Vous êtes sur la page 1sur 98

Child Health in the State PIPs

2008-09

Mapping Technical Assistance Needs


(Version 1.0)

National Health Systems Resource Center


National Rural Health Mission
Ministry of Health & Family Welfare
Government of India
New Delhi
1

Child Health in the Project Implementation Plan 2008-09


&
Mapping technical assistance needs

Version 1.0

Contents:

Section Topic Page


No. number
1 Mapping of TA needs for child health: 2 to 6

2 Analysis of the State PIPs- a cross state 7 to 21


appraisal.

3 Matching TA needs assessment from PIP 22 to 27


analysis with JRM recommendations.

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

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
2

Section 1
A preliminary mapping of TA needs for child health:
There are three sources for defining TA needs. The first is the JRM and CRM reports, the
second is discussions with programme officers and mission directors in each state and the
third is the examination of the state data and the state PIP. This note analyses the PIPs
and then compares its findings with the JRM and builds upon the latter to define the TA
requirements.

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


prior reading of section 2 before reading this summary. .Please note that on school health
and immunization separate notes are being submitted.

TA TA task TA task needs TA task


Task Description modality
Sl. No.
1 Provide CH division with a tool As JSY has brought One agency
kit ( manuals , guidelines, newborns to every selected at
strategies, equipment list, PHC, all of them need national level
to have a clear set of and nodalising a
enabling orders etc) for
guidelines and tools working group.
propogating SNCU level 1 of provided with an
care in all PHCs and CHCs orientation programme,
within 18 to 24 months. The while over time they
training manuals in this tool kit are trained for this
would be integrated with the
IMNCI module for medical
officers.
2 Agencies could be specifically A tool kit would not One support
recruited for each state who move by itself. A agency for each
would work with the state to catalyst agency that state with a clear
would the district TOR – the
help it conduct the training
health bottom line of
programmes and support the socieities/directorates which is that the
state in putting in place SNCU 1 help introduce this tool kit is
level care in all PHCs and across the states in a available in
CHCs. short period would be every PHC and
needed. Though CHCs the staff there
need higher level, let at have been
leas this level be put in introduced the
place kit.
3 Provide CH division with a tool a tool kit has list of One agency
kit for reaching SNCU level 2 of equipment, list of recruited at the
supplies, HR skills national level

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
3

care in all CHCs eventually but required, training working with


within three years in all places manuals, training UNICEF and CH
able to handle basic or strategy, model MOUs division.
to be signed with PPP
comprehensive emergency
centers for providing
obstetric care. As part of TA task training, copies of
3 would also be to provide a tool enabling orders,
kit for reaching SNCU level 3 advocacy brochures,
where required. standard treatment
protocols, consultation
back up, evaluation
processes etc. The
multi-skilling module
in this is one big part of
this task
4 Assist each state to draw up a The tool kit has to be Development
road map to reach SNCU 2 and 3 applied. Central to this partners in each
in every FRU and district is defining a few state could assist
hospital and walk down that agencies where SNCU in this work , NE
road. This would include an 2 and 3 level training RRC for the
advocacy unit for supporting the would be provided and northeastern
task. The aim should be to have placing them in control states and for the
all in place in three years not only of training but others national
also of post training coordinating
follow up to ensure that agency could
every center becomes recruit one
functional. agency
5 Quality assurance in IMNCI, The scale and quality Same consultant
attend to gaps in IMNCI and comprehensiveness team as
implementation that have been of IMNCI roll out identified for TA
identified. Build up capacity in needs to improve. For task 2 would be
SIHFW to supervise and guide this the TA should put in place. In
overall functioning across the evolve state specific addition
training centers of the state. guidelines which the consultants may
state mission directors be recruited and
would issue in placed with the
consultation with the agency/SIHFW.
CH division.
6 Help each state draw up or The Child health Select agencies
improve on their plans for concern has to be who are part of
provision of home based new woven into the the ASHA national
born care through ASHAs. This design of the support mentoring group
cannot be done at a national structure, the mentoring could undertake
level, but only in a state specific and monitoring process this.
format. This would include ways for ASHAs and its
of strategising and simplifying training programme,

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
4

the Search model and integrating material and training


it with learnings from IMNCI strategy, into the
and making it more cost ASHA drug kit and
effective and applicable to into the ASHA
ASHA. payment schedule
7 Develop monitoring and Need to have a quick One agency to
facilitatory systems where appraisal of the issues study use across
EMRC type ambulance services in sick childuse of ambulance
ambulance services services.
are established to ensure that we
where they are in place
can track usage by sick children For other places the
and we can facilitate this. need is to develop such
Appraisal of current pattern of ambulance services and
use this is discussed
elsewhere.
8 Evaluate existing NRCs, and NRCs are working and One team to be
based on it build guidelines so expanding – but need set to appraise
that the large numbers of NRCs appraisal – not to see and develop a
whether it works- tool kit which
starting up can do so well. Seek
(because wasting other states could
to integrate training for NRCs childen have rights to use to start up
with SNCU- 2 and a simpler set care) but how to and manage
of protocols with SNCU-1 optimize this strategy. NRCs.
training. ( TA task 8)
9 Handhold states starting up Many states have Could be done
Nutrition Rehabilitation Centers proposed NRCs, but through a team
to do so. Build up linkages of the have been unable to of consultants for
start it up. They need three to four
NRC with ICDS and preventive
not have to discover states.
aspects too so that each reinforce “how to” for
the other. themselves
10 Develop and implement an Global best practices 5 to 10 agencies
action research programme in have shown that a 50% may be involved.
about 100 blocks or about 10 reduction in 5 years is Choose
possible. Need community
districts for a significant time
action NGOs for
bound reduction in childhood this and a few
malnutrition. Convergent district districts with
planning and implementation is special quality
taken as the key principle. govt .leadership.
11 Develop and implement an Childhood anemia is May be
action research programme in high and increasing and combined with
about 100 blocks or about 10 too little work on its above TA in a
districts for achieving a determinants , effects few districts but
significant reduction in and workable solutions. there is some

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
5

childhood anemia, epidemiological


work also that is
indicated.
12 Study to quantify the malaria Malaria is fourth most Suggest agency
attributable maternal and child common cause of death like VCRC
mortalities and morbidities with globally and nationally. nodalise a task
correspondience to API levels In endemic areas it force on this
and to recommend ways of may be most common issue.
addressing this effectively and cause. Need to assess
efficiently- and with integration what is happening
as a central principle. today and what needs
to happen
13 Build up a BCC hub in each BCC programme Contract in one
state SIHFW which can plan for design is a critical agency for each
integrated BCC and as part of bottleneck. ( see state . Agency to
SIHFW work. Includes capacity discussion in PIP work with
to do formative research and to analysis) Few SIHFWs SIHFW and a
help develop district specific are in position to do few or all
BCC plans and hand hold this today. districts.
districts for one year to
implement and evaluate these
plans.
14 Helping state health society to This is described n Contract in one
draw up a state specific school detail in separate agency for each
health plan and building capacity accompanying note on state. Brief these
in SIHFW to do so for the future school health agencies well
as well and let them then
design with
SIHFW.

Coordination of TA in child health:

Over all this effort of organizing these TA on 14 areas would need considerable
coordination with the division, with the states and with the development partners. This
coordination is difficult for on many of the above 14 items we may have to hire one
separate agency for each state or for a group of states. UNICEF has already been
instrumental in taking it so far, and would have a major role in taking it forward but
another point of coordination is also needed. Given the way TA development in this area
is being shaped, the choices are firstly: the NIHFW which is now being supported by
development partners in many ways including a major grant to develop as a National
Child Health Resource Center. This work would help them emerge as such a center. Or it
could be the child health division of the ministry itself. The criteria should be the ability
to ensure time schedule and quality outcomes. The entire “state- support” TAs would
have to be set in place in three months and implemented in one year and the national

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
6

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

If however the work of coordination devolves to NHSRC, the latter would assemble a
team of three senior consultants to organize this work in such a time frame as indicated
above. It would be advisable anyway for the CH division to involve NHSRC to ensure
quality of output needed as well as a lot of free advice . But there is no insistence that this
is done.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
7

Section 2
Analysis of State PIPs:

The PIPs for the current year have improved dramatically in how they address child
health. Now most states are seized of the different strategies that make up a child health
plan and are struggling to put them in place. Technical assistance at this stage could make
a huge difference and indeed is mandatory to reduce learning time.

There are many ways of examining child health in the state PIPs. We chose to examine
the various strategies from the view point of three levels of contact between the health
sector and the child and maximizing the opportunity available at each of these points of
contact.
The three levels could be described as the
¾ Family and community setting- of which the most important are the ASHA
programme, the village health and nutrition day and the BCC programmes.
¾ Outreach setting: which includes the sub-center and the anganwadi and the
school in school health programmes
¾ Facility setting- primary as well as secondary and tertiary.

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

1. ASHA programme:

The most important vehicle here is the ASHA or equivalent health care worker. Though
anganwadi workers(AWWs) and ANMs are also expected to interact at the family level,
in practice they remain centred around their institutional setting – the anganwadi center.
Also the anganwadi worker has a four hour work profile which is barely able to provide
time for her anganwadi center level functions – feeding the children, weighing them
periodically and providing some sort of day care, and it is only the more motivated ones
who manage the home visit. Potentially though the AWWs could be more involved in
this task. The ANM’s tour programme is such that the best that can be expected of her is
to visit the village anganwadi center for the immunization session at the stated time, and
perhaps throw in a home visit where it is specially requested of her. It is unrealistic
therefore to expect the ANM to be able to visit at the family level.

In child health – the ASHA contributes by being a very effective medium of inter-
personal behaviour change communication regarding child care practices. The most
important of these relate to breast feeding and to complementary feeding but also to
appropriate prevention for common illnesses. The ASHA also has the possibility of
reaching the child delivered at home, in time to provide essential new born care, as well
as in times of sickness to provide early and correct management of the diarrhea, the acute
respiratory infection or the fever- simple measures that can save lives and no other health
care provider is situated to reach and provide care. To the extent that deliveries are home

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
8

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

We see from the PIPs and from review reports that Chhattisgarh and the Mitanin
programme have leveraged this dimension well. The Rajasthan PIP also has brought
adequate focus on this. In Uttar Pradesh the CCSP programme is a conscious effort to
weave in this concern, but their problem is that the rate of expansion of the programme
falls far short of this. Book 2 of the ASHA training modules and to some extent book 1 of
the ASHA training modules does cover this – but is not skill based and not adequate to
take action at her level. Therefore, unless the states put in a specific effort this
opportunity would not be utilized.

In many states this opportunity is not made adequate use of, or missed altogether. For
example, in Andhra Pradesh, Arunachal Pradesh, Assam, Bihar, Jammu and Kashmir,
Orissa, Tripura, Uttaranchal though there are full fledged ASHA programmes in place the
synergy with child survival goals is not apparent in the PIP. In states like Gujarat,
Karnataka and Kerala, Punjab, West Bengal, the ASHA programme is proposed only for
tribal areas and as a rule these states have not made for a linkage of the ASHA with child
survival goals. One reason for the states missing this linkage, is that their key child
survival strategy is the IMNCI package and as it stands in most places the IMNCI is seen
as focused on AWWs and ANMs and not for ASHAs. This is partly because the IMNCI
strategy was elaborated before ASHA was proposed and partly because of poor
confidence in the viability of the ASHA concept. It was the HBNCC programme of
Ghadchiroli that took the focus of child survival intervention to ASHAs and almost as a
response to that ‘challenge’, IMNCI is being extended to ASHAs – in a very limited
manner. The HBNCC package in the original Ghadchiroli format is proposed in many
PIPs – but almost as a token or pilot gesture- five blocks in one district in Rajasthan,
Bihar, Orissa, Madhya Pradesh. There are two close concepts that we need to clarify. One
is the HBNC as a well defined package delivered in a particular format which is similar
to Ghadchiroli. The other is training ASHAs to provide home based care for the neonate
and for any sick child without sticking to every element of the Ghadchiroli model,
especially excluding the injectable antibiotic and the birth asphyxia management.

The Maharashtra, Meghalaya, Mizoram, Himachal Pradesh and Delhi PIPs also envisage
HBNC training for their ASHA workforce though it may not be with the same rigor and
format as the Ghadchiroli model. In Chhattisgarh, UP and Rajasthan also similar home
based care by the ASHA is being planned. The Jharkhand PIP in the text discusses
HBNC as a focus for 22 districts but in the budget it is a very limited six training camps
that is seen. However from our reports there is a better understanding at the level of
district level implementation. In Tamilnadu where there is a decision not to introduce
ASHAs some element of neonatal care is sought to be introduced through women
volunteers from self help groups, who are trained for the purpose. Thus about one third of
the states have recognized the life saving use of home based community health worker
programme in child survival, about one third do not have an ASHA programmes and
about one third have ASHA programmes in place but have yet to leverage it for

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
9

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

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

The difference between the IMNCI and HBNCC applied to ASHAs has become less and
less with HBNC including sick child care and IMNCI including neonatal care. Currently
IMNCI has most elements of HBNC except injectable gentamycin and birth asphyxia
management. But due to problems of logistics even HBNC is becoming pragmatic on
these two elements and have shifted this to the last part of their training modules. The
main strength of HBNCC in this context where technical content is convergent, is the
insistence on rigorous post training follow up. IMNCI also calls for it, and its best
example is in Mayurbhanj, which had more of such field support than even HBNCC. But
since such field support is not insisted upon in the roll out, IMNCI proceeds somewhat
faster and appears less expensive, but this would be at the cost of effectiveness. We thus
have a situation where IMNCI is being rolled out without this post training support and
HBNCC initiation is being delayed – perhaps out of hesitation to support what is taken as
a too-intensive and therefore too expensive human resource deployment. There is a need
for some sort of “historic compromise’ between the two- but the terms should be that the
rigorous training and post training structure that the HBNCC has and that the IMNCI
calls for is not compromised.

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

In practical terms there is an urgent need to front child survival within the ASHA
programme. The focus of technical assistance must be to help the ASHA programme by
a) providing a post training support that provides ASHA the skills and support needed to
provide home based care of the sick child( this includes appropriate referral).
b) build child survival priorities into the monitoring structure.
c) ensure that training programmes provides necessary skills in addition to knowledge.
d) develop a communication kit and strategy for ASHAs to be able to influence key child
care practices that would make a difference.
d) that there is an adequate ASHA support structure in place, as envisaged under the
ASHA programme, to ensure that the above four items do take place.

At the community level- there are three activities that are critical:
First is the village health and nutrition day. The second is village level BCC and the third
is the strengthening of village level structures for the objective of child health.

2. Village Health and Nutrition day:


In most states every village has such a day every month. Many states report such a day
every week. Could this be a misunderstanding? Or is it the plan? If the immunization
session is the key component of this session, then the ANM has 3 to 7 villages to visit (
average 4 to 5) and would manage to hold one immunization session per village per week
or a maximum of two per week. So though it is weekly for her, for the village it is

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
10

monthly activity. This is what is happening at present- and most states merely call the
immunization session as the VHND. This serves as a point of provision of antenatal care,
distribution of iron and folic acid tablets, deworming tablets, vitamin A administration to
those for whom it is intended and from ICDS for the distribution of take home rations.
This is thus a point of convergence. In most states sporadically and in some states more
systematically there is an effort to ensure that there is some component of social
mobilization and health education built into this day to meet the sort of expectation that
national guidelines suggest. However even this provision of the minimum set of services
in a planned immunization session, monitored by that great indicator, percentage of
planned immunization sessions that were held is adequate to most purposes of service
delivery. One could leave the more mobilizational description of this session to happen as
and when the system is seized with enthusiasm for this event, when it is rediscovered as a
major strategy and celebrates a short half life of attention before it relapses back into the
more mundane immunization session. Mobilisation per se is best when done sporadically
and it would be difficult to mobilise enthusiasm month after month for such a routine and
tame affair. The other indicator we suggest adding is the presence of the ASHA in the
session. For a large scale district level monitoring this may be taken as indicating that
convergence between ASHA, AWW and ANM is happening.

The creation of the village health and sanitation committee creates new opportunities for
strengthening the VHND and indeed many aspects of child survival. Thus activity
content of both the VHND and the VHSC needs to include elements of child survival as
are relevant to it. Almost no PIP mentions this synergy, though on the ground this may be
happening.

3. Behaviour Change Communication:

This could make a substantial difference to child survival. BCC planning has improved
considerably over the last two years. Many plans now clearly define what child care
practices are being identified for change, what are the determinants and what mix of
media- message- and communicator is to be used to change this child care practice.
However in most instances the link between media barrage that creates an enabling
environment for change and inter-personal communication at family and local
community level which could actually trigger the change and ways of evaluating the
impact are weak.
Amongst messages, through breastfeeding practices are found in most PIPs,
complementary feeding is very weak and appropriate responses for childhoold illness –
fever, diarrhoeas and ARI are almost missing. In a few PIPs the child health messages in
the BCC are completely missing.
No where is the previous year’s research or even experience or evidence of any sort
influencing the plans though such inputs would have been useful to locate barriers to
change.

Technical Assistance for the BCC component:

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
11

1. The district plan approach allows for crafting of very powerful and effective BCC
campaigns but very focused technical assistance would be required to make these
plans and even more in implementing them.

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

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

4. Child Health in the Outreach Facility:


This is a convenient category to discuss the interventions planned at the health sub-
center, into which we can take in all the activities of the ANM and to a lessor extent of
the male health worker(MPW). We also discuss the interventions of the anganwadi
center. We also note that if we define the child to be upto the age group of 12 years and
12 to 19 year olds as adolescents, then school becomes the major outreach facility and
school health a major child health programme ( age of 18 is the pediatrics definition of
the child). Since school health and adolescent health is described in separate notes, it is
only the health sub-center and the ICDS anganwadi center that we are taking into this
section.

The major strategy of RCH-II, (the component of NRHM that deals with child health)
this is undoubtedly IMNCI, and every state has, without exception, built it in. That is the
positive part. There are however three areas of concern regarding the roll out of the
IMNCI strategy- its scale of roll out and as part of it, the training outcomes being
secured; the post training follow up and the service delivery improvements being gained;
and finally the linkages of IMNCI with the community and facility level care
interventions and with improved drug supply so as to impact on child survival optimally.

Rajasthan and Madhya Pradesh have gone to scale. This is largely because in the
previous year there has been an appropriate investment in the development of training
centers and in training of trainers , so that this year the training programmes can be rolled
out across the state. In many states the lack of training centers and the need for first
training of trainers have come to be perceived a bit belatedly. This years PIP however
expresses a major thrust to strengthen training centers and TOTs, and it follows that only
in the next year will the programme have a field level impact. But better late than never.
In many states however the realization is not yet there- and there is still ‘a few districts
every year’ approach. There is a need to organize technical assistance so that training
centers are strengthened and TOTs are completed in all districts in the coming year – so
that in the next two years all the peripheral workers are trained. In terms of percentages:
in Rajasthan almost 90% of districts would be completed this year, in Madhya Pradesh
over 70% .

There are also many changes in who is being trained. Rajasthan has planned to train all
ANMs, anganwadi workers and ASHAs. Many states have left out anganwadi workers
out for which there is not sufficient justification. Many states have left out the ASHAs –

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
12

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

If we take the entire strength of ANMs and AWWs as requiring IMNCI training, the
numbers being trained per year would be less than 10% on the whole and if we add in
ASHAs not even that. This estimate matches with the JRM estimate which states 20,000
trained last year and about 46000 in all. For a country of about 2 lakh ANMs and 10 lakh
AWWs, this is about 15%- not counting in other categories like LHVs and MOs and staff
nurses etc. The rate of roll out is therefore less than 10% per year. We need to achieve at
least 30% coverage per year.

Curiously many states also report “medical officer training” for IMNCI and we are
informed that a module for medical officers is under preparation/ available. Is this IMNCI
for MOs an orientation programme for them to be able to supervise the ANMs who have
been trained or is it for them to have the skills needed to manage the sick children
referred to them by the peripheral worker? If it is the latter the training must be the
SNCU 1 training or FBNC training as it is often being called. At any rate there is no case
for giving a “only IMNCI” package to medical officers or for that matter to staff nurses
posted in the facility, unless it is well integrated with the facility based care component.
Even if there is clarity on this at the level of the strategy- makers, this certainly is not
there in any PIP.

