NIPI is an initiative designed to facilitate States to improve delivery of child health services with efficient

techno-managerial support structures. Sustainability based on uptake by the system is fundamental.

”

Orissa, Bihar, Madhya Pradesh and Rajasthan

Program Update, January 2009

under
in

Norway – India Partnership Initiative

Activities by State Health Societies
Introduction
The Norway India Partnership Initiative was NIPI interventions. The NIPI strategy document
started in 2006 after discussions between the defines three Focus Areas for NIPI interventions.
Indian Prime Minister Dr Manmohan Singh A) Quality Services for Child Health, B) Enabling
and the Norwegian Prime Minister Mr Jens Mechanisms, and C) Learning and Sharing of
Stoltenberg. The idea was to create a tool Experiences. In addition, the interventions fol-
that in a flexible manner could fill gaps and lows a “continuum of care” approach, based
provide catalytic support to the National Rural on the the understanding that preventive and
Health Mission (NRHM). This Government curative interventions must go hand in hand,
of India (GoI’s) country programme seeks to and that health service providers at lower levels
provide effective health care to the rural need to have a functioning system of referal to
population throughout India. NRHM places higher level services in order to obtain credibility
special focus on 18 States identified as having from the recipients. The current NIPI interven-
weak public health indicators and/or weak infra- tions are listed in the textbox below, and will be
structure. Under NRHM, resource allocations to further explained in the following pages.
States, to strengthen public health management
and expand the scope and quality of service
delivery, have increased significantly. The geo-
graphic focus of NIPI is five NHRM States that
contribute 60 percent of India’s child mortality:
Bihar, Madhya Pradesh (MP), Orissa, Rajasthan
and Uttar Pradesh (UP). Within the overall fram-
ework of NRHM, NIPI focuses on newborn and
child health.

