Program Management Group - United Nations Development

Program Management Group May 28, 2012

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Norway India Partnership Initiative

Program Management Group

May 28

2012 Meeting notes for the 13th meeting of the Program Management Group


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Table of Contents Agenda .............................................................................................................................................. 3

Decisions from 12th JSC ...................................................................................................................... 4

1.0 Executive Summary ..................................................................................................................... 5

1.1 Background ................................................................................................................................. 5

2.0 Expenditure and Budget Statements ............................................................................................ 6

2.1 UNICEF ........................................................................................................................................ 6

UNICEF ...................................................................................................................................... 6

2.2 UNOPS LFA ................................................................................................................................. 7

UNOPS LFA NIPI Programme ...................................................................................................... 7

Disbursements to States (in INR) ................................................................................................ 7

2.3 NIPI Secretariat Budget / Expenditure ......................................................................................... 8

2.4 WHO .......................................................................................................................................... 9

3.0 Programme Progress ................................................................................................................... 9

3.1 WHO ........................................................................................................................................... 9

3.2 UNOPS NIPI-LFA ........................................................................................................................ 10

3.3 UNICEF ...................................................................................................................................... 13

3.4 Progress Report NIPI Secretariat .............................................................................................. 14

3.4.1 Gender Equity ......................................................................................................................... 14

3.4.2 PCPNDT Techno Managerial Support ..................................................................................... 15

3.4.3 SNCU Techno Managerial Support .......................................................................................... 16

3.4.4 Rapid Assessment of Yashodas Mamtas – Top-line Findings .................................................... 17

3.4.5 Data Management Information System DMIS ........................................................................ 19

3.4.6 Save the Baby Girl Analysis ..................................................................................................... 23

3.4.7 M&E Report ........................................................................................................................... 24

State Allocations for MCH ............................................................................................................ 24

Orissa ........................................................................................................................ 26

Bihar Rajasthan ............................................................................................................. 28

4.0 Operational Research Results.................................................................................................... 32

4.1 PHFI Study on ASNI .................................................................................................................... 32

4.2 ANSWERS Assessment of pivotal issues related to infant feeding and child nutrition in India: .... 33

4.3 Exploratory Research for Identification of Determinants of Neonatal Health With Reference to Survival of Neonates across Health Facilities in Selected Districts of Rajasthan and Maharashtra..... 34

Annexure 1 PHFI Cost Analysis Inception ....................................................................................... 35

Annexure 2 ANSWERS BF Study Recommendations ....................................................................... 37

Annexure 3 OR Inception Report ................................................................................................... 44

Annexure 4 12th JSC Minutes .......................................................................................................... 52

ACRONYMS AND ABBREVIATIONS ......................................................................................... 53


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XIII NIPI Programme Management Group (PMG) meeting on 28th May 2012 at 3.00 pm Venue: Conference Hall on the 2nd floor,

A wing, Nirman Bhawan, MOHFW. The NIPI Programme Management Group (PMG) acts as technical advisory board for the Joint Steering Committee of the Norway India Partnership Initiative. The role of the PMG is to review proposals of Partners of NIPI and give its recommendations to the Joint Steering Committee.

Agenda 1. Opening remarks:

Mission Director, MoHFW, Government of India

Director, NIPI Secretariat

2. Decision from 12th JSC

3. NIPI partnership Disbursement Overview : UNICEF, UNOPS LFA, NIPI Secretariat, WHO

4. 5 year summary of achievements and results update by WHO (new concepts, proposals and

budgets for 2012 requiring JSC decision)

5. 5 year summary of achievements and results update by UNOPS LFA NIPI Programme ( proposals

and budgets for 2012 requiring JSC decision) pages 10-13

6. 5 year summary of achievements and results update by UNICEF (new concepts, proposals and

budgets for 2012 requiring JSC decision) page 12

7. NIPI Secretariat update

a) Gender Update b) PCPNDT Techno Managerial Support c) SNCU Techno Managerial Support d) Rapid Assessment of Yashodas e) Data Management Information System f) Save the baby Girl g) M&E Report

8. Operational Research update

9. Any other business with permission from the Chair.


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Decisions from 12th JSC

The 12th JSC endorsed UNICEF’s proposal on Baseline assessment of quality of maternal-newborn care

o USD 500,000 was approved for the model development intervention, then subsequent funding was contingent on the outcome of the baseline. The Joint Secretary said that this should include the cost of sensitising other Development Partners to this model so that they can take this up in those States where they are functioning. The additional budget was shared with the NIPI Secretariat.

RNE agreed to funding NCHRC as far as the 12th budget plan. Only short term bridging funding after that date would be possible if for some reason there was a delay in GoI picking up financial support.

o The Chair requested NIPI engage a professional to raise the visibility of NCHRC and make it more functional as a resource centre.

o The budget of NCHRC would remain at the same level for the next 6 months [to the end of June 2012]. SCHRCs will not receive NIPI funding after April 2012. The Joint Secretary said that the focus should be on strengthening the National Child Health Resource Centre (NCHRC). States may take up supporting SCHRCs should they feel they are contributing to the goals of NRHM. NIHFW will subsume NCHRC into the Library department. Maintaining the repository for Child health resources should be the focus of NCHRC’s work.

The JSC Chair suggested that the NIPI Secretariat could be placed in their new setting by the 1st week of January 2012.

o The need to maintain and independent and objective presence serving all the NIPI Programme partners equally was recognised.

o Current host agency of NIPI Secretariat strongly resisted the re-location. NIHFW open to housing NIPI Secretariat but is willing to defer arrangements until such logistical and managerial issues are resolved.

WHO budgeted for USD 875,000 in 2012 but no additional funds were required to meet this.

o 12th JSC approved of this budget assessment.

The 12th JSC approved the 2012 UNICEF Budget of USD 5,300,000

The 12th JSC approved that the UNOPS NIPI LFA budget would be settled bilaterally between the NIPI LFA and RNE, and in the interim a provisional budget would be used.

o The UNOPS LFA Budget was approved in April 2012.

The 12th JSC approved that the NIPI Secretariat budget would be settled bilaterally between the NIPI LFA and RNE, and in the interim a provisional budget would be used.

o The NIPI Secretariat Budget was approved in April 2012.


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1.0 Executive Summary

1.1 Background

The 13th NIPI Programme Management Group has departed from the traditional format of previous PMGs and has focused on a retrospective analysis of the past 5 years of NIPI partnership results, and the past 2 years for the NIPI Secretariat. NIPI’s original program has entered into its final year, and taking stock of results achieved and challenges encountered is timely. The information will provide input to the planning of a second phase of NIPI up to 2017, as agreed by the Governments of Norway and India. Each implementing partner shall present a report summary of their first phase of NIPI interventions, and provide some suggestions as to where they may shift their focus. As the following partner reports will indicate NIPI interventions fall under 3 main categories implemented by 3 UN agencies viz., UNOPS, WHO and UNICEF within the NRHM framework.

Quality services for mother and child

Enabling mechanisms

Learning and sharing The implementation of Integrated Management of Neonatal and Childhood Illness (IMNCI) and Home Based Newborn Care (HBNC) have increased health monitoring coverage of mothers and newborns in their own communities. The British Medical Journal in a recent study concluded Implementation of the IMNCI resulted in substantial improvement in infant survival and in neonatal survival in those born at home. The IMNCI should be a part of India’s strategy to achieve the millennium development goal on child survival.1 Other research conducted by Public Health Foundation of India (PHFI) on NIPI interventions suggested bringing these aspects of health care together, facility and community, to improve referral systems and follow up post discharge, in order that the continuum of care is maintained has a significant impact on infant survivability. The combined benefits of Yashoda (facility based maternal assistants) and ASHA (Community based health activists) on newborn care showed that the dual exposure of mothers to both Yashoda and NIPI trained ASHA had an incremental effect on newborn care indicators, in both counselling and practice. For example, mothers in one NIPI focus district were three times more likely to have received counselling on keeping the baby warm compared to mothers in the control district. Similarly, birth registration was two and a half times greater among mothers who had dual exposure to Yashoda and ASHAs in the same focus district compared to mothers in control districts. These results suggest that NIPI interventions on the whole have resulted in improved information among mothers and better outcomes for the newborn.

1 BMJ 2012;344:e1634 doi: 10.1136/bmj.e1634 (Published 21 March 2012)


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Simply promoting facility-based newborn care has significant potential to improve newborn survival. In another study the Lancet estimates that health-facility based interventions can reduce neonatal mortality by as much as 25-30%2 . If NIPI is to continue assistance to Government of India in a second phase to achieve national health targets and Millennium Development Goals to bring down childhood mortality, it will remain committed to finding ways to make existing health systems function so as to improve quality new born care services and provide quality health care for women, infants and young children under the NRHM and its reproductive and child health program (RCH II).

2.0 Expenditure and Budget Statements

2.1 UNICEF

UNICEF

UNICEF NIPI DISBURSEMENT DETAILS 2006-2012

YEAR NOK USD Date Ex rate

2006 14,600,000 2,332,204 13.12.2006 6.27

2007 13,950,000 2,305,796 29.06.2007 5.9

2008 25,910 5,121 26.06.2008 5.06

2008 25,884,090 5,115,473 08.07.2008 5.177

2009 16,753,826 2,694,015 27.08.2009 6.219

2010 20,500,000 3,497,710 15.10.2010 5.861

2011 7,100,000 1,311,157 02.08.2011 5.415

2012 16,000,000 2,730,400 21.02.2012 5.86

TOTAL 114,813,826 19,991,875

2 Lancet 365:977-88


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2.2 UNOPS LFA

UNOPS LFA NIPI Programme

Summary of NIPI LFA Funds Received and Expenditure from the year 2006-2011

(in figures in USD)

Particulars Amount

Funds Received 21,755,875.00

Interest Earned 125,685.00

Total Funds Received (A) 21,881,560.00

Expenditure

National Level including State offices 5,018,500.67

Disbursement to State 14,699,593.33

Total Expenditure (B) 19,718094.00

Remaining Fund Balance (A-B) 2,163,466.00

Disbursements to States (in INR)

States

Total Amount Released to the States 2008-2009

Fund released in Year 2011

& 2012

Total Fund released to

the States till March 2012

UC + Expenditure Report as on

Mar' 2012

Fund Balance as on 1st Apr

2012

Budget for next 3 Qtrs

Fund Requirement

in States

Bihar 140,015,536

79,625,455

219,640,991

173,918,186

45,722,805

40,820,700 -

Rajasthan 156,000,000

20,000,000

176,000,000

147,744,116

28,255,884

49,742,396

21,486,512

Orissa 148,500,000 -

148,500,000

110,315,770

38,184,230

36,350,600 -

Madhya Pradesh

156,500,000 -

156,500,000

116,323,513

40,176,487

50,013,258

9,836,771

Total INR 601015536 99625455 700640991 548301585

152339406 31323283


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2.3 NIPI Secretariat Budget / Expenditure

NIPI Secretariat Budget Statement from the period of 2011

(all amounts in USD)

Particulars 2011

Approved Budget 1,948,374

Expenditure 964,210

F & A 47,360

Total Expenditure 1,011,570

Budget Balance 936,804

NIPI Secretariat Cash Statement from the period of 2006-2011

(all amounts in

USD)

Particul-ars

2006 2007 2008 2009 2010 2011

Cash Balance

1,152,249

5,161,530

977,463

847,630

1,208,759

Fund Received

1,147,285

11,127,296

814,372

671,550

1,708,361

884,696

Interest Income

4,964

76,232

155,416

8,101

3,704

5,272

Transfer Funds

(10,624,687)

TOTAL INCOME

1,152,249

12,355,777

(4,493,369)

1,657,114

2,559,695 2,098,727

Expend-iture

-

6,851,663

(5,210,316)

770,946

1,286,605

964,210

F & A

-

342,584

(260,516)

38,539

64,331

47,360

TOTAL EXPEND-ITURE

-

7,194,247

(5,470,832)

809,485

1,350,936 1,011,570

CASH BALANCE

1,152,249

5,161,530

977,463

847,629

1,208,759 1,087,157


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2.4 WHO

WHO NIPI Disbursement Details 2006-2012

Year NOK USD Date EX rate

2006

1,400,000

223,285 20.12.2006 6.27

2007

6,279,700

1,064,356 28.06.2007 5.90

2008

13,835,298

2,650,440 11.08.2008 5.22

2009

814,530

141,166 14.12.2009 5.77

2010

1,500,000

251,256 24.12.2010 5.97

2011

1,000

180 14.05.2011 5.56

2012

1,000

175 29.04.2012 5.72

TOTAL to date 23,831,528 4,330,858

3.0 Programme Progress

3.1 WHO

W H O P R O G R E S S R E P O R T

Presentation on progress will be made at PMG meeting.