One problem apprehended with scaling up is loss of training quality. But when anyway
training has to go through at least two cascade steps- state and district – and often needs a
third block level team, then, the importance is on building systems of quality control and
training evaluation into each level of training. If these systems are built, then it does not
matter how many districts we take up, ten or a hundred, since essentially after the training
of the district team is over the rest proceeds in parallel. If on the other hand the quality
systems are not in place, even the small number of districts being covered now will have
quality issues. The quality systems are not evident in most PIPs, though these may be
practiced on the field.

The other issue with IMNCI training is that it is predicted to give results only if the
package includes three essential elements in addition to IMNCI training- improved
facility care, improved community level action and improved post training follow-up
both for on the job support and for trouble-shooting problems of supplies. Few state PIPs
show any effort to synergise facility care and there are states which distribute the
programme components for ‘easier’ implementation with IMNCI being done in some
districts and facility based care being done in others. The point of the necessary synergy
between creating capacities in local health facilities for handling the referrals that proper
implementation of IMNCI would result in is obviously being missed. Even fewer states
are focusing their BCC campaigns as back up to situations where IMNCI trainees return
to work. As for improved drugs and supplies that need to accompany the post-IMNCI
training situation, many states mention this- but no state has the logistics system in place
by which the procured drugs can reach the ANM or AWW. The drug kit supply is an

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
13

incomplete approach for what is needed is not kits but mechanisms to refill the kits as and
when they are exhausted. Further there is almost no mention of reaching drugs to the
AWW who is being trained with such effort – neither kits being supplied nor is refill
being proposed.

The prototype of the IMNCI training, its claim to success in the Indian context, lies in the
Mayurbanj model, in which all of this was attended to- but almost no state except
Rajasthan shows this in the PIP. Examining the Mayurbanj model we find that almost
180 trainers/facilitators were hired and a large part of them paid on a daily basis for
almost one year to follow up the trainees on-the-job, trouble shoot problems of lack of
drugs and referral linkages and support them in initiating the use of newly acquired skills.
These trainers were largely Ayush practitioners, or nurses or NGO workers hired in for
this purpose. The Rajasthan PIP reflects this post training support workforce and budgets
for it. No other PIP does so. In the NIPI presentations we note that UNICEF has proposed
recruiting such staff for a number of districts in the five NIPI states (excepting UP),- and
this would certainly make a big difference. But for the other states the gap would remain.

The focus of technical assistance for IMNCI would therefore be in


a) Identifying training centers and training of trainers in these centers such that they
can cater to all districts.
b) Creating capacity in the SIHFW or equivalent institution to be able to monitor and
evaluate quality of training in the district and sub-district level so as to ensure
training outcomes as the trainings get scaled up.
c) Planning for post training support so that training outcomes translate into service
delivery outcomes.
d) Planning for community level interventions and facility level interventions to
match the advance of IMNCI training.
e) Checking the logistics systems and improving it to ensure corresponding drugs
and supplies are in place.
The exact emphasis on each of these elements would differ across the states, but no doubt
they are needed in all the states.

5. Facility Based Newborn ( and Child) Care:

It is here that the PIPs are the weakest. One cannot escape the impression that the
hierarchies of sick neonatal and facility care are simply not understood. We have three
competing terms often used interchangeably– FBNC(facility based newborn care);
newborn corners(NBCs); and SNCUs( Sick Newborn and Child Units also known as
Stabilisation units) and NICU( Neonatal intensive care unit).

Thus taking Assam as an example, we have IMNCI focused in 5 districts and deliberately
to distribute the programmes, SNCU distributed to 5 more districts and quite curiously
something else called FBNC distributed to 5 more districts and in addition a line that 32
MOs from FRUs would be trained in newborn care. In Andhra we have 1000 of the 2200
doctos being trained in IMNCI along with 2000 staff nurses and all of them are in

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
14

facilities. In addition we have emergency neonatal care for PHCs and NICUs in all 50
Cemonc centers, plus something called facility level care in all 24 hour child health
centers. This is the case in most PIPs- a liberal sprinkling of these terms used in all sort of
combinations. And at no time do we get in almost any PIP a sense of what percentage of
PHCs or CHCs are now having the capacity to deliver their respective service guarantee
or even of what is their respective level of service guarantee as regards child health. Bihar
would train 450 MOs in 8 days IMNCI, train 100 MOs in a one day training programme
for a neonatal stabilizing unit at every PHC (which is however billed for 6.25 crores and
all 397 blocks) and in 13 districts create SNCU-IIs with an unknown match between the
activities and districts. In Chhattisgarh the term FBNC is used synonymous with the
Neontal intensive care unit, is very capital intensive and located at the medical college
level. There are other 4 SNCUs which may be district hospital level and 21 out of 32
FRUs are being covered as FBNC again but with a different definition in terms of inputs
and skills. In states like Gujarat, Himachal and Jammu and Kashmir there is a declaration
of intent to make all CHCs/block PHCs into “newborn care centers” without specifying
level of care but proposing that they would be contracting in pediatricians to do the task.
Whether such huge number of pediatricians with such dispersal would be available is
another issue. There is no clear training or equipment list that seems indicated in their
PIPs.

In our discussion below we would use the term facility based neonatal care for covering
this entire domain of treatment of any sick child, not necessarily a neonate. We would
then, in line with the national neonatology forum further categorize such facility based
care into three levels- SNCU-1, SNCU-2 and SNCU- 3 level. The SNCU-1 level is for all
practical purposes synonymous with the newborn corner concept.
SNCU-1 is at the primary health center, though due to operational constraints most
CHCs/block PHCs/FRUs may in practice be only providing this level of care. A large
number of babies are born in such institutions and they all need essential newborn care.
Since basic emergency obstetric care is deployed in these centers a large number of sick
neonates can be expected. Also due to IMNCI/HBNCC/ASHA programmes improving
referrals there would be a big load of such newborn and sick child care on every PHC.
Therefore there is no getting away from the commitment to develop this capacity in every
PHC and certainly in every 24*7 hour PHC on a 24*7 hour basis. There is also no reason
why this cannot progress on par, not just with the roll out of IMNCI, but with the roll out
of Janini Suraksha Yojana. The creation of a SNCU-1 is in effect the addition of a
minimum list of skills, a minimum list of equipment and supplies, the identification of a
suitable space in the PHC( the notion of newborn corner), the putting in place of a
standard treatment protocol and the inclusion of this service in the list of services that the
PHC delivers. The inputs are not costly and potentially could be got from the untied
funds . A standard treatment protocol could be printed and distributed, or better still
introduced through a one day workshop.(we would recommend building on the
Maharasthra Standard Treatment Guidelines(STGs) which have a much better pediatrics
component than all other STGs prepared to date, and adapting this with some of the
National Neonatology Forum (NNF) recommendations). The skills required are not much
more than what is given to health workers in the Ghadchiroli HBNC model, in that

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
15

includes injectable antibiotics and birth asphyxia management and this could be imparted
to the doctor or nurse who conducts the delivery. The use of the baby warmer ( purchased
or locally rigged) is additional. There is also every reason for merging IMNCI training
for MOs with SNCU-1 level training and it is quite irrational not to do so. In other words
the creation of SNCU-1 in every PHC ought to be a one year agenda- if the tools could be
prepared centrally, the concept could be explained systematically, and then taken down as
a systematic catch-up campaign. The critical input to achieve this objective would be the
quality of technical assistance made available.

The SNCU-2 is for the FRU level. Here sick neonates are referred when specialist
pediatric skills are required. Here a baby with birth asphyxia would not only get an
Ambous bag resustication but also could get intubation if required. Thus the main input is
of pediatric skills which could be got either by getting a pediatrician or by getting a
medical officer multi-skilled for pediatrics as has been done in the Purulia model. The
equipment needed includes the pulse oximeter and the phototherapy unit.

The SNCU- 3 is for the district hospital level and should be seen as synonymous to the
NICU( Neonatal intensive care unit).However often it is used synonymous to SNCU-2
thus creating considerable confusion. This needs much more sophisticated equipment and
it definitely would need pediatricians. Multi-skilling will not do, and special refresher
training in neonatology for pediatricians is desirable. Analogous to the problems in
setting up FRUs, in practice what has to happen in CHCs can be made to happen only at
district hospitals and what has to happen at district hospitals, happens only at the medical
college hospital. Thus by default rather than intention, CHCs remain at SNCU-1 level,
district hospitals become SNCU-2 level and medical college hospitals become SNCU-3
level. Even if this is accepted, where CHCs are functional as FRUs providing
comprehensive emergency obstetric care, one could insist on reaching a SNCU-2 level of
child care. It is worth examining the Purulia model in this regard. Purulia district hospital
is officially SNCU-2, but with support it provides almost all the level of services that a
SNCU-3 will provide. The CHCs provide a level of service somewhere between SNCU 1
and 2, and the PHC is not a focus at all. That may have been acceptable when there was
no JSY, but in the post JSY period every PHC would require SNCU-1 level skills in
place.
Madhya Pradesh has used this category and clarity- proposing level 1 SNCUs in 2
Cemoncs each of 10 districts, level 2 SNCUs in all district hospitals and level 3 SNCU in
2 medical college hospital. Orissa has proposed level one in 45 places and level 2 in 23
district hospitals. Rajasthan is near with SNCUs – probably level 2 at 39 CHCs and what
it calls FBNCs which may be level 2 in 33 districts. But again if we look at the skills
being required for each level, the equipment being required, it is clear that even in these
best case scenarios what exactly is the outcome is a bit hazy.

If we take 2000 FRUs as the objective over the RCH-II project period, then we should be
approaching about 400 FRUs and therefore about 400 SNCUs per year. The sum of
proposed FRUs is now 57 such centers in this coming year, for the entire country- which
not suggestive of being on any sort of road map. The training for SNCU-2 and SNCU- 3
are almost identical and could be delivered over 4 weeks with two more one week

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

follows up with 4 to 6 month gaps. This would need to be accompanied by good standard
treatment protocols and operational manuals. Few states have planned this and for the
most part the training programmes are suggestive of SNCU-1, while equipment is
suggestive of SNCU-2 or 3 levels. If we read the corresponding sections of all the PIPs
together, it is a bit chaotic and really sets out a huge agenda for those in the business of
providing technical assistance.

There would be only one way to accelerate the achievement in SNCUs of the 2 and 3
levels – and that is to integrate it into the TOTs of IMNCI at the district level and the
training institutes where the TOTs are being conducted.

Technical Assistance Needs:

1.Set out clear guidelines for the SNCU-1, integrating it with IMNCI training for medical
officers, and the newborn corner and FBNC terms. Create simple manual or toolkit for
this which has the Standard treatment guidelines, a state specific address from which the
facility can procure whichever equipment they do not have, and a training manual for the
nurse and the medical officer of the PHC.

2. Set out clear guidelines for SNCU- 2 and SNCU 3, along with developing the
concept/protocols of multi-skilling medical officers for pediatric skills needed in this
setting.

3. Set out an advocacy and communication tool for explaining to key officers (district
health officer;district collector; programme officers at district and state level,mission
director, director health services etc) what is meant by each of these concepts, how it
relates to IMNCI and to emergency obstetric care etc, what are the inputs that go into
each of these facilities and what are the outputs needed.

4. Identifying sites and persons for provision of training for SNCU-2 and 3, including
appropriate pediatricians in the private sector or even private institutions providing sick
child care.

5. Arranging a team with necessary skills and protocols for visiting each of these SNCUs
and providing training on the job to supplement the one month training at the training
site.

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


Equipment Skill sets and Laboratory Services
Human support Provided with
resources clinical level of
care.
PHC level: SNCU-1
Oxygen concentrator 3 nurses,
Oxygen hood with connecting tubes trained in
Open care system: Radiant baby SNCU-1 level

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
17

warmer, Portable Suction Pump, Two medical


Suction Tubes( sterile, disposable) officers trained
Resuscitator set( Ambu bag) in SNCU-level
infant/child, 1 training
Sterile Mucus Extractor, 20ml,
disposable.
CHC-FRU level: SNCU-2
All the above PLUS 9 nurses of
Phototherapy unit- single head which at least 4
Laryngoscope set- neonate. have received
SNCU-2 level
training
3 to 5 para
nurses.
District Hospital/Medical college
level: SNCU-3
All the above PLUS
Vital sign monitor for ECG,BP,
HR,SpO2, RR, Temp
Neonatal bedside Pulse Oxymeter,
Bilirubinometer,
10,20,50 ml, single phase Syringe
pump,
Electronic baby weighing scale 10
kg
Fully automatic Washing Machine
with dryer

6. Referral Transport systems:

One important adjuvant to the SNCUs is the referral transport arrangement. Across the
PIPs a formula is at work. This formula estimates the approximate number of newborns
that would need referral at 5% of all live births and provides a sum of money for each
referral. In Madhya Pradesh and Karnataka it is Rs 200 per referral, in Arunachal and
Jharkhand, this is Rs 300, it is Rs 500 in Bihar, Himachal and Assam,. This is much like
the RCH-1 approach with the difference that the fund now flows through the health
department, which is useful to ensure that utilization certificates are received on time.
However, the RCH-1 experience shows that in the absence of a communication and
ambulance network the administration and utilization of this fund is not effective. It is not
possible to create a viable ambulance service for RCH services alone. It needs to be an
ambulance service for all emergencies of which RCH emergencies is a part. In states like

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
18

Andhra, Gujarat and now Assam where EMRC type ambulance services are put in place
or proposed, one can ensure utilization of this- but even here the linkages of this fund
with that service are not thought through. In other states where no such ambulance
services are available, integration and utilization of this fund will remain a challenge.
There is room for much more state specific adaptation of this component.

Technical Assistance needs:

a. Assisting states in developing referral transport-communication systems.


b. Developing monitoring tools for estimating access of sick newborns to existing or
created ambulance referral services.

7. Nutrition and Malnutrition:

There is no coherent RCH-II plan on child nutrition and anemia, but such an approach is
beginning to evolve. This year a number of PIPs have addressed this issue. Most
important of these are Madhya Pradesh, Rajasthan, Bihar and West Bengal.

There are five approaches in the PIPs – one is the Nutrition rehabilitation centers ( Guna -
Shivpuri model); the second is the IYCF programme, the third is breastfeeding promotion
which is the main part of IYCF , but can exist outside it also, the fourth is measures to
address pediatric anemia and the fifth – perhaps the most important is the prevention of
malnutrition which requires convergent planning with ICDS and which perhaps is still the
weakest component. Most states have taken up one or more of these areas and some
states have taken up no area related to child malnutrition or anemia.

Nutrition Rehabilitation Centers are required wherever nutritional wasting is an issue- say
above 10%. Wasting (low weight for height) in contrast to stunting represents acute
malnutrition which in turn signifies either starvation or serious illness. Broadly grade IV
and over half of grade III children would qualify to be called wasted. A simple principle
in use is that all grade III and grade IV children need a medical examination, and
treatment of underlying medical causes is almost always required. Some of the children
would require hospitalization and special attention to feeding to turn them around and
break them out of the vicious cycle of increasing wasting and recurrent illness. Hence the
concept of the NRC. Madhya Pradesh has proposed 136 NRCs, up from 61 last year for
its 48 districts. Rajasthan has 39 malnutrition treatment centers, 6 in medical college
hospitals and 28 in district hospitals and 2 CHCs in each district , thus reaching a total of
about 137 such centers. It has built in adequate training for the same. Bihar in 18
districts, Delhi in two, Maharashtra in 15 tribal districts plus training 309 medical officers
in PHCs, Orissa in two, Uttar Pradesh in 20 CHCs of 12 districts. In Chhattisgarh 48
centers were proposed last year, but not implemented and whether this is to be carried
over this year is not clear. This year the focus seems to have shifted to micronutrients –
zinc and vitamin A. In all other states the agenda of wasting and malnutrition is not
addressed as a medical issue.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
19

One key question is whether the NRC is a district hospital level service or a CHC level
service. Or do we also propose a level 1 and level 2 and level 3 in this. At any rate even if
it is only a district hospital level service, is it not advisable to include this into the SNCU-
2 or SNCU 3 training and skills package. The main input for the medical
officer/pediatrician is the set of standard treatment protocols and a good sensitization to
the programme which should be possible to fit into the FBNC training or the IMNCI
training of trainers. The starting up of the SNCU- 2 and the NRC may thus not be seen as
two separate activities but as one…with targets for both being upscaled. There are some
infrastructure arrangements – especially bed space that needs to go along with the NRC-
but these can be provided in parallel and if needed use the untied funds to close gaps. The
critical input to the NRC would be the training of nurses for this role. There is a case for
creating training sites for NRC training of nurses and for sensitization of medical officers
to the issue.

The IYCF programme is included in most PIPs, but rather mechanically and the
interpretation of what this means could vary. To most it has included initiation of
breastfeeding and exclusive breastfeeding- largely by BCC activity. Complementary
feeding is in contrast almost not mentioned and the other dimensions of child feeding are
also not mentioned. There was a need to integrate this IYCF with prevention of
malnutrition and social mobilization for the same as well as with the ICDS programme
and no PIP examines the possible convergence in this area. The best plan benchmark for
the IYCF component is undoubtedly West Bengal, which has thought this component
through.

The questions we need to ask are how does IYCF differ from and overlap with the
IMNCI? What is the way that IYCF can be expanded into an effective programme of
elimination of child malnutrition? This would be one of the key questions for technical
assistance and there is a case for piloting in a number of districts an approach that could
lead to the having of child malnutrition in a three to five year period. There are a number
of states especially Uttar Pradesh and West Bengal( positive deviance model) which have
tried to address the issue of prevention of malnutrition- but we are still short of a viable
inter-sectorally convergent, district level approach.

In breastfeeding promotion, other than what is part of the IYCF, there is little to be added
in. Some states have leveraged the ASHA programme towards this goal especially a three
district ASHA plus experiment in Uttarakhand where they are incentivising ASHAs for
this. Chhattisgarh has shown results in this area without incentivisation. Other states
have included baby friendly hospitals. There is a case for taking up these interventions in
many more states.

In pediatric anemia- the RCH-II programme is yet to get seized of the problem and even
if they do, answers would not be easy. Though deworming and vitamin A once in every
six months have become part of the routine ( though only with a 15% coverage) a once a
day pediatric iron tablet for 30 days every six months or some similar regime has been
added on in one or two states – like Uttar Pradesh where an iron syrup is proposed along
with vitamin A. This would be an useful addition in all states if we have to go the bi-

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
20

annual way, but this has not yet caught on. Some states have added on Only Assam has
mentioned that per health worker 20 children would have their anemia corrected through
pediatric iron supplements. Meghalaya also has mentioned an effort on pediatric anemia.
At least for malnourished children this could be insisted on, given the correlation of
anemia with anorexia. This is an area that requires technical assistance- in creating
replicable successful models, in improving logistic and the introduction of pediatric iron
preparations, and in integration with child malnutrition management.
Sickle cell anemia as a significant cause of childhood anemia and childhood pneumonia
is another area which the RCH-II programme design had provided for state level plans.
But this had also not been taken advantage of.

Biannual drive for vitamin A and deworming figures in almost all PIPs. Figures of past
coverage and expected improvement need to be studied. States which have proposed
newer micronutrients are Calcium and Vitamin A as part of atta fortification in Gujarat
and zinc in Chhattisgarh(for 1.53 crores with another 1.32 crores on the vitamin A drive).

Areas for technical assistance:

a. Assessment of the NRC approach and working out ways to maximize outputs
from the same.
b. Evolving replicable models of halving malnutrition rates in 3 to 5 year periods.
c. Evolving replicable models of addressing childhood anemia.
d. Assessing the BCC and IYCF strategies and integrating them with other activties.
e. Assisting states in identifying nutrition related issues and helping them in
evolving strategies to address child malnutrition.
f. Examining the RCH-II programme design for the linkages of child health and
child nutrition and recommending on the same.

