Innovation to InstitutionalizationNewborn Care in India

(2001-2010)

CARE-India’s experiences

Mukesh KumarProgram Director, CARE India

Objective• Integration of key-family practices for prevention

and timely management of neo-natal and childhood illnesses into existing national programs

• Appropriate and accessible care and information about prevention and management of neonatal and childhood illnesses from community-based service providers

• Better partnership between health facilities and the communities

Rational for the objective

71

21

Infant mortality Child mortality

20

51

Neonatal mortality Postneonatal mortality

Per 1,000

Source: DHS- 3Source: DHS- 3

Early Childhood Mortality Rates

57

18

Infant mortality Child mortality

18

39

Postneonatal mortality Neonatal mortality

India

Chhattisgarh

INHP Timeline in global context

Baseline Survey Jan 2001

Endline Survey, Feb 2006

2001

2006

Lancet, CS, 2003

Lancet, Neonatal Survival,

2005

NRHM launch, 2005

Newborn Evaluation Study

(1 district,

UP)

Early Learning phase Apr 02

2001 2002 2003 2004 2005 2006

Institutionalization phase

2007-2010

ESD Project

Innovation

Documentation

External marketing

Advocacy

Scale-up & Institutionalize

Fram

ework

for I

nnovatio

n

to in

stitu

tional

izat

ion

IDEAS

Early learning Sites( 150 Villages across eight

states)

Demonstration sites- Approx. 10,000 villages

Key Interventions Promoted

• Tetanus Toxoid along with basic ANC for mothers.• Essential home-based newborn care:

Clean delivery, cord care, handling Adequate thermal care (warmth) Early and exclusive breastfeeding

• Early recognition of and extra care for the weak (premature/LBW) newborn.

• Recognition and referral of sick newborn

Scale up phase

Project universe = 95,000 AWC, 747 blocks, 78 districts, 9 states, 100 m + population

Modifications

– Did pilot test the intervention package with the help of ICDS and RCH functionaries in ‘early learning sites’.

– Referral of sick and weak neonates were promoted only if there were health facilities

Program Approaches to Promote NBC

Home visits and advice by AWW, ANM, Volunteers with emphasis on: Late pregnancy, first day, first week Family, not just the mother Immediate care at birth Recognition of preterm / LBW at birth, marked for

extra careHome visit planner for AWW and close supervisionSupplemented by varied BCC and community-based monitoring efforts

What did CARE do?

• Facilitation and catalysis:– Capacity building: ICDS, RCH, volunteers,

community bodies– System strengthening: functional

convergence, Supportive supervision (ICDS) – Behavior Change Communication

• Advocacy:– Prioritizing neonatal care– Measuring and Monitoring

Progress made

Composite neonatal care indicator increased across most statesBaseline-Endline (2001-06 ), home deliveries last 6 months

Table 3.1

Denominators: BL ~ 105-170

EL ~ 330-550

0

10

20

30

40

50

60

70

80

90

100

AP CG JH MP OR RA UP WB

Baseline (2001) Endline (2006)

Factors that possibly influenced change

Those who reported receiving home visits also provided better care (composite indicator)Endline (2006), Mothers of children 0-5 months old)

Table 3.2

0

10

20

30

40

50

60

70

80

90

100

AP CG JH MP OR RA UP WB

No Home Contacts At least one Home Contact

Those who reported receiving advice also reported practice more often (early breastfeeding)Endline (2006), Mothers of children 0-5 months old)

Table 3.2

0

10

20

30

40

50

60

70

80

90

100

AP CG JH MP OR RA UP WB

No advice on immediate BF Advised immediate BF

Women were visited at home during the last trimester more often over timeRAPs (2003, 04, 05), home delivered 0-5 month children

Figure 3.16

Denominators: Round 1: ~ 90-130 Round 2,3: ~ 250-400

0

10

20

30

40

50

60

70

80

90

100

AP CG JH MP OR RA UP WB

Round 1 (2003) Round 2 (2004) Round 3 (2005)

More families were visited at home on the day of childbirthRAPs (2003, 04, 05), home delivered 0-5 month children

Figure 3.17, 3.18

Denominators: Round 1: ~ 90-130 Endline: ~170-550

0

10

20

30

40

50

60

70

80

90

100

AP CG JH MP OR RA UP WB

Round 1 (2003) Endline (2006)

Institutional birth did not affect most indicators of basic newborn careEndline (2006), children 0-5 months old

Figure 3.14

0

10

20

30

40

50

60

70

80

90

100

AP CG JH MP OR RA UP WB

Institution Home

Institutionalization phase(2007-2010)

ESD project started in Chhattisgarh to institutionalize best practices through IMNCI program of Govt. of India

Total Districts: 16Blocks : 168AWCs : 33000

Chhattishgarh

Activities

Capacity Building of ICDS state, district and project level program leaders was done through ongoing forums and structured CB events.

Different communication materials (leaflets/booklets /modules) developed and distributed in close collaboration with state resource center, department of women and child development.

Communication Campaign organized through multi-media channels & structured home contacts by AWW / ANM / Volunteers.

Mainstreaming C-IMNCI & HTSP into ICDS / RCH program at district & state level through PIP development process and Kuposan Mukti Abhiyan (state sponsored malnutrition eradication drive)

Institutionalization– Incorporating C-IMNCI components into the training

modules for Supervisors and Outreach workers jointly developed with SRC.

– Undertook training of key ICDS functionaries in collaboration with W & CD

– Incorporated the key messages into website developed for the department

– District level advocacy efforts undertaken for discussion of key components during ongoing forums

Challenges– Programming in civil unrest areas

– Varied capacities of outreach workers

– Competing priorities of health department

– Engagement of AWWs / ICDS block functionaries time for back to back training

Lessons

What does this imply?

1. Current programs can deliver

• The changes were brought about by ICDS and RCH staff

• Change was brought about in “difficult” states and districts

• Efforts were multi-dimensional: all other services continued

• What worked was probably:– Focus on effective interventions– Strengthening accountability mechanisms –

internal, external

2. Can ICDS continue to contribute to neonatal care?• It can, and must:

– ICDS has a mandate for addressing mortality

– Basic neonatal care is simple– AWW is available to the community– AWW has greater credibility than ASHA– AWW is backed by a mature, well-defined

support structure– AWW has proven she can deliver

3. Let us do what is doable

• More aggressive interventions have yet to be shown to be scalable

• Basic care must be scaled up until more effective ones are available

• Much needs to be done, and time is slipping by….