In the overall context of NRHM resources provi-

ded by GoI, NIPI funds provided by Norway are
but a drop in the bucket. At the same time, this
drop is considered by India and Norway to be
an important one, as it provides flexibility and UNOPS / State health societies interventions
space for innovation.
The special feature of NIPI is that it’s funds • Techno-Managerial Support to NRHM
are to be used catalytically, strategically, inno- • Yashoda/Mamta (Newborn aides)
vatively and flexibly to test and evaluate new • Home-Based Post Natal Care (HBPNC)
methods, demonstrate and evaluate new appro- • Sick Newborn Care Units (SNCU)
aches for possible scale-up, conduct operational
research, and overcome gaps and constraints. Unicef interventions
Importantly then, NIPI funds are not parallel to
NRHM, but rather complementary, intended to • Immunization (cold chain)
be used to create up-scalable interventions that • Integrated management of neonatal and childhood illnesses
are financially viable and sustainable in Indian (IMNCI)
• Sick newborn care units
State contexts.
WHO interventions
NIPI setup. Norwegian funds can not be
transferred directly to GoI, but will have to be
• Immunization
channeled through UN agencies with estab- • Measles control
lished offices and ongoing operations in India. • IMNCI
Thus UNICEF, WHO and UNOPS were selec- • Emergency obstetric care (EmOC)
ted. UNICEF and WHO have the responsibility • Curriculum development for ANM/nurse training
for specific programmes in cooperation with • Establishment of an accreditation system for facilities
India in the health sector, whereas UNOPS are
engaged to set up and fund operation of the
NIPI Secretariat, and as local fund agent (LFA)
for the assistance to NIPI Focus States.
 Techno-Managerial Support
The National Rural Health Mission (NRHM) has since 2005 been very successful in
increasing the resource allocations to States to provide effective health care to rural
populations throughout India. With the increase of range and scope of services
provided, the demand for effective managment arises.
NRHM States and specifically NIPI States have
had difficulties absorbing all potentially available
funds due to centralised planning processes, low
performing health services systems, and over-
burdening, resulting from significant increases
in transactions accompanying rapid expansion
of activities and expenditures. In this context,
the UNOPS LFA is facilitating the State Health
Societies to access NIPI funds to strengthen their
techno-managerial structures and systems so
they can more efficiently and effectively deliver
quality child health services under the NRHM
programme.
The NRHM requires that the States now estab-
lish decentralised planning processes and are
themselves responsible for implementation of
NIPI supported managerial inputs
For each state (directly employed by NIPI)
Senior Program Officer (State, reports to Mission Director NRHM)
State Program Officer (State, reports to Senior Program Officer)
Program Associate (State, reports to Senior Program Officer)
The following personnel is employed by the state, but supported
by NIPI funds:
For each focus district (3 per state)
District Child Health Manager (District PMU, Reports to DPM)
Child Health Supervisor (and 2 deputies)
For each block in focus districts
Block Child Health Manager (Block PMU, reports to BPM)
In addition NIPI supports the States with other categories of per-
sonnel according to the State’s specified needs. The possitions
identified by the states are as follows:
State Finance Assistant (States except Rajastan, placed in SPMU)
State Data Assistant (Bihar and Orissa State, placed in SPMU)
State Data Analyst (Madhya Pradesh, placed in SPMU)
Training Officer (One district MP, reports to DPM)
District Training Coordinator (1 district Orissa, placed in DPMU)
State Child Health Consultant (Placed in SPMU)
Divisional logistic Manager (MP, Divisional level)
District Public Health Nurse Manager (Rajastan focus districts)
State HR Assistant (Orissa)
State Media & Communication consultant.
programmes. Accordingly, a number of related
responsibilities have shifted to District and to some
extent to Block level. In this process, a structure
of Program Management Units (PMUs) at State,
District and Block levels has been set up to sup-
port managerial facilitation of service delivery.
NIPI States have identified critical staff positions
that if filled can help the existing health mana-
gement system reach its potential. Additional
techno-managerial support to accelerate activities
aimed at attaining the MDG 4 goal is thus being
supported as an enabling mechanism intervention
in the four NIPI States. Such support is intended
to strengthen implementation of child health inter-
ventions and to bring the child health agenda to
the forefront.
NIPI-funded management staff are being recruited
using NRHM procedures and are placed within
existing PMUs established under NRHM. Using
these procedures, the idea is that the personnel
will be absorbed by States under NRHM in the
short-term future, assuming of course that they
are determined as being useful and effective.
