# Presentation: 212801

## USAID NATIONAL INTEGRATED CHILD SURVIVAL AND MATERNAL HEALTH PROGRAM-“NIP”

- Dr. Rajiv Tandon
- MCHUH/PHN/USAID India
- 27TH JAN. 2006
- NEW DELHI

## Presentation Outline

- Background – Situation in India
- Operational/Program Framework
- GoI programs and challenges
- NIP details
- NIP interventions

## MNCHN Scenario in India

- High rates of maternal, newborn, infant, and child mortality
- Substantial share of global mortality and malnutrition burden – need progress in India to achieve MDGs
- Slow or no progress in recent years (90s)
- Major inequities:  economic (quintiles), social, gender, geographic (EAG)

## India’s child survival challenge 

** **

**India’s child survival challenge **

**Birth rate 25 **(2002)
**2.7 crore neonates to take care **
**U5MR 95 **(1998-99)
**25 lakh die before completing 5 years**
**IMR 60 **(2003)
**16 lakh die before completing 1 year**
**NMR **** ****40 **(2002)
**11 lakh die before 4 weeks of age**

***Greatest burden in the world!***

## Why do children die

## Direct Causes of Maternal Death (MDG 5)  

- Direct Causes of Maternal Death (MDG 5)
- India, 1998

- Toxemia

- Obstructed labor

- Sepsis

- Anemia

- Hemorrhage

- SRS 1998

*Active mgt. of 3**rd** stage of labor*

*IFA, malaria control, deworming*

*Clean delivery, antibiotics*

*Magnesium sulfate*

- Abortion

- Other

*Caesarean section*

*Family planning, *
*post-abortion care*

- Malnutrition

*Food, IFA, workload reduction, deworming*

## Operational Framework

**Community linkages to health services**

**Care delivered in the community**

**Family practices**

*Barriers, constraints,        facilitating factors*

*Public*

***1******st****** level -  Private Services***

***1******st****** level - Public Services***

***Referral Level Care***

- Community Health Interventions

- “Outside” Health Service Interventions

-  Breastfeeding
-  Feeding
-  ORT
-  Birth planning
-  Newborn care
-  Care seeking
-  etc.

-  Safe/clean delivery
-  Active mgt. 3rd stage of labor
-  IFA
-  LBW special care
-  ORT
-  Vitamin A, zinc
-  Abx. for pneumonia
-  etc.

-  ANC
-  Immunization
-  AWW, ASHA, supervision & supply
-  Health information
-  Private provider training
-  etc.

-  Transport of complicated deliveries and sick children
-  Organization for ANC &  immunization
-  Community oversight and monitoring
-  etc.

*Private*

-  Basic preventive services (ANC, immunization, etc.)
-  Primary treatment of MNCH illness (IMNCI, basic essential and emergency obstetric care)
-  Counseling

-  Comprehensive obstetric care
-  Treatment of severe newborn & child illness

*>60% of Deaths*

## Family Planning is key to Mother and Child Survival

- Family Planning is key to Mother and Child Survival

**Family Planning**

**Fertility Reduction**

**Birth Spacing**

**Increased infant birth weight and survival**

**Improved maternal health & nutrition**

**Reduced lifetime risk of maternal death**

## National goals & MDG context

|  | Current | X Five Year Plan
2007 | National Population Policy
 2010 | MDG
2015
 |
| --- | --- | --- | --- | --- |
| IMR | 60 (2003) | 45 | <30 | 27 |
| NMR | 40 (2002) | -- | <20* | <20* |

***Estimated**

**National goals & MDG context**

## GoI programsRCH I (1997-2005) interventions   

**GoI programs****RCH I (1997-2005) interventions   **

**Immunization**
**Diarrheal disease control**
**ARI control**
**Essential newborn care ****(at limited facilities)**
**Vitamin A**

## RCH II: how different?

**RCH II: how different?**

**From project to program mode**
**State ownership, states in driver’s seat**
**Decentralized planning**
**Institutional strengthening**
**Some states to have link volunteers**
**Pooling of external funding**
**Improved financial flows**
**Equity-based monitoring**
**Performance-based funding**

## National
Rural Health 
Mission 
(NRHM)

Goal IMR, MMR reduction

18 high burden states
>300,000 new community health workers (ASHAs) in 10 states; more to follow

**Rural Health **
**Mission**** **
**(NRHM)**
- _Goal IMR, MMR reduction_
- 18 high burden states
- >300,000 new community health workers (ASHAs) in 10 states; more to follow

- Launched in April 2005

## Backdrop to 11th Plan

**Backdrop to 11****th**** Plan**

**High level of political commitment to health, in particular IMR reduction**
**Increased health outlay**
**Health system reform environment**
**RCH II, an improvement over RCH I**
**High economic growth**
_**Launch of NRHM**_

## The Challenge of NRHM

- The challenge of **human resources **for reaching  **quality health services** to the **poorest households** in the **remotest rural areas**
- Making the public health system accountable, affordable and accessible by improved management and community action.
- Developing pro-people partnerships with the non-governmental sector to provide quality health care services to the poor.
- Making health professionals and para medics deliver quality health services in remote rural areas through improved human resource & management.
- Forging alliances with wider determinants of health under the PRI umbrella like water, sanitation, social and gender equality.