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3.2 UNOPS NIPI-LFA

U N O P S L F A P R O G R E S S R E P O R T

UNOPS NIPI Program Financial Report and Budget

Presentation on progress will be made at PMG meeting. Development of Comprehensive Newborn Care Package at District

HBPNC Yashoda SNCU IMMUNIZATION MMT

Health System Strengthening • NCHRC at NIHFW • NCRC at PGIIMER • DTCs at Districts • Supportive Supervision systems for HBPNC

Tools • Operational Guidelines • Training packages for Yashoda, Yashoda Supervisors, HBPNC, ASHA Supervisors,

SNCU , SNCU-Plus and Managers. • Job aids - Counseling Cards, referral Booklets

Newborn kits, HBPNC kits • Checklists & reporting systems – Checklists for monitoring of Trainings, PNC Card,

Supervisors and Managers checklists and Customized HBPNC , SNCU Software Promoting Gender Equity as a cross cutting issue across interventions

Quality Services for Child Health SNCU

• Model SNCUs operationalized (Total 9 in 3 states) Gender segregated data being monitored & follow up

HBPNC • Operationalization of HBPNC through ASHAs (4 states). ASHA empowered • Supportive supervisory mechanisms (3 states)

SNCU-Plus Initiated in 2 states (Care and follow up of newborns discharged from facility) offering platform for Early Child Care and Development. Special focus on Girl Child Yashoda

• Strengthening quality of care for mothers and newborns in institutions. Ensuring mother’s entitlement

Techno-managerial support • Strengthening program management capacity for Child health and Immunization at state,

district and block level through managers. Gender specific planning. • Institutional strengthening

• Establishment of NCHRC • Establishment of Newborn Care Resource Center, IPGMER Kolkata • Establishment of District Training Resource Centers • State level, district based SNCU Training and Treatment Centers (Hoshangabad) • Strengthening ANM and GNM Training Centers through Jhpiego (Bihar)


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• Establishment of State Nodal Training Sites for PPFP/PPIUCD, (Jaipur) • Guidelines & Tools

Capacity Building, Operational process and AV aids etc. • Payment & Payment Processes

• Mobile Money Transfer process • ASHA referral Fund • Mobility support for managers • Monitoring processes • HBPNC Software development • Tools for review of HBPNC and Immunization at District and Block • SNIMMS

Learning & Sharing • Guidelines and Tools

– Contribution to National HBNC and FBNC Guidelines – Facilitated National Health Managers Guide for Immunization

• Building learning platforms – NCHRC – NCRC – SCHRC

• Experiences in organization of district Vaccine stores (Hoshangabad) • Technical support towards operationalization of comprehensive newborn care interventions

in Haryana state • Experiences in DTRC (Orissa, MP) • Field assessment for development of Health care delivery models for facility based care

through PPP (Access: Bihar and Orissa)

Interventions Bihar Odissa Madhya Pradesh

Rajasthan

SNCU Under construction

SNCU training and treatment center Under progress

SNCU plus ( and follow up Care of cases discharged from SNCU

Under progress

Delivery of HBPNC services

Delivery of Supportive Supervision through PPP model

Strengthening system supervisory support

Under progress

Operationalization of Yashoda Process


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Strengthening management skill in Immunization

District Health Training and Resource Centers Manual to be developed

Under progress

Hoshangabad functional,

Narsinghpur under

progress

Under progress

NIPI-LFA work at a glance 2009 onward….

Intervention Input Output

SNCU All manpower of 9 SNCU trained

26,313 sick newborns have been treated in the above mentioned SNCUs..

HBPNC

14684 ASHAs oriented and provided supportive supervision

440,718 Mother-Newborns provided 6 home visit by ASHA While, 6096 sick newborns indentified & referred to health facility for treatment

Yashoda / Mamta

1469 Yashodas trained & supported

Annually More than 4 lacs mother –newborns are being served in 148 health facilities

Techno managerial support

177 manpower at different level

Programme management support at state , district and block for child health & immunization programme .

Unfinished Agenda (2007-2012)

• Existing Districts – SNCU-TTC – SNCU-Plus – DTRC – Capacity building for supervision and programme management

• Continued technical support to Haryana Suggestions for Phase-II (2012-2015)

• Completion of unfinished agenda • Expansion of district based comprehensive newborn package in newer geographical area • Technical expansion to include interventions for infants (ARI, Diarrhea, Fever and ECCD)


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3.3 UNICEF

U N I C E F P R O G R E S S R E P O R T



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3.4 Progress Report NIPI Secretariat

N I P I S E C R E T A R I A T R E P O R T


3.4.1 Gender Equity Promotion of gender equity is one of the overarching principles of the NIPI Programme. The Joint Steering Committee (JSC) in several meetings gave direction to the three implementing partners (UNICEF, WHO and UNOPS) that gender mainstreaming efforts must be made, across all NIPI interventions. Except Yashoda intervention by LFA, and some of the management trainings for the block and district level trainings in Rajasthan and Orissa by LFA, an organized NIPI gender strategy did not emerge till 2010. The reasons include: assumption made by the implementing teams that almost all the RCH services are for women and majority of the service providers at the grassroots level are women and therefore NIPI programs are automatically gender sensitive; As NRHM focuses on equity, which subsumes gender equity, NIPI need not have a gender strategy; as the UN agencies followed the umbrella UN gender policy, NIPI need not have a gender strategy The Secretariat, without dedicated gender practitioner could not enthuse the partners to address the gender equity concerns in systematic way in their interventions. In the 5th JSC the Co Chair recommended developing an inter ministerial approach to addressing common gender concerns within the NRHM .The NIPI Strategy document of 2008 highlighted that “Under NIPI, it is especially important to be highly proactive on gender issues, as successful outreach and provision of quality child and maternal health services can often be affected by, if not dependent on, how well gender considerations are identified, then dealt with during implementation”. Followed by this the Mid Term Review (MTR) document 2009 pointed out that the “current programs do not explicitly address gender issues or have a strong gender component. As an overarching principle, gender mainstreaming processes need to be firmly embedded into NIPI initiatives. As a follow up, a Gender Advisor was recruited and placed in the NIPI Secretariat from September 2010. In January 2011, during a NIPI partner retreat, it was agreed by all the partners that gender as a cross cutting issue, will be reflected in operational research studies and other interventions. All the reports will collect sex disaggregated information where possible and make appropriate analysis for corrective measures. The semi- annual reports have started reflecting sex disaggregated data as a starting point. The NIPI Secretariat adopted a three pronged approach which included (a) working with the partners (b) working with the national government (c) working with other UN agencies. Based on a request from government of Rajasthan, a gender manual was developed for enhancing gender understanding and application in the day to day work of grass roots health service providers. The secretariat is engaged with UNFPA for developing a national level communication and education strategy for addressing declining child sex ratio issues; and with partners UNICEF for developing standards and guidelines for making the facilities mother and baby friendly; and with WHO on an adolescent reproductive health intervention focusing on postponing the first pregnancy and spacing


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the other pregnancies. Two consultants (legal, and monitoring) have been provided to the PCPNDT division of the MoHFW. (see report below.) Gender Results: The gender manual is being used in the HBPNC, SNCU plus trainings of the health service providers in Rajasthan. Orissa has included the budget in their PIP for developing the gender manual in Oriya, as per the local context and for dissemination in the three districts. Bihar in their five day HBPNC training of trainers scheduled in June will make the gender manual as part of the self learning material for further dissemination to ASHAs. Facilitation is provided to the UNOPS LFA team to integrate the gender aspects in their ‘supportive supervisory’ trainings curriculum and worksheets for the emerging supervisory cares at the district and block levels. Through cooperation with UN Women, for convergence of gender and governance issues, the gender manual will be integrated with the TOT manual prepared by NIRD Hyderabad, for capacity building PRI members.

As per the request of the PCPNDT Division of the government of India, a communication package has

(two one minute TV Spots, two radio jingles and print advertisements) been developed and the

concept has been approved by the ministry. The production processes as on currently. The package

aims to empower the youth to question the practice of sex selection and commit to protect and

nurture the girl child. The final products are expected by the third week of June 2012, which will

have 12 language adaptations.

3.4.2 PCPNDT Techno Managerial Support The PCPNDT M&E Consultant has been coordinating with members of PNDT Central Supervisory Board for the 18th meeting held on 14th January 2012 in Mumbai. During the meeting some of the rules and regulations of PC & PNDT Act were amended. A one day orientation programme was organised by Indore Division of Madhya Pradesh for Medical Officers and DPMU staff on PC & PNDT Act, where M&E aspects of the implementation of the PC & PNDT Act were discussed. This included 50 participants from all 8 districts of Indore division. A desk review was conducted in consultation with JS and Director with Nodal Officers of State/ UTs pertaining to the status of implementation of PC & PNDT Act. A calendar and agenda was finalised and communicated to all Principal Secretary, Health of States/ UTs. Four States (Manipur, Andhra Pradesh, Uttar Pradesh and Delhi) were called for desk review on 2nd and 3rd Feb.2012. All aspects of implementation were covered during the desk review followed by State specific recommendations. A monitoring visit to Aizawl to track the status of implementation of PC & PNDT Act was carried out in the State of Mizoram. States/ UTs have sent their State PIP for next financial year (2012-12) to the Ministry of Health to provide comments against each components of the PIP. The Director of PNDT in consultation with the PCPNDT M&E consultant furnished comments on the components of 16 State PIPs which has been sent to the concerned State/ UTs. A monitoring visit was conducted to track the status of implementation of PC & PNDT Act in the State of Karnataka.


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A two day orientation programme on PC & PNDT Act was organised between 27 - 28 February 2012 in Heritage Village, Gurgaon for State Appropriate Authorities and State Nodal Officers. Presentation on “Activities under PC & PNDT in State/ UTs Programme Implementation Plan” was delivered by the PCPNDT M&E consultant. 20 State PIPs for FY 2012-13 were further reviewed for final approval of programme activities and related budgets by the PNDT Division. A monitoring visit was conducted to review and monitor status of implementation of PC & PNDT Act in the State of Bihar in April 2012. The PNDT Division also prepared answers for 4 Parliamentary questions which arose in the past 5 months. The PCPNDT M&E Consultant presented at a one day workshop on PNDT in Kolkata, where State specific issues pertaining to implementation PNDT and activities for future consideration were discussed. At the workshop were 150 participants including the State Health Minister and other first line administrators of Health Department of West Bengal. THE PCPNDT legal consultant visited Chandigarh to follow up on a Writ Petition which was filed in the High Court there in which Ministry of Health was impleaded as a party. The Panel Counsel who was supposed to represent the UoI was briefed on the legal stand of the Government in the issue involved. On-going capacity building of the judicial fraternity and an ongoing process of sensitisation on PCPNDT is an important component of the PNDT Division’s programme. The PCPNDT legal consultant has been actively involved in coordinating and organizing several workshops, recently travelling to Hyderabad to participate in a capacity building forum organized for Judicial Officers at the Andhra Pradesh Judicial Academy. The PCPNDT legal consultant has also been working on the amendments pertaining to the portable machines have been approved and duly notified by the Ministry. A copy of the notification is available from the PNDT division at the Ministry. Finally the PCPNDT legal consultant has been involved in replying to legal queries posed by the implementing agencies and other cases in different courts, and is working on another set of amendments to the PC & PNDT Rules, which the Ministry is looking to notify in the coming months.

3.4.3 SNCU Techno Managerial Support At the beginning of 2012 there were 304 SNCUs, 1210 NBSUs and 9824 NBCC registered with the Ministry of Health and Family welfare. Whereas now at the time of the PMG, as per the current figures, the number of SNCUs is now 374. Similarly the number of NBSUS have risen to 1638 and the NBCCS are11324. From April 2012 the Ministry has been able to persuade various States to begin the reporting from the SNCUs on a monthly basis. The line listing of NBSUs has been streamlined and reports from the NBSUs are expected to begin to be received. The daunting task of contacting all the 35 States and UTs for the reporting results of SNCU is being done by the National SNCU coordinator, in order that the inflow of reports may be streamlined.


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Monthly meetings with the National Collaborative Centre and the team of NCHRC are planned so that any mid course corrections if required may be considered and to encourage better coordination amongst the interested parties. During this quarter of 2012 the National SNCU Coordinator visited five States covering the Eastern (Assam and Meghalaya 15-18 Apr,12) and the Western (Rajasthan 22-24 Apr 12) regions of the Country. Haryana (22-24 Feb 12) the state which is planning a large number of SNCUs was also visited to assess the implementation progress. Haryana State visit was especially useful because the changes that were suggested in the floor plan could be executed as the construction is ongoing. The coordinator’s visit to West Bengal (21-24th Mar 12) assisted with providing an insight to plan for Treatment and Training Centres in other States. These specific inputs will be very useful while planning for the State Perinatal Resource Centres which are in the pipeline. The National SNCU Coordinator also worked with the Head Office of National Polio Surveillance Project (WHO INDIA) and the GIS system which is used for maintaining a large number of units spread all over the country, with the view of replicating this model for SNCUs. Other fora attended by the SNCU National Coordinator were the 12th Thematic group meeting for Child health, and the first meeting of the Neonatal Action Group Meeting. The group decided on some important action points related to the reporting and quality of the newborn health care in the country. The minutes of the meeting will be shortly disseminated. NIPI has contributed to the development of monitoring tools for SNCUs, HBPNC and has developed supportive supervision tools. NIPI also has also contributed to the development of the model of State Perinatal Resource Centres. The National SNCU Coordinator was also involved in finalising of the State PIPs of two states and 4 UTs, which included the first comments on Delhi and UP PIPs. As Uttarakhand has the highest rate of mortality in India the SNCU national coordinator is planning a visit to this state and also Jammu and Kashmir as they have requested for help from National experts to help in improving quality of Newborn Care.