8. Malaria:

Most charts of causes of child deaths show malaria at 8%, about twice that due to
measles. These are global charts and in most of the world the API is less than 2( non
endemic for malaria) In areas where the API is more than 2, especially if that is more
than 5, one can expect the proportion of child deaths attributable to malaria to reach over
30%.
RCH-II design provided space for this in its state plans, but as the state planning process
becomes increasingly structured, malaria perhaps needs to become visible in its grids.
Malaria finds a place in the IMNCI module as the management of fever- but
incompletely. Compare for example, with the effort made on measles and we can realize
the importance. Though malarial deaths are difficult to identify we can assume case
fatality ratios in falciparum to be in the range of 5% and this should give us an
approximation of the number of child cases and child deaths due to malaria.

Child specific preventive measures, a child focus in the EDCT( early diagnosis and
complete treatment) strategy and in the ITBNs ( insecticide treated bed nets) strategy etc
could make a huge difference to child survival in these areas.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
21

The effectiveness of IMNCI protocols to address the sick child with malaria also needs to
be studied. The entire area of recognition and integration of malaria as the fourth major
cause of childhood mortality (following neonatal deaths, ARI and diarrohea) would be an
important area for technical assistance.

The link between chronic childhood malaria( the typical tribal child with a pot belly due
to splenomegaly but thin matchstick-like emaciated limbs) and child malnutrition and
severe childhood anemia also needs to be explored. Meghalaya is the only state that has
mentioned this problem and tried to address it.

9. PPPs In the PIPs.

There is very minimal use of PPPs. Assam has proposed 4 CHCs being outsourced and
150 hospitals being not only accredited but provided a cash support of Rs 15 lakhs for
equipping themselves to provide services. Gujarat has proposed a Bal Chiranjeevi project
on the lines of Chranjeevi scheme. There are voucher scheme in operation in Agra,
Kanpur and Haridwar.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
22

Section-3

Matching TA needs from PIP analysis with Joint Review


Mission Recommendations
Many of these issues raised above were already raised in the JRM report. However many
of these issues were to be corrected by the time of this current years PIPs. By referring to
the JRMs articulation of issues, adding in our analysis of the PIPs, and further taking
inputs from discussions with number of programme officers and mission directors in the
states, we can arrive at a matrix of TA needs: In the table below we have shown the JRM
recommendation and then the corresponding recommendation from PIP analysis.

Areas of Concern Recommended Action


a) The surveys of FRUs and 24x7 1) By March 2008, the CH division
PHCs clearly show huge gaps in the and states will ensure that the state PIPs
provision of adequate newborn care in for 08-09 address the gaps identified in the
facilities where deliveries are taking place. survey findings (Relevant for the eight
erstwhile EAG states, Andhra Pradesh and
Assam where surveys were undertaken).
2) We suggest that all PHCs
conducting deliveries should aspire for
SNCU-1 level of care at the earliest. All
CHCs/FRUs should aim for SNCU level 2
of care within three years, but in the
meantime they should be part of the
process to reach level 1 SNCU care in all
facilities..
3) TA (task 1) would be to provide CH
division with a manual and a tool kit for
reaching SNCU level 1 of care in all PHCs
and CHCs within 18 months. This tool kit
with would be integrated with the IMNCI
module for medical officers.
4) Agencies could be specifically
recruited (TA task 2) for each state who
would work with the state to help it conduct
the training programmes and support the
state in putting in place SNCU 1 level care
in all PHCs and CHCs.

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

Areas of Concern Recommended Action


5) TA task 3 would be to provide CH
division with a tool kit for reaching SNCU
level 2 of care in all CHCs eventually but
within three years in all places able to
handle basic or comprehensive emergency
obstetric care. As part of TA task 3 would
also be to provide a tool kit for reaching
SNCU level 3 where required. ( a tool kit
has list of equipment, list of supplies, HR
skills required, training manuals, training
strategy, model MOUs to be signed with
PPP centers for providing training, copies
of enabling orders, advocacy brochures,
standard treatment protocols, consultation
back up, evaluation processes etc).
6) TA task 4 would be hire/ equip and
empower agencies for each state to help
the state draw up a road map and walk on
it. This would include an advocacy unit for
supporting the task.
b) Highest priority should be given by 7) By June 2008, the CH Division will
all States to ensure that at least the frame guidelines and disseminate the
essential newborn care is available in all same to the states.
delivery sites so that the opportunity
This guideline is the same as TA task 1
provided by JSY is not lost. This
and TA task 2 given above- but such a
opportunity should also be utilised to
delineation is needed to make it happen..
provide counselling to the women who
deliver in the institutions on immediate
initiation of breastfeeding, exclusive
breastfeeding for six months, immediate
postpartum care and also contraception.
c) Although IMNCI implementation is 8) By April 2008, UNICEF will provide
being monitored, there is still concern that assistance to the CH division in setting up
the process is not comprehensive or a mechanism for monitoring IMNCI training
detailed enough. and implementation across the country,
and ensure continuum between community
and facility-based care for newborns.
9) Same consultant team as identified
for TA task 2 would be put in place for also
identifying the processes of quality
assurance in IMNCI and to attend to the

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
24

Areas of Concern Recommended Action


gaps in IMNCI implementation that have
been identified. They would hand hold one
agency in each state to develop the
capacity to oversee the entire child health
implementation (TA task 5)- preferably it
would the SIHFW. For this purpose
consultants may be recruited and placed
with the agency/SIHFW. They would
evolve state specific guidelines which the
state mission directors would issue in
consultation with the CH division.
d) As IMNCI roll-out is taking time, 10) By June 2008, the CH division will
States need to step up other actions for provide and disseminate clear guidelines
improving newborn care and care of sick to states on “how to” address new born
children. care essentials (through the PIP appraisal
process). States will ensure that these
e) There is a need for greater actions are reflected in their PIPs for 08-
emphasis on essential new born care both 09.
at facilities and at homes, including in non- 11) States may request TA for
IMNCI districts. implementing guidelines ( for modalities
refer to Section 16 of the Aide Memoire).
f) Greater attention is needed
towards: Improving home based newborn care: By
i. Management of asphyxia in July 2008 select agencies/consultants
newborns as part of care at birth would visit each state and after
under JSY quality assurance; discussions help each state draw up or
ii. Increasing use rates of ORS and improve on their plans for provision of
Zinc as an adjunct therapy in home based new born care through
children with diarrhoea; and ASHAs .(TA task 6) The CH concern has
iii. Reducing deaths due to to be woven into the the design of the
Pneumonia and SAM (Severe support structure, the mentoring and
Acute Malnutrition). monitoring process for ASHAs and its

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
25

Areas of Concern Recommended Action


g) The Search model on Home-based training programme, material and training
Newborn and Child Care is difficult to scale strategy, into the ASHA drug kit and into
up due to high costs and intensive the ASHA payment schedule.This cannot
monitoring and supervision support be done at a national level, but only in a
required. This is being attempted in 2 state specific format. This would include
districts in each of five states under the ways of strategising and simplifying the
NIPI, at an approximate start up cost of Rs. Search model and integrating it with
7 crores per district and a recurring cost of learnings from IMNCI and making it more
about Rs. 2 crores per district per year. cost effective. ( these cost projections are
anyway unrealistic)- learning from the
Chhattisgarh and UP experience where
this has already been done..

Improving roll out of IMNCI: putting in


place necessary agencies who can ensure

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
27

achieving a significant reduction in childhood anemia, which


includes ( 5 to 10 agencies may be involved) TA task 11.
s) Malaria as an 25) Commission a study to look at the data, to estimate
RCH issue the malaria attributable maternal and child mortalities and
morbidities with correspondience to API levels and to
recommend ways of addressing this effectively and
efficiently. (TA task 12)
t) PPPs in child 26) These have been all mentioned in the proposed
health studies and scaling up TA for “ Innovations”that the
development partners and the DC division have worked out
and are therefore not being duplicated here. There are
anyway few learning that are of scale.
u) BCC in child 27) Build up a BCC hub in each state SIHFW which can
health plan for integrated BCC and as part of this include child
health issues. Help them develop up communication material
on key themes identified for the state and for each district for
three levels – a) community level: ASHA and AWW, VHND,
VHSC etc; b) the facility level including the sub-center. And
c) the mass media level. To help do this and handhold the
BCC hub we would need to hire in an appropriate TA agency
for each state. (TA task 13)
v) School health ( 28) TA agency to plan out and support school health in
see NHSRC note on each state. This needs to be coordinated between health
school health in the dept, education dept and NACO.(TA task 14)
PIPs)

Note: a, b d, e h, and l above refer to the same issue – the nature of facility based care –
and this much duplication is reflective of the need for conceptual clarity on this.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
27

achieving a significant reduction in childhood anemia, which


includes ( 5 to 10 agencies may be involved) TA task 11.
s) Malaria as an 25) Commission a study to look at the data, to estimate
RCH issue the malaria attributable maternal and child mortalities and
morbidities with correspondience to API levels and to
recommend ways of addressing this effectively and
efficiently. (TA task 12)
t) PPPs in child 26) These have been all mentioned in the proposed
health studies and scaling up TA for “ Innovations”that the
development partners and the DC division have worked out
and are therefore not being duplicated here. There are
anyway few learning that are of scale.
u) BCC in child 27) Build up a BCC hub in each state SIHFW which can
health plan for integrated BCC and as part of this include child
health issues. Help them develop up communication material
on key themes identified for the state and for each district for
three levels – a) community level: ASHA and AWW, VHND,
VHSC etc; b) the facility level including the sub-center. And
c) the mass media level. To help do this and handhold the
BCC hub we would need to hire in an appropriate TA agency
for each state. (TA task 13)
v) School health ( 28) TA agency to plan out and support school health in
see NHSRC note on each state. This needs to be coordinated between health
school health in the dept, education dept and NACO.(TA task 14)
PIPs)

Note: a, b d, e h, and l above refer to the same issue – the nature of facility based care –
and this much duplication is reflective of the need for conceptual clarity on this.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
28

Section- 4
Child Health in the RCH Project Implementation Plan
2008-09

Brief Preliminary Analysis


of each state PIP:

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


each state in consultation with the state. As also a need to improve
the statistical picture in child health performance in that stage. That
would become available in version 2.0

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
29

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


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

Year 2001 2002 2003 2004 2005 2006


IMR 66 62 59 59 57 56

2. Key strategies outlined


Past and proposed strategy Appraisal comments
Through the main strategy of having ASHA No link has been made between
in all the in habitants the Child Health care WHV and ASHA with regards to
has been addressed. Child Survival. This could be done
Focus is also built on having convergence and could contribute greatly to
with other related departments improved child survival. Also 31 %
of deliveries are conducted in homes
(NFHS III) and therefore essential
neonatal care should be addressed
through ASHA.
IMNCI : IMNCI training for 1000 doctors Scale of training good – but
out of 2214 doctors (RHS 2007) and 2000 evaluation systems and post training
staff nurses for 8 days in batches of 6. The follow up systems should be put in
emergency neo-natal care for all medical place.
officers in 1570 PHCs and 167 CHCs total of The MOs could be selected on the
2214 doctors. high priority based districts for
training rather providing training for
all MOs at once. Theirs is not
IMNCI trg but a different skill set.
Proposed NICUs in all 50 CEMONC center, The coverage provided is one center
but the human resource are appointed up to per 16 lakhs. This needs to be scaled
project period. Infrastructure development at up to one per 5 lakhs and then once
these centers @ Rs 7,00,000 per unit. per lakh if it has to make an impact.
CHCs and PHCs should have
SICUs/ newborn corners etc. HR
planning for NICUs to be made
explicit.
Newborn care kit being provided to all births Scheme operational since 2006-07.
in government institutions for SC/ST/BPL Need to plan appraisal/evaluation
families.
Facility Level care: 24 hr child health centers Details needed especially as regards
in all 800 units with obstetric and pediatric availability of skills for the same.
services, for 1,00,000 rural population.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
30

Nutrition:
a. Malnourished: 79% (NFHS III) of No strategy that addresses
children are anemic. malnourishment or anemia of
children is proposed.
b. Breastfeeding: only 22.4% (NFHS III) More specific promotion measures
of children were breastfed with one could be outlined like in sections on
hour. Habitation level workshops by BCC. a plan for this would help.
ASHA to sensitize community on
breastfeeding practices.
c. Referral transport being strengthened This is going on well from all
through “Rural Emergency Health reports and would be good to know
Transportation Scheme” for poor and what percentage of sick babies
SC/ST, population. transported.
School health and immunization described
separately:

Overall comments on Andhra Pradesh PIP

a. Strategic focus on Child Health in ASHA programme would be helpful.


b. More rapid roll out on scaling up of IMNCI and its integration with facility
development needed.
c. HR and skills for facility based care need to be planned for.
d. Focus on malnourishment is needed.
e. District specification/ variation on child survival need to be studied and acted on.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
31

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2008-09
Arunachal Pradesh
1. Basic Health indicators regarding Child Health
a. Infant Mortality Rate
i. Current IMR: 40-44-19 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)
iii. IMR 61 in NFHS III and 63 in NFHS II
Year 2001 2002 2003 2004 2005 2006
IMR 40 39 34 38 37 40
(SRS)

2. Key strategies outlined


Past and proposed strategy Appraisal comments
Home based neo-natal care and facility based The HBNC is very crucial for this
neo-natal care yet to be addressed following state as 69 % of deliveriess are
the GOI guideline. conducted in homes (NFHS III).

Therefore, ASHA (3290 ASHA)


training with IMNCI skills is should
be the focus of the state.
IMNCI: The number proposed for IMNCI Only 33% of deliveries are attended
training has increased from the previous year by skilled birth attendants (NFHS
(from 64 MOs to 90 MOs) 1 . III) and only 23% receive PNC
IMNCI training for AWW (320 proposed) (NFHS III), therefore the IMNCI
and ANM (60 proposed) is inadequate as the training should focus more on
total percentage trained is only 16% of training of ASHA/ANM/AWW.
AWW and 8.33% of ANM.
Facility Level Care: Facility level The terrains and the difficult areas
strengthening particularly in case of Neonatal could be accessed with the help of
Care should be focused, as there is an MMUs. There is a need for scaling
increasing trend in IMR. up of MMUs in the state.

Two MMUs functioning should be evaluated


so that it could be scaled up to other districts.
Referral transport for mother and children has More concentration could be paid on
been proposed with Rs 300 per case, however the implementation of referral
only 8 ambulances are provided. This seems transport. The MMUs could also act
to be inadequate for improving the as referral transports in areas visited.
institutional deliveries and thereby child
survival.
Nutrition:
a. Malnourished: 66% of children below 3
years are malnourished (NFHS III) and

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

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
32

intervention designed with SWWCD and


DFHW should be evaluated for continued
support.
b. Breastfeeding: only 55% (NFHS III) of The details of the IEC are
children are breastfeed within one hour. encouraging to reach the
The interventions could be made community.
following ASHA training.

c. School health and immunization


described separately

Overall: The state of Arunachal Pradesh, should concentrate more on Home Based Neo-
natal care (HBNC). Considering the terrain more ASHAs should be trained in HBNC.
Some districts where the “female under five mortality” is prevalent (mainly in East
Kameng) should have more BCC/IEC activates proposed by ASHA and other health
workers (ANM, AWW) and also community level participation for bringing behavior
change. Moreover number of ASHA selected from this region is also inadequate, and
should be addressed immediately.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
33

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2008-09
Assam
1. Basic Health indicators regarding Child Health
a. Infant Mortality Rate
i. Current IMR: 67-70-42 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data) (total/rural)

Year 2001 2002 2003 2004 2005 2006


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

2. Key strategies outlined


Past and proposed strategy Appraisal comments
a. Home Based New Born care: health Described in BCC section – but
workers from 20/23 districts are to be not detailed under ASHAs
trained with SBA providing home based
neonatal care.
b. IMNCI : IMNCI training in 5 focus Need to synergized between
districts through 120 TOTs and 2880 where outreach workers are
H&N workers. TOT for health workers trained in IMNCI and FBNC and
@ Rs 12.91 lakhs and IMNCI training SNCU I in proposal been planned.
for ANM/AWW Rs 184.33 lakhs There is a need for these to go
c. IMNCI, two kits per trained workers. together to go together for making
Kits are provided to 6000 H&N workers an impact. We assume that FBNC
@ Rs 1850/kit refers to PHC staff and SNCU to
d. To achieve a target of 65% from existing district and CHC staff – but this is
35% (NFHS III) awareness and not clear and we hope they have
treatment about ARI, health got it right.
functionaries are provided training for Details of a six month course for
early detection and referrals and also newborn care needs to be
ambulance services are proposed. understood.
e. Multiskillng of 32 MOs from
FRUs/CHC on newborn care @
GMCH/AMCH/SMCH for 6 months, Rs.
28.57 lakhs

f. Facility Level care: This is an area that requires


i. SNCU training in 5 focused districts technical assistance. The
for 100 MOs (Jorhat, Dibrugarh, difference and content of the three
Kamrup, Goalpara, Barpeta, Darrang, programmes – SNCU at CHC,
Cachar, Sonitpur and Sivsagar) and SHCU at district hospital and
setting up stabilization centers in all FBNC are different.
108 CHCs and 149 BPHCs. SNCU
training for 5 batches of 100 MOs
would cost Rs 2.73 lakhs/batch.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
34

ii. Setting up of SNCU in 10 district


hospitals (Goalpara, Sibsagar Barpeta,
Darrang, Sonitpur ,Bongaigaon,
Golaghat, Nagaon, Karbi Anglong &
Cachar) @ Rs 112.91 lakhs

g. FBNC training to all MOs (80 MOs) in


Bongaigaon, Nagaon, Cachar, Sonitpur,
Dibrugarh @ Rs 43,66,080/ . TOT for
FBNC @ Rs 12.128 lakhs.
Nutrition:
a. Malnourished: 40% of children Strategy on malnutrition
are underweight and 13% are inadequate. There is an anemia
wasted (NFHS III). strategy that needs to be followed
b. Anemia: 76.7% to address up. Breastfeeding is well focused.
childhood anemia, 20 mg Need to be able to monitor
elemental iron and 100 mg of outputs and outcomes of BCC
folic acids (600 IFA tablets) and separately.
deworming to be done through
health workers @ 20 children per
worker per year.
c. Further integration with ICDS
functionaries, for midday meal
programme.
d. Mass campaign of vit A by health
workers and Vit A solutions with
AHSA/AWW/ANM.
e. Breastfeeding: 50.6% (NFHS III)
of newborn are breastfed within
hour of delivery. IEC/BCC by
health workers for exclusive
breastfeeding. The highlight is of
prohibition on artificial milk and
bottle feeding in health
institutions
h. Referral transport being strengthened This is an inadequate approach to
and separate budgetary head placed for referral transport and will face the
neonatal transport facility and for ARI same problems as RCH-1 faced.
and Diarrhea for Rs 500/case Need to integrate with Emergency
(complicated cases) @ an estimate of 5% transport system with a process
might need transport. indictor related to the sick child.
i. Integration with Medical, Fire and Police
Department for EMRI; 300 ambulance
@ Rs 115.13 crore.
j. PPPs: developing partnership with j.Details need to be examined for
private sector for PPP in providing comment.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
35

newborn care services by outsourcing 4


CHCs. Total cost Rs 0.86 crore for k. This PPP specfies that Rs 15
administration, documentation and lakhs to be give n to 150 pvt
management. hospitals but with no clarity on
k. 150 Pvt. Hospitals are proposed under returns or terms of MOU given.
PPP @ an annual grant of Rs 15 lakhs. Possibly more details need to be
given – but now it looks very
much like a hand out.
l. Innovations: maternal and child health
month Æ bi annually
m. 31 MMUs proposed @ Rs16.88 Crore., ANM posts are vacant in 80/5109
with 2 MOs, 2 GNM & ANMs. HSCs (GOI, 2007) 2 and it is
However, 27 MMUs are implemented in proposed that MMUs will be
10 districts of the state. having two ANMs.
n. Boat clinics are proposed in three new
districts (making to a total of 5 districts)
in partnership with C-NES Rs. 2.41
Crore.
o. School health and immunization
described separately:
p. Introduction of a communication
package of home based new born care by
all workers: IEC/BCC activities through
6000 LHVs @ Rs 2.25 crore/-
Overall: 77% of deliveries are conducted at home and its even worse for rural area i.e.,
82% and only 31% of deliveries (NFHS III) are attended by health personnel and only
13.8% receive PNC (NFHS III). The Assam state government has to strengthen the home
based newborn care (HBNC), followed by strengthening of referral system and the
facility based newborn care.