At District level, District Child Health Managers/
Deputy Managers/Maternal and Child Health
Coordinators are being placed. These managers
will support District health systems in formulation
of District programme implementation plans (PIPs)
for the child and maternal health under NRHM.
Besides remuneration, NIPI support includes pro-
visions that allow recruited personnel to perform
their jobs efficiently, i.e. mobility support, budget
for attending meetings, office expenses, etc.
Finally at Facility level where Yashodas/Mamtas
are placed, one Child Health Supervisor and two
Deputy Child Health Supervisors are being recrui-
ted. These female supervisory functionaries will be
responsible for training, monitoring, mentoring,
and generally creating overall conducive working
environments in which Yashodas operate.
Yashoda/Mamta
Increased utilisation of birth facilities has resulted in gaps between expected and
available services. The Yashoda programme helps fill such gaps by recruiting and
training women volunteers to be helpers for mothers and newborns in birthing
facilities. These women, known as Yashodas, are non-clinical workers and act as
advocates and communicators for mothers and their newborn babies.
In 2005, the Indian government (GoI) introduced the
Janani Suraksha Yojana (JSY) scheme to improve
safe delivery for women living below the poverty
line. JSY contains service standards for duration
of stay at the facility, quality of services, services
available at the hospital, safety of mother and child,
and availability of counselling in breastfeeding,
immunisation, family planning, newborn care and
diarrhoeal management. JSY also introduces a
financial incentive scheme to cover costs associa-
ted with giving birth away from home.
JSY has thus resulted in dramatic increases in
use of birth institutions and higher standards for care
and service. A consequence is that existing staff at
birthing facilities are severely overstretched. The
Yashoda programme has been created to alleviate
this situation to some extent. Yashoda is a Hindi
word meaning “foster mother”, the idea being that
the Yashoda serves as advocate and guide for the
mother and her newborn child. In Bihar, the word
Mamta is used instead of Yashoda. Importantly,
Yashodas/Mamtas fulfil new roles at birthing facili-
ties for mothers and newborn children while freeing
up nursing and paramedical staff to better perform
their prescribed duties.
Similar to the ASHAs (voluntary health activists
working part-time at community level), the Yashoda/
Mamta is not a regular employee of the health
system at present, but rather a volunteer support
worker paid a performance-linked incentive. She
is trained in accordance with a curriculum that
includes orientation training, induction training, and
on-the-job recurrent training.
Developed in cooperation. In the initial phase of
the Yashoda/Mamta programme, much effort has
gone into developing and testing the Operations
Manual to guide States in implementing and sca-
ling up the Yashoda programme, and into preparing
teaching modules and information materials. This
process has been done in close cooperation with
the Nursing Council of India, the Trained Nurses
Association of India, the National Neonatology
Forum (NNF) and the National Institute of Health
and Family Welfare (NIHFW)
A flip chart as a hands-on tool for the Yashoda/
Mamta to use when counselling mothers and family
members has been prepared in English, Oriya and
Hindi at the Secretariat and was field tested and
published in 2008.
The NIPI States have quickly appreciated this
intervention, and have started rapid scale up of
Yashoda services.
Program indicators. As this program involves a
vast number of facilites across large geographical
areas, good monitoring routines are crucial. NIPI
Secretariat has formalised a reporting form that
will help States monitor the developement through
a set of key indicators. In addition the monitoring
form will help the States track the implementation
process itself. The indicators are shown in the tex-
tbox.
Challenges. At the local level, the very important
work of integrating and consolidating the Yashoda’s
role into hospital structures requires continued
attention. Therefor the role of Child Health Supervi-
sor (and her Deputy) has been established. These
supervisors are there to ensure that the Yashodas
are able to perform their duties within the system,
to handle administrative issues and to supervise
the Yashoda.
Key indicators of the yashoda intervention
• Percent increase in mothers staying at least 48 hours in the
birth facility
• Percent increase in mothers initiating breastfeeding early on
• Percent increase in newborns being weighed
• Percent increase in newborns being immunised (BCG and
polio)
 Birthing kits for facilities
As a result of JSY, States are experiencing unprecedented increases in institutional
deliveries. This places tremendous challenges for maintaining basic standards of
quality for the delivery and the care of the newborn. To ensure safer deliveries,
birthing kits are being introduced at birthing facilities having Yashodas/Mamtas.