3.4.4 Rapid Assessment of Yashodas Mamtas – Top-line Findings Overall Recommendations

Mamtas/Yashodas is an innovative intervention

As an intervention, it has the potential to contribute to child survival

Key findings demonstrate that Mamtas/ Yashodas do contribute to main indicators for child survival

o Initiation of Breastfeeding within 1 hour o Wrapping of newborns to keep them warm o Immunization of newborns

Mamta / Yashoda has demonstrated her role in: o Creation of a comfortable environment o Counselling of mothers on key indicators:

Initiation of breastfeeding within 1hour of birth Correct positioning of newborns for breastfeeding Stay at health facilities for at least 48 hours Regular weight check up of neonates


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Provision of services for mother & new born o Providing moral support to women in labour room and maternity ward o Assist in initiation of breastfeeding within 1 hour of birth o Assist in correct positioning of newborns for breastfeeding o Cleaning & Wrapping newborns o Weighing newborns o Immunization o Assisting in ensuring immediate medical attention for sick newborns

Linkages with ASHAs o Support to ASHAs o Enables ASHAs to focus more on community work

Scaling up should be undertaken in a Phased manner with strong components of o Involvement of the health system in defining the role of Mamtas/ Yashodas o Continuous capacity building of Mamtas/ Yashodas o Trained supervisory cadre to be in place o Continuous and regular training of Child Health Supervisors

Need to strengthen the linkages of Mamtas/ Yashodas with ASHAs to effectively implement continuum of care approach

Standardized guidelines required for payment modality. Monthly payment is a preferred mode

Along the continuum of care, Mamtas/ Yashodas are an important connect between health service providers and the community. Their role is significantly important in the lives of the mothers in an environment away from home. Mamtas/ Yashodas are facilitators and friends to these women, just as ASHAs are.

Household Hospital


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3.4.5 Data Management Information System DMIS ‘Data Management Information System’, henceforth referred as DMIS, in its current form has been evolved over the past one year. ‘A systematic approach to a systematic data management system’ has been the core principle while developing the same. As mentioned above, the underlying principles during the development process included the following steps: 1. Understanding the needs of the Client 2. Developing a DMIS framework to include all interventions of the implementing Partners 3. Prioritising the interventions into phases 4. Defining key indicators for representation 5. Review of existing formats for data collection at source 6. Developing input and output formats to ensure standardization of data collected at source 7. Software development 8. Beta testing of software to smoothen all emerging issues 9. Finalisation of software 10. Training of Data Entry Operators (DEOs)

11. Data analysis for old data not captured on DMIS 12. Launch of DMIS Phase 1 Client Needs A series of consultative meetings were organized to understand the needs of the client viz. MoHFW and develop the DMIS framework. Since one of the key tasks of the Secretariat is to track the progress of the programme, many iterations occurred to reach definitive conclusions on ‘what one expects from DMIS’.

Developing a DMIS framework to include all interventions of the implementing Partners NIPI as a programme is many layered given multiple implementing Partners. De-layering of each intervention was undertaken to define key indicators as ‘dashboard indicators’ to be reflected on DMIS. Following the key aspects of the NIPI programme, the matrix was designed around:

Quality of Health Services

Enabling mechanisms

Learning & Sharing Prioritising the interventions into phases Given the enormity of task at hand, a decision was taken to roll out in a Phased manner. UNOPS was the 1st implementing Partner to be focused upon. Two key interventions of this Partner viz., Sick Newborn Care Units (SNCUs) and have been focused upon in Phase 1. During the initial discussions, it was clear that since UNOPS has another software already in place for capturing data for its


20

intervention ‘Home Based Post Natal Care’, rather than duplicating, the focus would be on ‘integration’. However, with the passage of time, it was realized that Government of India has issued ‘Home Based Newborn Care’ Guidelines’ to the States to adapt and adopt. Since the information collated differed from UNOPS HBNPC, a decision was taken to work on the development of this aspect. Defining key indicators for representation Critical indicators were identified and defined for representation in the automated reports. Review of existing formats for data collection at source. Consultative meetings with the client brought out the fact that each State had designed their own formats for SNCU and Yashodas. Since the objective of DMIS was to have real time information available to all relevant stakeholders at a give point of time, there was a pertinent need to standardize the formats. First and foremost, a comparative analysis of the information being garnered through varying formats was undertaken. This enabled in a complete understanding of the commonalities and differences existing across States and in fact many a time across Districts. With reference to HBNC, the format attached with GOI guidelines was reviewed to ensure all relevant data gets captured. Developing input and output formats to ensure standardization of data collected at source. As already mentioned in the preceding paragraph, variations were noted across Districts especially with regards to SNCU and Yashodas. In a bid to address this critical aspect, standardized input and output formats were designed for SNCU and Yashodas. These were finalized in consultation with the client. HBNC input and output formats were also finalized before development of the software. This process involved a series of iterations and consultations with NIPI Secretariat resulting in the development of the final input and output formats. An example of the format is illustrated below. Other input and output formats are attached separately. Software development An integral part of DMIS is the software developed for the interventions. This software has been developed along with the IT Partner- i-Stream Technologies. Broadly, the steps involved in software development include: a) System Design and Architecture: Detailed design and architecture of the system was developed for data model, programming model, GUI design, workflow definitions etc. b) System Development: Development of Data Management Information System was established for Business Logic and Presentation Layer. c) System Testing (Beta Testing): Exhaustive testing to ensure smooth functioning of the system. d) Deployment and Handover There are two versions of the software:

Online

Offline The offline version has been developed to cater to poor internet connectivity in Districts of the NIPI States. Given that a Phased approach was adopted for the development of DMIS, the first intervention to focus on was SNCU. This was followed by Yashoda and HBNC. Some mock images of the website are provided below.


21


22

Beta testing of software to smoothen all emerging issues Beta Testing of the online versions has been undertaken for all 3 interventions viz., SNCU, Yashodas and HBNC. Two Districts selected for beta Testing included Hoshangabad in the State of Madhya Pradesh State and Bharatpur in the State of Rajasthan. A training of the District Child Health Managers (DCHMs), Block Child Health Managers (BCHMs) and Data Entry Operators (DEOs) was undertaken for them to understand the need for beta testing. Beta testing of HBNC was undertaken using old data from the field. Finalisation of software Emerging issues from beta testing were considered and addressed. The final online and offline versions of DMIS software are ready for launch. Training of Data Entry Operators (DEOs) State wise trainings have been organized for District Child Health Managers (DCHMs), Data Entry Operators (DEOs), Block Child Health Managers (BCHMs), to get a ‘hands on’ experience on usage of DMIS. Other relevant stakeholders involved in this training included State Management Information System officials, NIPI State representatives. These trainings have been phased. Round 1 of training included the States of Rajasthan and Bihar and the focus was on SNCU and Yashoda. During Round 2, all 4 States i.e. Bihar, Madhya Pradesh, Orissa and Rajasthan as well as Delhi will be covered. All 3 interventions –SNCU, Yashoda and HBNC- will be covered.

Data analysis for old data not captured on DMIS While the development of the software was ongoing, data analysis of old data was undertaken. A detailed report has been shared separately. Launch of DMIS Phase 1 In the last week of May 2012, DMIS Phase 1 was be launched and demonstrated to MoHFW.


23

Way Forward- Phase 2 As mentioned above, Phase 1 of DMIS focused on 3 key interventions – SNCU, Yashodas and HBNC. This process is not completed. Therefore, DMIS Phase 2 is required to meet these un-reached potentials. UNICEF’s SNCU software version needs to be integrated. Since the NIPI Programme has 3 implementing Partners with different interventions, there is a need to further develop DMIS in Phase 2. Focus of DMIS Phase 2 will be on:

UNOPS- Techno managerial support, Routine immunization

UNICEF- IMNCI, Techno managerial support, Routine immunization

WHO- Training calendar, number of trained health personnel on Skilled Birth Attendance, C sections, number of accredited hospitals

This would enable capturing of data from all interventions on a single platform. Furthermore, since case specific data is available for the key interventions, there is potential for cross analysis providing enriched insights into maternal and neonatal health along the continuum of care. To strengthen the current set up of DMIS, a gap analysis would need to be undertaken in Phase 2. Sustainability is critical for any project. DMIS needs to be made sustainable through regularization and monitoring of the system. A critical aspect of this would involve further standardization of the indicators and therefore, strengthening of the system. Random checks on data need to be regularly undertaken to ensure correct entry at source. Data for decision making is key for any programme. There needs to be substantial hand holding and capacity building required across levels for proper use of data. Simultaneously, high level statistical analysis will need to be continuously undertaken for programmatic decision making. Data validation and triangulation will need to be built into the system to make it more reliable and complete. DMIS was presented to Government of India in May 2012 as an integrated “umbrella” package under which software applications can be incorporated, ultimately into HMIS. Such applications include UNICEF’s Madhya Pradesh SCNU software (where much collaboration has already occurred with DMIS), SNIMMS software developed by UNOPS LFA and IPGMER, SHSRC software. The NRHM Mission Director and JS (RCH) advised that DMIS should be linked directly to MCTS as the central data reference point for all health information systems.

3.4.6 Save the Baby Girl Analysis The implementation of PC & PNDT Act lies within the domain of the State Governments. Technological interventions such as part of the Save the Baby Girl (STBG) Project have been implemented in Kolhapur, Maharashtra. However, impact of the use of technology including on-line reporting of Form-F's and tracking of maternal scans is not yet clear. NIPI Secretariat was therefore requested to conduct an assessment on the initiative and submit a report to the Ministry as a matter of priority. The report is being submitted to the Norwegian Embassy, JS RCH and Additional Secretary &Mission Director NRHM for their initial approval.


24

3.4.7 M&E Report

Data for 2002 not available (Source SRS)

State Allocations for MCH

2010-2011 o Maternal Health: INR 555.55 lakhs o Child Health: INR 2165.52 lakhs

2011-2012 o Maternal Health: INR 696.86 lakhs o Child Health: INR 2238.37 lakhs

40

50

60

70

80

90

100

2000 2001 2003 2004 2005 2006 2007 2008 2009 2010

Nu

mb

er o

f in

fan

t d

eath

s p

er

10

00

live

bir

ths

IMR across 5 States

Orissa

MP

UP

Rajasthan

Bihar

All INDIA

AHS Infant Mortality

Rate

Neonatal

Mortality Rate

Bihar 55 35

Jehanabad 53 31

Nalanda 52 27

Sheikhpura 58 31

Madhya Pradesh 67 44

Hoshangabad 68 49

Narsimhpur 68 47

Raisen 78 54

Betul 68 48

Orissa 62 40

Anugul 50 31

Jharsugudha 51 41

Sambalpur 56 35

Rajasthan 60 40

Alwar 59 35

Bharatpur 55 42

Dausa 57 33

Uttar Pradesh 71 50

Distrct wise 2010-2011(Annual Health Survey)

Source: Annual Health Survey 2010-2011, (Reference

Period of Estimates 2007-2009)


25

Orissa Orissa

Institutional Delivery Labour Rooms with Newborn Corners

Source HMIS Govt of Orissa

85.8 89.3

92.8 90.6 91.7 94.3

0

20

40

60

80

100

Anugul Jharsugudha Sambalpur

Pe

rce

nta

ge

District

2010-11 2011-12

14 10

28

39 44

90

0

20

40

60

80

100


Per

cen

tage

District

2010-11 2011-12


26

Orissa Orissa

Average Length of Stay at Hospitals for at least 48 Hrs Newborns Breastfed Within 1 Hour of Birth

Source HMIS Govt of Orissa

71.3

57.1

39.1

83.5

53.1 48.1

0

20

40

60

80

100


Per

cen

tage

District

2010-11 2011-12

69.3 65.9

53

91.1 82.9 81.1

0

20

40

60

80

100


Per

cen

tage

District

2010-11 2011-12


27

Bihar Bihar

Institutional Delivery Newborns Breastfed within 1 Hour of Birth

Source HMIS Govt of Bihar

76.7 78.2

86.3 87.7 86.7

74.1

0

20

40

60

80

100

Nalanda Jehanabad Sheikhpura

Per

cen

tage

District

2010-11 2011-12

48.2

90.4

59.9 66.6

69.7

78.3

0

20

40

60

80

100


Per

cen

tage

District

2010-11 2011-12


28

Bihar Rajasthan

Post Natal Check Up Within 14 Days After Birth Institutional Delivery

Source HMIS Govts of Orissa & Rajasthan

32.8

89.9

29

44.3 38.7

34.2

0

20

40

60

80

100

Nalanda Jehanabad Shiekhpura

Per

cen

tage

District

2010-11 2011-12

65.1

56.1

68.7 67 73.3 73.8

0

20

40

60

80

100

Alwar Bharatpur Dausa

Per

cen

tage

District

2010-11 2011-12


29

Rajasthan Rajasthan Average Length of Stay at Hospitals for at least 48 Hrs Post Natal Check Up Within 14 Days After Birth