2
GOI (2007), Bulletin on Rural Health Statistics in India, Ministry of Health and Family Welfare, Chapter
II, Table 19, Number of Sub-centers, PHCs, and CHCs functioning , pp 32.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
36

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 60-62-45 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 62 61 60 61 61 60

2. Key strategies outlined


Past and proposed strategy Appraisal comments
HBNC training for ASHAs/MPWs/AWWs. Has only a mention. Details of how
this would be done needs to be
worked out.
Orientation for ASHA for diarrhea and ARI There is no system in place to
and ASHAs training for detection and support or monitor ASHA in this or
identification of danger signs., administer any task. This needs to be put in
ORS and co-trimoxazole tablets. place
- Seven day orientation has been completed to
57,000/66701 selected ASHAs.
IMNCI training for “community level We assume community level
workers”, for 8 days, in PNC visits, workers refers to the categories
counseling for breast feeding and new born given below and not to ASHA. But
practices, immunization. 10 day TOT for state ASHA needs HBNC or IMNCI
level trainers on training techniques of training. The plans are largely for
IMNCI and HBNC; similarly TOT at district AWW and ANM training.
level and training of ANMs /LHVs /Nurses is
also proposed.
8 days training for AWWs and 8 day training
for MOs in basic training tools and
techniques, IMNCI including HBNC
IMNCI: pilot ongoing in Vaishali district Exact strategy of expansion and
(24 MOs from medical college and 44 public scaling up not clear- but broadly
sector doctors trained). programme plan seems adequate.
- Six more districts ongoing. Plan to
expand to 18 more districts in phased
manner
IMNCI training proposed: Complete IMNCI training
- 40 ICDS workers TOT @ Rs 20.00 programme well developed.
lakhs( note high cost) UNICEF providing technical
- 450 MOs @ Rs 225.00 lakhs assistance and financial support for
- 450 SNs @ Rs 180 lakhs many components. But need to

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
37

- 380 ANM/LHVs @ Rs 152.00 lakhs ensure no duplication and re-check


- 1500 AWW @ Rs 600 lakhs the high costs suggested. The
- 25 health workers on follow –up @ IMNCI annexure figures do not
Rs 5.00 lakhs. match the budget annexure figures.
Total : IMNCI training – Rs 18.06 Cr.
100 Neonatal stabilizing units in high- Corresponds to SNCU I or simpler
mortality blocks at PHC level, following one level- training from UNICEF.
day training.
- one pediatrician, MOs trained in pediatrics
and MO/SN trained in FBNC
- establishment of level I neonatal
stabilization units in 397 blocks – equipment,
civil works/renovation and skilled manpower
@ Rs 1.57 lakhs/district – supported by GoB
and NRHM: Neonatal stabilization unit – Rs
6.25 Cr

Æ training on essential newborn care to be


supported by UNICEF.
- Comprehensive newborn care unit in Facility based care focused in 13
13 district near to SNCU II @ Rs districts. Seems to have put in place
39.36 lakhs /unit from the state and a comprehensive plan for SNCU
another 7 lakhs from UNICEF : Total development for these 13 districts.
on Level II SNCU – Rs 3.93 Cr
a four day training and strengthening 12 bed
SNCU with equipments and manpower in 13
districts (proposed)
- two pediatricians
- four MO
- one PHN
6 SNs & 8 ANMs
Nutrition:
a. Malnourished: 58% of children are Comprehensive Nutrition plan but
underweight and 28% are wasted how it would be effected at the
(NFHS III). village level and at the ARC level
i. diet supplementary to be given by would be the challenge
AWW in convergence with ICDS
programme, for all underweight BPL
mothers as a measure to address
LBW babies
ii. growth monitoring of children by
ASHAs, AWWs during VHNDs
iii. 20 bed NRC functional in 8 districts
and similar NRCs are proposed in 10
more districts @ Rs 1,41,800/NRC
(includes training and infrastructure)

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
38

a detailed plan has been laid down for


management of severe and acute
malnutrition. However for manpower
and other recurring cost per NRC is
@ Rs 16,75,200
iv. Æ exposure visits to NRC @ Rs 1.68
lakhs total
v. Æ NRC total cost for establishing 10
new NRCs and operationalising 10+8
NRCs and the exposure visits would
cost Rs 100.00 lakhs. 155 MOs
training in care of sick and severe
malnourished children @
Rs 77.50 lakhs.( part of NRC?)

b. Anemia: 87.6 % of children below the No strategy on anemia apparent.


age of 3 years are anemic (NFHS III).

c. Breastfeeding: 4% of infants are Well planned BCC focus on


breastfed within one hour of birth breastfeeding.
(NFHS III) and exclusive breastfed for
0-5 months is 27.9% (NFHS III).
i. mass media communication to promote
breast feeding, through jingles, folk
songs. Etc.
ii. involving AWW, PRIs, TBAs, local
NGOs to promote breastfeeding and
complementary feeding through IPC
and group meetings.
iii. 3 days training on IPC for PRIs, AWW,
CBO and NGO., on breastfeeding,
ARI, immunization, HBNC, referral
services.
Æ Vitamin A supplements: a detailed Past performance figures would be
programme on management of nutritional useful to assess coverage and
status of children is outlined, initiated in impact.
2000-01 conducted bi-annually. The budget
proposed for one round is Rs 989.53 lakhs.
d. Referral transport: This is in inadequate solution to
- Rs 500/ care is proposed for referral of referral problems.
sick infants to health institutions
e. MUSKAAN prog: launched in New initiative – would be worth
October 2007 studying.
- to track all pregnant women and
newborn children, by ASHA, AWW
and ANM

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
39

- data center in all 533 PHCs to


monitor the programme.
-total Rs 1609.40 lakhs.
f. School health and immunization
described separately:

Overall:
A plan that captures almost all dimensions of child health planning in these 13 districts at
least. The weak areas are in the deployment of ASHA towards this end. The concern is
whether the underlying systemic issues would be overcome. In the short run a substantial
UNICEF investment in this area promises to fill these gaps – but even for them it is a
challenge. In the long run such project support will not continue and the additional
manpower for managing these interventions needs to be part of the regular staff and they
need to be skilled and organized to take care of these roles.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
40

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 61-62-50 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 77 73 70 60 63 61
2. Key strategies outlined
Past and proposed strategy Appraisal comments
Community and home based approaches towards Adequate strategy – but findings
improving child health. of monitoring system may be
- Navajaat Swagat Bheit indicated.
- Home based newborn care awareness
generation through mitanins (Community
Health Worker)
- Sisu Sanrakshaan Maah twice a year along
with RCH services., vit A, albendazole, foam
banners etc @ total Rs. 132.30 lakhs
IMNCI: IMNCI training for ASHAs has
- 20,000 mitanins (ASHAs) trained in covered only one thirds. Training
IMNCI and HBNC by December 2007. for ANMs/AWWs/LHVs is going
- 18 doctors are trained as masters trainers slow so far – but need to follow
and 30% and 60% of doctors are proposed whether it can be accelerated as
to be trained in quarter 3 and 4 respectively proposed, given very poor
in 2008-09. (total MOs 1345 in the state). coverage as of date. Issue is also –
Similarly 24 ANM/AWW/LHV are trained is IMNCI the training to give
in IMNCI and 30%,30% and 60% of them MOs or should it not be facility
are proposed to be trained in 2008-09 3 based care? Is separate MO
- Newborn assessment forms and referral module on IMNCI in use?
forms for mitanin and mitanin help desk at
district hospitals and CHCs
- Total IMNCI is budgeted at Rs 74.04 lakhs
Facility based care: Hierarchy of facility based care
- One provider in 21/32 FRUs are trained in does not seem reflected- how
FBNC it is proposed that all FRUs will many SNCU-1, how many of II
have one provider trained in FBNC by 3rd and how many of III are
quarter. proposed? Is FBNC same as
- Renovation of four SNCUs at total cost of SNCU-1? But then for Raipur
Rs 116.75 lakhs medical college it should be

3
IMNCI training for MO, Nurse, ANM and AWW.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
41

- Accreditation of health institutions for child SNCU-III level? At any rate the
friendly practices promoting breast feeding, scale of improvement in facility
immunization, management of severe acute based care and the systems of
malnutrition; accreditation by state task training and gap filling seem
force for child friendly health facilities @ inadequate. May like to take a re-
Rs 29.15 lakhs look at this design and improve it
- Essential newborn care in 24*7 hospitals. within the approved budget.
- Swagath Package for mothers and newborn
for institutional deliveries neonatal
incentives for an estimate of 4 lakh children
in rural and 3 lakh by mitanins. However
the total budget for the scheme is Rs. 49.50
lakhs and number of beneficiaries to be
reached is not mentioned
- Renovation and equipments at four hospital
with FBNC @ total cost of Rs 306.75 lakhs
- Strengthening FBNC in Raipur Medical
college @ Rs 116.75 lakhs
- None of the staff nurse are trained in FBNC
and 30% -30% are proposed to be trained in
quarter 3 and 4 respectively.
-
Nutrition:
a. Malnourished52% of children are No measures needed to
underweight and 18% are wasted (NFHS operationalise this are seen. No
III). Care of children with severe or acute training, no exposure visits, no
malnutrition- establishment of 48 Bal support – may be there in
Suposhan Kendras in CHCs was budgeted UNICEF budget or may remain
in 2007-08 PIP; therefore recurring cost of unutilized like last year.
these kendras are budget in 2008-09.
b. Anemia: 81% of children less than 3years No strategy on anemia.
are anemic (NFHS III).
c. Breastfeeding: 24.5% (NFHS III) within Seems a good initiative. UNICEF
one hour of birth and 0 to 5 months is 80%. two hour of birth figures show a
- Baby Friendly Hospitals (accreditation of much better picture and it matches
baby friendly hospitals mentioned) with design of Mitanin
- A total of 205 health staff (Pediatricians, programme.
MOs and SNs) in breastfeeding practices at
National Training center for breastfeeding
@ total cost of Rs 18.45 lakhs
- details on further strengthening of
institutions on baby friendly hospitals
mentioned @ total cost of Rs 29.15 lakhs
(including training).
- 24 hour Crèches in all district hospitals
manned by 4 staff.

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

d. Administration of Zinc in management of Large investment for zinc in


diarrhea is proposed in 3 districts through diarrhea- and that too for merely
ANMs, AWW and mitanians three districts. According NFHS
Management of diarrhea with ORS and ZINC III 42% of children with diarrhea
@ Rs 1,53,79,217.28 received ORS and 65.3% were
taken to the institution, but
estimation is for total coverage. Is
this the priority when IMNCI and
FBNC is still at such low
coverages. Can all be trained? Is
the logistics system to deliver this
in place.
e. School health and immunization described
separately:
Overall:
The Mitanin and breastfeeding promotion component is well developed. The facility
based care improvement plans needs careful assessment and strengthening. The IMNCI
training is far behind schedule and does not budget for follow up and such a rapid
expansion seems wishful. The measures on nutrition are also half hearted. Vitamin A is
however receiving adequate emphasis. In the midst of so much lagging behind in priority
areas the emphasis on zinc in diarrhea is questionable. Even to implement this zinc
strategy requires considerable training and support which would take away a lot of effort.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
43

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2008-09
Delhi
1. Basic Health indicators regarding Child Health
a. Infant Mortality Rate
i. Current IMR: 37-42-36 SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 34 31 28 32 35 37
iii. IMR according to NFHS II was 47 and NFHS III is 40

2. Key strategies outlined


Past and proposed strategy Appraisal comments
Implementation of HBNC and IMNCI in all nine HBNC and IMNCI must be
districts in a phased manner two districts in undertaken in the same districts
2008-09. simultaneously for maximal
effect.
Inclusion of IMNCI curriculum in UG trainings
a sum of Rs 10 lakhs was provided to 5 medical
colleges in the previous plan and the same
amount is also proposed this year.
Proposed budget for IMNCI is Rs 29.5 lakhs and
training load of health workers for IMNCI yet to
be finalized.
Identification of danger signs by Mechanisms for honouring
ASHA/AWW/ANM and refer to near by neo- referrals by the peripheral health
natal care facility. workers and PUHCs need to be
- 240 ASHA training in HBNC proposed developed at the secondary and
tertiary public facilities.
Strengthening neo-natal care services through TOR must specify the service
private sector participation. An estimate of 200 guarantees, standards and pricing.
newborns through IMNCI/HBNC project and
IEC/publicity of the private facility@ Rs 60 Rationale for Rs. 60 lakhs
lakhs. unclear.
TOR for Registered nursing homes, to be framed
by the Neonatologists Expert Group. Private facilities providing
Monitoring budget 2.16 lakhs. maternity services under PPP
arrangements should be combined
with neonatal care.
FBNC (training) How many facilities start up this
- 90 MO training proposed @ Rs 5000/MO, and service? What are the links with
20 TOTs (MO) proposed @ Rs 5000/TOT IMNCI, what is the correlation
- 90 SN training proposed @ Rs 3000/ SN with other elements of putting
FBNC in place?

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
44

IYCF proposed in two districts @ Rs 2.00 lakhs


/district.
Care of sick and severe malnourished children
two per DH @ Rs 3.00 lakhs/ DH

Nutrition:
a. Malnourished: 33% of children are Linkage with ICDS/ASHA for
underweight and 16% are wasted. referral and community-based
- Care of sick and severe malnourished follow-up to prevent relapse is
children two per DH @ Rs 3.00 lakhs/ crucial for effective nutritional
DH rehabilitation.
- 15 TOTs (MO) @ Rs 5000/ TOT and 10
MO training @ Rs 5000/MO Difference between the ‘Nutr.
- Nutrition rehabilitation facility one per Rehab. Facility’ and the ‘Care of
district @ Rs 3 lakhs per hospital (total 8 sick and severe malnourished
hospitals) and counseling centers at these children’ not clear.
hospitals @ Rs one lakh/hospital.
b. Anemia: 69% of children were anemic in
NFHS II and 63% in NFHS III.
c. Breastfeeding: 19.3% (NFHS III) within Greater focus needed in view of
one hour of birth had improved from very poor performance in this
NFHS I 6.3% to 23.8% NFHS II and score. When 61% are institutional
34.5 % of children are breastfed for 0 to delivery why should only 23.8%
5 months (NFHS III). be breastfeeding within the first
- BCC/IEC by ASHA/AWW/Basti hour. Need to address this.
Sevikas.
School health and immunization described
separately:

Overall: BCC/IEC should be focused more to increase breastfeeding with in one hour of
delivery., promotion by ASHA/ANM/AWW. Inadequate thrust to taking IMNCI and
FBNC to scale which could be much easier to achieve in Delhi by innovative PPPs for
training. However PPPs proposed are limited to reimbursement schemes for private clinic
which would offer only a limited coverage. Need to understand this proposed PPP model
better. At least every site of institutional delivery could be converged with sick child care.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
45

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 15-14-16 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 19 19 16 17 16 15
(total)
IMR 20 21 18 17 16 14
(rural)

2. Key strategies outlined


Past and proposed strategy Appraisal comments
Focus on JSY, to approach Urban Slums IMR urban is now worse than
rural. More comprehensive urban
strategy may be needed.
Monthly health days at all AWWs, but not
explicitly stated the strategy
IMNCI : The earlier version of PIP in its
IMNCI TOT has been flagged off, in 2007-08 budget lines had elaborated the
due to poor interdepartmental co-ordination. details of IMNCI training. Where
30 MOs trained in IMNCI and no other health as the revised version doesn’t
worker is trained. However, the PIP doesn’t mention about the details of
mention the how many health workers are training in IMNCI.
proposed to be trained and no district is supplied The IMNCI activities should be
with IMNCI logistics. implemented in districts which
- Implementation of IMNCI activities @ have trained health workers.
Rs 1.25 per quarter for four quarters,
total Rs 5.00 lakhs.
- IMNCI training proposed @ Rs 5.00 IMNCI 0 adequate scale of roll
lakhs. out. But no provision for post
training follow up and support and
FBNC roll out does not match this
Performance appraisal as HRD strategy utilized An encouraging approach towards
for improving performance of ANMs human resource management
- Facility Level care: Expressed difficulty in Training and equipment and
getting specialists service. referral support for neonatal
- NICU proposed at two district hospitals to corners should go together for the
address congestion at medical colleges, 50CHCs. The strategy for facility
without providing any further details. based care is not clear.
However renovation of OT, maternity wards Contractual appointments of
and NICU at one district hospital in south specialists could be an alternative

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
46

Goa is allotted Rs 50.00 lakhs. to attract, or on a per visit basis.


- Implementation of FBNC proposed at Rs - NICU operationalisation is not
10.00 lakhs addressed properly in the PIP. The
- Implementation of IYCF proposed at Rs 3.00 establishment is only made on the
lakhs basis to reduce crowding.
- Care of sick children and severe malnutrition - training of health workers on
at FRUs @ Rs 3.00 lakhs. management in FBNC, IYCF and
care of sick children and severe
malnutrition is not clear therefore
implementation could cerate
serious problems.
- strengthening of facility to
provide child health care is
inadequate.
Nutrition:
a. Malnourished: 29% of children are No clear strategy about how the
underweight and 12% are wasted and state government will address
1.33 % under 5years of age children these issues. But have projected to
received Vit A supplements (NFHS III) meet 75 % (NFHS III) of under 5
b. Anemia: 49% (NFHS III) children are years of age children to receive
anemic Vit A by 2008-09
c. Targeting all children between 6-35 We assume that the community
months, to provide pediatric IFA tablets will be approached by only 1012
and aldendazole to control worm ANMs, and which is inadequate
infestations. and therefore ASHA selection and
training should be emphasized in
these aspects.
d. Breastfeeding: 27.1% (NFHS III) within Focus on this is welcome but need
one hour of birth. Breastfeeding for 6 to address divergence between
months is 18% and 70% for nine months. high institutional delivery rates
e. IYCF promotion to be enhanced to and low initiation of breastfeeding
promote breast feeding. rates.
f. “human milk bank” and lactation
management cell
- BCC/IEC activities flip charts and child
feeding practices @ Rs 4 lakhs and one
lakhs per year respectively
Referral transport mentioned, but no strategy
quoted in the PIP.
PPPs: orientation of Pvt pediatricians for Details of scheme could be sent
IMNCI is proposed with state pediatric separately.
association.
School health and immunization described
separately:
Overall:

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
47

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 53-62-37 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 60 60 57 53 54 53
2. Key strategies outlined
Past and proposed strategy Appraisal comments
Community Health workers/ASHA: this is being Focus could be built in by
implemented in tribal areas but no special focus appropriate programme design
on using it to improve child survival specified. changes and support to ASHAs
IMNCI :
Training was organized for 1.68 lakh MOs. The IMNCI training already
ICDS functionaries, ANMs and SNs on implemented in 10 districts and
IMNCI in 10 districts out of which 3620 were the target for this year is just one
trained out of 168580 MOs, AWWs, ANMs district and for which Rs 598
and staff nurses lakhs proposed. The detail needs
proposed IMNCI training for 22 batches @ Rs to be provided.
1.00 lakhs per batch, total of Rs 22 lakhs. This rate is inadequate- but will
proposed IMNCI training for 576 batches @ probably speed up as TOTs are
total cost of Rs 576 lakhs. completed. Need to project when
monitoring follow-up of training @ Rs 100/p.m. whole state will be covered and
per supervisor, in 11 districts proposed @ Rs also how training outcomes would
12.83 lakhs. be monitored and followed up to
become service delivery outcomes
and health outcomes. The
programme description does not
provide for this.
879 ANMs and 3788 AWWs of four districts
trained.(out of 25 districts)
Facility Level care: Existing 102 FRUS reported Time schedule and budget lines
as strengthened for neonatal critical care. Details and description does not give
not described. Pediatrician to be contracted in on picture of how this would be
call basis at Rs 72,000 per CHC per year. Effort achieved. Need to ensure that
to extend post partum stay to two days every PHC can manage out
mentioned. General statement that all PHCs, patient referral care for the sick
CHCs and FRUs would be strengthened. child and every CHC has a
ENBC training proposed for 242 batches of stabilization unit level of care
FHW/FHS @ Rs 87.96 lakhs. ANC check what % of sick
newborns and children are getting

