompanying note on

school health

Contract in oneagency for each

state. Brief these

agencies welland let them then

design withSIHFW.

Coordination of TA in child health:

Over all this effort of organizing these TA on 14 areas would need considerable

coordination with the division, with the states and with the development partners. This

coordination is difficult for on many of the above 14 items we may have to hire oneseparate agency for each state or for a group of states. UNICEF has already been

instrumental in taking it so far, and would have a major role in taking it forward butanother point of coordination is also needed. Given the way TA development in this area

is being shaped, the choices are firstly: the NIHFW which is now being supported bydevelopment partners in many ways including a major grant to develop as a National

Child Health Resource Center. This work would help them emerge as such a center. Or it

could be the child health division of the ministry itself. The criteria should be the abilityto ensure time schedule and quality outcomes. The entire state- support TAs would

have to be set in place in three months and implemented in one year and the national


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guidelines creation TAs would have to set in place in one month and be completed inthree months.

If however the work of coordination devolves to NHSRC, the latter would assemble ateam of three senior consultants to organize this work in such a time frame as indicated

above. It would be advisable anyway for the CH division to involve NHSRC to ensurequality of output needed as well as a lot of free advice . But there is no insistence that thisis done.


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Section 2

Analysis of State PIPs:

The PIPs for the current year have improved dramatically in how they address child

health. Now most states are seized of the different strategies that make up a child healthplan and are struggling to put them in place. Technical assistance at this stage could makea huge difference and indeed is mandatory to reduce learning time.

There are many ways of examining child health in the state PIPs. We chose to examine

the various strategies from the view point of three levels of contact between the healthsector and the child and maximizing the opportunity available at each of these points of

contact.

The three levels could be described as the Family and community setting- of which the most important are the ASHA

programme, the village health and nutrition day and the BCC programmes.

Outreach setting: which includes the sub-center and the anganwadi and theschool in school health programmes Facility setting- primary as well as secondary and tertiary.

Thus in each state one has to study the strategies that are being attempted and whatimpact they make at each level and relate it to the child health issues as pertinent to that

state.

1. ASHA programme:

The most important vehicle here is the ASHA or equivalent health care worker. Though

anganwadi workers(AWWs) and ANMs are also expected to interact at the family level,

in practice they remain centred around their institutional setting the anganwadi center.Also the anganwadi worker has a four hour work profile which is barely able to provide

time for her anganwadi center level functions feeding the children, weighing them

periodically and providing some sort of day care, and it is only the more motivated oneswho manage the home visit. Potentially though the AWWs could be more involved in

this task. The ANMs tour programme is such that the best that can be expected of her is

to visit the village anganwadi center for the immunization session at the stated time, and

perhaps throw in a home visit where it is specially requested of her. It is unrealistictherefore to expect the ANM to be able to visit at the family level.

In child health the ASHA contributes by being a very effective medium of inter-personal behaviour change communication regarding child care practices. The most

important of these relate to breast feeding and to complementary feeding but also to

appropriate prevention for common illnesses. The ASHA also has the possibility ofreaching the child delivered at home, in time to provide essential new born care, as well

as in times of sickness to provide early and correct management of the diarrhea, the acute

respiratory infection or the fever- simple measures that can save lives and no other healthcare provider is situated to reach and provide care. To the extent that deliveries are home


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deliveries and access to health care services are more difficult, such home based curativecare becomes the most critical intervention to save child lives.

We see from the PIPs and from review reports that Chhattisgarh and the Mitaninprogramme have leveraged this dimension well. The Rajasthan PIP also has brought

adequate focus on this. In Uttar Pradesh the CCSP programme is a conscious effort toweave in this concern, but their problem is that the rate of expansion of the programmefalls far short of this. Book 2 of the ASHA training modules and to some extent book 1 of

the ASHA training modules does cover this but is not skill based and not adequate to

take action at her level. Therefore, unless the states put in a specific effort this

opportunity would not be utilized.

In many states this opportunity is not made adequate use of, or missed altogether. Forexample, in Andhra Pradesh, Arunachal Pradesh, Assam, Bihar, Jammu and Kashmir,

Orissa, Tripura, Uttaranchal though there are full fledged ASHA programmes in place the

synergy with child survival goals is not apparent in the PIP. In states like Gujarat,Karnataka and Kerala, Punjab, West Bengal, the ASHA programme is proposed only for

tribal areas and as a rule these states have not made for a linkage of the ASHA with child

survival goals. One reason for the states missing this linkage, is that their key child

survival strategy is the IMNCI package and as it stands in most places the IMNCI is seenas focused on AWWs and ANMs and notfor ASHAs. This is partly because the IMNCI

strategy was elaborated before ASHA was proposed and partly because of poor

confidence in the viability of the ASHA concept. It was the HBNCC programme ofGhadchiroli that took the focus of child survival intervention to ASHAs and almost as a

response to that challenge, IMNCI is being extended to ASHAs in a very limitedmanner. The HBNCC package in the original Ghadchiroli format is proposed in many

PIPs but almost as a token or pilot gesture- five blocks in one district in Rajasthan,

Bihar, Orissa, Madhya Pradesh. There are two close concepts that we need to clarify. Oneis the HBNC as a well defined package delivered in a particular format which is similar

to Ghadchiroli. The other is training ASHAs to provide home based care for the neonate

and for any sick child without sticking to every element of the Ghadchiroli model,especially excluding the injectable antibiotic and the birth asphyxia management.

The Maharashtra, Meghalaya, Mizoram, Himachal Pradesh and Delhi PIPs also envisage

HBNC training for their ASHA workforce though it may not be with the same rigor andformat as the Ghadchiroli model. In Chhattisgarh, UP and Rajasthan also similar home

based care by the ASHA is being planned. The Jharkhand PIP in the text discusses

HBNC as a focus for 22 districts but in the budget it is a very limited six training campsthat is seen. However from our reports there is a better understanding at the level of

district level implementation. In Tamilnadu where there is a decision not to introduce

ASHAs some element of neonatal care is sought to be introduced through womenvolunteers from self help groups, who are trained for the purpose. Thus about one third of

the states have recognized the life saving use of home based community health worker

programme in child survival, about one third do not have an ASHA programmes andabout one third have ASHA programmes in place but have yet to leverage it for


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improving child survival. Of those who have used it only Chhattisgarh and Rajasthanhave scaled up to the whole state.

A.1.2. Narrowing the gap between IMNCI and HBNCC:

The difference between the IMNCI and HBNCC applied to ASHAs has become less andless with HBNC including sick child care and IMNCI including neonatal care. Currently

IMNCI has most elements of HBNC except injectable gentamycin and birth asphyxia

management. But due to problems of logistics even HBNC is becoming pragmatic on

these two elements and have shifted this to the last part of their training modules. Themain strength of HBNCC in this context where technical content is convergent, is the

insistence on rigorous post training follow up. IMNCI also calls for it, and its best

example is in Mayurbhanj, which had more of such field support than even HBNCC. Butsince such field support is not insisted upon in the roll out, IMNCI proceeds somewhat

faster and appears less expensive, but this would be at the cost of effectiveness. We thus

have a situation where IMNCI is being rolled out without this post training support andHBNCC initiation is being delayed perhaps out of hesitation to support what is taken as

a too-intensive and therefore too expensive human resource deployment. There is a need

for some sort of historic compromise between the two- but the terms should be that the

rigorous training and post training structure that the HBNCC has and that the IMNCIcalls for is not compromised.