JSY has brought vast numbers of poor rural women

to birthing facilities in the Districts. Through NIPI,
States are being facilitated in ways that enable them
to provide clean, safe and comfortable delivery
experiences for women giving birth in accordance
with quality standards of hygiene and care of the
newborn, plus teach new mothers how to practice
better hygiene and care at home.
Good obstetric infection control measures
during the intra-partum period are essential fea-
tures of good-quality practice. At present, State
hospitals and private facilities use disposable
delivery kits. Such kits are not available at District
and sub-District levels, which is where the surge of
rural women wanting institutional deliveries is being
experienced.
To improve quality of care, the Yashoda scheme
has already been introduced to provide counselling
and guidance on child care to new mothers and  Labour room at Block Level PHC in Madyah Pradesh
family members during the stay at the birthing faci-
lity. As a linked additional measure, States are now
being assisted through NIPI to give a birthing kit (a NIPI birthing kit
delivery and neonatal kit) to every mother visiting
any facility offering Yashoda/Mamta-attended deli- The NIPI birthing kit contains a selection of the following items.
very under JSY.
Under this scheme, the Yashoda/Mamta will • A baby sheet for the neonate (Disposable)
hand over one such kit to the mother in the labour • A maternity pad for the mother (Disposable)
room. There are two intended effects here – bonding (This pad has a collection bag for blood and amniotic fluid to
prevent spillage)
between the Yashoda/Mamta and the mother, and
• A full length plastic gown, cap, mask and gloves for the service
introduction of principles of cleanliness and hygiene provider
from the start. With a starting point of confidence, • Umbilical clamps
the Yashoda/Mamta can help the mother under- • Cotton diapers (to be taken home)
stand and adhere to good practices of cleanliness • Bed sheet for mother (to be taken home)
for the baby, plus learn what to do to extend good • Flanel blanket for the baby (to be taken home)
practices at home to prevent infection or hypother- • A rubber/oil cloth for the baby (to be taken home)
mia of her newborn.
The exact make up of the kit will vary from state to state, as the
needs are different. The total cost of the kit should not exceed Rs
The contents of the kit, which is to cost no more
100 to facilitate future uptake of the kit into JSY thus providing
than Rs 100 (less than NOK 15/$2), is shown in the sustainability.
textbox. Use of Yashodas/Mamtas and birthing kits
is supposed to yield significant quality improvements The kits are procured by the state NRHM through normal chan-
in delivery and care at a cost of only 10 percent nels, and funded by NIPI. In the startup period, an additional cost
of the JSY budget, which is a low enough amount of Rs 50 per set is allowed in the case were the states see the
that it can be absorbed by GoI. This is extremely need of adding items that will help ensure that the concept of
important in order to secure the scalability and hygenic obstetric and newborn care can take root in the system.
sustainability of the the intervention, with significant
impact potentials for MDGs 4 and 5 achievement.
Home Based Newborn Care
Neonatal mortality accounts for 64 percent of infant mortality in India. Even after
the introduction of JSY, 40-50 percent of births take place at home, and those who
choose to deliver at institutional facilities often return home within a day or two.
Thus home continues to be an important point of care for the neonate.
Home-level neonatal and infant care is considered
to be a weak link in the service chain. If a further dif-
ference is to be made in neonatal and child health,
there must be refocused energies to address
and affect what happens in the home. Infections,
asphyxia, hypothermia and prematurity are leading
causes of neonatal mortality. About a third of all
newborns have low birth weight (less than 2,500
grams), which is important given the significant
proportion of mortality occurring in low-birth weight
babies.
It is well established that care during or immedia-
tely after birth plays an important role in preventing
deaths in the early neonatal period. In the case of
home delivery, the visiting of mothers and newborn
babies in the home is a critical intervention for pre-
venting sickness and death. Post-natal care has
not received sufficient attention until recently, and
almost no women and babies are being visited by
health workers during the first week after birth.
NRHM includes a comprehensive package of new-
born and child health interventions for implemen-
tation, the aim being “a decisive breakthrough in
neonatal, infant and child mortality”. The strategy
encompasses home-, community- and facility-level
care to reflect a “continuum of care” for reducing
neonatal mortality and infant mortality.
Reflecting quite positive developments of
late, plans in NIPI States now include a range of
responses related to continuum of care. And health
authorities in all NIPI States express strong desire
to take action to increase home visits and improve
home-level care.
In October 2008, State Coordination Committees
in all four NIPI States decided to request NIPI for
technical and financial assistance to initiate home-
based neonatal care (HBNC) in their three NIPI
focus Districts. Funds have accordingly been sent
to these Districts to roll out HBNC.
At this point, more than 14,000 ASHAs (com-
munity-level volunteer health workers, 1 per 1,000
population) are in place in all 12 NIPI focus Districts
in the four NIPI States. All have received NRHM
training covering theoretical aspects of essential
new born care.
A HBNC package of services related to informa-
tion, counselling and referral has been designed for
ASHAs to use in home visits during the post-natal
period (Post natal check up, PNC). PNC cards for
recording use during these visits have also been
developed.
Another very important tool for the ASHAs is the
possibility of refering infants identified with danger
signs. By giving the ASHAs a right to refer her
patients, and by giving her a small fund to pay for
transport of the sick child, her role as a preventive
health worker is strengthened by an ability to pro-
vide curative treatment.
A specific induction training module dealing
with delivery of home-based services has been
developed under the leadership of India’s premier
national level medical institute, the All India Institute
of Medical Sciences (AIIMS), with inputs from the
Secretariat and support from national experts from
the National Neonatology Forum, Indian Academy
of Pediatrics, WHO, etc.
As the volume of training is enormous, it has been
decided to split the training into a two day orienta-
tion followed by a five day comprehensive training.
The two day induction focuses on the outlines of
the HBNC package and use of the PNC card. The
AHSAs then start doing PNC visit stimulated by a
incentive package under the supervision of local
technical personnel. It is estimated that 2.5 million
households and 450.000 newborns per year will
be included in this intervention in 12 NIPI focus
districts.
 Sick Newborn Care Units
The concept of continuum of care implies that curative services for sick newborns
must be available. This is seen as important for the credibility of the lower levels of
the chain. Although, being a rather expensive intervention, aimed at a percentage of
the neonates, it carries a great importance in the sense that referrals to these unit are
one of the tools in the grassroot workers toolbox.
Sick newborn care units (SNCUs) are planned as very specific newborn intervention.
part of the continuum of care efforts under NIPI and Before scaling up SNCUs too quick, it will be
will initially be established in the three NIPI focus important to document experiences and make
Districts of each NIPI State. States have adopted proper assessments of such operational aspects
an integrated approach for establishing and equip- as training, logistics, staffing, and costs and
ping SNCUs (level II), which are 12-bed facilities, benefits associated with SNCUs for learning and
with staffing structures varying slightly between improvement purposes. In terms of sustainability
States. Medical colleges in each State are assig- and impact, it is important that the value added
ned key roles for training and oversight of SNCUs. from all entry points of the continuum of care cycle
In addition to the intervention at district level, NIPI be properly analysed so as to optimise child and
is supporting the strengthening of the existing maternal health impacts based on integrated, com-
SNCU at VSS Burla Medical College i Orissa, as prehensive interventions in the future.
it’s pediatric department currently doesn’t have a
SNCU at level II.