Source HMIS Govt of Rajasthan Demographic Cell Report (PCTS/MIS)

46 41

72

62

56 51

0

10

20

30

40

50

60

70

80


2010-11

2011-12

47

59

36

51 47

61

0

10

20

30

40

50

60

70


2010-11

2011-12


30

Rajasthan Newborns Breastfed within 1 Hour of Birth

Rajasthan State Allocation

Source Finance Division - NRHM

72

85

59

72

82

57

0

10

20

30

40

50

60

70

80

90


2010-11

2011-12

Head 2010-11 2011-12

Approved PIP

Approved PIP

RCH Flexipool In Lakh Rupees

Maternal Health 561.72 5309.61

Maternal Health -JSY 14200.00 18406.41

Total (MH) 14761.72 23716.02

Child Health (CH) 956.10 1316.70

Total MH & CH 15717.82 25032.72


31

Madhya Pradesh Madhya Pradesh

Institutional Delivery Newborns Breastfed within 1 Hour of Birth

Source: Health Bulletin MP State Level Allocation of NRHM funds for Neonatal Child Maternal Health Maternal Health - Rs. 22341.42 (2010-11)

Rs. 20843.57 (2011-12) Child Health - Rs. 1763.38 (2010-11)

Rs. 1322.30 (2011-12) - (all values in lakhs). These figures do not include the costs for procurements, constructions and trainings.

78

93

85

77 79

94 89

80

0

10

20

30

40

50

60

70

80

90

100

2010-11

2011-12

83

92

76

91 85

98

88 82

0

10

20

30

40

50

60

70

80

90

100

2010-11

2011-12


32

4.0 Operational Research Results

4.1 PHFI Study on ASNI

a. A summary report was submitted by PHFI at the last PMG meeting b. Cost Analysis of NIPI Interventions in Rajasthan and Orissa

Introduction / Background In 2006, the Norway- India Partnership Initiative (NIPI) was launched within the NRHM framework

focusing on reduction of child mortality and improvement of child health to attain the MDG-4 by the

year 2015. The initiative focused on five states: Orissa, Bihar, Madhya Pradesh, Rajasthan and Uttar

Pradesh which together constitutes 40 percent of India’s population and contributes to almost 60%

of child deaths in India. The objective of NIPI is to provide up-front, catalytic and strategic support to

accelerate the implementation of the National Rural Health Mission (NRHM) in these states,

specifically to improve child health and related maternal health service delivery by focusing on

quality and access.

Assessing and Supporting NIPI Interventions (November 2009 to September 2011, led by PHFI) was an implementation research project designed to assess the various NIPI interventions in the states of Orissa and Rajasthan. The study found that Yashodas provided significant support to mothers and newborns during the postnatal period at the facilities and resulted in improved knowledge and practice indicators. Further analysis of the combined effect of Yashodas and ASHAs (trained by NIPI for home based new born care) showed that the dual exposure of mothers to both Yashoda and NIPI trained ASHA had an incremental effect on newborn care indicators (both counselling and practice). Thus this study proposes to estimate the costs of these interventions to inform the scalability of the NIPI interventions and the cost-effectiveness of Yashoda program in improving neonatal health outcomes.

Objectives

Specific objectives of this study are: 1. Estimate the cost of implementing the NIPI intervention package--Yashoda program and

home based postnatal and neo-natal care (HBPNC) program. 2. Estimate proportion of additional NIPI investment as compared to the total maternal and

child health budget in the district

3. Estimate the unit cost of the intervention in terms of per mother/ newborn cohort who received services from Yashoda and HBPNC package

4. Estimate the incremental cost-effectiveness of Yashoda interventions in terms of cost per

change in knowledge and practice indicators

5. Comparison of the expenditure patterns/reporting of NIPI funds in Rajasthan and Orissa

Full inception report may be found in Annex 1


33

4.2 ANSWERS Assessment of pivotal issues related to infant feeding and child nutrition in India:

Inputs for improving interventions within the NIPI Report of Studies in three Districts of Madhya Pradesh Hoshangabad, Raisen and Narsinghpur

Early initiation of breast feeding and exclusive breast feeding (EBF) for the first six months are acknowledged as key interventions for child survival and health. Interventions implemented through the Norway India Partnership Initiative (NIPI) were designed to enhance the above practices. Research into ‘Pivotal issues related to infant feeding and child nutrition’ was undertaken in three districts of Madhya Pradesh- Hoshangabad, Narsinghpur and Raisen- during 2010 and 2011 as part of operations research under NIPI. Six components related to infant feeding and child nutrition were identified for study: Breast feeding, complementary feeding, childbirth related experiences, health and illness of infant and mother, contraception and gender issues, and health services and service providers. Recommendations:

1. Include the mother-in-law in newborn, infant and maternal health: The mother-law was the strongest influencer on infant feeding, nutrition and health of infants and their mothers. Special programmes with focus on mothers-in-law need to be implemented to strengthen healthy practices.

2. Redefine role of dai and utilize her for newborn and postnatal care: Village dai’s role must be redefined to focus on postnatal and newborn care. Her role must be strengthened and remunerated.

3. Enhance role of husbands and address their needs: Husbands felt neglected and expressed a need for information and services, especially related to contraception. Their role in health and nutrition of infants and mothers needs to be strengthened. Contraception service must be regularly and readily available to men within villages.

4. Utilize potential of ANMs: Several field ANMs were skilled in assisting during delivery as a result of long years of practice. They could fill gaps in hospitals, especially where shortage of midwives exists.

5. Strengthen and expand role of ASHAs: ASHAs should be more actively involved in behaviour change activities, particularly in EBF and CF practices, and elimination of unhealthy foods given to infants.

6. Review and streamline the functions of AWCs: Clear guidelines and regular monitoring should be used at AWCs for streamlining growth and health monitoring of infants, and for food distribution.

7. Clarify the role of Yashoda and expand it to include postnatal follow up while the mother and family are still in the hospital so that there is higher emphasis on counselling family members on newborn care, EBF, avoiding other fluids

Full report may be found in Annex 2


34

4.3 Exploratory Research for Identification of Determinants of Neonatal Health With Reference to Survival of Neonates across Health Facilities in Selected Districts of Rajasthan and Maharashtra 1.0 Key Objectives

Overall Objective: The overall objective of this study is to identify the determinants of neonatal health in reference to survival of the neonates at the level of the Community, Sub Centre, Primary Health Centre, Community Health Centre and District Hospital. Specific Objectives: The specific objectives shall focus on: 1. Identification of and addressing socioeconomic, cultural and logistical enablers for and barriers to proper maternal and newborn care and care seeking behaviour.

2. Identification of factors promoting and hindering immediate access to neonatal care at the Community, and Facility levels viz., Sub Centre, Primary Health Centre, Community Health Centre and District Hospital.

3. Studying the critical factors that enable and/ or hinder referral of sick neonates in an effective and timely fashion.

4. Studying the role of platforms such as Integrated Management of Neonatal and Childhood Illnesses, HBPNC, Yashodas, SNCUs and any other innovative initiatives in the proposed Research Study States as enabling or disabling factors with reference to survival of neonates.

Full inception report may be found in annex 3


35

Annexure 1

Cost Analysis of NIPI Interventions in Rajasthan and Orissa Introduction / Background In 2006, the Norway- India Partnership Initiative (NIPI) was launched within the NRHM

framework focusing on reduction of child mortality and improvement of child health to

attain the MDG-4 by the year 2015. The initiative focused on five states: Orissa, Bihar,

Madhya Pradesh, Rajasthan and Uttar Pradesh which together constitutes 40 percent of

India’s population and contributes to almost 60% of child deaths in India. The objective

of NIPI is to provide up-front, catalytic and strategic support to accelerate the

implementation of the National Rural Health Mission (NRHM) in these states,

specifically to improve child health and related maternal health service delivery by

focusing on quality and access.

Assessing and Supporting NIPI Interventions (November 2009 to September 2011, led by PHFI) was an implementation research project designed to assess the various NIPI interventions in the states of Orissa and Rajasthan. The study found that Yashodas provided significant support to mothers and newborns during the postnatal period at the facilities and resulted in improved knowledge and practice indicators. Further analysis of the combined effect of Yashodas and ASHAs (trained by NIPI for home based new born care) showed that the dual exposure of mothers to both Yashoda and NIPI trained ASHA had an incremental effect on newborn care indicators (both counseling and practice). Thus this study proposes to estimate the costs of these interventions to inform the scalability of the NIPI interventions and the cost-effectiveness of Yashoda program in improving neonatal health outcomes.

Objectives

Specific objectives of this study are: 6. Estimate the cost of implementing the NIPI intervention package--Yashoda

program and home based postnatal and neo-natal care (HBPNC) program. 7. Estimate proportion of additional NIPI investment as compared to the total

maternal and child health budget in the district

8. Estimate the unit cost of the intervention in terms of per mother/ newborn cohort who received services from Yashoda and HBPNC package

9. Estimate the incremental cost-effectiveness of Yashoda interventions in terms of

cost per change in knowledge and practice indicators

10. Comparison of the expenditure patterns/reporting of NIPI funds in Rajasthan

and Orissa

Methods Some of the data about cost and effectiveness of NIPI interventions will be obtained from ASNI study. Additional information on NIPI will be collected as required from the state, district and NIPI offices. The analysis will include expenditure data from 2010 until 2012 (expenditure data for 2012 may be incomplete) for Anugul, Orissa and Alwar, Rajasthan. Details of data collection are as below:


36

Objective 1: Cost of implementing NIPI intervention package Resource utilization data will be obtained from ASNI study. Additionally a cost data collection format will assess:

1. HBPNC ASHA intervention—Costs of training of ASHA specific to HBPNC, supervision,

incentives, kit, data management, refresher training (5-day), and any other activities

under the HBPNC program

2. Cost of Yashoda intervention package –training, incentives, supervision, materials

etc.

All research costs like data collection and rapid assessment of facilities, supervisory visit for evaluation will not be included in the calculation of costs of the program.

Objective 2: Additional investment compared to state budget Data for the same will be obtained from state and district PIP, and NIPI budget and district level fund utilization statements. Objective 3: Unit cost of the Yashoda and HBPNC intervention

Information on numbers of mother and newborn who received services from the Yashoda during the study period will be obtained from facility records of total deliveries. For HBPNC, the denominator would be mothers who were reached by ASHA, estimated from the # of incentives provided to ASHAs (which are based on # of PNC forms submitted)..

Objective 4: Cost effectiveness of Yashoda interventions in terms of change in knowledge and practice indicators Cost data would be obtained through Objective 1. Effectiveness data would come from ASNI study --increase in proportion of various knowledge and practice indicators in the NIPI intervention district will be used to arrive at incremental cost effectiveness. Objective 5: Comparison of the expenditure patterns/reporting of NIPI funds in Rajasthan and Orissa Financial management practices in Orissa and Rajasthan will be compared for their variability and benefits of each system. Outcome Indicators

Possible indicators for which data will be collected are listed below.

1. Total Cost and additional cost for implementing the NIPI Intervention packages

2. Cost per beneficiaries reached

3. Cost per unit change in practice and knowledge indicators related to maternal and

child health

Evaluation Time frame 1. Preparatory Stage (Month 1 (From March 15): Development of data collection

tools; field visits; discussions with NIPI team to review and understand results from various rapid assessment of facilities, record keeping tools and systems.

2. Data collection and analysis (Month 2-3): The focus would be on collection of cost data, and review of service statistics.