A.1.3. Scope of Technical Assistance: Fronting child survival within ASHA programme:

In practical terms there is an urgent need to front child survival within the ASHAprogramme. The focus of technical assistance must be to help the ASHA programme by

a) providing a post training support that provides ASHA the skills and support needed to

provide home based care of the sick child( this includes appropriate referral).b) build child survival priorities into the monitoring structure.

c) ensure that training programmes provides necessary skills in addition to knowledge.

d) develop a communication kit and strategy for ASHAs to be able to influence key childcare practices that would make a difference.

d) that there is an adequate ASHA support structure in place, as envisaged under the

ASHA programme, to ensure that the above four items do take place.

At the community level- there are three activities that are critical:

First is the village health and nutrition day. The second is village level BCC and the third

is the strengthening of village level structures for the objective of child health.

2. Village Health and Nutrition day:In most states every village has such a day every month. Many states report such a dayevery week. Could this be a misunderstanding? Or is it the plan? If the immunization

session is the key component of this session, then the ANM has 3 to 7 villages to visit (

average 4 to 5) and would manage to hold one immunization session per village per weekor a maximum of two per week. So though it is weekly for her, for the village it is


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monthly activity. This is what is happening at present- and most states merely call theimmunization session as the VHND. This serves as a point of provision of antenatal care,

distribution of iron and folic acid tablets, deworming tablets, vitamin A administration to

those for whom it is intended and from ICDS for the distribution of take home rations.This is thus a point of convergence. In most states sporadically and in some states more

systematically there is an effort to ensure that there is some component of socialmobilization and health education built into this day to meet the sort of expectation thatnational guidelines suggest. However even this provision of the minimum set of services

in a planned immunization session, monitored by that great indicator, percentage of

planned immunization sessions that were held is adequate to most purposes of service

delivery. One could leave the more mobilizational description of this session to happen asand when the system is seized with enthusiasm for this event, when it is rediscovered as a

major strategy and celebrates a short half life of attention before it relapses back into the

more mundane immunization session. Mobilisation per se is best when done sporadicallyand it would be difficult to mobilise enthusiasm month after month for such a routine and

tame affair. The other indicator we suggest adding is the presence of the ASHA in the

session. For a large scale district level monitoring this may be taken as indicating thatconvergence between ASHA, AWW and ANM is happening.

The creation of the village health and sanitation committee creates new opportunities for

strengthening the VHND and indeed many aspects of child survival. Thus activitycontent of both the VHND and the VHSC needs to include elements of child survival as

are relevant to it. Almost no PIP mentions this synergy, though on the ground this may be

happening.

3. Behaviour Change Communication:

This could make a substantial difference to child survival. BCC planning has improved

considerably over the last two years. Many plans now clearly define what child carepractices are being identified for change, what are the determinants and what mix of

media- message- and communicator is to be used to change this child care practice.

However in most instances the link between media barrage that creates an enablingenvironment for change and inter-personal communication at family and local

community level which could actually trigger the change and ways of evaluating the

impact are weak.

Amongst messages, through breastfeeding practices are found in most PIPs,complementary feeding is very weak and appropriate responses for childhoold illness

fever, diarrhoeas and ARI are almost missing. In a few PIPs the child health messages in

the BCC are completely missing.No where is the previous years research or even experience or evidence of any sort

influencing the plans though such inputs would have been useful to locate barriers to

change.

Technical Assistance for the BCC component:


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1. The district plan approach allows for crafting of very powerful and effective BCCcampaigns but very focused technical assistance would be required to make these

plans and even more in implementing them.

2. Formative research to develop BCC material and to identify barriers to change.

3. Building up capacity for guiding BCC work in the districts in state level agencieslike the SIHFW/SHSRC.

4. Child Health in the Outreach Facility:This is a convenient category to discuss the interventions planned at the health sub-

center, into which we can take in all the activities of the ANM and to a lessor extent of

the male health worker(MPW). We also discuss the interventions of the anganwadicenter. We also note that if we define the child to be upto the age group of 12 years and

12 to 19 year olds as adolescents, then school becomes the major outreach facility and

school health a major child health programme ( age of 18 is the pediatrics definition ofthe child). Since school health and adolescent health is described in separate notes, it is

only the health sub-center and the ICDS anganwadi center that we are taking into this

section.

The major strategy of RCH-II, (the component of NRHM that deals with child health)

this is undoubtedly IMNCI, and every state has, without exception, built it in. That is the

positive part. There are however three areas of concern regarding the roll out of theIMNCI strategy- its scale of roll out and as part of it, the training outcomes being

secured; the post training follow up and the service delivery improvements being gained;and finally the linkages of IMNCI with the community and facility level care

interventions and with improved drug supply so as to impact on child survival optimally.

Rajasthan and Madhya Pradesh have gone to scale. This is largely because in the

previous year there has been an appropriate investment in the development of training

centers and in training of trainers , so that this year the training programmes can be rolledout across the state. In many states the lack of training centers and the need for first

training of trainers have come to be perceived a bit belatedly. This years PIP however

expresses a major thrust to strengthen training centers and TOTs, and it follows that only

in the next year will the programme have a field level impact. But better late than never.In many states however the realization is not yet there- and there is still a few districts

every year approach. There is a need to organize technical assistance so that training

centers are strengthened and TOTs are completed in all districts in the coming year sothat in the next two years all the peripheral workers are trained. In terms of percentages:

in Rajasthan almost 90% of districts would be completed this year, in Madhya Pradesh

over 70% .

There are also many changes in who is being trained. Rajasthan has planned to train all

ANMs, anganwadi workers and ASHAs. Many states have left out anganwadi workersout for which there is not sufficient justification. Many states have left out the ASHAs


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but that is understandable as there is as yet no structure for training ASHA. Nowhereexcept in UP and Chhattisgarh have the modules been rewritten to be appropriate for

ASHAs.

If we take the entire strength of ANMs and AWWs as requiring IMNCI training, the

numbers being trained per year would be less than 10% on the whole and if we add inASHAs not even that. This estimate matches with the JRM estimate which states 20,000trained last year and about 46000 in all. For a country of about 2 lakh ANMs and 10 lakh

AWWs, this is about 15%- not counting in other categories like LHVs and MOs and staff

nurses etc. The rate of roll out is therefore less than 10% per year. We need to achieve at

least 30% coverage per year.

