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Norway India Partnership Initiative

Program Management Group

November 3

2010 Meeting notes for the 10th meeting of the Program Management Group

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NIPI Program Management Group, 3rd November 2010 The NIPI Program Management Group (PMG) acts as technical advisory board for the Joint Steering Committee of the Norway India Partnership Initiative. The role of the PMG is to review technical proposals and to give recommendations to the Joint Steering Committee.

Agenda: 1. Opening remarks:

Mission Director, MoHFW, GoI

Director, NIPI Secretariat.

2. Specific update on programs from the Focus States (including future Plans for 2011-12)

1. Bihar

2. Madhya Pradesh

3. Orissa

4. Rajasthan

3. Program update by WHO ( including proposals for 2011)

4. Program update by UNICEF ( including proposals for 2011)

5. Program update by UNOPS LFA (including proposals for 2011)

6. Program update by UNOPS Secretariat

1. Monitoring & Evaluation Strategy

2. Gender Mainstreaming

3. Operations Research

7. NCHRC update

8. Any other with permission of the chair.

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For decision The Program Management Group is requested to recommend the following technical proposals for the Joint Steering Committee

1. Strengthening Control of Vaccine Preventable Diseases - Strengthening Measles Control Activities in NIPI States: Brief proposal enclosed below. (Proposed Budget: US$ 1,824,000)

2. Accelerating Child Health Interventions: (Proposed Budget: US$ 450,000 )

Strengthening Pre-service IMNCI training

Capacity building of district level Programme Managers in Child Health programme review and management

Community monitoring of MCH activities at village level

Strengthening Essential Newborn Care (ENBC

Strengthening management of Childhood Malnutrition

3. Accelerating Maternal Health interventions: (Proposed Budget: US$ 330,000)

Strengthening Quality Assurance of RCH trainings under NRHM

Strengthening SBA Training under NRHM

Developing Implementation Model for Strengthening Maternal and Newborn health services.

Strengthening Accreditation of RCH Service providers

Capacity building of AYUSH practitioners in SBA / IMNCI skills

Supporting techno-managerial capacity building of Program Managers

Supporting techno-managerial capacity building of Program Managers 4. Strengthening of Nursing and Midwifery Pre-Service Education in Bihar (SHS Bihar,

NIPI Child Health Resource Network, UNOPS). A sum of USD 780, 836 is proposed for the TA by JHPIEGO. (Detailed proposal with budget as annexure 1)

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1.0 Executive Summary

1.1 Background Xth PMG meeting is being held in the backdrop of National Discourse on Focus District Approach. NIPI Partners are already contributing to the process while facilitating interventions along the continuum of care. NIPI Secretariat has been established headed by a Director with key functionaries. The role of the Secretariat is to coordinate with and support JSC, PMG, as well NIPI Partners viz., UNICEF, WHO and UNOPS LFA as well as Research Institutes. In 2010 the NIPI funds have been utilized to continue support for:

Yashoda (State Health Societies Bihar/Orissa/MP/Rajasthan through UNOPS)

Home Based Post Natal Care by ASHA (SHS in focus states through UNOPS)

Catalytic support to IMNCI (UNICEF)

Improved cold chain and vaccine management (UNICEF)

Techno managerial support (SHS through UNOPS)

Special care newborn units, SCNU (UNICEF)

Sick newborn care units, SNCU (SHS through UNOPS) Additionally, funds were also used for support to Mobile Payment of incentive money to ASHAs, strengthening State Child Health Resource Centres (SCHRC) at SIHFW, One Stop Shop for SNCU establishment and functioning etc.

2.0 Proposed new activities at a glance Activities planned for 2010 were approved in the JSC in November 2009 and mid 2010 and are ongoing. The State Health Societies and the NIPI Partners will be presenting an update in the meeting. WHO brings to the meeting several new proposals while UNOPS LFA part brings an improved version of PSE of Nursing Education in Bihar based on JSC inputs.