3. Report and manuscript Writing (Month 3-5): Final Report will be submitted at JSC.


37

Annexure 2

Recommendations emerging from the ANSWERS studies: NIPI Operational Research

A. Initiation of Breast Feeding:

Findings from the studies on initiation of breast feeding showed that even among those who delivered in hospital, there were gaps in initiating breast feeding within one hour. 15% mothers, who delivered in hospitals with Yashodas present during delivery, did not initiate breast feeding within one hour. The percentage was much lower in community study (only 54% initiated breast feeding within one hour) and the in-depth study (only 5 out of 22 started breast feeding within one hour). There is a positive perception across the community about the importance of early initiation of breast feeding. This should be supported and promoted. Recommendations:

i. The role of Yashoda needs to be clarified, understood and informed to hospital staff and

stressed to the supervisors of Yashodas. In many cases they were not present at the time of

birth and waiting out of

ii. Birth Chart with details of the baby should be maintained in the labour room indicating the

time of birth, the time of initiation of breast feeding and other specific points such as sex

and birth weight etc. This chart could be one of the responsibilities of Yashodas.

iii. Yashoda’s monthly remuneration could be linked with their overall monthly performance for

the care provided to mother and baby during the child birth process.

iv. One factor responsible for delayed initiation of breast feeding was the tiredness of the

mother. Standard labour room practices should include adequate hydration and nutrition.

v. Special instructions must be given to operation theatre staff about early initiation since

there was a delay in initiation of breast feeding was much more and longer in babies born by

cesarean section.

vi. LR staff and obstetricians have to be given a refresher training programme related to

evidence based child birth practices. Episiotomy was found to be a factor influencing

initiation of breast feeding.

vii. Healthy Birth Committee could be formed in each hospital for assessing the type of birth the

health of baby and the healthy- evidence based practices followed for mothers and babies. A

hospital should be declared as mother and baby friendly only if it reaches above 90% on

criteria for healthy practices. A study could be carried out to test this model in labour rooms

and theatres of some hospitals.

viii. Cultural sensitivity towards the posture immediately after delivery, sensitivity to the

mothers’ condition while initiating breast feeding should be part of Yashodas training. For

example, if the mother-in-law wants to give a hot fermentation or cleaning (Khil removal or

discarding the first few drops of milk), should be allowed.

ix. Persisting in putting the baby to the breast and encouraging mother and baby should be part

of training of Yashodas and other care providers within labour rooms. To discourage the

myth of not enough milk or no milk coming after delivery.

x. Almost a quarter of the deliveries are still taking place at home. The role of family members

in early initiation of breast feeding is important. The dais and mothers-in-law have to be


38

given special training on birth preparedness. Breast preparation must be included as a key

point in birth preparedness classes.

xi. The importance of colostrum feeding has to be further strengthened though there is already

a growing awareness of its importance.

B. Exclusive Breast Feeding:

Exclusive Breast Feeding is not being practiced as per the findings across the studies. Giving water and janam ghutti were commonly seen across all communities. Giving water was related to season when the baby was born. Almost all babies were given water during the hot season. Almost all babies had received other fluids before six months. Health workers also perceive water and janam ghutti to be beneficial for babies. They are constantly plagued by dilemma of whether to stop water and janam ghutti or allow it. Sometimes their verbal messages instructed women not to give water or janam ghutti but their body language conveyed a different message. Recommendations:

i. Since water and janam ghutti by themselves were not perceived as harmful to the babies

but were being strongly promoted both for cultural and climatic reasons; it is recommended

that a case control study be taken up to relate babies’ health and infection status with the

practice of administering water and janam ghutti.

ii. Information about hygienic practices has to be further stressed, and at different levels.

Structured sessions on preventing infections and maintaining hygiene have to be developed

and implemented. Messages should focus on basic issues like: ‘hand washing before breast

feeding’, ‘daily bath for breast feeding mother’ etc.

iii. Every immunization visit of babies during the first six months should be linked with detailed

health assessment of the infants.

iv. An ‘Integrated Infant Card’ should be prepared and used. The Card will contain information

about- Feeding (including unhealthy foods and early introduction of other foods), growth,

immunization, mile stones and episodes of illness and treatment.

v. The responsibility of the card could be with the ANMs since she is the one giving

immunization and has to visit the baby at least once a month. but maintenance of the cards

vi. Cultural practices like giving hareera and laddu and sawa mahina (confinement) which allow

the woman to rest and promote nutrition; healing, well being and bonding should be

encouraged. Further studies are required to identify the problems associated to this period

are addressed.

vii. To promote the health of baby, frequent and need based feeding should be given. A scheme

incorporating social and economic measures for the mother so that she does not have to go

out for work during the EBF period. This could be linked with AWWs or ASHAs regular

education programme. This measure will enhance the proportion of babies exclusively

breast fed for six months.

viii. The role of Health Triad in giving information related to breast feeding has to be

strengthened and supervised. Whether should be paid immediately after delivery or after

submitting a filled checklist including events and processes related to child birth and

initiation of BF should be decided. The remuneration paid to ASHA should not only be linked

with event and place of child birth but also to the processes such as


39

ix. The factors promoting introduction of other fluids such as cow’s milk and processed milk

products before six months have to be further studied so that clear messages and

information strategies can be developed.

C. Complementary Feeding:

The findings of the studies revealed that Complementary Feeding is the most neglected area in infant care. This period in the infants’ life also had the highest susceptibility to respiratory and gastro intestinal infections. Complementary Feeding was often initiated at incorrect time (too early/ too delayed), consisted of unhealthy food items like kurkures/ biscuits, and associated with unhygienic practices. It was unplanned and unguided and therefore, inadequate and inappropriate. Recommendations:

1. The AWCs need to be strengthened and supported to play a greater role in CF as the health

of the child from six months onwards is the critical function of the Centre. Home cooked

food using food items available in the local area was believed to be good but not practiced.

2. CF Days on information, discussion and demonstration related to babies who are between

six months to one year should be held once a week at the AWC. ASHAs could be used to

motivate and mobilize the mothers and mothers-in-law to attend these sessions.

3. The Annaprasan function should include a weekly plan for each baby using food items

available at home and distributed by the AWC. Mothers in law who have babies older than

one year should be identified as resource persons to prepare different food items, explain

their preparation and use.

4. Mothers-in-law who do not go out to work could be encouraged to prepare these foods and

supply them to families with 6-12 month old infants. They are willing to spend Rs. 5 to buy

punga from the shop, thus they may be motivated to buy healthy food for similar costs or

lower costs from AWCS prepared by mothers-in-law.

5. Reducing harmful practices: Punga and other junk food from the village shops are

responsible for poor nutrition and non acceptance of healthy food by infants because they

become used to junk food that contains salt and oil. Moreover, the preparation and

preservation is unhygienic. Poor quality and duplicate brand biscuits are sold in village shops

and given to babies as easily available food to appease the babies.

a. Village based activism towards ‘banning punga to babies’ should be taken up. ASHAs

will be guided to spearhead the campaign against junk food for babies.

b. Discussion sessions with sellers not to sell junk food for infants and toddlers on the

lines of banning tobacco.

Infant neglect between 5- 10 months to be addressed: Period of 5- 10 months is critically important in infants’ growth but this is the period which is most ignored by health programmes. It is the period of rapid growth and development where babies start to creep and crawl, teethe and pick up items. More infants fell ill between 5- 10 months and growth was faltered. ANMs as key health care providers in villages have to be strengthened with planned activities for infants.

1. Every infant must be checked for health status at least once a month by the ANM till one

year.

2. ANMs should use the Integrated Infant Card for recording and also assess whether the AWW

has completed her section.


40

3. ASHAs will mobilize all mothers and/ or grandmothers of infants between 6- 12 months of

age for a meeting on the afternoon of the Health and Nutrition Day.

D. Increase focus on mothers-in-law for implementing interventions for infants and mothers:

The studies highlight the strong influence of mothers-in-law in infant feeding, child nutrition and health care of children. In addition, mothers-in-law also determine the general health of the infants’ mothers by sanctions and restrictions on care, rest and nutrition during pregnancy, child birth and postnatal period. We found that mothers could not implement good practices even when they received some information and counseling from the health triad because their mothers-in-law had not received the messages, internalized the concepts or accepted them as valid. Recommendations: 1. Health education programmes with focus on mothers-in-law should be designed and

implemented in villages. These programmes could be implemented through the health triad.

The AWCs which appear to be the hubs for MCH service delivery could be the focal points for

these programmes.

A. Mothers-in-law committees and discussion groups could be formed and those with a

pregnant or postnatal daughter-in-law could be invited to the AWCs for discussions. Selected

mothers-in-law with progressive health and nutrition behaviors could become resource

groups and share their positive experiences other mothers-in-law. It is mothers-in-law who

stay at home more often and have more time to care for infants. Therefore complementary

feeding concerns- when, how and why- may be better addressed by well informed mothers-

in-law.

B. Birth preparedness class should be held for groups of mothers-in-law since they are the main

accompanying persons to hospital during childbirth. They need to be empowered with

information to seek quality services from hospital staff including the Yashoda.

C. Mothers-in-law are often the main care providers of infants and brought them to AWCs for

immunization and other services. They could be the main group for designing a growth

monitoring and health chart for infants. Alternate forms of the growth curve could be

designed and used for mothers-in-law to monitor and foster growth and health of the infant.

2. Specially organized information programmes for mothers-in-law:

A. Melas for mothers-in-law could be organized where they could be encouraged to both

express and deal with work burden, diet and nutrition and other concerns related to the

health of their daughters-in-law and growth and nutrition of infants. The mela could be

combined with exhibition of healthy practices for feeding, food preparation, role plays and

puppet shows on harms of punga feeding to infants, etc. It is necessary to organize the

melas as joint activity by women and child department, with the AWW, the ANM and their

supervisors playing an active role. Non- punga feeding mothers-in-law could be awarded.

Healthy Infant Checklist could be used for assessing.

B. Mothers-in-law appeared to be strong proponents of the need for male child in every family.

Valuing the girl child could be developed using folk and social messaging. Mass

communication through radio and TV on the role of the mothers-in-law should be increased.

So far, the messages are focusing mainly on the mother and sometimes on the father.


41

3. Mothers-in-law are the main decision makers about when, where and how the sick child

should be treated. It is the mothers-in-law’s health seeking behaviour which needs to be

influenced and changed in a more positive direction in the interest of infants and their

mothers. Respectful and proactive behavior change interventions rather than reactionary

responses are more likely to be accepted, especially when they deal with long held beliefs

and practices. Clean ways of giving janam ghutti or the importance of clean water and

hygienic practices could be demonstrated to mothers-in-law.

4. Interactions with mothers-in-law have indicated that oral methods in the form of

discussions, songs, mnemonics and games are more likely to be remembered and used.

Empathy-oriented and sensitization sessions with mothers-in-law on work burden, fears and

health of daughters-in-law would help in enhancing a sense of caring.

5. Intervention models for involving mothers-in-law could be designed and tried out in several

villages or blocks to assess the more effective models for scaling up.

E. Continue to use the influence and services of dais for postnatal and newborn care:

Culturally sanctioned seclusion of the mothers during postnatal period isolates her from outside family and outside world. The mother is considered untouchable during this period (sutak). The period of intense confinement ends around the fifth or seventh day during the sutak removal ritual. During this period in most villages the dai or a similar person is the only one allowed entry to provide services to mother and baby. The gradual elimination of dais from intranatal arena has resulted in depriving the mother of services such as cleaning, postnatal assessment for signs of complications and comfort measures such as massage. The dai provides the woman an opportunity for expression of feelings. Helping in initiation of breast feeding, giving tips on issues related to problems with breast feeding were roles played by dais. Mothers-in-law and other participants in the focus groups mentioned that the discontinuation of dais has resulted in loss to the mother and family.

Recommendations:

1. The dai be retained as the postnatal and newborn care provider since her services will be

beneficial to both the mothers and the baby and readily accepted by the families.

2. Dai training be reintroduced with modified content and scope

3. Dai was the first person contacted after the family on onset of labour pains. Dai is the only

skilled maternity care provider and still the first person contacted after the family, before

going to hospital. The risk assessment skills of dais also need to be strengthened so that they

give appropriate advice to the family of woman in labour.

4. Several incidences of inconvenience experienced by families and mothers where they did

not follow the dais’ advice

5. Remuneration for dais in case they accompany the women in labour to hospital on

6. Home deliveries are still common in rural Madhya Pradesh. The role of dais cannot be

undermined in such cases

F. Address the felt need of fathers for information and services:

Fathers of the babies were not involved in any aspect of maternal and child care. The studies revealed that their knowledge related to contraception, childbirth, breast feeding, complementary feeding, growth and development of babies as well as immunization etc. was very poor. Fathers expressed the need for information and services related to contraception, childbirth and sensitivity to male perceptions.


42

Men found it difficult to ask for information on contraception and related sexual and reproductive health matters because the ANM was found busy dealing with women and children. The AWCs did have condoms but men hesitated to go and ask. They felt that they were excluded from health education sessions. Recommendations:

i. Special depots for condom distributions should be organized through identified active male

members. Help of the male schools teachers/ PT teachers should be utilized

ii. Male health worker could make a planned visit to address the needs of addressing needs for

information and services related to reproductive health of men.

iii. Male discussion groups could be formed and these meetings to be held away from AWCs.

iv. Two meeting of husbands during pregnancy and two during infancy should be held and

these meetings should be structured with planned content.