Curiously many states also report medical officer training for IMNCI and we are

informed that a module for medical officers is under preparation/ available. Is this IMNCIfor MOs an orientation programme for them to be able to supervise the ANMs who have

been trained or is it for them to have the skills needed to manage the sick children

referred to them by the peripheral worker? If it is the latter the training must be theSNCU 1 training or FBNC training as it is often being called. At any rate there is no case

for giving a only IMNCI package to medical officers or for that matter to staff nurses

posted in the facility, unless it is well integrated with the facility based care component.

Even if there is clarity on this at the level of the strategy- makers, this certainly is notthere in any PIP.

One problem apprehended with scaling up is loss of training quality. But when anywaytraining has to go through at least two cascade steps- state and district and often needs a

third block level team, then, the importance is on building systems of quality control andtraining evaluation into each level of training. If these systems are built, then it does not

matter how many districts we take up, ten or a hundred, since essentially after the training

of the district team is over the rest proceeds in parallel. If on the other hand the qualitysystems are not in place, even the small number of districts being covered now will have

quality issues. The quality systems are not evident in most PIPs, though these may be

practiced on the field.

The other issue with IMNCI training is that it is predicted to give results only if the

package includes three essential elements in addition to IMNCI training- improved

facility care, improved community level action and improved post training follow-upboth for on the job support and for trouble-shooting problems of supplies. Few state PIPs

show any effort to synergise facility care and there are states which distribute the

programme components for easier implementation with IMNCI being done in somedistricts and facility based care being done in others. The point of the necessary synergy

between creating capacities in local health facilities for handling the referrals that proper

implementation of IMNCI would result in is obviously being missed. Even fewer statesare focusing their BCC campaigns as back up to situations where IMNCI trainees return

to work. As for improved drugs and supplies that need to accompany the post-IMNCI

training situation, many states mention this- but no state has the logistics system in placeby which the procured drugs can reach the ANM or AWW. The drug kit supply is an


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incomplete approach for what is needed is not kits but mechanisms to refill the kits as andwhen they are exhausted. Further there is almost no mention of reaching drugs to the

AWW who is being trained with such effort neither kits being supplied nor is refill

being proposed.

The prototype of the IMNCI training, its claim to success in the Indian context, lies in theMayurbanj model, in which all of this was attended to- but almost no state exceptRajasthan shows this in the PIP. Examining the Mayurbanj model we find that almost

180 trainers/facilitators were hired and a large part of them paid on a daily basis for

almost one year to follow up the trainees on-the-job, trouble shoot problems of lack of

drugs and referral linkages and support them in initiating the use of newly acquired skills.These trainers were largely Ayush practitioners, or nurses or NGO workers hired in for

this purpose. The Rajasthan PIP reflects this post training support workforce and budgets

for it. No other PIP does so. In the NIPI presentations we note that UNICEF has proposedrecruiting such staff for a number of districts in the five NIPI states (excepting UP),- and

this would certainly make a big difference. But for the other states the gap would remain.

The focus of technical assistance for IMNCI would therefore be in

a) Identifying training centers and training of trainers in these centers such that theycan cater to all districts.

b) Creating capacity in the SIHFW or equivalent institution to be able to monitor andevaluate quality of training in the district and sub-district level so as to ensure

training outcomes as the trainings get scaled up.

c) Planning for post training support so that training outcomes translate into servicedelivery outcomes.

d) Planning for community level interventions and facility level interventions tomatch the advance of IMNCI training.

e) Checking the logistics systems and improving it to ensure corresponding drugsand supplies are in place.

The exact emphasis on each of these elements would differ across the states, but no doubt

they are needed in all the states.

5. Facility Based Newborn ( and Child) Care:

It is here that the PIPs are the weakest. One cannot escape the impression that thehierarchies of sick neonatal and facility care are simply not understood. We have three

competing terms often used interchangeably FBNC(facility based newborn care);

newborn corners(NBCs); and SNCUs( Sick Newborn and Child Units also known asStabilisation units) and NICU( Neonatal intensive care unit).

Thus taking Assam as an example, we have IMNCI focused in 5 districts and deliberatelyto distribute the programmes, SNCU distributed to 5 more districts and quite curiously

something else called FBNC distributed to 5 more districts and in addition a line that 32

MOs from FRUs would be trained in newborn care. In Andhra we have 1000 of the 2200doctos being trained in IMNCI along with 2000 staff nurses and all of them are in


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facilities. In addition we have emergency neonatal care for PHCs and NICUs in all 50Cemonc centers, plus something called facility level care in all 24 hour child health

centers. This is the case in most PIPs- a liberal sprinkling of these terms used in all sort of

combinations. And at no time do we get in almost any PIP a sense of what percentage ofPHCs or CHCs are now having the capacity to deliver their respective service guarantee

or even of what is their respective level of service guarantee as regards child health. Biharwould train 450 MOs in 8 days IMNCI, train 100 MOs in a one day training programmefor a neonatal stabilizing unit at every PHC (which is however billed for 6.25 crores and

all 397 blocks) and in 13 districts create SNCU-IIs with an unknown match between the

activities and districts. In Chhattisgarh the term FBNC is used synonymous with the

Neontal intensive care unit, is very capital intensive and located at the medical collegelevel. There are other 4 SNCUs which may be district hospital level and 21 out of 32

FRUs are being covered as FBNC again but with a different definition in terms of inputs

and skills. In states like Gujarat, Himachal and Jammu and Kashmir there is a declarationof intent to make all CHCs/block PHCs into newborn care centers without specifying

level of care but proposing that they would be contracting in pediatricians to do the task.

Whether such huge number of pediatricians with such dispersal would be available isanother issue. There is no clear training or equipment list that seems indicated in their

PIPs.

In our discussion below we would use the term facility based neonatal care for covering

this entire domain of treatment of any sick child, not necessarily a neonate. We would

then, in line with the national neonatology forum further categorize such facility basedcare into three levels- SNCU-1, SNCU-2 and SNCU- 3 level. The SNCU-1 level is for all

practical purposes synonymous with the newborn corner concept.SNCU-1 is at the primary health center, though due to operational constraints most

CHCs/block PHCs/FRUs may in practice be only providing this level of care. A large

number of babies are born in such institutions and they all need essential newborn care.Since basic emergency obstetric care is deployed in these centers a large number of sick

neonates can be expected. Also due to IMNCI/HBNCC/ASHA programmes improving

referrals there would be a big load of such newborn and sick child care on every PHC.Therefore there is no getting away from the commitment to develop this capacity in every

PHC and certainly in every 24*7 hour PHC on a 24*7 hour basis. There is also no reason

why this cannot progress on par, not just with the roll out of IMNCI, but with the roll out

of Janini Suraksha Yojana. The creation of a SNCU-1 is in effect the addition of aminimum list of skills, a minimum list of equipment and supplies, the identification of a

suitable space in the PHC( the notion of newborn corner), the putting in place of a

standard treatment protocol and the inclusion of this service in the list of services that thePHC delivers. The inputs are not costly and potentially could be got from the untied

funds . A standard treatment protocol could be printed and distributed, or better still

introduced through a one day workshop.(we would recommend building on theMaharasthra Standard Treatment Guidelines(STGs) which have a much better pediatrics

component than all other STGs prepared to date, and adapting this with some of the

National Neonatology Forum (NNF) recommendations). The skills required are not muchmore than what is given to health workers in the Ghadchiroli HBNC model, in that


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includes injectable antibiotics and birth asphyxia management and this could be impartedto the doctor or nurse who conducts the delivery. The use of the baby warmer ( purchased

or locally rigged) is additional. There is also every reason for merging IMNCI training

for MOs with SNCU-1 level training and it is quite irrational not to do so. In other wordsthe creation of SNCU-1 in every PHC ought to be a one year agenda- if the tools could be

prepared centrally, the concept could be explained systematically, and then taken down asa systematic catch-up campaign. The critical input to achieve this objective would be thequality of technical assistance made available.

