Norway India Partnership Initiative (NIPI)

 
2. Expected outcomes

• Introduction of innovations that can contribute for up scaling of child health interventions by the state governments.
• Sustaining routine immunization coverage rate in the country at 80% or more
• The development of best practises for large scale roll-out of interventions addressing MDG 4 also in other countries.
• Contribution to overall heath reform in the 5 states for achieving MDG4.

3. Overarching principles of NIPI

As NIPI is neither a project nor a program but an initiative, it  provides catalytic support for innovation and experiments by the States to fill critical gaps in child health & generate options for scaling up by the state.

• All activities are within National Rural Health Mission (NRHM) framework.
– Support NRHM child health initiatives placed as part of State and district plans, developed with full participation of the State health system.
– Work within the existing institutional mechanism at the state level. No parallel structure created.
– Identify and bridge critical gaps, stimulate innovation, and promote reforms through evidence based advocacy.
• Promote an equity based, gender sensitive empowering approach.
• Recruitment and financial accountability through existing state procedure.
• Leverage NRHM resources for child health.
 
4. NRHM efforts for quality Maternal and Child Health Care (MCH)
The commitment of the government of India to achieve MDG 4 is reflected in the 11th Plan ((2007-2012) approach paper of the Planning Commission of India, which places health, infant mortality and child development as part of the 27 detailed national targets to be achieved. This is based on the understanding that, the realization of these targets in India is vital not only for attaining human development and economic growth within the country, but given its enormous size, they are critical for reaching the MDGs worldwide. 
The multi-pronged approach adopted by the Government of India through the National Rural health Mission from 2005 has opened many vistas for addressing maternal health and child health in public health.  The key strategies include:
• Recruitment of Accredited social Health Activists (ASHA) at the home and community level.
• Introduction of ‘Janani Suraksha Yojana’ (JSY) – a safe motherhood program for increasing Institutional deliveries.
• Introduction of improved processes for increasing immunization coverage.
• Strengthening of public health infrastructure facilities.
• Empowering states and districts through decentralization of management.
Further, NRHM also pledges to implement package of interventions with the “aim of achieving a decisive breakthrough in neonatal, infant and child mortality” during the 11th plan period.

5. NIPI Support to NRHM efforts for quality MCH Care through State health system.

The NIPI implementation at the state level is facilitated with technical support by UNICEF, WHO and UNOPS. Memorandum of Understanding was signed with MP, Rajasthan, Bihar and Orissa in December 2007 by the NIPI Secretariat-UNOPS and funds have been transferred. All Interventions are Joint learning effort with the state.

The implementation mechanism through the state health society is as follows:

 Funds are placed with the state Health society for identified child health activities under the State Action plan, within the state financial and audit rules framework. The objective is to leverage the NRHM funds for child health by providing funds for catalytic activities. 
 Activities are identified by the SHS and reflected as part of the district/state plans.
 Implemented in selected districts in each state to demonstrate innovations. Flexible to expand state wide or as required by the state.
 States will take up all successful experiments in a cycle of about 18-24 months.
 The funds are channeled through an agreement between United Nations Office for Project Services (UNOPS) through NIPI Secretariat and State health Society.
 The Secretary, Heath and Family Welfare of the respective States, as the chair person of the State Coordination Committee finalizes /modifies the state action plan as per the requirement of the state, through bottom up planning.

6. High lights of Key interventions:

a) Accelerating NRHM efforts for quality MCH care at facility- YASHODA/ MAMTA 

Safe motherhood program, Janani Suraksha Yojana (JSY) in India under its NRHM has increased institutional delivery from 10.85 million in 2005-06 (NRHM was operationalized in 2005) to 13.59 million in 2007-08. The scheme focused on expectant mothers belonging to the poor and disadvantaged families in high-mortality, low-infrastructure and low-performing States

Institutional deliveries under JSY reported by State Missions to Government of India (in Millions)

This sudden influx of beneficiaries in the public health institutions is a definite opportunity in the history of public health in India; but also it has emerged as a challenge to provide quality health service. The public health facilities are challenged with lack of infrastructure, manpower and other facilities to coordinate and ensure quality service delivery.