G. Improving quality of services during child birth:

Increasing demands of hospital deliveries have resulted in overburdening the institutional labour rooms. Most of the labour rooms in CHCs covered in cross sectional survey report 200- 300 deliveries per month on an average. The number triples or quadruples in case of district hospitals. However, most of the labour rooms are too small for accommodating, mothers in labour, Yashodas, health care providers required to care for mothers in labour at any given time. Lighting, ventilation, set up and organization need immediate improvement. Staff nurses are rotated within all wards, including those in labour room, thus there is no sense of ownership for improving LRs. Neither do the nurse-midwives gain any expertise in managing maternity cases. These issues largely impact the quality of care provided in labour rooms in terms of safety, skills and sensitivity towards mothers. Recommendations: 1. Improving quality of LR facilities: It is recommended that the labour rooms in various

government institutes be improved to ensure high quality maternity care:

- The space in the labour room as well as the facilities and organization has to be improved.

- Staff nurses have to be posted in adequate numbers according to IPHS and the load of child

births. Their skills have to be strengthened. Frequent rotation has to be avoided.

2. Standard procedures have to be established for responsibilities of staff nurses, Yashodas and

dais in the labour room.

3. A clean labour room is a prerequisite for the health of the newborn. This requires a detailed

review and over hauling.

4. The family members who are important for the mother and newborn are left out. If there are

more Yashodas, one of them could engage the family.

5. Waiting areas of LRs should be equipped for giving communication and health education.

6. Improving quality and regularity of food at AWCs:

The study revealed that the supplementary food packages supplied for mothers and under five children were of poor quality and were often supplied irregularly. It was reported that the soybean taste was unpalatable. Well off families were feeding it to their livestock. Due to social restrictions, women were not in a position to avail food meant for them.

It is recommended that the quality of food being supplied under ICDS be evaluated. Storing of ICDS food packs also needs improvement. Similarly, there is a need to ensure that adequate numbers of food packs are supplied to AWCs in well kept timelines. There is again a felt need to

A. Convince mothers-in-law to feed the food packs only to daughters-in-law


43

B. Provide meals for whole family having a pregnant mother during pregnancy for the first two

pregnancies.

7. Women’s health and nutrition:

The study findings show that majority of women were not healthy enough during antenatal and post natal period. Poverty and inadequate food availability were quoted as major factors influencing women’s nutrition. Unfavourable traditions and over burden of household work is also influences women health. Under nutrition is major cause of maternal and neonatal health in India. Several programmes were launched to address these issues. There a need to have programme focusing the involvement of family members especially mother-in-law and Husband and need to change in the approach of current nutritional and health programme of Women during antenatal and post natal period. Low consumption of IFA tablets:

Consumption of IFA tablets was found to be extremely low. Only few mother said they consumed all 100 IFA tablets or took them continuously for three months during pregnancy. Majority of the mothers discontinued taking them after some time. Vomiting and giddiness were cited as reasons for discontinuing or not taking IFA Tablets. There was a huge gap in distribution and consumption of IFA tablets. There is an urgent need of address the issue through IEC or change in IFA regime. There is also a need to promote and educate consumption of iron rich food rather focusing on IFA tablet.

8. Delay in going to hospital:

Safe motherhood program, Janani Suraksha Yojana (JSY) and appointment of ASHA in India under its NRHM has increased institutional deliverers and the study findings shows that hospital is most preferred place for delivery. However the finding shows delay in reaching hospitals due to inconveniences, expenses and poor treatment of staff. Utilization of Janani express is very low and majority of the families hired private vehicles to reach the hospital. Overcrowding in the hospital also one of the reason for women delaying in seeking services. The public health facilities are challenged with lack of infrastructure, manpower and other facilities to coordinate and ensure quality service delivery in the hospitals. There is an urgent need to address these strengthen the services in the hospitals and improve the services of Janani Express so that more and more rural women can benefited by the services.


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Annexure 3

Operational Research for Identification of Determinants of Neonatal Health With Reference to Survival of Neonates across Health Facilities in Selected Districts of Rajasthan and Maharashtra

1.0 Key Objectives Overall Objective: The overall objective of this study is to identify the determinants of neonatal health in reference to survival of the neonates at the level of the Community, Sub Centre, Primary Health Centre, Community Health Centre and District Hospital. Specific Objectives: The specific objectives shall focus on: 1. Identification of and addressing socioeconomic, cultural and logistical enablers for and barriers to proper maternal and newborn care and care seeking behaviour.

2. Identification of factors promoting and hindering immediate access to neonatal care at the Community, and Facility levels viz., Sub Centre, Primary Health Centre, Community Health Centre and District Hospital.

3. Studying the critical factors that enable and/ or hinder referral of sick neonates in an effective and timely fashion.

4. Studying the role of platforms such as Integrated Management of Neonatal and Childhood Illnesses, HBPNC, Yashodas, SNCUs and any other innovative initiatives in the proposed Research Study States as enabling or disabling factors with reference to survival of neonates.

2.0 Research Methodology Secondary Review Practices related to referral system for sick neonates Primary Research Retrospective

Concurrent

The research methodology of this review shall include the following: a. Secondary Review: In order to demonstrate some of the practices related to the referral

system for sick neonates, documentation of the same shall be undertaken from different geographical zones. The focus shall be to identify good practices. The proposed Districts from the 5 States across the different geographical zones viz., North, South, East, West and North East are as follows: Table 1: Districts for Secondary Review Geographical Zone

State District Composite Index

Ranking in India

North Bihar Nalanda 0.4098 487

East Orissa Anugul 0.5670 298

West Gujarat Ahmedabad 0.6450 212

South Tamil Nadu Kanchipuram 0.8219 30

North East Meghalaya East Khasi Hills 0.5972 265


45

b. Primary Research: Both quantitative and qualitative research methods shall be

undertaken. The rationale is to have a complete understanding of the entire situation through the lens of the community and service providers. Furthermore, primary research shall be undertaken at two levels. There shall be a retrospective and a concurrent element covered under primary research.

Retrospective Element: For the retrospective element, path analysis is being proposed

in order to identify the process adopted to seek care for the sick neonates which resulted in positive or negative outcomes viz., treatment or mortality respectively. The focus shall be to trace back the referral system which was adopted or not adopted during the health care seeking process for the sick neonate. For this aspect, those women who were not high risk but had sick neonates shall be covered. At the time of analysis, the different scenarios can be as reflected in Figure 1.

Figure 1

This protocol will be followed for home as well as institutional deliveries. Concurrent Review: For the concurrent review, pregnant with high risk pregnancies shall

be tracked from 9th month onwards till 28 days after birth of neonates. For this aspect, the focus shall be on identification of high risk mothers who were advised referral. At the time of analysis, the different scenarios can be as reflected in Figure 2.

Figure 2

This protocol will be followed for home as well as institutional deliveries. The inclusion criteria for all target women respondents shall be:

Mothers who had Sick Neonates which resulted in positive or negative outcome

Went to the referral centre which is registered

Went to a local health practitioner who is not

registered

Did not visit the referral centre or any medical health practitioner to

seek care

High Risk Mothers Advised Referral

Went to the registered referral

centre & sought care

Did not visit the referral centre to

seek care

Situation was managed locally by a

non registered practitioner


46

a. All women who have experienced a complication during delivery or post delivery irrespective of their obstetric history.

b. Mothers with sick newborns in the neonatal period.

c. The woman should be a resident of the village.

d. Married daughter visiting her natal home for delivery. In case of sick neonates at the time of the study, for the NIPI Focus District, records shall be taken from the ANMs and ASHAs for tracking the outcome of the neonates for 28 days after birth (neonatal period) using the Home Based Post Natal Cards. As an innovative element to this aspect and keeping in mind the sensitivities involved in such an issue such as neonatal morbidity and mortality, story-telling as a means to create a comfortable environment is being proposed. The rationale is to allow the respondents to feel comfortable to open up to a stranger and narrate what happened. Stories shall be first woven around ‘others’ in relation to strengths and weaknesses of an existing referral system and slowly the narrative shall focus on ‘self’. The idea is to map the entire process adopted from the time the woman became pregnant to delivery to post natal care for the mother and newborn. Special focus shall be given to bring out the gender differences if any in health care seeking behavior of the community. Photo essays shall be prepared for documenting the stories from the field.

3.0 Selection of Districts in the Selected States Two districts are being proposed to be selected from each of the two States- one NIPI Focus State (EAG) and the other a Progressive State (non EAG). The selection of the Districts has been done by referring to the 'Composite Index', presence of functional Sick Newborn Care Unit (SNCU) and cost effectiveness. The procedure of estimating the composite index is a Ministry of Health and Family Welfare, Government of India initiative in collaboration with the International Institute of Population Sciences. The Composite Index is the ranking and mapping of districts based on thirteen socio economic and demographic indicators. Selection of EAG and non EAG State shall enable understanding of the differences and commonalities across 2 States with regards to determinants of neonatal health linked to survival of the neonates. Based on the recommendations of the Technical Evaluation Committee, Pune District in Maharashtra has been added as one of the best performing Districts in the State. Alwar in Rajasthan has also been added given that it is a better performing District and also has a functional Sick Newborn Care Unit (SNCU).

Table 2: Selected Districts Sr No State District Composite

index Ranking within state

Ranking in India

1. Rajasthan Alwar 0.4804 22 408

2. Rajasthan Barmer 0.3955 32 504

3. Maharashtra Nandurbar 0.4569 31 439

4. Maharashtra Pune 0.8065 2 39

The calculations have been made using key indicators for estimating the number of beneficiaries to be interviewed as a part of this study. Since Annual Health Surveys have been recently undertaken in 2010-11 for the EAG States, District specific Crude Birth Rate has been considered for the estimation of the sample size. The crude birth rate as per published survey is: Alwar - 22.9 (Annual Health Survey Data 2010-2011) Barmer - 33.0 (Annual Health Survey Data 2010-2011) Nandurbar - 21.1 (SCD 2009)


47

Pune - 17.1 (SCD 2009)

Table 3: District Profile No District Population

as per Census 2011 (in lakhs)

Total Population (in lakhs)

District specific CBR

ANCs per 1000 population considering 10% Pregnancy wastage#

Males Females

1 2 3 4 5 6 7

1 Alwar 1938929 1733070 3671999 22.9 25.2

2 Barmer 1370494 1233959 2604453 33 36.3

3 Nandurbar 834866 811311 1646177 21 23.1

4 Pune 4936362 4490597 9426959 17.1 18.8

# Column 7 is calculated as follows: Alwar figures are taken for example: % of ANCs = CBR + (10% of CBR) = 22.9 + (0.10X 22.9) = 25.2 Since the study necessitates the involvement of a. Those women who experienced a complication during delivery and/or post delivery, the sample will further be reduced to include those women who experience a complication during delivery and post delivery and

b. Those women who were not identified as high risk but had sick newborns which resulted in positive or negative outcomes. The facility is taken as the unit for sampling given that records shall be taken from there for identification of target group of respondents. Lists from appropriate health facilities shall be used for identification of target respondents. From each selected district, the DH will be selected as facility to understand the neonatal health management and the referral mechanisms. In order to have an understanding of the referral mechanisms in place when a Sick Newborn Care Unit (SNCU) is present, it is proposed to cover the same in District Hospital Alwar. One SDH/RH with neonatal stabilization units functional could be selected. Under that facility, 50% of the PHCs will be selected (preferably where newborn care corners exist). Thus at the most 3 PHCs will be selected from one block. Under the selected PHCs, 2 SCs each will be selected wherein data on complications during pregnancy, complications during delivery and data on neonatal deaths will be taken from ANM registers. The rationale for selecting just 2 SCs under one PHC as this would enable reaching out to requisite number of target respondents. In all 6 SCs will be selected from each District. Thus, from each district 6 SCs shall be selected. One SC caters to 5000 population as per GOI norm and therefore 6 SCs will cover approx 30000 population. Based on this, the estimated number of ANCs and mothers of sick newborns are given below: Following Tables give estimates of - ANCs with complications (calculated @ 20% ANCs might develop complications)* and Sick Neonates (calculated @ 15% neonates might develop complications requiring hospitalization)* in a sample covered population of 30000.