The SNCU-2 is for the FRU level. Here sick neonates are referred when specialist

pediatric skills are required. Here a baby with birth asphyxia would not only get anAmbous bag resustication but also could get intubation if required. Thus the main input is

of pediatric skills which could be got either by getting a pediatrician or by getting a

medical officer multi-skilled for pediatrics as has been done in the Purulia model. Theequipment needed includes the pulse oximeter and the phototherapy unit.

The SNCU- 3 is for the district hospital level and should be seen as synonymous to theNICU( Neonatal intensive care unit).However often it is used synonymous to SNCU-2

thus creating considerable confusion. This needs much more sophisticated equipment and

it definitely would need pediatricians. Multi-skilling will not do, and special refresher

training in neonatology for pediatricians is desirable. Analogous to the problems insetting up FRUs, in practice what has to happen in CHCs can be made to happen only at

district hospitals and what has to happen at district hospitals, happens only at the medical

college hospital. Thus by default rather than intention, CHCs remain at SNCU-1 level,district hospitals become SNCU-2 level and medical college hospitals become SNCU-3

level. Even if this is accepted, where CHCs are functional as FRUs providingcomprehensive emergency obstetric care, one could insist on reaching a SNCU-2 level of

child care. It is worth examining the Purulia model in this regard. Purulia district hospital

is officially SNCU-2, but with support it provides almost all the level of services that aSNCU-3 will provide. The CHCs provide a level of service somewhere between SNCU 1

and 2, and the PHC is not a focus at all. That may have been acceptable when there was

no JSY, but in the post JSY period every PHC would require SNCU-1 level skills inplace.

Madhya Pradesh has used this category and clarity- proposing level 1 SNCUs in 2

Cemoncs each of 10 districts, level 2 SNCUs in all district hospitals and level 3 SNCU in

2 medical college hospital. Orissa has proposed level one in 45 places and level 2 in 23district hospitals. Rajasthan is near with SNCUs probably level 2 at 39 CHCs and what

it calls FBNCs which may be level 2 in 33 districts. But again if we look at the skills

being required for each level, the equipment being required, it is clear that even in thesebest case scenarios what exactly is the outcome is a bit hazy.

If we take 2000 FRUs as the objective over the RCH-II project period, then we should beapproaching about 400 FRUs and therefore about 400 SNCUs per year. The sum of

proposed FRUs is now 57 such centers in this coming year, for the entire country- which

not suggestive of being on any sort of road map. The training for SNCU-2 and SNCU- 3are almost identical and could be delivered over 4 weeks with two more one week


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follows up with 4 to 6 month gaps. This would need to be accompanied by good standardtreatment protocols and operational manuals. Few states have planned this and for the

most part the training programmes are suggestive of SNCU-1, while equipment is

suggestive of SNCU-2 or 3 levels. If we read the corresponding sections of all the PIPstogether, it is a bit chaotic and really sets out a huge agenda for those in the business of

providing technical assistance.

There would be only one way to accelerate the achievement in SNCUs of the 2 and 3

levels and that is to integrate it into the TOTs of IMNCI at the district level and the

training institutes where the TOTs are being conducted.

Technical Assistance Needs:

1.Set out clear guidelines for the SNCU-1, integrating it with IMNCI training for medicalofficers, and the newborn corner and FBNC terms. Create simple manual or toolkit for

this which has the Standard treatment guidelines, a state specific address from which the

facility can procure whichever equipment they do not have, and a training manual for thenurse and the medical officer of the PHC.

2. Set out clear guidelines for SNCU- 2 and SNCU 3, along with developing the

concept/protocols of multi-skilling medical officers for pediatric skills needed in thissetting.

3. Set out an advocacy and communication tool for explaining to key officers (districthealth officer;district collector; programme officers at district and state level,mission

director, director health services etc) what is meant by each of these concepts, how itrelates to IMNCI and to emergency obstetric care etc, what are the inputs that go into

each of these facilities and what are the outputs needed.

4. Identifying sites and persons for provision of training for SNCU-2 and 3, including

appropriate pediatricians in the private sector or even private institutions providing sick

child care.

5. Arranging a team with necessary skills and protocols for visiting each of these SNCUs

and providing training on the job to supplement the one month training at the training

site.

An indicative table of the guidelines that would need to be finalized .

Equipment Skill sets and

Human

resources

Laboratory

support

Services

Provided with

clinical level ofcare.

PHC level: SNCU-1

Oxygen concentrator

Oxygen hood with connecting tubes

Open care system: Radiant baby

3 nurses,

trained in

SNCU-1 level


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warmer, Portable Suction Pump,

Suction Tubes( sterile, disposable)

Resuscitator set( Ambu bag)infant/child,

Sterile Mucus Extractor, 20ml,

disposable.

Two medical

officers trained

in SNCU-level1 training

CHC-FRU level: SNCU-2

All the above PLUSPhototherapy unit- single headLaryngoscope set- neonate.

9 nurses ofwhich at least 4have received

SNCU-2 level

training

3 to 5 paranurses.

District Hospital/Medical college

level: SNCU-3

All the above PLUSVital sign monitor for ECG,BP,HR,SpO2, RR, Temp

Neonatal bedside Pulse Oxymeter,

Bilirubinometer,10,20,50 ml, single phase Syringe

pump,

Electronic baby weighing scale 10kg

Fully automatic Washing Machine

with dryer

6. Referral Transport systems:

One important adjuvant to the SNCUs is the referral transport arrangement. Across thePIPs a formula is at work. This formula estimates the approximate number of newborns

that would need referral at 5% of all live births and provides a sum of money for each

referral. In Madhya Pradesh and Karnataka it is Rs 200 per referral, in Arunachal andJharkhand, this is Rs 300, it is Rs 500 in Bihar, Himachal and Assam,. This is much like

the RCH-1 approach with the difference that the fund now flows through the health

department, which is useful to ensure that utilization certificates are received on time.