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
48

referred.
Nutrition:
a. Malnourished: 47.4% children are Need to build in a focus at least
underweight and 17% are wasted (NFHS on severe malnourished where it
III) and both wasting and malnourished would immediately save lives?
show no change between the two NFHS. Health dept contribution is needed
nutrition co-ordination committee is set up to to this group which is often a
monitoring the status and a medical problem and often
comprehensive strategy has been beyond the AWW level of skills.
outlined to deal with malnutrition that
includes micronutrients supplementation, Mere proposing setting up of
protein substitution and treating committees for monitoring
infections along with provision of safe malnutrition and supplying
water and sanitation facilities nutrients is inadequate without
promotion of spacing methods is used as a proper outlining of the activity
strategy to reduce malnutrition. and who will be doing the same.
Awareness campaigns are proposed to deal Is thinking to relate spacing and
with under nutrition and anemic mothers. malnutrition acceptable?
b. Anemia: 80% of children below the age
of 3 years are anemic (NFHS III ).
c. - standard protocol has been developed
for management of anemia among - the protocols are made available
children at all levels. by GOI and still the government
is thinking of developing one?
d. Breastfeeding: 27.1% (NFHS III) within Specific promotion measures
one hour of birth. The activities are could be outlined like in sections
merged with the Mamta Mulakat (post on ASHA, BCC etc. a plan for
natal care visit) by ICDS, ASHA this would help. Improvement in
workers, weighing newborns at home, this could lead to a significant
support and counseling for breastfeeding improvement in child survival
initiation, etc. figures.
e. - 6 days training for MOs and ANMs on
counseling mothers about breast feeding,
newborn care, management of diarrhea
and ARI.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
49

f. Micronutrient: fortification of atta with Could evaluate the atta


calcium and vitamin A ongoing. iodised programme and its impact.
salt being promoted. Deworming also Pediatric anemia management
mentioned. needs to be addressed as state has
80% child anemia which has
increased by 6% in as many years.
Introduction of pediatric iron
syrup into ICDS programme or
some such measure could be a
priority in addition to general
measures related to diet.

g. Referral transport being strengthened. This is very promising and the


state could track its use for sick
neonate and child health care.
h. PPPs: Bal Chiranjeevi scheme proposed. Details of scheme could be sent
Child Specialist services to high risk separately.
newborn of Chiranjeevi deliveries with
transportation in one district, Rs 2000 is
proposed for specialist care per child, this
project is proposed in Kutch district only @
total cost of Rs 18.00 lakhs.
Followed by this transport facility for high
risk new borne babies @ Rs 500 per referral
proposed in Kutch district at Rs 10.00 lakh.
i. Innovations: Nirogi Balak scheme This should be effective and one
proposed. Details not described- but could follow up on this.
appears to be a packaging of all current
inputs with a clearer delineation of
indicators.
j. School health and immunization
described separately:
Overall: Child survival in Gujarat is stagnating or on slow decline and the planning needs
to specifically address this more effectively through more effective primary care
improvement strategies and through an effective plan for improving facility based care.
The current rate and depth of programme maybe falling short of requirements.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
50

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2008-09
Himachal Pradesh
1. Basic Health indicators regarding Child Health
a. Infant Mortality Rate
i. Current IMR: 50-52-26 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 54 58 49 51 49 50

2. Key strategies outlined


Past and proposed strategy Appraisal comments
2512 ASHAs are selected and 5238 ASHAs Further focus could be built in by
are yet to be selected. It has been proposed appropriate programme design
that all selected 7750 ASHAs to be trained in changes and support to ASHAs also
HBNC. The general training of ASHAs is
proposed to be done through TOTs
establishments in 13 Health Training Centers.
-proposed to strengthen home based care
through ANM/AWW/TBAs within seven
days of delivery with emphasis on first vist in
24 hours.
IMNCI : : Proposed to be implemented in all Training MOs in IMNCI is
districts in phased manner. inadequate for facility care. Rate of
- 5 day training of 36 district level trainers in progress of IMNCI is too slow to
IMNCI (MOH, Pediatrician, SNs) @ Rs make an impact. Need to complete
90,450 (total) TOTs this year and expand to the
- one week training for 120 SNs @ Rs 3.38 entire state in the next year.
lakhs
- one week training for 200 FHWs @ Rs 5.01
lakhs
- 12 days training for 105 MOs @ Rs 5.14
lakhs.
- 7 days preservice training for 8 faculty of
medical college @ Rs 80,000
Facility Level care: Strengthening 17/60 Scale of coverage is low and even
FRUs, and 186/448 PHCs for trained where proposed availability of
manpower, drugs and materials for neonates. trained manpower at all the newborn
Equipping all newborn care centers in all centers, like pediatricians is not
62/73 CHCs. Proposes Rs 5.00 lakhs for stated.
20/60 FRUs which is 20% of total. Needs to elaborate more on how the
manpower in CHCs and skills in
PHCs would be put in place.(other
than contracting)

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
51

Nutrition:
a. Anemia: 58% (NFHS III) less There has been an improvement
than 3 years are anemic and between successive NFHS,.
showed improvement. However no clear strategy
b. Malnourished: 36% of children mentioned for further improvement.
are underweight (NFHS III).

c. Breastfeeding: improvement A strategy should be outlined to


from previous NFHS, still only tackle this. Perhaps built into ASHA
43 % of children are breastfed and in BCC section.
within one hour of delivery
q. Referral transport for an estimate of No transport and communication
2500 neonates from BPL population is modality planned. Allocation of a
planned @ Rs 500. budgetary sum per estimated sick
child is inadequate to reach such
children
r. PPPs: developing partnership with Details on which aspect of PPP of
private sector for PPP is mentioned newborn care is not clear.
s. School health and immunization
described separately:
Overall:
1. IMR of Himachal Pradesh has remained at 50 for the past five years, and the
strategies outlined are not addressing specifically this issue.
2. The child health agenda doesn’t inform ASHA and the BCC in the given text
3. There is no strategy on malnutrition
4. The referral transport is sub-critical
5. IMNCI and facility care improvement is limited in scale and not matched to each
other.
6. Facility based care does not cover skills and HR needs.
Some benefits may however come in from measures relating to increased staffing and
drugs for facilitation.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
52

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 52-54-38 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 48 47 44 49 50 52

2. Key strategies outlined


Past and proposed strategy Appraisal comments
IMNCI : Training in 5 districts (out of 14
districts)., major hurdle expressed in
implementation of IMNCI is lack of availability
of doctors and trained nurses in remote areas.
Therefore outreach services have been designed
to be linked with village health day.

IMNCI training of MOs focused in three districts No linking with earlier trained
of Jammu (Kathua, Doda and Rajouri) and persons, Rebar-e-sehat
Kashmir (Anantnag, Baramulla and Leh). At the
block level nearly 400 health workers (including
ICDS) would be trained in batches of 20 and
MOs at block level will be master trainers for
AWW/ANMs. A target of 3363 ANMs and
AWWs are proposed to be trained in the four
districts. However, ASHAs has been included
for IMNCI training, no activity has been
mentioned.
-- IMNCI training to ANM/LHV/SN/ASHA for
8days @ total cost of Rs 2.1912 lakhs
-- IMNCI training for MOs Rs 5390/participant
(total cost Rs 1.186 lakhs)

Facility Level care: No plans for how 412


Proposed to set-up an IMNCI cell in the state paediatricians will become
HQ @ Rs 5.00 lakh. available for contracting. Multi-
Establishment of Neo natal corners in phased skilling of MOs and staff nurses
manner in all CHCs (50 in first year and 32 in would be necessary as an
second year). However as per IPHS norms there immediate measure.
are only 19 Pediatricians in the state health
system @ CHCs, therefore a contracting of 412
pediatricians has been proposed at CHCs.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
53

- newborn management training for SNs @ Rs


7500/MO and 4500/SN total cost Rs 0.264 lakhs

Inter-personal communication strategy between This seems to be promising.


ASHA/ANM/AWW addressed regarding, inter-
personal exchange of materials, counseling and
conducting village health days.

Nutrition:
a. Malnourished: 29% of children are Enhancing ANC coverage and
underweight and 15% children are IFA intake through
wasted. ANM/ASHA/AWW
b. Anemia: 68% (NFHS III) children are
anemic and no strategy has been
outlined.
c. Breastfeeding: only 31.9% (NFHS III) ICDS linkage?
of children are breastfed within one hour
of birth.
- Therefore the new strategy targets to
change behavior starting from ANC
services and continued to PNC services
provided by ANMs and counseling of
mothers by doctors at institutions and
IEC campaigns to address myths
associated with breastfeeding among
community.
- Well baby clinics and healthy baby
shows at all CHCs is proposed.
d. PPPs: emergency transport for mother
and child cases addressed, under JSY.
e. SEHAR innovation to get health worker
teams to remote areas with private
support for travel to provide basic
preventive and curative care.
f. School health and immunization
described separately:
Overall: Once must take notice that 46% deliveries are conducted in homes and Jammu
and Kashmir state should focus on home based newborn care through ASHAs which is
lacking in the PIP.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
54

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 49-52-32 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 62 58 51 49 50 49

2. Key strategies outlined


Past and proposed strategy Appraisal comments
IMNCI : Budgetary provisions need to be
- scaling up of IMNCI training to 6 examined for matching. The clear
districts from two identification and TOTs for the
- orientation workshops for IMNCI district level are not known.
- it is proposed to create 100 state level
facilitators to initiate IMNCI in 20
districts; followed with freelance
- NGO partnership in providing additional
training, monitoring and supervision of
IMNCI activities.
- IMNCI reports from HSCs to district and
from district to state (monthly) and from
state to center (quarterly).
Training has been proposed for all frontline Budget shows for only six
workers in HBNC and IYCF. workshops – very small amount
TOT on HBNC (Gadchirolli Model) has been and that too only at district level.
proposed one at state level and 24 at district This is not the Gadchiroli model
level (6/6/6/6 districts per quarter) @ a total cost at all.
of Rs 5.3 lakhs
TOT for frontline workers on HBNC
(Gadchirolli model) @ PHC level workshops ,
70/70/54 per quarter starting from second
quarter @ total cost of Rs 9.7 lakhs.
Training:
IMNCI
- 192 MOs to be trained in batches of 24 - huge vacancy(vacant 1878 MOs
MOs/batch @ Rs 1.65 lakhs per batch; 8 and 991 SNs in APHCs) would
batches are proposed. (assuming in 7 affect outcomes.
intervention districts)
- 86 SNs/ANM/AWW/LHV/MPW are to
be trained in 20/33/33 from quarter 2 @

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
55

Rs 1.65. 1763 MOs in CHC and132 in


APHC and 266 SNs in CHCs and 14 in
PHCs.
- 12 supervisory training for field workers
@ Rs 75, 000 in 4/4/2/2 per quarter (is it
batch or individuals?)
- 21, 600 TOT supervisory training for
NGOs/ government officials in batches
of 300 from third quarter with 24 per
bathc @ Rs 8,000 per batch.
- Refresher training for 480 ANM/AWW
in batches of 12 @ Rs 5000 per batch of
40 participants.

Facility Level care:


- Setting up of NRC; proposed to have 5 1763 MOs in 105 CHCs (surplus)
beds in pediatric ward of 22 DHs as NRC and 241 SNs posts are vacant and
- Proposed to have a essential newborn 232 LHVs are in position.
care units in 4 districts However, 1878 MO posts are
- Level II SNBC in 16 districts- same as vacant in PHCs.
districts as IMNCI districts. (5.2.4.4.1-
5.2.5)
- 229 facilities identified to be upgraded to
CEmONC and newborn care unites.
- None of the health center has any
professional trained in FBNC and it is
proposed 10 of them would be trained in
FBNC and care of sick children. 30 SNs
and 15,000 ASHAs are also proposed to
be trained in quarter three; 10,000
ASHAs are to be trained in quarter four.

Nutrition:
a. Malnourished: 59% of children are Training for NRCs are proposed.
underweight and 31% are wasted (NFHS and a fund for establishing them
III). at district level- but it is not clear
management of sick children and severe how this is being done. Planned
malnutrition @ FRUs through TOT for 22 districts in text, and 24 in
workshops one at state level and 24 budget.
workshops for medical officers @ Total cost
for Rs 5.3 lakhs.
b. Anemia: 77.7% of children less than 3 No strategy mentioned to address
years are anemic (NFHS III). this
c. Breastfeeding: 10.9% of infants are No strategy mentioned to address
breastfed within one hour of delivery. this

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
56

d. Micronutrient: Vitamin A supplements, Emphasis on this aspect- compare


iron and folic acid, biannual for children with earlier two aspects.
two to five years of age.
e. “Zero Diarrhea death” programme is Difficult to understand how this
ongoing, however the 17.8% of children programme is situated with
with diarrhea are treated with ORS respect to other components like
(NFHS III). Management of diarrhea IMNCI, why a separate
workshops -- TOT at state (one) and at programme for this etc and how it
district level (6 in Q1 and 6 in Q2) and at would be followed up etc. How
block level (50 in Q1 and 50 in Q2) @ would it achieve zero death- is
total cost of Rs 7.65 lakhs. there any follow up for severe
- dehydration? Or is zinc being
proposed?
f. Referral transport: Rs 300 for referral Referral transport provision is far
transport for sick and severely out of proportion to improvement
malnourished children @ an estimated of facilities. Anyway this is an
that 7000 children might need referral. inadequate way of addressing
However the target set for referral referral.
transport is approximately 10-11 cases
per month per PHC @ Rs 300 per child.
@ Total cost for Rs 19.4 lakhs. There are
271 ambulance in 212 blocks (pp 26,
table 3.1.4)
g. Mobile Health Clinics: MOU with
recognized NGOs for operating mobile
health clinics.
h. Innovations:
- Maternal and Child Health Survival cell
for planning and co-ordination of IMNCI
activities, supported by UNICEF.

i. School health and immunization


described separately:
Overall: 80% of deliveries are conducted in Home and only 17% of mothers receive
postnatal care for first two days.
Serious mismatches between text and budget. Budget provides for procurement of
equipment for 194 SNCUs all in the first quarter, but makes no provision for training or
any other dimension. Text talks correctly of level II SNCUs in 16 districts where IMNCI
is being done – but this figure does not come in budget at all. Contradictions in text.
Referral transport provision is also far out of proportion to other dimensions.
HBNC training highlighted in text has a very slow rollout in the budget – only 6
workshops in the year.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
57

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 48-53-36 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 58 55 52 49 50 48

2. Key strategies outlined


Past and proposed strategy Appraisal comments
a. 8266/36,000 ASHAs are selected, trained Link with child survival to be made
and in position in six poor performing explicit.
districts. It is proposed that in 2008-09
26, 800 ASH
b. Human resource situation: 1744 ANMs ANM training centers could be
are to be recruited in HSCs without any established in the northern districts
ANMs and 1500 second ANMs is also and preference should be given to
proposed under RCH II in six C category women from that region only then
districts and 498 doctors and 2374 SNs to the ANM posts will be filled. Could
be appointed on contractual appointments consider sponsorship of local
in 1187 PHCs. candidates for undertaking the
c. It has been proposed that 9 ANMTCs will course and contractual appointment
be established in 3rd and 4th quarter of on return.
2008-09.
d. IMNCI : IMNCI training to be started in TOTs for all districts may be
9/27districts (includes 5 northern completed this year , so that in the
districts) @ Rs 28 lakhs. Further details next there could be in parallel state
are needed on how many health workers wide expansion.
are to be trained. 4 Investment in post training follow
up and support needs to be included.
e. 66.53% of total child death is from two IMNCI training should be provided
districts (Belgaum and Gulbarga). It is for health workers in these three
proposed that ANMs will be provided districts and also concentration on
with weighing kits and medical and para- ASHAs also to be made. In parallel
medical staffs are to be provided IMNCI facility based care for these two
training. PIP does not mention about any districts.
training in this regard.

4
The previous draft version stated that 100 MOs, 27 TOT from 5 districts were trained: refer pp 89,
however no other health personnel are trained. It was mentioned that 1000 MOs, 1000 SNs and 4000
ANMs were to be trained.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
58

f. Home based neo-natal care is addressed More focus on home based curative
through AWW/ASHA for early first level care beyond paracetamol
recognizing early signs and in areas where facility is weak.
administration of “paracetamol” and also Corresponding training needs to be
to have village nutrition and health days built in.
to encourage community participation
(number of days in a month are not
specified)
g. Facility Level care: Vacant posts can hinder the facility
¾ newborn corner proposed in the labour strengthening and provision of
wards services. The facility strengthening
¾ 1280/1679 PHCs will be provided with and filling of vacant posts and skills
neo-natal Resuscitation for facility level care should be
Equipment 5 (399/746 PHCs in backward carried out simultaneously in line
region are equipped) with equipping the facilities.
¾ 108/254 CHCs (GOI, 2007) 6 equipped Incentives are useful but more is
with neonatal equipments and oxygen needed.
cylinders and doctors and staff nurses are
provided training on neonatal care.
¾ Incentives for doctors and nurses has
been proposed for filling up of 746 PHCs
identified in the remote and rural areas.
h. Nutrition:
i. Malnourished: 41% of children are There is a need for more detailed
malnourished and 18 % are wasted explanation about the approach to
(NFHS III). reduce malnutrition and anemia
j. Anemia: 82% (NFHS III) of children among children
below 3 years of age are anemic
k. Breastfeeding: Only 35% (NFHS III) of Community awareness through
children are breastfeed within one hour BCC/IEC is proposed, could have
and no strategy mentioned for the same. more involvement of health workers
Breast feeding week observation in training in improving breastfeeding
hospitals, and growth monitoring by practices.
health workers and training of MOs in
managing stunned growth of children.

l. Referral transport: It is expected that Probably an ASHA following the


through SBA training , recognition of training should be allowed to use the
high risk newborn and referral will be funds in areas with vacant ANM
done. Rs 200 for arranging referral post in consensus with panchayat
transport has been proposed following leader. The exact way in which this
identified as high risk by ANMs. cost of referral per sick child will be
delivered needs to be planned.

