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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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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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Areas of Concern Recommended Action
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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Areas of Concern Recommended Action
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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Areas of Concern Recommended Action
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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NHSRC PIP appraisal of
Child Health in the RCH Project Implementation Plan Phase II 2008-09
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
2. Key strategies outlinedPast and proposed strategy Appraisal comments
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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NHSRC PIP appraisal of
Child Health in the RCH Project Implementation Plan Phase II 2008-09
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)
2. Key strategies outlinedPast and proposed strategy Appraisal comments
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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NHSRC PIP appraisal of
Child Health in the RCH Project Implementation Plan Phase II 2008-09
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
2. Key strategies outlinedPast and proposed strategy Appraisal comments
HBNC