However, the RCH-1 experience shows that in the absence of a communication andambulance network the administration and utilization of this fund is not effective. It is not

possible to create a viable ambulance service for RCH services alone. It needs to be an

ambulance service for all emergencies of which RCH emergencies is a part. In states like


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Andhra, Gujarat and now Assam where EMRC type ambulance services are put in placeor proposed, one can ensure utilization of this- but even here the linkages of this fund

with that service are not thought through. In other states where no such ambulance

services are available, integration and utilization of this fund will remain a challenge.There is room for much more state specific adaptation of this component.

Technical Assistance needs:

a. Assisting states in developing referral transport-communication systems.b. Developing monitoring tools for estimating access of sick newborns to existing or

created ambulance referral services.

7. Nutrition and Malnutrition:

There is no coherent RCH-II plan on child nutrition and anemia, but such an approach is

beginning to evolve. This year a number of PIPs have addressed this issue. Most

important of these are Madhya Pradesh, Rajasthan, Bihar and West Bengal.

There are five approaches in the PIPs one is the Nutrition rehabilitation centers ( Guna -

Shivpuri model); the second is the IYCF programme, the third is breastfeeding promotion

which is the main part of IYCF , but can exist outside it also, the fourth is measures toaddress pediatric anemia and the fifth perhaps the most important is the prevention of

malnutrition which requires convergent planning with ICDS and which perhaps is still the

weakest component. Most states have taken up one or more of these areas and somestates have taken up no area related to child malnutrition or anemia.

Nutrition Rehabilitation Centers are required wherever nutritional wasting is an issue- say

above 10%. Wasting (low weight for height) in contrast to stunting represents acute

malnutrition which in turn signifies either starvation or serious illness. Broadly grade IVand over half of grade III children would qualify to be called wasted. A simple principle

in use is that all grade III and grade IV children need a medical examination, and

treatment of underlying medical causes is almost always required. Some of the childrenwould require hospitalization and special attention to feeding to turn them around and

break them out of the vicious cycle of increasing wasting and recurrent illness. Hence the

concept of the NRC. Madhya Pradesh has proposed 136 NRCs, up from 61 last year for

its 48 districts. Rajasthan has 39 malnutrition treatment centers, 6 in medical collegehospitals and 28 in district hospitals and 2 CHCs in each district , thus reaching a total of

about 137 such centers. It has built in adequate training for the same. Bihar in 18

districts, Delhi in two, Maharashtra in 15 tribal districts plus training 309 medical officersin PHCs, Orissa in two, Uttar Pradesh in 20 CHCs of 12 districts. In Chhattisgarh 48

centers were proposed last year, but not implemented and whether this is to be carried

over this year is not clear. This year the focus seems to have shifted to micronutrients zinc and vitamin A. In all other states the agenda of wasting and malnutrition is not

addressed as a medical issue.


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One key question is whether the NRC is a district hospital level service or a CHC levelservice. Or do we also propose a level 1 and level 2 and level 3 in this. At any rate even if

it is only a district hospital level service, is it not advisable to include this into the SNCU-

2 or SNCU 3 training and skills package. The main input for the medicalofficer/pediatrician is the set of standard treatment protocols and a good sensitization to

the programme which should be possible to fit into the FBNC training or the IMNCItraining of trainers. The starting up of the SNCU- 2 and the NRC may thus not be seen astwo separate activities but as onewith targets for both being upscaled. There are some

infrastructure arrangements especially bed space that needs to go along with the NRC-

but these can be provided in parallel and if needed use the untied funds to close gaps. The

critical input to the NRC would be the training of nurses for this role. There is a case forcreating training sites for NRC training of nurses and for sensitization of medical officers

to the issue.

The IYCF programme is included in most PIPs, but rather mechanically and the

interpretation of what this means could vary. To most it has included initiation of

breastfeeding and exclusive breastfeeding- largely by BCC activity. Complementaryfeeding is in contrast almost not mentioned and the other dimensions of child feeding are

also not mentioned. There was a need to integrate this IYCF with prevention of

malnutrition and social mobilization for the same as well as with the ICDS programme

and no PIP examines the possible convergence in this area. The best plan benchmark forthe IYCF component is undoubtedly West Bengal, which has thought this component

through.

The questions we need to ask are how does IYCF differ from and overlap with the

IMNCI? What is the way that IYCF can be expanded into an effective programme ofelimination of child malnutrition? This would be one of the key questions for technical

assistance and there is a case for piloting in a number of districts an approach that could

lead to the having of child malnutrition in a three to five year period. There are a numberof states especially Uttar Pradesh and West Bengal( positive deviance model) which have

tried to address the issue of prevention of malnutrition- but we are still short of a viable

inter-sectorally convergent, district level approach.

In breastfeeding promotion, other than what is part of the IYCF, there is little to be added

in. Some states have leveraged the ASHA programme towards this goal especially a three

district ASHA plus experiment in Uttarakhand where they are incentivising ASHAs forthis. Chhattisgarh has shown results in this area without incentivisation. Other states

have included baby friendly hospitals. There is a case for taking up these interventions in

many more states.

In pediatric anemia- the RCH-II programme is yet to get seized of the problem and even

if they do, answers would not be easy. Though deworming and vitamin A once in everysix months have become part of the routine ( though only with a 15% coverage) a once a

day pediatric iron tablet for 30 days every six months or some similar regime has been

added on in one or two states like Uttar Pradesh where an iron syrup is proposed alongwith vitamin A. This would be an useful addition in all states if we have to go the bi-


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annual way, but this has not yet caught on. Some states have added on Only Assam hasmentioned that per health worker 20 children would have their anemia corrected through

pediatric iron supplements. Meghalaya also has mentioned an effort on pediatric anemia.

At least for malnourished children this could be insisted on, given the correlation ofanemia with anorexia. This is an area that requires technical assistance- in creating

replicable successful models, in improving logistic and the introduction of pediatric ironpreparations, and in integration with child malnutrition management.Sickle cell anemia as a significant cause of childhood anemia and childhood pneumonia

is another area which the RCH-II programme design had provided for state level plans.

But this had also not been taken advantage of.

Biannual drive for vitamin A and deworming figures in almost all PIPs. Figures of past

coverage and expected improvement need to be studied. States which have proposed

newer micronutrients are Calcium and Vitamin A as part of atta fortification in Gujaratand zinc in Chhattisgarh(for 1.53 crores with another 1.32 crores on the vitamin A drive).

Areas for technical assistance:

a. Assessment of the NRC approach and working out ways to maximize outputsfrom the same.

b. Evolving replicable models of halving malnutrition rates in 3 to 5 year periods.c. Evolving replicable models of addressing childhood anemia.d. Assessing the BCC and IYCF strategies and integrating them with other activties.e. Assisting states in identifying nutrition related issues and helping them in

evolving strategies to address child malnutrition.

f. Examining the RCH-II programme design for the linkages of child health andchild nutrition and recommending on the same.