5
As specified by UNICEF
6
GOI (2007), Bulletin on Rural Health Statistics in India, Ministry of Health and Family Welfare, Chapter
II, Table 9, Number of Sub-centers, PHCs, and CHCs functioning , pp 22.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
59

m. Innovations: post natal kit “Madilu” for Since 33% of deliveries (NFHS III)
BPL/SC/ST mothers. This scheme are conducted at home, the Madilu
concentrates on post-natal mothers to scheme if provided to all mothers
provide information about managing delivered in institution through
children and mosquito nets. ASHAs would help to increase
institutional deliveries.
However, the 95% any ANC checks
are not converted to institutional
deliveries needs immediate
attention.
n. School health and immunization
described separately:

Overall:
Need to bring focus on two high IMR districts- to examine the district plans of this
separately.
Need to expand the scale of roll out of IMNCI by TOTs for all districts.
Need to plan for more effective IMNCI by building in post training follow up costs and
strategy.
Need to plan for skills for facility based care and estimate manpower requirements.
Need for more strategy development for malnutrition, anemia and referral transport areas.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
60

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2008-09
Kerala
1. Basic Health indicators regarding Child Health
a. Infant Mortality Rate
i. Current IMR: 15-16-12 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 11 10 11 12 14 15

2. Key strategies outlined


Past and proposed strategy Appraisal comments
a. 565 ASHAs in tribal area are the main Focus on having ASHA in the
drug depot for providing care to underserved region seems good.
mother and children and 12, 192 link With number of ASHAs trained the
workers are proposed. coverage is minimal.
Budget required for ASHA is
Rs. 781.2 lakhs
b. IMNCI : IMNCI training will be Inadequate IMNCI training
carried out 50% in class room and proposed for health workers.
50% in field visiting homes of sick
children for developing applied skills There is a need for providing an
of managing sick children. estimated number of health workers
i. IMNCI: separate clinical training for 5 to be trained.
doctors, pediatricians and 5 staff nurses Focus could be built on training
@ district level for 8 days @ Rs 20,000 JPHNs in IMNCI.
(total of Rs 14 lakhs)

c. Facility level care:


ii. 65 FRUs certified and only 35 are At this rate the number of FRUs to
functioning be made functional can not be met
iii. Strengthening of 5 women and child therefore W&C Hospitals could be
hospitals @ Rs 50 lakhs each and 7 upgraded to FRUs.
new W& C hospitals are proposed in
northern districts @ Rs 200 lakhs each.
d. Training and IEC/BCC activity has Simple IEC/BCC and training of
been proposed for control of infectious health workers would not be
diseases, which has been highlighted sufficient for prevention of
as major contributing factor for child nosocomial infection. Cleanliness in
mortality. the wards, partition of pediatric ward
e. Proposed for training for prevention of from general wards, isolation of
hospital acquired infection in 9 infectious cases, would help to
women & child hospital @ Rs. 22.24 prevent transmission.
lakhs.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
61

Nutrition:
b. Malnourished: 29% of children are Management strategy for
under weight and 16% are wasted (NFHS Malnourishment, Anemia and Breast
III) feeding are not promising. Activity
i.Counseling services for improving should have been integrated with
nourishment has been proposed. ICDS programme and provide
weighing machines for health
c. Anemia: 55.7% (NFHS III) children workers to weigh all under five
are anemic below 3 years of age. children on VHND and provide
prompt treatment.
d. Breastfeeding: 55.4% of children are
breastfed within one hour of delivery
- Counseling services by health workers
for improving breast feeding has been
proposed.
f. Innovations: Childhood Disability Elaborately stated on prevention of
Project for children below 10 years, childhood disability. The
proposed to be implemented in experiences of the project would
Trivandrum. help to replicate in other states as
i. ASHA and JPHN workers to do well.
community based screening for
childhood disability between 2 and 9
years of age will be done using NDST
(tool).
ii. PHC based medical camps for
confirmation of disability and setting
up of child development referral units
(CDRUs) in three rural hospitals and
one at Childhood development center
(CDC) in Trivandrum (urban).
iii. Therapy and rehabilitation would be
followed @ CDRUs
Total cost of the scheme is 35.25 lakhs.
g. School health and immunization
described separately:
Overall:

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
62

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
iii. Current IMR: 74-79-52(SRS 2006- Total- rural -urban)
iv. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 86 85 82 79 76 74

2. Key strategies outlined


Past and proposed strategy Appraisal comments
a. IMNCI : 15/45 districts covered under IMNCI Would 5 regional centers help in
activities, and IMNCI cell at district level and scale up? Should we aim to
IMNCI co-ordinator. 3 districts added this year complete all districts TOTs in
two years is it linked to facility –
training
b. 4500 health and ICDS workers have been This is good progress – but what
trained, included private medical colleges for % it is of total needed –
providing master training. coverage.
c. Supportive supervision planned for referral This is discussed with referral
transport funded provided for inter-department transport comment below.
collaboration.
d. HBNC in 3 districts and training of ASHA and This is inadequate to reach the
AWWs in HBNC in four tribal districts. whole state and there is no
projection of how it can be taken
forward. In other districts the
key is to build it into the ASHA
programme.
e. Facility level care: level 1 SNCUs in 2 The plan largely looks at
CEmONC each of 10 districts where level 2 equipment purchase. Skills is
SNCUs are being established in district hospitals weak and overall HR issues not
and level 3 in 2 colleges. present. Thus scaling up to reach
whole state is not really in the
plan.
Nutrition:
a. Malnourished: 62% of children are Need to show convergence with
underweight and 33% of children are ICDS and other preventive
wasted (NFHS III). malnutrition aspects
b. Anemia: 82.6% children below 3 years are
anemic (NFHS III) “Bal shakti yojana” Need to develop indicators for
and “Nutrition Rehabilitation Center NRC performance. As
(NRCs)” to mange severely malnourished programme expands monitoring
children is main strategy. 61 NRC are and support becomes a critical

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
63

operational and 75 more proposed. issue that could be addressed.


c. Breastfeeding: Only 15% children are Need more focus within BCC to
breastfed within one hour (NFHS III) and encourage breast feeding and
strategy outline is to communicate 100% PNC visits within one
mothers through house based new born hour by frontline workers is
care (HBNCC) in 3 districts and this needed.
frontline workers on IYCF in 32 districts
and make all district and civil hospitals
baby friendly
d. Micronutrient: Micronutrients Need more sustained access to
supplement proposed pediatric iron syrup for anemia
management.
e. Referral transport being strengthened This is an incomplete approach
with Rs 200/ child.(includes, as reaching this referral fund to
malnourished and sick newborn children. the child in need requires far
more inputs.
Overall: The range of intervention is comprehensive but the depth and scale of each
intervention leaves large gaps. Only 15 % of 10.79 crores under Child Health Budget of
2007-08 has been spent.
The scale of IMNCI accelerated but a plan for scaling up the rate could be elaborated.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
64

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2008-09
Maharashtra
1. Basic Health indicators regarding Child Health
b. Infant Mortality Rate
iii. Current IMR: 35-42-26 (SRS 2006- Total- rural -urban)
iv. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 45 45 42 36 36 35

2. Key strategies outlined:


Past and proposed strategy Appraisal comments
a. Achieving 100% immunization of
children has been slow and more focus is
given towards this.
b. Involving NGOs (MNGOs and FNGOs) We assume the co-ordination
is stated, but what aspect of child health towards immunization programme.
NGO co-ordination is seeked is not
outlined.
c. IMNCI training:
- 40 TOT on IMNCI done till Jan Extensive training proposed for
2008 and 17 proposed @ Rs 5.64 IMNCI and monitoring and
lakhs follow-up of the training also
- 183 MOs trained and 155 proposed mentioned.
@ Rs 12.61 lakhs
- 444 SNs trained and 247 proposed
@ Rs 50.62 lakhs
- 2078 ANM/LHVs trained and 1385
proposed @ Rs 166.36 lakhs
- 73 Supervisory trained and 3
proposed @ Rs 0.84 lakhs.
- 2290
SN/AWW/AWS/ACDPO/CDPO
trained and 3629 proposed @ Rs
255.42 lakhs.
- Total 490.65 lakhs proposed
- monitoring and follow-up after
training is mentioned and budgeted
@ Rs. 10.95 lakhs
d. Home based newborn care:
- 90 TOTs conducted on HBNC and Training has been exclusively
41 proposed @ Rs 0.75 lakhs (total) stated, but there is no mentioning
- 300 ASHAs trained in HBNC and of the strategy about how HBNC
692 proposed @ Rs 21.86 lakhs would be done.
(total) As per ASHA guidelines we can

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
65

- The activities under HBNC for assume that ASHA would make
dissemination of guidelines, home visits to record the details of
operational plan, implementation newborn, make referrals of sick
and monitoring and follow-up with children.
training has been budgeted @ Rs
88.51 lakhs (total)

e. Facility Level care: FBNC: Training of health staff has been


10 FBNC centers proposed @ Rs 15.90 extensively stated, however the
lakhs and FBNC activities including institution strengthening has been
monitoring and follow-up of training has weaker. To mention, newborn care
been outlined in the budget, @ Rs 26.90 corners at FRUs, etc. are not
lakhs. outlined in the PIP.
- Training for MOs in FBNC in 24*7
PHCs is proposed without budget.
- 125 SNs in each quarter are to be
trained in FBNC, 2008-09. (no
budget proposed)
- Monitoring and follow-up after
training is mentioned and budgeted
@ Rs. 0.33 lakhs (total)

f. The procurement of equipments for


strengthening institutions (CHCs/FRUS),
in IMNCI, FBNC, others
Total Rs. 105.05 lakhs., proposed.

- Newborn care training for MOs in Nasik, 2


MOs proposed to be trained at Rs 1.50 lakhs.
g. Nutrition:
i. Malnourished: 40% of children are Well outlined management of
underweight and 15% wasted (NFHS malnourished children, with
III). intersectoral co-ordination.
- Nutrition rehabilitation centers
(NRC) have contributed in reducing
malnourished children. NRC in 15
tribal districts @Rs 261.20 lakhs.
- Development of recipes by nutrition
bureau, nutrition demonstration at
village level by ANM, training of
ANMs at PHC level, a detailed
budget is outlined.
- Monitoring growth records of under
5 at AWC by ANM & AWW.
- Training for 308 MOs proposed to
manage care of sick children and

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
66

severe malnourished at FRUs @


total cost of Rs 0.60 lakhs
- Encouraging concept on team
approach towards child health, with
Women and Child welfare
department.
- Micronutrient mentioned in the
activity.

ii. Anemia: 72% (NFHS III) of children - Ranking of anganwadis doesn’t


below 3 years of age are anemic. help much when the region might
- Ranking of anganwadis on have more malnourished children,
malnutrition status of children is if the ranking is made on the basis
encouraging, further course of of priority. Ranking made on the
action/activity should have been basis of performance would help
mentioned. to manage malnourished children.
- Scheme to reduce LBW, no clear - the targeted number of children
activity or strategy outlined but 340 to be treated for the LBW is
children were provided the service inadequate.
and 1234 children are proposed
target for the year budgeted @ Rs
19.38 lakhs.

iii.
Breastfeeding: 51% (NFHS III) of BCC should be emphasized by
children are breastfed within an hour, training ASHAs, ANMs, and
to be increased by staff motivation LHVs on promoting exclusive
and counseling of mothers for breast breast feeding practices.
feeding.
h. Innovations: 3551 “Healthy Baby This has seldom been useful as it
Contest” conducted and 4867 target favours better off families- but not
proposed @ Rs 53.12 lakhs particularly harmful either.
i. Crèches for children @ Rs 44.91 lakhs
j. IEC/BCC activity: specific activity is
outlined in the budget details @ Rs 37.93
lakhs (immunization not included)
k. School health and immunization
described separately:
Overall: The strategies and the activities stated are more general and not specific to child
health most importantly there is no linkage between the strategy and the activity.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
67

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2007-08
Manipur

3. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
v. Current IMR: 11-11-11(SRS 2006- Total- rural -urban)
vi. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 20 17 16 14 13 11

4. Key strategies outlined


Past and proposed strategy Appraisal comments
Proposed periodic training for 500 ASHAs on HBNC training should be more
HBNC. At present 3000 ASHAs are trained and focused on ASHA, ANMs and
878 more are needed. LHVs., for the simple reason that
51% of the deliveries are
conducted at home.
Post partum visits should also be
promoted followed by incentives
for AHSAs, AWWs and ANMs
IMNCI: IMNCI implemented as pilot project in Implementation of IMNCI is at
3 districts (Churachandpur, Imphal West and slowest phase. The problem that
Thoubal), but was not materialized. However led to non-implementation of
proposed to implement in all 9 districts, by 2009. IMNCI activities in the three pilot
- proposed training for 100 MOs from districts needs to identified and
three districts on IMNCI, and RIMS as care should be taken during
nodal training agency @ total cost of Rs scaling –up.
5.00 lakhs.
- Proposed district level training for 150
FHS/GNM/ANM for three districts @ Rs
13.125 lakhs.
Facility Level care:
FBNC proposed in 7 DHs, 14 CHC and 10 Budget details on proposed
PHCs by last quarter of 2008. strengthening of FBNC, ENBC
ENBC proposed in 6 districts ( non – IMNCI and NCC is not mentioned in the
districts) PIP.
NCC proposed in FRUs and 24*7 PHCs
Nutrition:
f. Malnourished: 24% of children are
underweight and 8% are wasted (NFHS No clear strategy outlined except
III). for setting up of NRCs.
g. Anemia: 52.8% of children are anemic
(NFHS III). - it is not clear on what exchange
- NRCs in FRUs and 24*7 PHCs, with basis?

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
68

supplementary feeds on exchange basis


h. Breastfeeding: 57.2% of children are To achieve 100% breastfeeding,
breastfed within one hour of delivery there is a need for counsceling of
(NFHS III). mothers by health workers at
i. IYCF- through BCC, and IPC through ANCs, natal and PNC.
ASHAs
j. School health and immunization
described separately:
Overall: The IMR trend of Manipur state shows a gradual decline. However the
strategies are not much focused on further declining the IMR and or improving the status
of children.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
69

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 53-54-43 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 56 60 57 54 49 53

2. Key strategies outlined


Past and proposed strategy Appraisal comments
Proposed to improve home based newborn care by More focus is built in the Home
5438 ASHAs, 724 ANM and 3193 AWWs, at Based Newborn care and it is
ANC and PNC contact points., as per IMNCI important that more manpower
guidelines. needs to be trained in managing
- Newborn babies are weighed regularly by newborns in homes as 70% of
AHSA, health cards, growth monitoring deliveries are conducted in
charts and drug kits, with ORS and homes.
Cotrimoxazole tablets are issued during
contact points
- Referral of sick neonates, using funds form
RKS committees.
- ORS promotion for management of
diarrhea will be made through ASHAs.

IMNCI for service delivery of newborn care at The pilot project is well designed
home and instirution is proposed to implement in and the scaling up of the IMNCI
pilot bases at Ri Bhoi District., therefore training is very crucial and is not outlined
for MO/ANM/LHVs/AWW and CDPOs. it the PIP. With only one center
- Awareness generation on IMNCI by ASHA providing IMNCI facilities the
, ANM & AWW. case load would be high, this
- IMNCI training for 22 MOs @total cost Rs might present a false out put.
4.17 lakhs
- IMNCI training for 410 ANMs,
CDPOs/AWW/LHVs/SNs. @ total cost of
Rs 18.05 lakhs.
Facility level care: In the two day stay at institution
- Newborn corners is proposed for 26 PHCs of delivery, attention could also
@ Rs 40,000/ corner be paid for providing nutritional
- One NICU at Ganesh Das Hospital- supplements and diet.
Shilong with 400-beds to be built in two
phases, well elaborated design of NICU or Well outlined establishment of
SNCU., with necessary staff NICU, however budget details are

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
70

- Two day stay in the institution of delivery not outlined.


is focused

Nutrition:
j. Malnourished: 46% of children are Considering the terrain, the
underweight and 28% are wasted. VHNDs should be utilized to the
k. Anemia : 68.7% of children are anemic maximum
below 3 years of age (NFHS III)
- Malnourished children screened for malaria
and also supplied with IFA tablets/syrup
during VHNDs and promotion on use of
green leafy vegetables.
- Routine administration of vit A during
VHNDs.
l. Breastfeeding: 58.6 % of children are
breastfed within one hour of delivery and
26.3% upto 6 months.
- counseling of mothers during VHNDs
- communication activities proposed for
early breastfeeding.
- Proposed to follow IYCF guidelines for
breastfeeding.
- BCC/IEC activities proposed at R s 9.05
lakhs.
m. Referral transport: an estimate of 2640 Sick
neonates @ Rs 500/child is budgeted for
transport.
n. School health and immunization described
separately:
Overall:

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
71

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2008-09
Mizoram
1. Basic Health indicators regarding Child Health
a. Infant Mortality Rate
i. Current IMR: 25-32-13 (SRS 2006- Total- rural -urban) and 34
(NFHS III).
ii. IMR Trend for last five years (as per SRS data)
(T = total and R = rural)

Year 2001 2002 2003 2004 2005 2006


T(R) T (R) T (R) T (R) T (R) T (R)
IMR 19 (23) 15 (16) 16 (18) 19 (23) 20 (26) 25 (32)

2. Key strategies outlined


Past and proposed strategy Appraisal comments
a. Home Based Neonatal care: Home Provision has been made for
based neonatal care training for ASHA training HBNC in last quarter.
in the last quarter of the year??? Only about15%ASHAs have
Which should have been in the first been trained. Utilization of
quarter. ASHA for child health issues
not addressed.
IMNCI : - 9 districts are provided with No post training followup
IMNCI logistics and 66 MOs (66%) have evident.
been trained. No linkage with facility
- IMNCI training proposed for ANMs development or referral
to improve FBNC and HBNC transport or community process
- proposed to train 180 ANM (35%) evident
for 8 days in batches of 20 @ Rs 4.5
lakhs.
b. - 150 SNs training proposed
c. Facility Level care: Strengthening Need for state to understand and
mentioned but not specified post a facility level care for
d. 120 SNs training proposed in FBNC child health in place
e. Only 7 % of the health facility is
having a trained health care personnel
in FBNC.
Nutrition:
a. Malnourished: nearly 22% of More inter co-ordination of
children are underweight and departments required. Need to
9% are wasted (NFHS III). address high-level of
b. Anemia:51% (NFHS III) of underweight.
children are anemic and only
IEC/BCC strategy outlined.
Marginal decrease.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
72

c. Breastfeeding: 65.4% of
children are breastfed within
one hour (NFHS III) and
IEC/BCC by health workers is
proposed for exclusive
breastfeeding.

f. Referral transport being strengthened


and separate budgetary head placed
for acquiring Ambulances under
NRHM.
Overall: The IMR trend in Mizoram is gradually raising and the rise is evident in rural
areas than in urban areas. Managing LBW babies at all health institutions should be on
the priority of Child Health Plan of Mizoram. Due to drought there is a need to integrate
grass root level health workers with ICDS functionary

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
73

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2007-08
Nagaland

Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 20-18-27 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR Na Na 16 (U) 17 18 20

Key strategies outlined


Past and proposed strategy Appraisal comments
Orientation for ASHA and AWW in HBNC and Since 88% of deliveries are
promoting kangarro care, methods. Recognition conducted in homes there is a
of danger signs in newborns and timely referral need for an rigors training on
to health institutions. HBNC for all
BCC for HBNC for management of diarrhea and ANMs/AWWs/ASHAs/LHVs.
ARI.
Æ no training has been proposed for any health
worker under HBNC.
IMNCI :
A. Promoting management of Acute diarrhea Very elaborate on IMNCI in the
and ARI in non IMNCI focused 6 districts. focused districts and also care is
Proposed one day orientation on ADD and ARI taken to orient health workers in
management for 40 MOs and 60 ANMs in the the non-IMNCI districts is very
non-IMNCI districts. encouraging.
B. IMNCI introduced in 3 districts in 2007-08
(Kohima, Dimapur and Mokokchung) and
proposed two more districts in 2008-09.
(Wokha and Phek)
- 10 MOs, 5 SNs and 15 district trainees
are trained in 2007-08
- Proposed 22 MOs from 5 districts during
2008-09 to create district pool of trainers
- bi-monthly or quarterly review of
implementation of IMNCI by the state
nodal officer
- Health and ICDS supervisors will be
given follow-up training to ensure
regular support and supervision for this 5
personnel from each 5 districts will be
selected and trained for 2 days – includes
MOs, Pediatrican, CDPOs and LHVs

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
74

- 122 MOs @ Rs 17.78 lakhs in batches of


25 and 168 SNs @ Rs 8.10 lakhs, ANMs
and AWWs in IMNCI training.
- Inservice training for the existing staff in
phased manner.
- Naga Hospital for training all health
workers and district hospitals as district
nodal training institute.
C. infrastructure support: Includes, projectors,
computers, teaching accessories,
translation/printing of materials, mobility, DMU
and contingency – Rs 37.40 lakhs.
D. Proposed Rs 15.00 lakhs for monitoring and
evaluation.
Training related to child health is mentioned @ Can we assume this training to be
Rs 1.19 lakhs in the non-IMNCI focused
districts? If so then the budget is
less.
Facility Level care:
- Newborn care centers at all FRUs and Proposed for establishment of
24* 7 Newborn care centers at all FRUs
- Establish stabilization units at 11 district is encouraging, however one
hospitals should compare the cost of
- Newborn corners at 11 DH and 21 establishing following increased
CHCs, with Ambubag, radiant warmer, utilization of health facilities, that
suction machine and incubator @ total could come through BCC and
Rs 156.10 lakhs. motivation by ASHAs.
- Establish SNCU in identified 5 DHs.
- 15 MOs trained in FBNC and proposed FBNC training proposed with out
to train 22 MOs in FBNC and 107 SNs budget should be addressed along
trained and proposed to train 175 SNs.; with the details of training.
no budget proposed for the same.
Nutrition:
a. Malnourished: 30% of children are No strategy outlined in the PIP
underweight below 3 years of age (NFHS for managing malnourished
III) and 15% are wasted. children.
b. Anemia: na
- Counseling of mothers by ASHA,
AWW, ANM on feeding practices and
regular health check-ups
- Deworming for every 6 months
- Collaborate with school education
department for check-ups and routine
deworming.
c. Breastfeeding: 51.5% of children are More clear strategy needs to be
breastfed within one hour of delivery drawn on bringing about behavior