## Communitization – PRIs, User Groups, Rogi Kalyan Samitis, managing health institutions at village, Gram Panchyat, Block and District levels with large untied funds, flexibility and functions to manage budgets
Flexible contractual systems for engaging local, resident health workers – improved motivation and regulation of doctor/paramedics
Improved fund flow, timely procurement of goods and services, better cadre management, planning and monitoring through infusion of managerial skills
Contd...

- Communitization – PRIs, User Groups, Rogi Kalyan Samitis, managing health institutions at village, Gram Panchyat, Block and District levels with large untied funds, flexibility and functions to manage budgets
- Flexible contractual systems for engaging local, resident health workers – improved motivation and regulation of doctor/paramedics
- Improved fund flow, timely procurement of goods and services, better cadre management, planning and monitoring through infusion of managerial skills
- Contd...

## Planning as per people’s needs, mapping household needs, tracking facility performance, co-opting non-governmental providers
Autonomy to Health Institutions (SHC/PHC/CHC) through untied funds (responsibility to spend budget under community ownership / scrutiny

- Planning as per people’s needs, mapping household needs, tracking facility performance, co-opting non-governmental providers
- Autonomy to Health Institutions (SHC/PHC/CHC) through untied funds (responsibility to spend budget under community ownership / scrutiny

##  NIP (how)

- Focus on MNCHN/RH results at scale
- Leverage resources to influence larger programs
- Build on RCH II and the Rural Health Mission
- Work with both public and private sector
- Build on Indian competencies and build capacity
- Link with other CH/MH/RH health programs
- geographically
- programmatically

## NIP (who and where)

- Focus on vulnerable populations
- Promote equity
- Concentrate geographically
- Build on USAID investments and successful platforms
- Work where there is political commitment and opportunity for successful partnerships
- Support appropriate approaches for urban and rural populations

##  NIP (what)

- Evidence-based programming
- Focus on major causes of mortality and proximate determinants
- Address critical gaps and constraints
- Work in areas of USAID’s comparative advantage
- Five year timeframe

## USAID National Integrated Program/NIP2006 to 2011

- About $ 25 million over 5 years
- In states of U.P & Jharkhand
- Community action for maternal, neonatal, child and 	reproductive health interventions
- Focus on district level activities to help scale up through NRHM platforms
- Ensure governmental (MOHFW & DWCD) ownership/partnership – sustainability/exit

## NIP

**Complement and support GoI’s commitment to improving maternal, childhood and newborn health and nutrition**
**Focus on NRHM state-level policies, resource allocations and programs through effective introduction of best practices derived from and introduced through technical assistance at district and block level**
**Consider proposals that include innovative financing such as sub grants and loans to NGOs for furthering service delivery**
**Quick start, be flexible and innovative in it’s approaches  **
**Refine previous learning & bring together some best practices from previous programs**

## NIP 

**Cost-effective operational models that are community-focused on maternal and newborn care and are adopted by NRHM;**
**Effective approaches to improve selected Maternal Neonatal Child Health and Nutrition  outcomes in entire districts (rural and urban areas of less than 100,000)  and incorporated into NRHM**
**Cost effective models for increasing Reproductive and Child Health service delivery to vulnerable families and groups incorporated into NRHM**
**Effective approaches which incorporates private provision of key Maternal Neonatal Child Health and Nutrition  services incorporated into NRHM (Public Private partnerships); **
**Assist effective operationalisation and scale up of NRHM by government **

## NIP 

**complement other efforts that focus on health system strengthening and clinical care by USAID and others by supporting key sets of evidence-based and prioritized interventions:**
**Community ownership/participation through  mobilization of communities to create demand for improved services using community organizers at the local level e.g. (ASHA/SHG/PRI/MM) **
**Household skills building in essential maternal, childhood and newborn care and care-seeking through Behavior change of beneficiaries and service delivery personnel at district and block level**
**Facilitating access to skilled attendance at birth at the community and FRU levels and effective management of pneumonia with antibiotics in the community; and **
**Strengthening linkages between communities and the public and private health care systems. **

## NIP

**Collect, analyze and manage a knowledge base to determine what works, and identify best or promising practices.**
**Monitoring, by establishing base lines, support to routine monitoring, and effective information management.**

## Results Framework

**Improved maternal, newborn and child health & nutrition at scale in India**

**     ****Effective implementation of RHM**

**Improved**
**Policies**
**Program approaches**
**Resource allocation**

**Effective RHM program     implemented in key      states**

## “This is a call to action – not a call to rhetoric”

- 		- Secretary of HFW, Mr. P. K. Hota

## Thank you