8. Malaria:

Most charts of causes of child deaths show malaria at 8%, about twice that due to

measles. These are global charts and in most of the world the API is less than 2( nonendemic for malaria) In areas where the API is more than 2, especially if that is more

than 5, one can expect the proportion of child deaths attributable to malaria to reach over

30%.

RCH-II design provided space for this in its state plans, but as the state planning processbecomes increasingly structured, malaria perhaps needs to become visible in its grids.

Malaria finds a place in the IMNCI module as the management of fever- but

incompletely. Compare for example, with the effort made on measles and we can realizethe importance. Though malarial deaths are difficult to identify we can assume case

fatality ratios in falciparum to be in the range of 5% and this should give us an

approximation of the number of child cases and child deaths due to malaria.

Child specific preventive measures, a child focus in the EDCT( early diagnosis and

complete treatment) strategy and in the ITBNs ( insecticide treated bed nets) strategy etccould make a huge difference to child survival in these areas.


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The effectiveness of IMNCI protocols to address the sick child with malaria also needs to

be studied. The entire area of recognition and integration of malaria as the fourth major

cause of childhood mortality (following neonatal deaths, ARI and diarrohea) would be animportant area for technical assistance.

The link between chronic childhood malaria( the typical tribal child with a pot belly dueto splenomegaly but thin matchstick-like emaciated limbs) and child malnutrition and

severe childhood anemia also needs to be explored. Meghalaya is the only state that has

mentioned this problem and tried to address it.

9. PPPs In the PIPs.

There is very minimal use of PPPs. Assam has proposed 4 CHCs being outsourced and150 hospitals being not only accredited but provided a cash support of Rs 15 lakhs for

equipping themselves to provide services. Gujarat has proposed a Bal Chiranjeevi project

on the lines of Chranjeevi scheme. There are voucher scheme in operation in Agra,Kanpur and Haridwar.


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Section-3

Matching TA needs from PIP analysis with Joint ReviewMission Recommendations

Many of these issues raised above were already raised in the JRM report. However manyof these issues were to be corrected by the time of this current years PIPs. By referring to

the JRMs articulation of issues, adding in our analysis of the PIPs, and further taking

inputs from discussions with number of programme officers and mission directors in the

states, we can arrive at a matrix of TA needs: In the table below we have shown the JRMrecommendation and then the corresponding recommendation from PIP analysis.

Areas of Concern Recommended Action

a) The surveys of FRUs and 24x7PHCs clearly show huge gaps in the

provision of adequate newborn care in

facilities where deliveries are taking place.

1) By March 2008, the CH divisionand states will ensure that the state PIPs

for 08-09 address the gaps identified in the

survey findings (Relevant for the eight

erstwhile EAG states, Andhra Pradesh and

Assam where surveys were undertaken).

2) We suggest that all PHCs

conducting deliveries should aspire for

SNCU-1 level of care at the earliest. All

CHCs/FRUs should aim for SNCU level 2

of care within three years, but in themeantime they should be part of the

process to reach level 1 SNCU care in all

facilities..

3) TA (task 1) would be to provide CH

division with a manual and a tool kit for

reaching SNCU level 1 of care in all PHCs

and CHCs within 18 months. This tool kit

with would be integrated with the IMNCI

module for medical officers.

4) Agencies could be specifically

recruited (TA task 2) for each state who

would work with the state to help it conduct

the training programmes and support the

state in putting in place SNCU 1 level care

in all PHCs and CHCs.


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5) TA task 3 would be to provide CH

division with a tool kit for reaching SNCU

level 2 of care in all CHCs eventually but

within three years in all places able to

handle basic or comprehensive emergencyobstetric care. As part of TA task 3 would

also be to provide a tool kit for reaching

SNCU level 3 where required. ( a tool kit

has list of equipment, list of supplies, HR

skills required, training manuals, training

strategy, model MOUs to be signed with

PPP centers for providing training, copies

of enabling orders, advocacy brochures,

standard treatment protocols, consultation

back up, evaluation processes etc).

6) TA task 4 would be hire/ equip and

empower agencies for each state to help

the state draw up a road map and walk on

it. This would include an advocacy unit for

supporting the task.

b) Highest priority should be given by

all States to ensure that at least the

essential newborn care is available in all

delivery sites so that the opportunity

provided by JSY is not lost. This

opportunity should also be utilised to

provide counselling to the women who

deliver in the institutions on immediate

initiation of breastfeeding, exclusive

breastfeeding for six months, immediate

postpartum care and also contraception.

7) By June 2008, the CH Division will

frame guidelines and disseminate the

same to the states.

This guideline is the same as TA task 1and TA task 2 given above- but such a

delineation is needed to make it happen..

c) Although IMNCI implementation is

being monitored, there is still concern that

the process is not comprehensive ordetailed enough.

8) By April 2008, UNICEF will provide

assistance to the CH division in setting up

a mechanism for monitoring IMNCI trainingand implementation across the country,

and ensure continuum between community

and facility-based care for newborns.

9) Same consultant team as identified

for TA task 2 would be put in place for also

identifying the processes of quality

assurance in IMNCI and to attend to the


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gaps in IMNCI implementation that have

been identified. They would hand hold one

agency in each state to develop the

capacity to oversee the entire child health

implementation (TA task 5)- preferably itwould the SIHFW. For this purpose

consultants may be recruited and placed

with the agency/SIHFW. They would

evolve state specific guidelines which the

state mission directors would issue in

consultation with the CH division.

d) As IMNCI roll-out is taking time,

States need to step up other actions for

improving newborn care and care of sick

children.

e) There is a need for greater

emphasis on essential new born care both

at facilities and at homes, including in non-

IMNCI districts.

f) Greater attention is needed

towards:

i. Management of asphyxia in

newborns as part of care at birthunder JSY quality assurance;

ii. Increasing use rates of ORS and

Zinc as an adjunct therapy in

children with diarrhoea; and

iii. Reducing deaths due to

Pneumonia and SAM (Severe

Acute Malnutrition).

10) By June 2008, the CH division will

provide and disseminate clear guidelines

to states on how to address new born

care essentials (through the PIP appraisalprocess). States will ensure that these

actions are reflected in their PIPs for 08-

09.

11) States may request TA for

implementing guidelines ( for modalities

refer to Section 16 of the Aide Memoire).

Improving home based newborn care: By

July 2008 select agencies/consultants

would visit each state and afterdiscussions help each state draw up or

improve on their plans for provision of

home based new born care through

ASHAs .(TA task 6) The CH concern has

to be woven into the the design of the

support structure, the mentoring and

monitoring process for ASHAs and its


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g) The Search model on Home-based

Newborn and Child Care is difficult to scale

up due to high costs and intensive

monitoring and supervision support

required. This is being attempted in 2districts in each of five states under the

NIPI, at an approximate start up cost of Rs.