48

Table 4 ANCs that may experience a complication

Sr. No District ANCs per

1,000 popln in a year

Estimated Number of ANCs in 30000#

ANCs that may experience a complication (20% of all ANCs)#

1 2 3 4 5

1 Alwar 25.2 756 151

2 Barmer 36.3 1089 218

3 Nandurbar 23.1 693 139

4 Pune 18.8 564 113

Total 621

* These percentages are considered after talking to practicing Gynaecologists and Neonatologists. # Column 4 & 5 are calculated as follows: Alwar figures are taken for example: Estimated number of ANCs = (30000 X 25.2)/ 1000 = 756 ANCs that may experience complications = (756 X 20)/100 = 151 Table 5: Mothers of sick neonates (+ve or –ve outcome) Sr No District Estimated number of sick neonates (15% of estimated live

births)

CBR Estimated Live Births# Estimated sick neonates# (+ve or –ve outcome)

1 2 3 4 5

1 Alwar 22.9 680 104

2 Barmer 33 990 149

3 Nandurbar 21 630 95

4 Pune 17.1 520 78

Total 426

# Column 4 and 5 are calculated as follows:

Alwar figures are taken for example: Estimated Live birth = (30000 X 22.9)/ 1000 = 687 = rounded to nearest 10 = 690 Percentage of sick neonates = (690 X 15)/100 = 103.5 = rounded to 104 Table 6: Health facilities to be selected from each selected district SR NO STATE DISTRICT DH SDH/RH PHC SC

1 Rajasthan Alwar 1 1 3 6

2 Rajasthan Barmer 1 1 3 6

3 Maharashtra Nandurbar 1 1 3 6

4 Maharashtra Pune 1 1 3 6

Total 4 4 12 24


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Table 7: Summary Table for Quantitative Sample of Women and Husbands (as per the estimations in the above tables) District ANCs that may

experience a complication

Number of mothers of sick neonates (+ve OR –ve outcome)

Total Sample (number of women)

Total Sample (number of husbands)

1 2 3 4=2+3 5

Alwar (Rajasthan)

151 104 255 255

Barmer (Rajasthan)

218 149 367 367

Nandurbar (Maharashtra)

139 95 234 234

Pune (Maharashtra)

113 78 191 191

Total 1047 1047

Table 8: Quantitative Sample for, ASHAs, VHSNC members, and Community Key Influentials Sr No Respondent Groups Number per

village Number in 6 villages

Number in all 24 villages

1 ASHAs 6 36 144

2 VHSNC members (Sarpanch /female member)

6 36 144

3 Community Key influentials (Teachers, Gram Sabha members, Religious leaders, AWWs)

6 36 144

Total 432

5.0 Qualitative A qualitative component is also part of this research study. The proposed sample for the same would be: Table 9: Qualitative Sample

STATE Number of Respondents in a State

Total number of respondents across 2 States

State Level Officials – 3 States

Mission Director NRHM 1 2

State Principal Health Secretary 1 2

DISTRICT Number of Respondents in a State

Total number of respondents across 2 States

District Level Officials – 4 Districts across 2 States

District Health Officer 1 4

Block Level Officials – 4 Blocks across 2 States

Taluka Health Officer 1 4

Facility Level Providers – District – 4 Districts across 2 States

Civil Surgeon 1 4

Facility Level Providers – Block (SDH/RH) – 4 Blocks across 2 States

Medical Superintendent 1 4

Facility Level Providers – Community (PHC) – 6 PHCs across 2 States


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Medical Officer PHC 6 12

NM/ Staff Nurse – (PHC) 6 12

Facility Level Providers – Community (SC) – 18 SCs across 2 States

ANM (SC) 9 18

TOTAL 62

5.0 Output/Outcome Measurements SR NO OBJECTIVE ACTIVITY EXPECTED OUTPUT-

OUTCOME

1 Identification of and addressing socioeconomic, cultural and logistical barriers to proper maternal and newborn care and care seeking behavior.

a. Interviews with target respondent groups b. Use of storytelling as a means

a. Recording of events to know what exactly happened b. Reasons for current health seeking behavior

2 To identify the factors that promotes and hinders immediate access to neonatal care at community, SC, PHC, CHC and district level.

a. Identify the health facilities. b. Select the village. c. Enlist the ANCs. d. Identify the high risk delivery and post delivery cases. e. Track their health seeking pathways. f. Interview target women, and their spouses. g. Interview the concerned MO-PHC, MS-SDH/RH, in charge of referral centre/ who handled the referral. h. Interview the ANM – SC and NM- PHC.

a. Burden of specific complications during delivery and post delivery. b. Determinants of referral services. c. Male involvement in RCH d. Preparedness and skill of available health personnel. e. Health seeking behavior of mothers experiencing a complication.

3 To study the critical factors that enable referral of sick neonate as per the existing infrastructural arrangements

a. Assess the infrastructure/ resource availability at that point of time in the selected health facility. b. Document the social norms, prevalent in the selected district based on discussions with ASHAs, ANM, VHSNC (Sarpanch and female member) and Community Key influentials and their perceptions.

a. Availability of health personnel and specialist at referral centre. b. Availability of equipment, medicines at the public health facility c. Understanding of socio-cultural factors influencing health seeking behavior d. Perception of key community level stake holders on neonatal health services. e. Identify gaps in service


51

c. Process documentation-IDI with the health officials at the district, block and state levels about the current practices concerning neonatal health, of the programs being implemented at the block and districts levels. d. Interview the health officials at the state level about the health programs – history, current status and vision.

delivery.


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Annexure 4


53


54

Minutes of the 12th Joint Steering Committee NIPI Programme Date: December 10, 2011 Time: 11.00 to 13.15 hrs Venue: Conference Hall, 1st Floor, Ministry of Health & Family Welfare, Nirman Bhawan, New Delhi

The Chair of the Joint Steering Committee, Union Secretary of Health, Mr P K Pradhan

opened the meeting and highlighted the need for a focus on 3 main initiatives which were

initiated by the NIPI Programme and now taken up as National Government of India

programme. These 3 main initiatives included:

o Sick New Born Care Units (SNCUs): Government of India has brought out the

Operational Guidelines for adaptation by the States of India. He urged the NIPI

Partners to work on a streamlined monitoring system and format and also provide

technical support to the Government to ensure proper trained deployment of

Human Resources in the SNCUs.

o Home Based Post Natal Care: Home Based Post Natal Care started by the NIPI

Programme has now been adopted by the Government of India as Home Based New

Born Care (HBNC). This calls for a uniform format for HBNC and also there is a need

to link the incentives to ASHAs to child survival and not just coverage.

o National Child Health Resource Centre (NCHRC): Serious thought needs to be given

to the fact of how to make NCHRC located within NIHFW, sustainable. There is a

need to put a mechanism in place by way of which the role of NCHRC is better

understood in the States and consequently utilised in a better way.

The Co Chair, Deputy Ambassador Royal Norwegian Embassy (RNE), Mr. Aslak Brun

congratulated Mr Pradhan for his appointment as the Union Health Secretary. He expressed

satisfaction with the way NIPI has been functioning as a Partnership with the Ministry of

Health & Family Welfare (MoHFW) and all the implementing partners. Mr Brun was pleased

to see headway being made with the way NIPI coordinates with Union Government and with

the States.

He was also encouraged to see how gender is being mainstreamed through NIPI activities,

e.g. the development of a Gender Manual for the State of Rajasthan. Another example cited

by Mr Brun was strengthening midwifery and nursing initially started in the State of Bihar.

He also made a mention of the improvements noticed in the overall M&E reporting of the

Partnership indicators and through the results from the two Operational Research (OR)

studies which have been recently completed.

Furthermore, Mr Brun noted that while some NIPI interventions have worked well, few

others have not done so well. This should be taken note of. Also, he would like to see more

concise formats on overall indicators. He appreciated the single page financial reporting,

which enables quick decision making.

Although there has been progress under ‘Gender Mainstreaming’, he requested for more

sex disaggregated data reporting wherever possible. Finally, a mention was made of the

need to improve documentation and visibility of the NIPI programme including its history.

There is an urgent need to update and improve the NIPI website.

1. OPENING REMARKS


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Dr Paul Fife mentioned that current work on 5 year plans in India is exciting and would like

to discuss how NIPI can work within this broader framework.

The agenda of 12th JSC was adopted. The Minutes of the 11th Joint Steering Committee were taken note of by the members.

The Action Taken report (ATR) was tabled.

Point for Discussion from ATR Update

WHO Compendium of Different Models for

Management of Severe Acute Malnutrition

(SAM) among children in India

MoHFW has requested for a detailed note on the same from WHO. The concept note which was developed by WHO for the last JSC held in May 2011, has been shared with the Mission Director (MD) Madhya Pradesh, Dr Agnani. WHO stated that the draft version of the

compendium shall be ready by March 2012.

MUAC Study: WHO The Chair requested WHO to roll out the study

without delay.

Guidelines for Quality Assurance of all RCH

services across all MCH levels: WHO and

UNICEF

To be discussed during the current JSC (12th)

Pilot an intervention model to delay 1st

pregnancy and spacing of second child among

married adolescents and young adults: WHO

This is ongoing. Results shall be available by the

next PMG

UNOPS LFA funding and inclusion of 3 months

buffer to match with Government financial

cycle: UNOPS LFA

Approved

Save the Baby Girl (STBG) review Review in underway focusing on 1st the clinical

and technological perspectives

All the members took note of the 12th PMG Minutes. RNE raised the issue of the PMG minutes lacking the item of budget discussions in the PMG , with recommendation for the JSC. The Chair agreed that the minutes including the recommendations should be in the main body of the minutes.

UNICEF’s proposal update on Baseline assessment of quality of maternal-newborn care was based on the PMG’s recommendations to shift from assessment of quality to improvement of quality. Phase I would involve expanding quality improvement from District Hospital (DH) to Community Health Centres (CHCs) and medical colleges. Mentors from Mentor Cells would visit facilities every 3-

2. ADOPTION OF AGENDA OF 12TH JOINT STEERING COMMITTEE MEETING

3. ADOPTION OF MINUTES OF 11TH

JOINT STEERING COMMITTEE MEETING

4. ACTION TAKEN REPORT

5. TAKING NOTE OF THE 11TH PROGRAMME MANAGEMENT GROUP (PMG) MINUTES

6. UNICEF PROPOSAL – ASSESSING QUALITY MATERNAL AND NEWBORN CARE


56

Resolution USD 500,000 was approved for the model development intervention, then subsequent funding would depend on outcome of the baseline. The Joint Secretary said that this should include the cost of sensitising other Development Partners to this model so that they can take this up in those States where they are functioning. This additional budget will be shared with the NIPI Secretariat

4 months, identifying gaps in the delivery of quality health services and mapping these on a spider graph for the facility managers’ action. These Mentor Cells would comprise Nursing staff and Obstetricians. Experience in Rajasthan with establishing such mentoring cells have shown good results, e.g. bringing still births down from 24 to 12 per 1,000. The Joint Secretary was interested in how scalable the model would be. She said GoI is looking for a universal model for Quality Assurance (QA) and from where one could find the right people to be part of these mentoring cells. The Chair acknowledged that this model fits very well into the supportive supervision approach and it was a good intervention. Mentors’ skills themselves will be upgraded by participating in this exercise. Phase II would take lessons from UNICEF’s Madhya Pradesh SNCU quality of care follow-up approach, from institutional to community level. It would use survival, growth and development as key indicators. Uttar Pradesh also has its comprehensive child survival programme where child health managers identify areas where line supervision is weak then identify partners who can provide appropriate support. The Joint Secretary said the key issues would be who would be the supervisors, how do you keep them motivated, how do you incentivise their participation, and what would be the number of supervisors (e.g. 5 or 6). The Joint Secretary suggested that after phase I in the 44 Districts UNICEF can share the trialled model by end of March 2012 with GoI with the view of going to scale. The Chair said a budget line could be put in the state PIPs for this purpose so the States can then take this up on their own. Dr. Paul Fife mentioned the trend of shifting focus from coverage to quality assurance in health services is an international phenomenon and it is exciting to see India taking this up also. It is also by any means not an easy approach to monitor, as it has to do with a variety of aspects including measurement, human resource management, customers’ perceptions and how they view health services as a right. He requested the 44 districts include the NIPI focus districts. UNICEF responded that they were included in NIPI focus States. With regards to the budget, Phase I would require USD 500,000 where costing of Phase II would depend much on the baseline results from Phase I. Phase I would, be completed by March 2012. The full impact of Phase II would be seen only after a period of 2-3 years.

A National Child Health Resource Centre (NCHRC) 5 year plan was submitted on the basis that the NCHRC remain within NIHFW. The Acting Director, Prof Bhattacharya, outlined the previous and current activities of the centre including the extended scope of their work. She pointed out that the scope of the NCHRC is such that it can be subsumed with the National Health Portal. The Joint Secretary said linking NCHRC to National Health Portal under NIHFW is a policy decision and will be dealt with separately. The Chair requested the Director NIHFW ensure the internal funding systems were in place to take over NCHRC once NIPI funds ceased. RNE raised the issue of projected human resources costs and salaries, which should match the existing government rates and conditions so there is no disparity once the centre is handed over to NIHFW. The WR, WHO mentioned that WHO has had experience of setting up resource centres in the HIV field especially, where professional resources are needed to the raise the profile and make such centres more effective.

7. NATIONAL CHILD HEALTH RESOURCE CENTRE & SCHRC


57

Resolution RNE agreed to funding NCHRC as far as the 12th budget plan, then only short term bridging funding after that if for some reason there was a delay in GoI picking up funding support. The Chair requested NIPI engage a professional to raise the visibility of NCHRC and make it more functional as a resource centre. The budget of NCHRC would remain at the same level for the next 6 months. SCHRCs will not receive NIPI funding after April 2012. The Joint Secretary said that the focus should be on strengthening the National Child Health Resource Centre (NCHRC). States may take up supporting SCHRCs should they feel they are contributing to the goals of NRHM.

