Beruflich Dokumente
Kultur Dokumente
2008-09
Version 1.0
Contents:
Filename: Mapping Technical Assistance Needs/Child Health Created by: Dr T Sundararaman Date: 23/04/2008 16:42:00
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Section 1
A preliminary mapping of TA needs for child health:
There are three sources for defining TA needs. The first is the JRM and CRM reports, 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.
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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
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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.
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Section 2
Analysis of State PIPs:
The PIPs for the current year have improved dramatically in how they address child
health. Now most states are seized of the different strategies that make up a child 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
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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
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improving child survival. Of those who have used it only Chhattisgarh and Rajasthan
have scaled up to the whole state.
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.
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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.
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.
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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.
3. Building up capacity for guiding BCC work in the districts in state level agencies
like the SIHFW/SHSRC.
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 –
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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
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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.
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
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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
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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
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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.
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.
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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
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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.
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.
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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-
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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).
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.
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The effectiveness of IMNCI protocols to address the sick child with malaria also needs to
be studied. The entire area of recognition and integration of malaria as the fourth major
cause of childhood mortality (following neonatal deaths, ARI and diarrohea) would be 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.
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.
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Section-3
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Note: a, b d, e h, and l above refer to the same issue – the nature of facility based care –
and this much duplication is reflective of the need for conceptual clarity on this.
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Note: a, b d, e h, and l above refer to the same issue – the nature of facility based care –
and this much duplication is reflective of the need for conceptual clarity on this.
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Section- 4
Child Health in the RCH Project Implementation Plan
2008-09
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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:
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1
However according to Rural Health statistics of 2007, there are only 78 MOs in 85 PHCs.
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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.
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2
GOI (2007), Bulletin on Rural Health Statistics in India, Ministry of Health and Family Welfare, Chapter
II, Table 19, Number of Sub-centers, PHCs, and CHCs functioning , pp 32.
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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.
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3
IMNCI training for MO, Nurse, ANM and AWW.
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- 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.
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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.
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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.
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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).
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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)
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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.
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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
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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.
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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.
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.
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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.
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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:
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- 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)
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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.
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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
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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:
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c. Breastfeeding: 65.4% of
children are breastfed within
one hour (NFHS III) and
IEC/BCC by health workers is
proposed for exclusive
breastfeeding.
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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.
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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.
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7
367 CHCs and 24 SDHs are in position. Please refer to pp 32.
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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
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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
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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%).
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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.
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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.
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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
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demographic level. Need to dialogue with the state and see how acceleration is necessary
or feasible.
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