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
75

(NFHS III). change in breastfeeding. The


- promoting breast feeding by ASHA/AWW target audience could be
approached during VHNDs, and
ANC checkups.
d. Referral transport: The provision of ambulances
- 5 CHCs with ambulance and proposed 9 should be on priority basis.
ambulance in 07-08.
- Referral transport funds for hired
ambulances under RKS.
e. PPPs:
- 7 private institutions identified in 3 districts
(Kohima, Dimapur, Mokokchung), MoU yet
to be signed.
f. School health and immunization
described separately:
Overall: The budget proposed for the activities related to child health is very small (i.e.
0.79%) in proportionate with the total RCH II flexi pool budget of the state. With the
available data on IMR for the state one can say there is an increasing trend in the IMR
status in the state and state needs more rigorous strategy to manage IMR, one possible
option is home based newborn care through ASHAs.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
76

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 73-76-53(SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 91 87 83 77 75 73

2. Key strategies outlined


Past and proposed strategy Appraisal comments
ASHA and home based care This is not a prominent feature
of the ASHA programme and
the scope of this does not seem
to be fully realized.
a. IMNCI : IMNCI training has been provided IMNCI started well in Orissa
only in 2 districts (out of 30 districts). However, but scaling up has been poor.
IMNCI training is proposed in 10 districts. Post training follow up even
- 746 MOs are trained in IMNCI and it is now in this design is weak- has
proposed that 1392 MOs to be trained in only training – not payments for
IMNCI, , 240/480/240/432 MOs per field visits and on the job
quarter. support; unlike the investment
- One district in Orissa is supplied with in Mayurbhanj which is the
IMNCI logistics pilot on the basis of which
- - 4404 (13%) of total IMNCI was declared successful.
ANM/LHV/AWW/SNs are trained in
IMNCI and 16,460 of them are to be
trained in 2008-09
- as per proposed budget,
- IMNCI for MOs 24/batch @ Rs 1.36
lakhs in four batches
- IMNCI training for ANMs/LHV/AWW
24/batch @ Rs 1.26 lakhs in 120
batches.
- Budgeted separately for IMNCI training
in 12 districts: 7 MOs/batch @ Rs 1.36
lakhs per batch in 4 batches and 80
ANM/AWW/LHV/ @ Rs 1.26 lakhs per
batch in 132 batches and implementation
of IMNCI activities in one district @ Rs
5.00 lakhs.
-

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
77

b. Facility based neonatal care: 5 batches of 24 Only district level centers being
doctors per batch (MOs and pediatricians) would taken up for Facility based care-
be trained. this is not adequate and one
FBNC training has been proposed for 125 staff needs to address CHCs at least
nurse. in this year – and at least in the
ÆFBNC training for MOs 24/batch @ Rs 1.36 12 districts where IMNCI would
lakhs in 10 batches. be in place
- SNCU Level I in 25/30 districts @ Rs 2.93
per district, recurring cost of Rs 3000 and
operationalising existing 20 level I SNCU @
Rs 25,000/ district. However training on
FBNC is mentioned and budgeted for Rs
1.36 per district in 10 ( batches ??).
- SNCU Level II- in five districts @ Rs
59.00 lakhs and recurring expenditure Rs
1.75 lakhs per SNCU for 18 SNCU Level II
total cost Rs 31.50 lakhs

Nutrition:
a. Malnourished: 48% of children are Very slow scale of introduction,
underweight and 19% are wasted (NFHS and inadequate range of
III). activities.
“Pustikara Diwas”, for addressing malnourished
children is proposed and details are not mentioned
in the PIP. Support for this scheme, investigation
cost, essential drugs, referral transport and
equipments @ total cost of Rs 153.14 lakhs.
TOT on care of sick children and malnourishment
at FRUs, pediatrician/SN/sister tutor/ LHV in
32/batch @ Rs 1.05 lakhs one time
One time, six days NRC training for MOs and
paramedics in two districts (Khoraput and
Khalahandi) 20/batch.@ Rs 60,400
b. Anemia: 74.2 % of children are anemic No strategy mentioned in PIP
(NFHS III).
c. Breastfeeding: 54 % of children are ,. No strategy mentioned in the
breastfed within one hour in the state PIP.
-
Overall:
Perhaps due to lack of adequate programme structures in place in state and district level,
especially in the training pyramid, the roll out of many components is slower and the
scope is more limited. Would need to support the IMNCI and make sure facility based
care improves in parallel. Aim should be to reach full coverage by next year.
Systemic issues and inadequacy of centers and staff require a much stronger ASHA
programme with a focus on child health.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
78

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate & Neonatal Mortality Rate
i. Current IMR: 44-48-36(SRS 2006- Total- rural -urban)
ii. Current NMR: 30 (SRS 2006)
iii. IMR Trend and Neonatal Mortality Trend for last five years (as per
SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 52 51 49 45 44 44

Year 2001 2002 2003 2004 2005


NMR 31 34 32 30 30

Past and proposed strategy Appraisal comments


IMNCI training:
Training has been proposed for medical college Extensive training of Health Care
teachers, 19 DIOs, TOT of 22 district trainers, 360 staff in IMNCI mentioned.,
MOs, 46 staff nurses,335 LHVs and ICDS, 967 However no follow-up training
ANMs, 780 AWW for a duration of 8 to 10 days mentioned.
Training is also proposed for 335 LHVs and ICDS
Supervisors in 17 batches of 20 @
Rs 54, 405 per batch

Æ total Rs 87.43 lakhs (includes training


materials)

BCC/IEC activity is proposed for IMNCI at


Rs 6.85 lakhs

Note: Duplication on IMNCI training mentioned


under two heads in the detailed budget sheet of
RCH II Flexi-pool.

Training of MOs/ANMs/DAIs/ASHAs for pre 13,000 ASHAs are identified in


natal, natal, and post natal care of the women and the state, who could be utilized
adequate care of newborn. for mobilization activities.
Social mobilization to reduce IMR, promote Focus could be built in by
institutional deliveries and newborn care, educating appropriate programme design
mothers on exclusive breast feeding. changes and support to ASHAs

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
79

HBNC sensitization of birth attendants at PHCs by


MOs and educating about identification and
management of danger signs., no training has been
mentioned in the PIP.

Facility Level care:


IMNCI cell @ Rs 5 lakh in the state head quarters. Only 7.73 % of the total RCH
flexi-pool is budgeted for Child
Neo-natal corners @ Rs 25,000 in 50 CHCs in first Health under these circumstances
phase and 42 in second phase. it is inadequate to bring down the
IMR.
Facility level newborn care units/corners are not
mentioned in the PIP.
Nutrition:
a. Malnourished: 27% Children are No strategy specifically outlined
underweight and 9% are wasted (NFHS III) in the PIP, except for mentioning
b. Anemia: 80.2% children are anemic in less of integration of ICDS workers,
than 3years (NFHS III). ASHAs, and ANM.
- Proposed to develop special nutrition
supplementation programme for severely
anemic children.

c. Breastfeeding: 10.3% (NFHS III) within 100 % breastfeeding target has


one hour of birth. been set to achieve by 2010,
- Counseling of mothers during ANC and however no clear strategy
PNC clinics/services by ANMs described in this regard.
- Breastfeeding training has been mentioned,
but this is not clear for whom the training Breastfeeding training could be
will be provided., budgeted for Rs 20 lakhs focused on ASHAs and link
- Calcium tablets supplements proposed for workers. However the calcium
an estimate of 50,000 within one hour of tablet supplementation could be
institutional deliveries at 100 tablets/mother expanded to all JSY beneficiaries
@ Rs 30.00 lakhs. also.
-

Innovations:
Well baby clinics and healthy baby shows at all
CHCs.
d. School health and immunization described
separately:

Overall: The most critical child health aspect with respect to Punjab state is early
breastfeeding which is only 10% and 80% childhood anemia. Community mobilization
by community based health workers, ASHAs role is crucial and should be strengthened
by facility care at health institutions.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
80

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


b. Infant Mortality Rate
i. Current IMR: 67-74-41 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 80 78 75 67 68 67

2. Key strategies outlined


Past and proposed strategy Appraisal comments
. ASHA-specific orientation to reach child health This is an adequate orientation.
targets stated monitoring indicators to be put in
place and support to achieve the
plan.
HBNC is implemented in three districts aAlwar, This is a slow roll out- but is as
Bharatpur and Dausa) with support from per what the programme needs.
Norway India Partnership. Budget has been
proposed for pilot in 5 blocks of Dausa district Why is regular tracking beginning
@ Rs 300 lakhs in 2008-09. in Dausa so early? Can it be
Monitoring and follow-up post training is done? How?
mentioned
IMNCI : IMNCI initiated in 9 districts in 2006- The scaling up is as desired.
07 and nine more in 2007-08 and by end of Design is also adequate except
2008-09 all 32 districts is proposed to have that post training support has not
IMNCI service. been built in. Is perhaps there in
13,920 health functionaries are to be trained in the NIPI component via UNICEF
IMNCI. programme.
TOT on IMNCI @ Rs 96.00 lakhs.
445 district level training of SNs @ Rs 1.5 lakhs
per training.
Two day refresher training IMNCI @ total Rs
28.80 lakhs..
Facility level care: FBNC initiated in 8 districts Scale of roll out is adequate.
in 2007-08 concentrated on referrals made by Planning understands different
ASHA/ANMs ; it is proposed that in 2008-09 levels and costs at each level.
FBNC will be covered in all 33 districts. The Mentoring and post training
budget proposed is for 27 institutions @ Rs 2.66 follow-up not (?)in place.
lakhs
- TOT on FBNC Rs 2.02 lakhs.

7
367 CHCs and 24 SDHs are in position. Please refer to pp 32.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
81

- 33 MOs/SNs training proposed @ Rs 23.10


lakhs (total), supervisory training for IMNCI @
Rs 34.56 lakhs (total).

SNCUs in 39 CHCs/SDHs 7 @ Rs. 4.5 lakhs per


SNU (under SSY).
SNCU at district hospital Dausa Rs 15 lakhs.

Managerial level staff at various levels @ Rs


233.68 lakhs.

Nutrition:
a. Malnourished: 44% of children are Major start into malnutrition
underweight, 20% are wasted and 34% management. Rapid roll out. 237
are stunted growth (NFHS III). centers in one year, plus 39 MTCs
- Vitamin A supplements will be provided would be impressive. Need to
in all 10,333 HSCs @ Rs 250 lakhs. develop programme monitoring
- Care of Sick Children and severe strategy.
malnourished children to be provided in No programme as yet for anemia.
237 FRUs 8 by 2008-09. For which 237
Nurse grade II at total cost of Rs 127.98
lakhs
- Establishment of 39 malnutrition
treatment corners (MTC) in all district
hospitals and medical colleges. Proposed
budget for 30 MTCs @ Rs 1.08 lakhs
and 6 MTCs in medical colleges @ Rs
2.58 lakhs per unit. The PIP has also
proposed for compensation for mothers
of children in MTC in all 39 institutions
@ Rs 3.150 per institution; total cost Rs
122.85 lakhs.
- 156 Nurse grade II in 39 MTCs @ total
cost of Rs 84.24 lakhs.
- 237 PHNs @ total cost of Rs 174.91
lakhs.
- TOT on care of sick children and severe
malnutrition one at medical colleges @
Rs 1.28 lakhs.
- Training on care of sick children and
severe malnutrition for medical officers
@ Rs 17.52 lakhs (total).
- MOs/SNs from MTC in district hospitals

8
only 58 FRUS mentioned as functional in situational analysis: refer pp 32

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
82

in medical colleges @ Rs 12.40 lakhs.

b. Anemia: 79.6% of children within 3 year


of age are anemic (NFHS III)
c. Social marketing of ORS, Zinc,
pneumonia kit Rs 30.00 lakhs proposed
and for breastfeeding Rs10.00 proposed.
d. 5700 Mother and child health days per
month in 3 districts has been proposed

- Breastfeeding: 13.3% (NFHS III) within Not an adequate programmes.


24 hours of birth. and for breastfeeding How does the zinc and the
Rs10.00 proposed. pneumonia kit get used. Import of
these strategies both in scale and
scope remain unclear.
a. Referral transport : Shishu Raksha Fund, This may be better utilized here
Rs 1000 per ASHA for community level given the improved ASHA effect
care and referral of sick neonates. (paid and the huge inputs into facility
from ANMs untied fund) strengthening that are happening
together.
b. Innovations:
Piloting of Shishu Surakhsa Yojana (SSY)
in 3 districts proposed.
ÆYashodha (a volunteer similar to ASHA)
trained to take care of 4 newborns and 3
yahodhas in at CHCs/SDHs/DHs facility in 3
districts. Will receive Rs 100 per newborn
care and sick neonates brought to hospital.
Total cost Rs 46 lakhs (estimated 46,000
deliveries n 2008-09)
Æ kit for Yashodha with BCC/IEC
materials, initially with 5 kits in CHCs and
10 kits at District Hospitals (250 total @ Rs
500)
Grand total for the scheme is Rs 307 lakhs
2008-09.
Capacity building for ASHA and Yashodhas
in 3 districts @ Rs 50000/per block for 28
blocks account for Rs 14 lakhs.

Assessment of maternal and infant death by


NIPI team Rs 10.00 lakhs.

Assessment of maternal and infant death by


NIPI team Rs 10.00 lakhs.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
83

c. School health and immunization


described separately:
Overall: Tremendous acceleration planned in the coming year. The issue is whether
systemic bottlenecks especially in programme management have been addressed at the
same rate. Though minor strategies need further discussion – if the four main strategies,
ASHA, IMNCI and the facility based care and the nutrition centers take off there should
be a substantial impact. However need to develop adequate support and monitoring
structures , which could be a problem at times of acceleration.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
84

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2007-08
Sikkim

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 33-35-16 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 42 39 33 32 30 33
IMR as per NFHS III is 34 per 1000 live births
2. Key strategies outlined
Past and proposed strategy Appraisal comments
- Joint training of ASHA/AWW/ANM/LHV Well designed intersectoral co-
and issuing of common mother and child ordination, starting from training.
health cards. Follow up of PNC by
extensively by ASHA.
- Orientation of mothers and new born care
to promote good practices on neonatal and
infant survival in the community by ASHA
for eg. Avoid bathing new born, leaving
them in open etc.
- Weighing all newborn babies, within 24
hours by ASHAs.

- Adequate stock of ORS with ASHA and


AWW and availability of co-trimoxazole
- Passive surveillance and refresher training
for health workers mainly ANMs for early
detection and treatment of ARI and
Diarrhea.
Increase community participation in health care
through VHND at all AWCs once a month
(1620 per year). More number of VHNDs is
proposed to bring about behavior changes in
community for utilization of services at
institutions.
IMNCI: This detailed training schedule is
15 days training proposed for 4 maser trainers very useful, however the number
outside @ Rs 1.00 lakhs. of ANM proposed for training
8 days IMNCI training of all 30 MOs @ Rs should increase as there are 267
0.54 lakhs and for all 60 SN/ANM @ Rs 0.60 ANMs in the state (RHS 2007).
lakhs and 4 days for 17 LHVs @ Rs 0.20 lakhs.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
85

Facility Level care:


Establishment of new born care corners in all Encouraging strategy, but one
24 PHCs and neo natal care units in all district needs to see how far these corners
hospitals (4 district hospitals with would be functional. FBNC
pediatricians). training seems inadequate as each
7 days training proposed for 10 MOs and 10 facility, even PHC MO should be
SNs in FBNC @ Rs 0.60 lakhs. trained in FBNC, considering the
geographic terrain.
Nutrition:
a. Malnourished: 23% of children are Very promising strategy to track
underweight and 13% are wasted all the anemic children. The
(NFHS III). experience needs to be
b. Anemia: 56.9% of children less than 3 documented so that it can be used
year are anemic (NFHS III) and the in other states and areas where
proposed strategy of having active anemia is prevalent.
tracking of all malnourished children by
AWW and ASHA and prophylactic
treatment for anemia and supply of
pediatric IFA tablets, anti-helminthes,
anti-malarial and iron syrup for children.
c. Breastfeeding: 43.3% (NFHS III) within
one hour of delivery.
- BCC campaigns to promote
breastfeeding and basic hygienic
practices, orientation of mothers/family
of newborn through monthly meeting of
ASHAs,
- breastfeeding week at all PHCs
g. Referral: Community based emergency Provision of vehicle or arranging
transport for children with critically ambulances for transport through
illness. this mechanism would be
effective.
h. School health and immunization
described separately:
Overall:

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
86

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2008-09
Tamil Nadu
1. Basic Health indicators regarding Child Health
a. Infant Mortality Rate
i. Current IMR: 37-39-33 SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 49 44 43 41 37 37

2. Key strategies outlined


Past and proposed strategy Appraisal comments
Home based newborn care to SHGs 25 member per Grass root level functionaries are
HSC area and health education through NGOs @ not involved in the training on
Rs 1000 per HSCs in 1282 HSCs HBNC.
Æ total cost of Rs 12.82 lakhs

HBNC training:
District level orientation 15,500 per batch Rs 0.775
lakhs
PHC level orientation 3000, @ Rs 7.44 lakhs
Training on HBNC for SHG, 12,500 per batch,
Rs 196.625 lakhs
Æ total cost Rs 204.84 lakhs
IMNCI pre-service training completed with WHO The budget allocation is too
assistance in 14 medical colleges misleading.
- IMNCI training is proposed for MOs @ Rs The previous version of the PIP
71,452 / batch; total Rs 1.429 lakhs had mentioned the same number
- TOT for H & N workers Rs of health workers to be trained
83,500/batch,Rs 2.50 with same budget lines but under
- Training of H& N @ Rs 43,360/batch, Rs URBAN IMNCI.
35.99
- IMNCI followup (supervisor training) @
- Rs 21347/batch; total 1.71 lakhs
- IMNCI orientation workshop @ Rs
20,000/batch; total Rs 0.6 lakhs.
Facility Level Care: Setting up of NICUs in five
- NICU in 10 CEmONC centers @ Rs 25 districts with high IMR might not
lakhs per NICU, bring down the cause until the
- 9staff nurses per NICU centers @ Rs 5000 BCC towards utilization of the
and 3 pediatricians/MO trained in pediatrics health services is promoted.
per NICU @ Rs 20000
- Æ total cost for NICU is Rs 344.5 lakhs.
- Rs 250 per visit proposed for Pediatric
visits for management of emergency

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
87

newborn care, total budget proposed Rs


50.00 lakhs.
- Newborn care kits in 224/1421 PHCs @ Rs
1.00 lakhs and Neonatal warmth kits for
30000 mothers @ Rs 250/kit, total Rs 75
lakhs for neonatal warmth kits in selected 5
dsitricts.
- Hiring of pediatricians in PHC and
DHs/taluka hospitals @ Rs 250 per visit
and conveyance total cost of Rs 50 lakhs.