7 crores per district and a recurring cost of

about Rs. 2 crores per district per year.

training programme, material and training

strategy, into the ASHA drug kit and into

the ASHA payment schedule.This cannot

be done at a national level, but only in a

state specific format. This would includeways of strategising and simplifying the

Search model and integrating it with

learnings from IMNCI and making it more

cost effective. ( these cost projections are

anyway unrealistic)- learning from the

Chhattisgarh and UP experience where

this has already been done..

Improving roll out of IMNCI: putting in

place necessary agencies who can ensure


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achieving a significant reduction in childhood anemia, which

includes ( 5 to 10 agencies may be involved) TA task 11.

s) Malaria as an

RCH issue

25) Commission a study to look at the data, to estimate

the malaria attributable maternal and child mortalities and

morbidities with correspondience to API levels and to

recommend ways of addressing this effectively andefficiently. (TA task 12)

t) PPPs in child

health

26) These have been all mentioned in the proposed

studies and scaling up TA for Innovationsthat the

development partners and the DC division have worked out

and are therefore not being duplicated here. There are

anyway few learning that are of scale.

u) BCC in child

health

27) Build up a BCC hub in each state SIHFW which can

plan for integrated BCC and as part of this include child

health issues. Help them develop up communication material

on key themes identified for the state and for each district forthree levels a) community level: ASHA and AWW, VHND,

VHSC etc; b) the facility level including the sub-center. And

c) the mass media level. To help do this and handhold the

BCC hub we would need to hire in an appropriate TA agency

for each state. (TA task 13)

v) School health (

see NHSRC note on

school health in the

PIPs)

28) TA agency to plan out and support school health in

each state. This needs to be coordinated between health

dept, education dept and NACO.(TA task 14)

Note: a, b d, e h, and l above refer to the same issue the nature of facility based care

and this much duplication is reflective of the need for conceptual clarity on this.


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Section- 4

Child Health in the RCH Project Implementation Plan

2008-09

Brief Preliminary Analysis

of each state PIP:

Note: there is a process of verification of the assessment made for

each state in consultation with the state. As also a need to improve

the statistical picture in child health performance in that stage. That

would become available in version 2.0


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NHSRC PIP appraisal of

Child Health in the RCH Project Implementation Plan Phase II 2008-09

Andhra Pradesh

1. Basic Health indicators regarding Child Health

a. Infant Mortality Ratei. Current IMR: 56-62-38 (SRS 2006- Total- rural -urban)ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006

IMR 66 62 59 59 57 56

2. Key strategies outlinedPast and proposed strategy Appraisal comments

Through the main strategy of having ASHA

in all the in habitants the Child Health care

has been addressed.Focus is also built on having convergencewith other related departments

No link has been made between

WHV and ASHA with regards to

Child Survival. This could be doneand could contribute greatly toimproved child survival. Also 31 %

of deliveries are conducted in homes

(NFHS III) and therefore essentialneonatal care should be addressed

through ASHA.

IMNCI : IMNCI training for 1000 doctors

out of 2214 doctors (RHS 2007) and 2000

staff nurses for 8 days in batches of 6. Theemergency neo-natal care for all medical

officers in 1570 PHCs and 167 CHCs total of2214 doctors.

Scale of training good but

evaluation systems and post training

follow up systems should be put inplace.

The MOs could be selected on thehigh priority based districts fortraining rather providing training for

all MOs at once. Theirs is not

IMNCI trg but a different skill set.

Proposed NICUs in all 50 CEMONC center,

but the human resource are appointed up toproject period. Infrastructure development at

these centers @ Rs 7,00,000 per unit.

The coverage provided is one center

per 16 lakhs. This needs to be scaledup to one per 5 lakhs and then once

per lakh if it has to make an impact.

CHCs and PHCs should have

SICUs/ newborn corners etc. HR

planning for NICUs to be madeexplicit.

Newborn care kit being provided to all birthsin government institutions for SC/ST/BPL

families.

Scheme operational since 2006-07.Need to plan appraisal/evaluation

Facility Level care: 24 hr child health centers

in all 800 units with obstetric and pediatric

services, for 1,00,000 rural population.

Details needed especially as regards

availability of skills for the same.


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Nutrition:

a. Malnourished: 79% (NFHS III) ofchildren are anemic.

No strategy that addresses

malnourishment or anemia of

children is proposed.

b. Breastfeeding: only 22.4% (NFHS III)

of children were breastfed with onehour. Habitation level workshops by

ASHA to sensitize community onbreastfeeding practices.

More specific promotion measures

could be outlined like in sections onBCC. a plan for this would help.

c. Referral transport being strengthenedthrough Rural Emergency Health

Transportation Scheme for poor and

SC/ST, population.

This is going on well from all

reports and would be good to know

what percentage of sick babies

transported.

School health and immunization describedseparately:

Overall comments on Andhra Pradesh PIP

a. Strategic focus on Child Health in ASHA programme would be helpful.b. More rapid roll out on scaling up of IMNCI and its integration with facility

development needed.c. HR and skills for facility based care need to be planned for.d. Focus on malnourishment is needed.e. District specification/ variation on child survival need to be studied and acted on.


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Arunachal Pradesh1. Basic Health indicators regarding Child Health

a. Infant Mortality Rate

i. Current IMR: 40-44-19 (SRS 2006- Total- rural -urban)ii. IMR Trend for last five years (as per SRS data)iii. IMR 61 in NFHS III and 63 in NFHS II

Year 2001 2002 2003 2004 2005 2006

IMR

(SRS)

40 39 34 38 37 40


Home based neo-natal care and facility based

neo-natal care yet to be addressed following

the GOI guideline.

The HBNC is very crucial for this

state as 69 % of deliveriess are

conducted in homes (NFHS III).

Therefore, ASHA (3290 ASHA)

training with IMNCI skills is should

be the focus of the state.

IMNCI: The number proposed for IMNCI

training has increased from the previous year(from 64 MOs to 90 MOs)1.

IMNCI training for AWW (320 proposed)

and ANM (60 proposed) is inadequate as thetotal percentage trained is only 16% of

AWW and 8.33% of ANM.

Only 33% of deliveries are attended

by skilled birth attendants (NFHSIII) and only 23% receive PNC

(NFHS III), therefore the IMNCI

training should focus more ontraining of ASHA/ANM/AWW.

Facility Level Care: Facility level

strengthening particularly in case of Neonatal

Care should be focused, as there is anincreasing trend in IMR.

Two MMUs functioning should be evaluatedso that it could be scaled up to other districts.

The terrains and the difficult areas

could be accessed with the help of

MMUs. There is a need for scalingup of MMUs in the state.

Referral transport for mother and children has

been proposed with Rs 300 per case, however

only 8 ambulances are provided. This seems

to be inadequate for improving theinstitutional deliveries and thereby child

survival.

More concentration could be paid on

the implementation of referral

transport. The MMUs could also act

as referral transports in areas visited.