The Secretariat has facilitated technical support

and guidance to States via cooperation with the
Institute for Post-Graduate Education and Rese-
arch (IPGMER, West Bengal), represented by
Dr. Arun Kumar Singh, who was part of the team
which established the Purulia model of SNCU in
West Bengal.
SNCUs at District level will be providing
services to newborns requiring extra care during
the antenatal and postnatal period. At the same
time, SNCUs become important support mecha-
nisms for village-based AHSAs, allowing them to
refer sick newborns or infants to District hospital
care units and gain increased credibility and confi-
dence from the village population that will be useful
in future interactions with mothers and children.

The establishment of SNCUs represents a big leap

forward, in ways of technology and competence,
but not least in the status of curative services to
children within the public health care system.
Anyone visiting a pediatric ward in rural areas will
be struck by the low standard of the infrastructure,
the overcrowding and the lack of basic equipment
and hygiene. A secondary, but very important
goal for this NIPI intervention is that the know-
how as well as the general attitude towards sick
children will spill over from the newborn units to
the general pediatric wards, with focus on clean
premises and quality nursing as a key element of
pediatrics. Thus, advocacy of child health in gene-  15 day old baby recovering from a severe case of
neonatal meningitis in Burla, Orissa.
ral is expected as an important side effect of the
List of available publications from NIPI Secretariat:

Flip Chart - Aid for Yashoda/Mamta

Operational Guidelines for Yashoda/Mamta
Handout for field workers on immunization
Handout for field workers on newborn care

Publications in production
Facilitator’s Guide for Training Yashoda/Mamta
Orientation Handbook for District Child Health Managers
NIPI Strategy Document
Orientation Handbook for ASHA on Home based Newborn Care
Facilitator’s Guide for orienting ASHA on Home Based Newborn Care
Calendar for mothers
Facilitator’s Guide for Training ASHA in Home Based Newborn Care
Ready reckoner for Yashoda
Flip Chart – Aid for ASHA for Home Based Care

Contact NIPI:
NIPI Secretariat
UNOPS Building
11, Golf Links
New Delhi 110 003
Phone: 91 11 30417500 / 30417402
Fax: 91 11 43518587
Email: nipi@unops.org

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