FBNC:
- TOT on FBNC @ Rs 14,600 per batch total Discrepancy in the budget
0.146 lakhs proposed for training and the total
- training for Pediatricians/ CEmONC Rs budget.
34300/batch, total Rs 0.686 lakhs.
- FBNC for MOs (PHC) @ Rs 14800 per
batch, total Rs 3.7 lakhs
- FBNC for SNs (CEmONC) @ Rs 21500,
total Rs 10.249 lakhs
- FBNC for SNs (PHC) 27700, Rs 10.249

Nutrition:
a. Malnourished: 33% of children are No strategy outlined towards
underweight and 22% of wasted. reducing malnourished and
b. Anemia: 72.5% (NFHS III) children below anemic children
3 years are anemic and 29.0% of children
with diarrhea received ORS.
c. Breastfeeding: 55.3% (NFHS III) within Since 90% (NFHSIII ) is
one hour of birth. institutional delivery this scheme
- CEmONC centers will have provision of could be expanded to all 24*7
dietary supplements for mothers for two days PHCs to improve breast feeding.
and therefore promote exclusive breastfeeding
d. Referral transport : This initiative is an additional cost
Proposed 6 Ambulances in PHCs of Tsunami incurred against 146 MMUs
affected districts, supported by Unicef. However, available in the state.
manpower and vehicle maintenance to be provided
by state at Rs 32.28 lakhs.
e. School health and immunization described
separately: Ambulance services
Overall: Focus is provided on five districts with High IMR, strategy addressed are not
clear. There is also mentioning of strengthening of Pediatric units in tertiary care
hospitals @ Rs 9500 lakhs which is not in the mandate of NRHM. The numbers proposed
for training do not match with the budget proposed. Only 1.41 lakhs expenditure incurred
under child health in 2007-08, and this year 713.51 lakhs has been budgeted ( according
to the PIP it is 7% of the total, but the exactly it is around 4.7%).

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
88

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 36-37-30 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 39 38 32 32 31 36

2. Key strategies outlined


Past and proposed strategy Appraisal comments
IMR in Tripura stagnates in thirties NFHS District MIS records 508 deaths
and the latest SRS shows rise. could try to analyze this to
understand causes of rising IMR
IMNCI: - 6 TOT in IMNCI conducted, 15 Well planned distribution across
MOs, 5 SNs trained in IMNCI districts TOTs completed.
Proposed that 98 GDMOs(total 231), 98 SNs Linkage with facility improvement
(total 341) and 200 ANMs (total 489) for could be more explicit. Post training
training in IMNCI @ total cost of Rs 13.49 follow-up to achieve service
lakhs. improvements not planned for.
Community health worker and Home based The ASHA selection should build
interventions: 51% (NFHS III) of deliveries linkage with home based child care
are conducted at home. Building community and BCC issues. This is more
awareness on home based neonatal care important in high IMR districts of
through mega village health days organized at north and south Tripura. A Mega
AWC, with health workers and implement village health day is an inadequate
home-based care of newborn as per IMNCI strategy for this.
guidelines.
Facility Level care: Proposed to strengthen IMNCI is inadequate training for
newborn and neonatal care services in all 54, facility level care especially in
24*7 PHCs. FRUs. Training for such pediatric
4/11 SDH converted into FRUs, newborn care skills should be built in
corner in 54/76 PHCs @ Rs 37.00 lakhs and it
is proposed have neonatal care units in 4/11
SDH @ Rs 3.50 lakhs/unit (total Rs 14.00
lakhs)
Nutrition:
a. Malnourished: 20% wasted and 39% 1. develop and putting in SOP for
underweight (NFHSIII) children. It is referral to for medical care of
proposed to reduce LBWs by malnourished children
providing nutrition supplements to all 2. Weekly LBW weighing of limited
pregnant women through AWCs for use. Regular visits –upto 10/months
one district @ Rs 2.52 crores for LBW more useful.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
89

b. Anemia: To address 67.9% of children


are anemic a collaboration with
AWW,ASHA and ICDS and social
welfare and social education
directorates has been planned. Regular
supply of medications will be
provided through health workers to
reduce anemia.
c. Weighing and monitoring of all LBW
by ASHA/AWW.
d. Community awareness through mass
media on anemia
e. Breastfeeding: only 33% of children Well planned BCC focus
are breastfed within one hour of
delivery (NFHS III). Exclusive
breastfeeding register to be maintained
by ASHA/AWW.
f. Referral transport being strengthened No transport and communication
with standard operating procedures. modality planned
Focus provided in malaria endemic
areas of the state.
g. School health and immunization
described separately:
Overall:
Expected scale of impact:
- about 50% of facilities and outreach if human resource issues are attended to
- at community level BCC would have state wide state wide impact but other
dimensions would have little impact
Range of activities:
- management of severe malnutrition is left out
- Specific tribal issues and needs identification
- cause for increasing IMR/ where are these deaths happening most soul
determinants of these needs clarification.
- Human Resource and skills for establishing so many new born care units needs to
be factored in. without it this plan may achieve expenditure targets without
achieving outcomes.
Quality of activities:
- training follow-up for IMNCI not mentioned
- Monitoring and supervision for this needs to be planned.

Effective plan that should show results. Focus on monitoring which should be on
ensuring that all components including many which are low-budget but important items
get adequately implemented.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
90

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate
i. Current IMR: 71-75-53 (SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 83 80 76 72 73 71
2. Key strategies outlined
Past and proposed strategy Appraisal comments
IMNCI (CCSP-UP): Plan is to take up same no of
i. Implementation in 17 districts @ Rs districts next year and then all
35.29 lakhs per district and supportive remaining 36 districts in the last
supervision and monitoring by NGOs year. Next year objectives could
@ Rs 5.29 lakhs / district. be higher if we plan for
ii. IMNCI sensitization workshop at completing more TOTs this year.
district, block and PHCs @ Rs But TOTs for next year districts
15,000/workshop (17 workshops), Rs are not seen. This year 470 would
5000/workshop (221 workshops), Rs be trained for the 17 dts of this
2000/workshop (1105 workshops) year. However expansion of
respectively., @ Rs 40.70 lakhs (total). training centers in medical
Pvt hospitals being involved for more colleges may lay base for future
training sites: expansion.
iii. Last year 29 MOs trained, this year 1330 Post training follow up does not
iv. Last year 511 ANMs trained, this year read as adequate. Matching
4084 facility care improvements ?
v. Last year 34 LHVs trained, this year Referral transport outlay and
936, approach may be sub-critical for
vi. Last year 1800 ASHAs trained, this year outcomes. Last years progress in
29,300. training has been slow and the
increased plan is huge but this is
still a part.

Facility Level Care: The PIP does mention that none


i. It is proposed to make available one room of the units were made
to be converted into SNCU unit in 53 operationalized due to non-
district women hospitals that would be availability of staff. However no
operationalized by having one strategy has been proposed to
pediatrician, two medical officers and 6 recruit the proposed number of
staff nurse. Since this was proposed in manpower. The roll out of the
2007-08 PIP and Rs 447.17 lakhs was FBNC component does not match
allotted there is not budget proposed for the roll out of the CSSP
this item in 2008-09 component.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
91

ii. Training for FBNC plans to increase MOs


trained to 340, staff nurses to 80
iii. Procurement of 1765/district child
survival kits and job aid kit for ASHAs @
Rs 1000/kit and Rs 150 respectively is
proposed for 17 districts.
Nutrition:
Malnourished: 47% of children are underweight Feeding demonstrators?
and 14% are wasted (NFHS III). 12 districts- 20 CHCs is a very
Measures proposed: small coverage- but could be used
i. Two day training for 500 (total) MOs/SNs as a pilot. Even this needs
and feeding demonstrators in batches of linkages. This appears relatively
20 @ Rs 25,000/batch. symbolic while the main focus is
ii. Establishment of NRC at selected 12 on the micro-nutrients
districts in 20 CHCs proposed. However
an estimate of 10 cases of severely
malnourished per month would be
managed with cooked meals, medicines
etc. It is not mentioned clearly in the PIP
where these children will be admitted—is
it in NRC?
iii. A pilot project has been proposed in 20
districts identified as severely
undernourished, to integrate ANMs,
AWW and train them in counseling about
food and nutrition, and IEC. Total cost for
the pilot project Rs 27.60 lakhs.
a. Anemia: 85% (NFHS III) less than Focus on micronutrients, focus on
3years. Bal Swasthya Poshan Mah conditional cash transfers, focus
biannual strategy with ICDS, for on counseling all seem to indicate
biannual vit A supplementation, a belief that macronutrients have
complementary and breastfeeding, little role to play. Bi-annual
consumption of iodized salt and referral vitamin A strategy is the focus of
of severely malnourished children in the micro-nutrient initiative and in a
two fixed months and also Iron syrup and state already stressed by pulse
folic acid administration for children polio the time demands on health
between 6 to 60 months is promoted. All workers for the sort of care that
are included in Kit A being provided to CSSP implies would get affected.
70 districts. The total cost of Rs 20.50
lakhs is proposed for the scheme.
b. Large 14 crore investment in IFA tablets
for school children as part of school
health programme.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
92

h. Breastfeeding: 7.2% of children are Focus on colustrum feeding an a


breastfed within one hour of delivery. minimal notion of warmth in the
iv.‘good mother’ concept for mothers who BCC section- but no messages on
provide colostrums and warmth exclusive breastfeeding or
immediately after birth. complementary feeding. Still
v.ASHA/AWW/ANMs are to be trained in these are large interventions.
promoting appropriate breastfeeding
practices., ASHA will receive an
incentive of Rs 50 per child for
promoting breast feeding within one
hour of delivery. IYCF sensitization
workshop at block level and 3000 PHC
level workshop @ Rs 2000/ PHCs ( total
budget of Rs 199.62 lakhs including IEC
materials and other costs).
i. 12% of children with diarrhea received Would the supplies be enough?
ORS (NFHS III), to manage diarrhea How much ORS would be
cases kit A is supplied to all 70 districts
required if we estimate that each
that contains ORS and Zinc tablets. child has seven episodes per year
and only 12% of children would
approach and take it from the
public health system?
a. Innovations: Conditional Cash Is there evidence to back this
Transfer for all BPL families for strategy? Conditional cash
adequate maintenance of nutrition of transfer for under nutrition in BPL
child children for first two years in given only if they survive and are
Banda and Sonbhadra districts of Uttar normal weight?!! In which case
Pradesh, identified and followed up by they would not need it. This
ASHA for two years of age, would would necessarily attract
receive an incentive of Rs 75 in total as criticism- since BPL criteria are
incentive and beneficiaries would receive such that only those who have no
an incentive of Rs 100 at birth and Rs purchasing power should
500 at the end of two years @ Annual qualify!!! Something wrong here
budget Rs 182.50 lakhs. – something about the heart…
b. BCC: there is strong message on Priorities on messages need to
hepatitis infection in pregnancy esp with match load of diseases and
Hepatitis E coinfection with A. There is evidence of matching appropriate
one on colustrum feeding and hugging action. Thus exclusive breast
the baby at birth and there is one on feeding, or diarrhea prevention
immunization. and care does not have a mention,
but there is a major focus on
hepatitis A, B, C and E infection.
What is the action
proposed/behaviour change
proposed for hepatitis E-?
immunization? Or safe drinking

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
93

water. Or for example the stress


on messages of colustrum feeding
on beauty products that mothers
and mother in laws use- that too
in private sector mode. This
section on BCC has got the
principles of planning right,(
unlike in many other state PIPs)
but the inspiration appears non-
local and evidence base of these
would be weak.
c. School health and immunization
described separately:
Overall: The overall budget for child health for this year for the core strategies is quite
low, since the state is largely spending last years budget and implementing last years
targets. The only funds asked for are for strengthening the training centers and
provisioning that should anyway gone along with last years budget. Indeed this should
have been done last year so that the programme could be expanded this year- but better
late than never. In the three key strategies CSSP , facility based care and NRCs the
progress is limited. It is particularly limited in the last two where it is very much like a
symbolic step forward, than one that would have an impact.
It is only the micronutrients supply that it is to scale- both in operational terms and in
budget terms. Many elements of the proposed child strategies, other than the core are
innovative, but there is a lack of evidence base and a concern that it would distract from
the core strategies. all of them together have a direction and a lack of evidence base, that
is worrying. There is no reason why the core strategies could not have been implemented
much more vigorously and these innovations built into them (except the unusual
conditional cash transfer scheme which should really be examined). Probably basic
problems of work force inadequacy and training structure inadequacy are plaguing the
system. The recruitment of 1037 ANMs would help @ total cost of Rs 871 lakhs.
However the required no. of ANM is 1223., for the state.Though all these measures
would help, really sustainable acceleration would probably need more attention to the
core strategies of child health.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
94

NHSRC PIP appraisal of


Child Health in the RCH Project Implementation Plan Phase II 2008-09
Uttarakhand
1. Basic Health indicators regarding Child Health
a. Infant Mortality Rate
i. Current IMR: 43-54-22(SRS 2006- Total- rural -urban)
ii. IMR Trend for last five years (as per SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 48 44 41 42 42 43

2. Key strategies outlined


Past and proposed strategy Appraisal comments
l. IMNCI : Four district level officials were IMNCI training is provided to
trained in 2006-07 by UNICEF and this peripheral workers of only four
year two more districts will be taken up. districts (out of 13 districts), at this
IMNCI training doctors and other health rate it is really difficult to bring
workers, with TOT approach. down the child deaths, even focused
- The IMNCI training needs more in the high risk districts. The TOTs
elaboration on providing health are aimed for creating four teams in
workers with weighing kits and drug every district. If this is so some
kits. peripheral workers training should
- All staff of health and women and start in every district. Post training
child development department are to follow up and link with referral and
be trained in IMNCI facility improvement and BCC not
- Joint monitoring and implementation apparent.
plan for IMNCI proposed to be
developed at block level by health
and ICDS department. This
collaborative approach in monitoring
and also in TOT. This could bridge
the inter-departmental gap.
a. Facility level care: This would be enough only for one
b. 26 MOs and 26 staff nurses from 13 CHC. About 7 times this number
districts are being given 40 days and 60 needs to be planned for.
days training at MAMC,Delhi At another Improvement of facilities in
place in text it seems only 10 of each equipment and provisions? The
would be trained. difference between SNCU-1 and
SNCU- 2 needs to be brought out.
c. Lack of knowledge about childhood Which could have been done
illness is mentioned as main cause for through Home based neo-natal care
malnourishment, no strategy is mentioned is addressed through
in PIP. ANM/AWW/ASHA.
d. Comprehensive newborn and child health
package at household initiated through
AWW in 250 days

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
95

e. Nutrition:
f. Malnourished: 38% of children are Not an adequate strategy.
underweight and 16% are wasted.
- Periodic growth monitoring is stated.
without providing the details on who will
be monitoring the growth and the
availability of weighing kit
g. Anemia: 77% (NFHS III) of Children are Not adequately defined
anemic and no strategy has been outlined
in this aspect., except for periodic growth
monitoring.
h. Breastfeeding: 10.9% (NFHS III) of Since the breastfeeding is culturally
children are breastfeed within one hour routed the counseling part plays a
and 57% (NFHS III) exclusive breastfeed key role and needs more
for 0 to 5 months. sensitization of the health workers.
- Incentivizing ASHA for promoting The strategy in this regard is
breastfeeding and counseling for a target appreciable. But limitation of
of 60% deliveries is set. counseling to only district hospitals
- 13 one day orientation programme for is too slow and too cautious. Every
counseling mothers about breastfeeding site of institutional delivery should
will be given for all MOs have this in place.
- Counseling desk at all district hospitals,
managed by a trained counselor.

i. Social marketing of ORS has been


proposed
j. BCC: focus on breastfeeding good; also More focus on child care
on utilization of growth monitoring and practices related to
immunization services complementary feeding and care
during sickness would be useful.
How is it being taken to scale is
not clear.
k. School health and immunization
described separately:
Overall:
The scale of the roll out is far too low – IMNCI in 4 districts, expaning to only two more,
facility based care and counseling for breast feeding in only a few district hospitals. The
scope is also too low- malnutrition and anemia, complementary feeding and malnutrition
etc does not get adequate attention. The quality also needs to be followed up- since post
training follow up and programme management arrangements are not described. Perhaps
a model plan of how it could have been is worth making.. or just use currently sanctioned
budget more appropriately.

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
96

NHSRC PIP appraisal of


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

1. Basic Health indicators regarding Child Health


a. Infant Mortality Rate & Neonatal Mortality Rate
i. Current IMR: 38-40-31(SRS 2006- Total- rural -urban)
ii. Current NMR: 30 (SRS 2006)
iii. IMR Trend and Neonatal Mortality Trend for last five years (as per
SRS data)

Year 2001 2002 2003 2004 2005 2006


IMR 51 49 46 40 38 38

Year 2001 2002 2003 2004 2005


NMR 31 29 30 29 30

Past and proposed strategy Appraisal comments


Community level trained women 30/district This is a supplement to the
(ASHA) in neonatal care support the functioning Facility level care- there is no
of stabilization units in 5 districts @ Rs 1000 as major thrust at the community
honorarium and Rs 16000 one year training cost level except for the ASHA
per women. programme.
IMNCI : AWW training in IMNCI is being West Bengal has a total of some
conducted at state level, training corresponds to 341 blocks- to do 7 more blocks
strengthening of facility care. 2 TOTs and one in 3 more districts is in the nature
physicians training has been done. of a symbolic gesture in terms of
Scaling-up of IMNCI training to 3 more districts expected impact. Currently only
(7 blocks) from current one in Purulia @ Rs 18 one district is covered. No other
.00 lakhs per block. community strategy is visible
Facility Level care: Level II SNBC units in Currently in 4 districts- expansion
Purulia with support from UNICEF and three to 4 more proposed. Again far
more units proposed, total 5 units @ Rs 50 lakh behind the requirement. Worse in
per unit and existing 5 units @ Rs 1.00 lakhs per stabilization units only 5 units in 4
unit (total cost of Rs 255.00 lakhs). districts are planned- at best this
Scaling up of Sick newborn stabilization units represents some 5% of
drawing from experience of Purulia to 5 districts requirement at block PHC level
with 3 units, budgetary allocation has been made when the aim should have been to
for 11units. 5 units in 4 districts @ Rs 3 lakhs put it in place in all CHCs and
per unit. Funds for training for all MOs have not PHCs. Need to ensure that every
been released. PHC can manage out patient
referral care for the sick child and
every CHC has a stabilization unit
level of care ANC check what %
of sick newborns and children are

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
97

getting referred.
Nutrition:
i. Malnourished: 44% of children are Scale of intervention is small-
underweight and 19% are wasted (NFHS only 19 out of 341 blocks and
III). what it can achieve in terms of
ii. Positive deviance (PD) is a community reduction is unknown – though it
based approach to create awareness about is worth studying.The absence of
malnutrition and share experiences about measures to address severe
managing malnutrition. 15 blocks of malnutrition and wasting is to be
Jalpaiguri district and 4 blocks of 24 addressed.
Praganas are considered to initiate this plan
@ total cost of Rs 101.28 lakhs. The measures on IYCF however
are planned to scale- and probably
planned through the panchayats.
iii. Anemia: 69.4% of children are anemic This is the a programme – on
below 3 years of age (NFHS III). AWW vitamin A which approaches
with medicine kit, includes paracetamol, scale.
IFA and albendazole @ Rs 250 per AWC.
iv. It has been proposed through 16,000 Shishu
Sikshya Sahayikas (SSK) and 4500
Sahayikas, to cover 15,000 villages catering
for a 40% of total population health
information would be disseminated, mainly
of breastfeeding and bi-annual vitamin A
supplementation @ Rs 20.00 lakhs.
v. Mothers meeting @ SSK @ Rs 530.00
lakhs.
vi. Training exclusively for health
a. Breastfeeding: 23.7% (NFHS III) within This ICYF component has been
24 hours of birth. completely planned out and done
vii. Training for newborn aids @ Rs 50.00 to scale. Such an effort was
lakhs. workers in promoting IYCF outlined, needed in other dimensions also.
sensitization of health workers, PRIs, ICDS,
NGOs and general administration on
importance of child feeding practices by
ASHAs and ANMs and IEC in all 3354
gram panchayats. Activities @ Rs 100.00
lakhs.
b. School health and immunization Elaborate school health
described separately: programme discussed
elsewhere.

Overall: The over all improvement in west Bengal in child survival is remarkable and
either base line functioning is very good or social determinants are helping or good
community awareness is making up for weakness in facility functioning. This PIP is scale
and scope does not seem to be going to make any impact on health care services at a

Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
98

demographic level. Need to dialogue with the state and see how acceleration is necessary
or feasible.

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