Resolution The Chair mentioned that the NIPI Secretariat could be placed in their new setting by the 1st week of January 2012.

Dr. Paul Fife stated that in NIPI’s piloting of various interventions it should not automatically be assumed the pilot was successful, and some activities which have proved to be less than effective should be let go. He said State Child health Resource Centres (SCHRC)s would be one example of this.

GoI recommended relocating NIPI Secretariat closer to government and NIHFW was suggested as a suitable location. NIHFW has agreed to offering the space. The Co-chair Aslak Brun was grateful for offering this space to NIPI and said RNE were looking forward to a more defined and independent presence for the NIPI Secretariat.

The Secretariat’s update included alignment of reporting on NIPI outcomes and outputs with that of Government of India through HMIS, Annual Health Survey, District Level Household Surveys and NIPI Partners reporting. Documentation of NIPI programme will be centred on a web-server which is being built and housed within the Secretariat. Support to GoI included consultants to MoHFW, production of video film on neonatal health and radio jingles, print media on declining sex ratio. Operational Research is well underway, with Indian research agencies being connected with Norwegian counterparts. Two OR studies have been completed a) the ASNI study from PHFI and b) the optimal breastfeeding practice and nutrition study from ANSWERS. Costing of particular NIPI interventions will also be addressed through the recruitment of a health economist. Promoting innovation was also a NIPI Secretariat function, whereby the management of NIPI data is being systematised under the Data Management Information System (DMIS). NIPI Secretariat are working with UNICEF on one aspect of DMIS, which is integration of the Guna SCNU software model to shift to an online platform under DMIS. The Joint Secretary also requested a review of Save The Baby Girl STBG, which NIPI Secretariat is coordinating. Finally NIPI Secretariat is working to integrate gender and equity into the NIPI Programme. This is being done by direct assistance to the Government of Rajasthan by way of creating a gender manual for grassroots health workers. NIPI Secretariat was also represented in a core group to develop minimum standards for Mother and Baby Friendly Services and Perinatal Care during Transport. Gender mainstreaming efforts supported through NIPI semi-annual reporting and contributing to an all UN forum on declining sex ratio lead by UNFPA .

WHO

The WR WHO remarked that much of their budget projection for 2012 was linked to the Country Cooperation Strategy (CCS) which was just being finalised with GoI.

8. NIPI SECRETARIAT PROXIMITY TO GOVERNMENT

9. NIPI SECRETARIAT UPDATE

10. BUDGETS


58

Resolution JSC approved of this budget assessment.

Resolution The JSC approved the Budget of USD 5,300,000.

Resolution The Chair approved that the budget is settled bilaterally between the NIPI LFA and RNE. (Annex 1)

Resolution The Chair approved that the budget is settled bilaterally between the NIPI Secretariat and RNE. (Annex 2)

Three main pillars of the CCS were Scaling up, Quality and Human Resourcing. There was to be an alignment of the CCS with existing NIPI activities. No new proposals were there to be presented but WHO envisages that by the next PMG and JSC there will be a number of new initiatives for consideration. WHO are budgeting for USD 875,000 but no funds required at this time.

UNICEF

The total budget envelope was for USD 6,000,000 but given that they already have USD 700,000, a request for USD 5,300,00 was made. RNE commented that the budget was arranged per activity while the expenditure was arranged State wise. They requested for some consistency.

NIPI LFA Budgets for 2012

UNOPS LFA is seeking for USD 5,849,000 in the year 2011.Utilisation certificates from States amounted to 9.9 million USD (or 70% of the total disbursements) to Sept 30, 2011. RNE were not convinced of the need to retain the 3 month funding buffer addition for 2013 An updated budget can be found as an annexure.

NIPI Secretariat Budgets for 2012

Dr. Paul Fife raised queries on certain increased budget for 2012 based on expenditure from 2011. Questions on the “Other” budget category were also raised. It was explained that budgets do not consider cash in hand carry over from the previous financial year. A more appropriate comparison would be “funding required.” Plans to hold the next JSC abroad account for an increase in the travel budget, coupled with an increase in the number of consultants engaged under the Secretariat.

UNICEF

The UNICEF Representative reported participation in the recent meeting in Hanoi on sex ratio at birth. Addressing the issue of declining sex ratios required cross ministry engagement. The UNICEF representative suggested that NIPI be used as a forum for declining sex ratio discussion. She also suggested community based interventions in malnutrition would be needed to break the cycle of deprivation.

11. OTHER BUSINESS


59

The Joint Secretary Madam Anuradha Gupta supported the idea of inter ministry consultation and to integrate this into 5 year programme. Also, UNICEF Representative raised the question on NIPI’s stand on extending the programme beyond 2013.

NIPI beyond 2013

Dr Paul Fife said budgets needed to be assessed in the spirit of austerity which was now prevalent throughout most of Europe. He further informed that NIPI funding would likely to be extended past the current committed term into a new phase, perhaps to 2015 as only 60% of the committed funding of NOK 500 million has been spent. He suggested this would be the main topic of discussion at the next JSC. He proposed the date as the 14-18 May 2012 and the venue to be in Oslo. This would leave time leading up to the next JSC to assess current status and options for NIPI.

Closing Remarks from the Chair

MDG4 has 2015 as its target. This would be the NIPI goal also, continuing to use NIPI interventions as catalytic, technical support inputs. The details may be worked out in the next 6 months, with a formal request for extension pending. The 12th JSC meeting closed at 1.15 pm


60

NIPI LFA Budget

NIPI LFA Fund Requirement for the year 2012 (In USD)

States

Unspent Balance by Dec'11

(in USD) (A)

Budget for the Year 2012 (Jan-Dec) (in USD)

(B)

Fund required for (Jan-Dec 2012)

(in USD) (B-A)

M.P. 1,533,480

1,626,742

93,262

Orissa 912,087

1,335,270

423,183

Rajasthan 953,496

2,269,222

1,315,726

Bihar 1,369,062

1,042,127

(326,935)

Total 4,768,125 6,273,361 1,505,236

Opening Balance as

on Jan 2011 (in USD)

(A)

Funds received in

2011 (in USD)

(B)

Total Funds Available in the

Year 2011 (in USD) C=(A+B)

Expenditure as on

Nov'11 (in USD)

(D)

Expected Expenditure for Dec'11 (in USD)

(E)

Total Expected

Expenditure from Jan-

Dec'11 (in USD) F=(D+E)

Unspent Balance

by Dec'11 (in USD) G=(C-F)

1,774,852.11 3,497,414.18 5,272,266.29 2,208,609.12 2,255,441.44 4,464,050.56 808,215.73

Fund Requirement for 2012 Amount (in USD)

State Grants 1,832,171.04

National level 1,082,080.92

Grants to Partner Agencies, contracts and travel of state officers

1,588,484.80

ANNEX 1


61

Four state office

468,756.90

Total Fund Required 4,971,493.66

Less Expected Unspent Amount for the year 2011

808,215.73

Overall Fund requirement 2012 4,163,277.93


62

NIPI Secretariat Budget

BUDGET 2012

Award ID 00045792

Project Title- NIPI Secretariat

Project

#

Key

Activities

Accounts Budget Description Approximate budget

2012

00054184

61100 Salary NP Staff 12,000.00

Act

ivit

y 1

NIP

I S

ecre

tari

at

61200 Salaries GS Staff 58,104.67

61300 Salaries IP staff 258,075.00

62000 Recurrent payroll cost- NP Staff 25,659.00

62200 Recurrent payroll cost- GS Staff 16,661.00

62300 Recurrent Payroll cost- IP Staff 33,300.00

63400 Learning Costs 10,000.00

63500 Insurance and Security Cost 41,510.00

64300 Staff Mgmr Cost IP -

71200 International Consultant -

71300 Local Consultants 339,133.33

71600 Travel 162,222.22

72100 Contractual Services- Companies 71,843.23

72200 Equipment & Furniture 63,333.33

72400 Communication and audio Visual Equipment 13,361.11

72500 Supplies 4,500.00

72600 Grants 227,355.56

72700 Hospitality 8,333.33

72800 Information technology Equipment 35,555.56

73100 Rental & maintenance- premises 31,222.22

73200 Premises Alterations 33,333.33

73300 IT Equipments 50,000.00

73400 Rental & Maintenance of other Equipments 5,555.56

74200 Publishing & Print Products 50,000.00

74500 Miscellaneous Expenses 8,888.89

75100 Facilities and Administration 77,997.37

SUB-TOTAL 1,637,944.71

Act

ivit

y

4

OP

ER

AT

ION

AL

RE

SE

AR

CH

72100 Contractual Services- Companies 306,450.00

75100 Facilities and Administration 15,322.50

ANNEX 2


63

SUB-TOTAL 321,772.50

GRAND TOTAL 1,959,717.21

Proposed budget summary

Contract 605,648.79

Staff costs 794,443.00

Travel 162,222.22

Rent 31,222.22

Others 272,861.11

F& A 93,319.87

Total 1,959,717.21


64

12th Programme Management Group (PMG) on 22nd November 2011

S.No. Name of Participant Department

1 Mr. P.K. Pradhan CHAIR (JSC) & SECRETARY HEALTH &FW

2 Ms. Anuradha Gupta MOHFW

3 Dr. Ajay Khera MOHFW

4 Mr. Sharad Kumar Singh MOHFW

5 Dr. Madhulekha Bhattacharya NIHFW

6 Ms. Karin Hulshof UNICEF

7 Dr. Pavitra Mohan UNICEF

8 Mr. Paul Fife RNE/ NORAD

9 Mr. Aslak Brun RNE

10 Ms. Inger Sangnes RNE

11 Dr. Ashfaq Bhat Ahmed RNE

12 Dr. B. Dash Mohaptra NIPI State Bhubaneswar

13 Dr. M.P. Budania NIPI State Rajasthan

14 Mr. D.K. Samantray NIPI State Madhya Pradesh

15 Dr. Nata Menabde WHO

16 Dr. Paul Francis WHO

17 Dr. Archana Choudhury WHO

18 Dr. Kaliprasad Pappu LFA NIPI

19 Mr. Tony Cameron NIPI Secretariat

20 Dr. Urvashi Chandra NIPI Secretariat

21 Ms. Shanti Moktan NIPI Secretariat

22 Ms. Prasanna Narayanan NIPI Secretariat

23 Mr. Aditya Mishra NIPI Secretariat

ANNEX 3


65

ACRONYMS AND ABBREVIATIONS

ADS Auto Disable Syringe

AEFI Adverse Effects Following Immunisation

ANM Auxiliary Nurse Midwife ANMTC Auxiliary Nurse Midwife Training Centre

ASHA Accredited Social Health Activist

AWW Angawadi Worker

AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy BPHC Block Primary Health Care Centre

CES Coverage Evaluation Survey

CHRN Child Health Resource Network CMO Chief Medical Officer

DBT Department of BioTechnology

DHFW Department of Health and Family Welfare EmOC Emergency Obstetric Care

ENBC Essential New Born Care

EPI Expanded Programme on Immunisation

FP Family Planning FRU First Referral Unit

GAVI Global Alliance for Vaccines and Immunisation

GNM General Nursing and Midwifery GoI Government of India

HBPNC Home Based Post Natal Care

HIV/AIDS Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome ICDS Integrated Child Development Services

IGIMS Indira Gandhi Institute of Medical Sciences

IMNCI Integrated Management Of Neonatal And Childhood Illness

IMR Infant Mortality Rate IPMGER Institute of Post Graduate Medical Education & Research

INC Indian Nursing Council

IPHS Indian Public Health Standards JSY Janani Suraksha Yojana

LSAS Life Saving Anaesthetic Skills

M&E Monitoring and Evaluation

MCH Maternal and Child Health MMR Maternal Mortality Ratio

MNH Maternal and Neonatal Health

MNCH Maternal and Neonatal child health MO Medical Officer

MoHFW Ministry of Health and Family Welfare

NCHRC National Child Health Resource Centre NFHS National Family Health Survey

NIHFW National Institute of Health and Family Welfare

NIPI Norway India Partnership Initiative

NRHM National Rural Health Mission PHC Primary Health Centre

PHFI Public Health Foundation of India

PHN Public Health Nurse PIP Program Implementation Plan

PSE Pre Service Education

RCH Reproductive and Child Health SCHRC State Child Health Resource Centre

SCNU Special Care Newborn Unit

http://india.gov.in/outerwin.php?id=http://indianmedicine.nic.in/


66

SIA Supplementary Immunisation Activity

SMO Surveillance Medical Officer SNCU Sick New Born Care Unit

SBA Skilled Birth Attendant

SBM-R Standard Based Management and Recognition SS Supportive supervision

TA Technical Assistance

UP Uttar Pradesh UNFPA United Nations’ Population Fund

UNICEF United Nations’ Children Fund

UNOPS /LFA United Nations Office for Project Services Local Funding Agent

VPD Vaccine Preventable Disease WHO World Health Organization

Documents

Program Management Group - United Nations Development