Nutrition:

a. Malnourished: 66% of children below 3years are malnourished (NFHS III) and

1 However according to Rural Health statistics of 2007, there are only 78 MOs in 85 PHCs.


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intervention designed with SWWCD and

DFHW should be evaluated for continued

support.

b. Breastfeeding: only 55% (NFHS III) ofchildren are breastfeed within one hour.

The interventions could be madefollowing ASHA training.

The details of the IEC areencouraging to reach the

community.

c. School health and immunizationdescribed separately

Overall: The state of Arunachal Pradesh, should concentrate more on Home Based Neo-natal care (HBNC). Considering the terrain more ASHAs should be trained in HBNC.

Some districts where the female under five mortality is prevalent (mainly in East

Kameng) should have more BCC/IEC activates proposed by ASHA and other health

workers (ANM, AWW) and also community level participation for bringing behaviorchange. Moreover number of ASHA selected from this region is also inadequate, and

should be addressed immediately.


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Assam

1. Basic Health indicators regarding Child Healtha. Infant Mortality Rate

i. Current IMR: 67-70-42 (SRS 2006- Total- rural -urban)ii. IMR Trend for last five years (as per SRS data) (total/rural)

Year 2001T (R)

2002T (R)

2003T (R)

2004T (R)

2005T (R)

2006T (R)

IMR 74 (77) 70 (73) 67 (70) 66 (69) 68 (71) 67 (70)


a. Home Based New Born care: healthworkers from 20/23 districts are to be

trained with SBA providing home basedneonatal care.

Described in BCC section but

not detailed under ASHAs

b. IMNCI : IMNCI training in 5 focusdistricts through 120 TOTs and 2880

H&N workers. TOT for health workers

@ Rs 12.91 lakhs and IMNCI training

for ANM/AWW Rs 184.33 lakhsc. IMNCI, two kits per trained workers.

Kits are provided to 6000 H&N workers

@ Rs 1850/kitd. To achieve a target of 65% from existing

35% (NFHS III) awareness andtreatment about ARI, healthfunctionaries are provided training for

early detection and referrals and also

ambulance services are proposed.

e. Multiskillng of 32 MOs fromFRUs/CHC on newborn care @

GMCH/AMCH/SMCH for 6 months, Rs.

28.57 lakhs

Need to synergized betweenwhere outreach workers are

trained in IMNCI and FBNC and

SNCU I in proposal been planned.

There is a need for these to gotogether to go together for making

an impact. We assume that FBNC

refers to PHC staff and SNCU todistrict and CHC staff but this is

not clear and we hope they havegot it right.Details of a six month course for

newborn care needs to be

understood.

f. Facility Level care:

i. SNCU training in 5 focused districtsfor 100 MOs (Jorhat, Dibrugarh,Kamrup, Goalpara, Barpeta, Darrang,Cachar, Sonitpur and Sivsagar) and

setting up stabilization centers in all

108 CHCs and 149 BPHCs. SNCUtraining for 5 batches of 100 MOs

would cost Rs 2.73 lakhs/batch.

This is an area that requires

technical assistance. Thedifference and content of the three

programmes SNCU at CHC,SHCU at district hospital and

FBNC are different.


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ii. Setting up of SNCU in 10 districthospitals (Goalpara, Sibsagar Barpeta,

Darrang, Sonitpur ,Bongaigaon,Golaghat, Nagaon, Karbi Anglong &

Cachar) @ Rs 112.91 lakhs

g. FBNC training to all MOs (80 MOs) inBongaigaon, Nagaon, Cachar, Sonitpur,

Dibrugarh @ Rs 43,66,080/ . TOT forFBNC @ Rs 12.128 lakhs.

Nutrition:

a. Malnourished: 40% of childrenare underweight and 13% arewasted (NFHS III).

b. Anemia: 76.7% to addresschildhood anemia, 20 mg

elemental iron and 100 mg offolic acids (600 IFA tablets) and

deworming to be done throughhealth workers @ 20 children per

worker per year.

c. Further integration with ICDSfunctionaries, for midday mealprogramme.

d. Mass campaign of vit A by healthworkers and Vit A solutions withAHSA/AWW/ANM.

e. Breastfeeding: 50.6% (NFHS III)of newborn are breastfed withinhour of delivery. IEC/BCC by

health workers for exclusive

breastfeeding. The highlight is ofprohibition on artificial milk and

bottle feeding in health

institutions

Strategy on malnutrition

inadequate. There is an anemiastrategy that needs to be followed

up. Breastfeeding is well focused.

Need to be able to monitor

outputs and outcomes of BCCseparately.

h. Referral transport being strengthenedand separate budgetary head placed for

neonatal transport facility and for ARI

and Diarrhea for Rs 500/case(complicated cases) @ an estimate of 5%

might need transport.i. Integration with Medical, Fire and Police

Department for EMRI; 300 ambulance

@ Rs 115.13 crore.

This is an inadequate approach to

referral transport and will face the

same problems as RCH-1 faced.

Need to integrate with Emergencytransport system with a process

indictor related to the sick child.

j. PPPs: developing partnership withprivate sector for PPP in providing

j.Details need to be examined for

comment.


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newborn care services by outsourcing 4

CHCs. Total cost Rs 0.86 crore for

administration, documentation andmanagement.

k. 150 Pvt. Hospitals are proposed under

PPP @ an annual grant of Rs 15 lakhs.

k. This PPP specfies that Rs 15

lakhs to be give n to 150 pvthospitals but with no clarity on

returns or terms of MOU given.

Possibly more details need to begiven but now it looks very

much like a hand out.

l. Innovations: maternal and child healthmonth bi annually

m. 31 MMUs proposed @ Rs16.88 Crore.,with 2 MOs, 2 GNM & ANMs.

However, 27 MMUs are implemented in10 districts of the state.

n. Boat clinics are proposed in three newdistricts (making to a total of 5 districts)

in partnership with C-NES Rs. 2.41Crore.

ANM posts are vacant in 80/5109

HSCs (GOI, 2007)2 and it is

proposed that MMUs will behaving two ANMs.

o. School health and immunizationdescribed separately:

p. Introduction of a communicationpackage of home based new born care by

all workers: IEC/BCC activities through

6000 LHVs @ Rs 2.25 crore/-

Overall: 77% of deliveries are conducted at home and its even worse for rural area i.e.,

82% and only 31% of deliveries (NFHS III) are attended by health personnel and only13.8% receive PNC (NFHS III). The Assam state government has to strengthen the home

based newborn care (HBNC), followed by strengthening of referral system and thefacility based newborn care.

2 GOI (2007), Bulletin on Rural Health Statistics in India, Ministry of Health and Family Welfare, Chapter

II, Table 19, Number of Sub-centers, PHCs, and CHCs functioning , pp 32.


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Bihar

1. Basic Health indicators regarding Child Healtha. Infant Mortality Ratei. Current IMR: 60-62-45 (SRS 2006- Total- rural -urban)

ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006

IMR 62 61 60 61 61 60


HBNC

Documents

Child Health in the State PIPs 2008 09 Mapping Technical Assistance Needs Version 1 0-620