Norway-India Partnership Initiative

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   Information Sheet
    September 2008


1. Background

The Norway- India Partnership Initiative is an outcome of commitment by the Hon’ able
Prime Minister of Norway and the Hon’ able Prime Minister of India, focusing on the
issue of reducing child mortality and improving child health to attain the Millennium
Development Goal 4 by the year 2015. Norway has contributed USD 80 million over five
years for this purpose to five states of Orissa, Bihar, Madhya Pradesh, Rajasthan and
Uttar Pradesh. These States together constitute 40 percent of India’s population and
contribute almost 60% of child deaths in India. The NIPI activities is for five years (2007-
2012) corresponding the duration of the NRHM.

The objective is to provide up-front, catalytic and strategic support to accelerate the
implementation of the National Rural Health Mission (NRHM) in five focus states,
specifically to improve Child health and related maternal health service delivery quality
and access. The catalytic input will also be aimed at improving visibility of child health in
public health and create mechanisms that will ensure sustainability under NRHM

The activities under NIPI are put
into operation through state
health societies in the respective
states, with the facilitation of UN
organizations-UNICEF, WHO and
United Nation’s Office for Project
Services     (UNOPS).      All   the
interventions     are    aimed    at
accelerating the Child Health
interventions: (i) based on block,
district, region and state specific
situations (ii) through partnership
and collaborative arrangements
with professional organizations,
NGOs, local elected bodies and
administration with in the state.
                                                 (NIPI Focus States)

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
   •   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

               MP           Rajasthan   Bihar        UP        Orissa     All India
      06-07    0.39         0.38        0.11         0.17      0.22       2.76
      07-08    1.10         0.77        0.83         0.85      0.43       6.22

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.

                                                Launch of Mamta in Bihar by Chief Minister
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                          Hands-on training to Yashoda

nurse in various post natal care activities for making the newborn and the mother

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

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
                                                 Sick Newborn Care Unit
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
   Birth preparedness, Care at birth , Post natal care-for sick new born and
     referral, Immunization and Birth registration, Breast feeding &
     Complementary feeding. This will be implemented in the selected districts
     from each of the four focus states.

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
  Development and dissemination
     of          Behavior         change
     communication              materials
     targeted at high risk practices in ASHAs gathered for a monthly meeting
     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

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
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

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

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.

9. 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.

10. 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

 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.

A Secretariat under the leadership of Director is established to execute decisions made by
the JSC and function as a secretariat to the JSC and PMG.

In addition to the above, an International Strategy Group (ISG) has been established.
The ISG will advise NIPI, its Secretariat, and Agencies on global best practices towards

reaching the MDG4. At the same time the ISG will help disseminate lessons of the NIPI
and the NRHM to the international community.


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Description: A detailed overview of NIPI (Norway-India Partnership Initiative) - the joint program to improve maternal and child health in India (under the umbrella of NRHM services)