While the NRHM efforts are focused on strengthening infrastructure and manpower which are long term interventions, NIPI’s response to optimise the benefits of JSY during the stay of the mother and the newborn is introduction of an innovative volunteer support worker at the facility with high delivery volumes, named Yahsoda (a legendary foster mother of Indian mythology)/Mamta. She is a voluntary worker compensated based on performance incentive.   She will support and assist the nurse in the provision of various non clinical activities from the time the pregnant woman enters the facility till she leaves the hospital with the new born.

First 24 – 48 hrs after delivery is the most crucial phase for the newborn baby and mother. During this period, Yashoda will support mother for immediate and exclusive breast feeding; orient the mother about basic newborn care and immunization and assist the nurse in various post natal care activities for making the newborn and the mother comfortable.

Apart from helping the mother to de-stress, Yashoda will use this time to counsel the mother on family planning options and fertility choices. She will counsel the mother and her family on the various steps in newborn care after leaving the facility including, nutrition for mother and the new born, feeding practices, complementary feeding, immunisation including service delivery points, days,  use of referral  and other relevant information.

This innovative cost effective intervention has been introduced state wide covering 38 district hospitals and selected CHC in Bihar and 15 district hospitals in Orissa, with large delivery volume on a on daily basis. MP and Rajasthan have initially introduced this intervention in three districts. While Yashoda support can contribute to improving the confidence of the mothers utilising the services of the government facility and motivate them to stay for a longer duration, initiate immediate an exclusive breast feeding, immunization and learn basic newborn care, she is not a solution to all issues related to quality newborn care and she is not substitute to the existing nursing or paramedical staff in the hospital.

b)Accelerating NRHM efforts for quality MCH care at facility- Developing Sick Newborn Care Units (SNCU) and stabilization units.

Base on the Purulia model, UNICEF has established SNCUs in the NIPI States  and some other non –NIPI states. Based on the learning State governments are willing to upscale establishment of at District hospitals and UNICEF is in the process of strengthening the PHCs and CHCs with establishment of sick new born care units in selected districts, from the NIPI focus states. Additionally UNCEF has developed a comprehensive tool kit that can help the states in establishing/strengthening sick newborn care units.

Under NIPI state plan, a cost effective model of SNCU level II units in district and level I /stabilization units at block hospitals with large number of deliveries are initiated in four states. NIPI will engage technical agency to facilitate the establishment and operationalization of the SNCUs. This will initially be in three focus districts. NIPI will leverage utilization of the NRHM funds for developing these units and its components.

The additional fund requirement will be met from NIPI state plans. These SNCUs will be linked to medical colleges for technical assistance, training of medical officers and nursing staff and monitoring of quality of services. NIPI will build state technical expertise for scaling up this effort to other parts of state. UNICEF is also participating in the States in this process.

UNICEF’s intervention includes expansion of IMNCI in a phased manner in all the states including NIPI focus states. This aims to build ASHA skills to care for sick newborn children in the community and avail the referral services.

WHO’s intervention focuses on aaccelerating child health interventions by providing support to pre-service IMNCI, technical assistance to MOHFW for monitoring MCH.

• In collaboration with the Federation of Obstetric and Gynecological Societies of India (FOGSI) WHO initiated the accreditation of facilities to train Skilled Birth Attendants (SBA).
• An assessment of the ANM schools in all the NIPI focus states has been completed by WHO to assess ANM capacity for Pre service IMNCI training.
• Establishment of Quality Assurance Cells for specialized training programmes.

c) Accelerating NRHM efforts for quality MCH care- Home and Community based initiatives

As a process to support and contribute to NRHM efforts, NIPI places emphasis on identifying the need for, testing of, and introducing new ways of strengthening the ASHA service, including their support needs, and referral requirements and in particular building their skills. This becomes critical in the current context where, despite a quantum jump in the use of institutional facilities for deliveries, about half of the women in rural areas still deliver at home. Most of the women delivering in the institutions also return home with newborn within the first 24 hours. NIPI interventions include a package of home based new born care by ASHA through home visit for newborn care in the first 48 days. The services will include:

This effort will be strengthened by:

• Involving Panchayat Raj Institutions, Women Self help groups, Village Health and sanitation committees for development of village level plans and validation of ASHA activities.
• Development and dissemination of Behavior change communication materials targeted at high risk practices in the community.
• Provision of seed money to a community managed fund for arranging and managing referral transport to facilitate the timely transportation of the sick children to facilities and improving referral linkage with the institutions.

d) Accelerating NRHM efforts for quality MCH care - Strategic support for Immunization

NIPI state plans include strategic support to immunization for reaching the un- reached areas.  The strategy proposed is to create a bottom-up planning process in selected districts from the four of the focus states, where block level managerial support is available through NIPI support. Support will include:
• Analysis of each outreach site for performance.
• Articulation of logistic and access issues.
• Creation of extra vaccination sites, vaccinators, vaccine and transportation, based on community’s assessment through involvement of Women’s Self Help Groups and Panchayat members.
• Local resources and cooperation to handle the additional mobilization of children and local transport support.

UNICEF interventions contribute to revitalising training facilities, procurement of cold chain equipment, and provision of training to field functionaries.

WHO contributes to this process by strengthening vaccine security, logistics and management, measles surveillance and control.  Particular attention will be given to strengthening measles control program in Orissa and UP in the current year.

e) Accelerating NRHM efforts for quality MCH care - Enabling Child health efforts through techno managerial support
This intervention is a key enabling mechanism aimed at providing support to make NRHM child health investments efficient, by accelerating expenditure, fast tracking implementation and tracking the progress effectively. The support includes:
Recruitment and placing of child health managers, financial analysts, logistics managers at the state, District and Block levels within the respective Program Management Units, and hospital based child health supervisors. All the recruitments are done through state mechanism and within the state financial rules.

UNICEF supports the state health system by providing skilled resources to manage the ‘Child survival cell’ in selected districts from the NIPI focus states which includes child health and nutrition specialists.

7.  National Child health Resource centre (NCHRC)

The NCHRC is established in the National Institute of Health and Family  Welfare (NIHFW) a premier training institute with branches in several states of India.

The Child Health Resource Centre at the NIHFW functions as the nodal point for mainstreaming the child health agenda in public health. The NCHRC is fully staffed and functional. A technical advisory group comprising of eminent child health and public health professionals will guide the activities of the NCHRC.  The focus will be on demystifying child health and collection and dissemination of all the available reports, training materials, policies, program, case studies and other relevant information on Child Health and related maternal health aspects to all the workers at the primary level, located at the districts and below.  
 
 8. Other Initiatives

• Public Private Partnership (PPP): Expanding the resource pool for developing innovative strategies through Public Private Partnership (PPP) by involving non-government actors at all levels.

• Research and Innovation: Identifying new opportunities on a continuous basis through collaboration with technical, professional and academic institutions in and outside India for undertaking research, innovation and monitoring in child health in the overall context of primary health.

• Monitoring and Evaluation: Enhancing ownership at community, block, district and state level for concrete results in child health interventions by identifying filling the gaps in the existing survey and surveillance tools for monitoring and evaluation.

9.   Institutional Frame work and Organization

Joint Steering Committee: The institutional mechanism of NIPI is led by Joint Steering Committee with Secretary, Health and Family Welfare, Government of India as Chairperson and the Norway Ambassador to India as the Co-Chair. Additionally, there are representatives of Government of India, Government of Norway, WHO, UNIECEF and the NIPI focus States.

At the state level, activities under NIPI will be implemented by the State Health & Family Welfare Society, chaired by Secretary, Health & Family Welfare, of respective state government.

 Programme Management Group (PMG) is a forum for dialogue to form a platform for coordination between NIPI, NRHM leadership and other stakeholders, and for integration of activities with the NRHM operational framework. Under the chairmanship of Mission Director, NRHM, MoHFW, the PMG discusses key technical issues, reviews progress, makes proposals and recommendations to the JSC for decision making.