2.1.1 WHO Proposed Activities

1. Strengthening Control of Vaccine Preventable Diseases - Strengthening Measles Control Activities in NIPI States: Brief proposal enclosed below. (Proposed Budget: US$ 1,824,000)

2. Accelerating Child Health Interventions: (Proposed Budget: US$ 450,000 )

a. Strengthening Pre-service IMNCI training: Expanding Pre-service training in IMNCI for Medical and Nursing students in the NIPI states: Ongoing support being provided by the National Nodal Centre established at Kalawati Saran Hospital, New Delhi. Training of faculty completed in medical colleges and teaching of medical students has started in all NIPI states. The roll-out of pre-service IMNCI for nursing students is underway in Orissa and training of ANM faculty in all 16 government ANM

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training schools has been completed. The plan is to include two more states (Rajasthan and Madhya Pradesh) by March 2011. A review of Pre-service IMNCI training for medical students in two states (Bihar and Madhya Pradesh) also planned by March 2011. b. Capacity building of district level Programme Managers in Child Health programme

review and management A “Short Program Review” course of child health programs (SPR-CH) for district level managers was organized in September 2010 in Rajasthan. This package helps program managers to identify which areas need strengthening – based on available data and previous experiences - and to set new priorities if necessary. SPR-CH reviews all the interventions for child health directed anywhere along the continuum of care for the mother and child and thematic areas including policy, planning and financing, human resources and training, systems supports. It is proposed to conduct State level Short Program Review in other focus states in the country. The SPR-CH course was followed by a 5 day training (based on package developed by WHO) for district level Child Health program managers held at New Delhi in collaboration with Govt. of India, NIHFW, UNICEF and NIPI. The global package 'Managing Programs to Improve Child Health’ developed by WHO was demonstrated during the course. It is proposed to adapt this package for India, modify the modules to the current needs of the child health program in India and to integrate this course with similar training packages being developed for Maternal Health, Family Planning, Immunization etc. to produce an integrated training package for RCH for district level programme managers. Further workshops on the Programme Managers course planned in NIPI focus districts. c. Community monitoring of MCH activities at village level: During the Short Programme Review held at Rajasthan a need was identified to develop a simple tool for Village Health and Sanitation Committees to monitor maternal and child health activities in their villages. Hence it is proposed to develop and pilot a check list for monitoring of activities for use by Village Health and Sanitation Committees. d. Strengthening Essential Newborn Care (ENBC):

Self-learning tools (Webinars) are being developed by AIIMS to improve knowledge of health care providers on ENBC. These tools are proposed to be available free on the web making it accessible to health care providers placed in remote areas.

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e. Strengthening management of Childhood Malnutrition:

i. Training packages for capacity building of Medical Officers / Nurses in management of Severe Acute Malnutrition (SAM) children have been developed and the final module will be shared with GoI.

ii. A training package to integrate Infant and Young Child feeding (IYCF) in Pre-service IMNCI education is being developed and the second draft is ready for sharing with the Expert group.

iii. The study on ‘Determinants of under-nutrition in children and assessment of management at different levels of health care’ was completed in collaboration with INCLEN. The report was shared both with MoH and WCD and this was followed by a dissemination meeting with all stake-holders held in September 2010. A follow up to this study is being planned with INCLEN to develop and pilot community based model to address social determinants of undernutrition.

iv. Discussions are ongoing with DBT on a study titled ‘Impact of energy dense local diets on physiological recovery of children with Severe Acute Malnutrition (SAM): multi-centric study’. Once the proposal is ready, it will be forwarded to ORC for review.

3. Accelerating Maternal Health Interventions: (Proposed Budget: US$ 330,000)

a. Strengthening Quality Assurance of RCH trainings under NRHM: National (Mahatma

Gandhi Institute of Medical Sciences, Wardha, WHO CC) and State Nodal Centres for Quality Assurance of EmOC/LSAS trainings have been established for provision of technical support and monitoring of activities. Assessors in the NIPI states have been trained and field activities started in Orissa, Rajasthan, MP, UP and Bihar. Review of progress in each state and subsequent interventions to modify the QA process is planned in 2010 - 11.

b. Strengthening SBA Training under NRHM: i. Pre-service education for nursing students is underway. Training of faculty

initiated in Orissa and Training of trainers completed in all Government ANM training centres. Roll-out of pre-service training will be started shortly.

ii. Similar activity planned in Rajasthan before March 2011. iii. It is also planned to support the establishment of regional Centres of Excellence

(COE) in Nursing to upgrade the teaching skills of trainers in nursing schools and training capacity of the COEs by providing teaching tools, aids and training modules.

c. Developing Implementation Model for Strengthening Maternal and Newborn health services:

i. The baseline for MNH project on ‘Developing Implementation Model for Strengthening Maternal and Newborn health services in Bharatpur district (Rajasthan) using health systems approach under NRHM’; is underway. The baseline review will be completed by second week of October. The final report is expected to be disseminated by November 2010.

ii. Further interventions will be planned based on review findings. Program Manager’s course and capacity building of SBAs, ASHAs and other community based interventions are also anticipated.

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d. Strengthening Accreditation of RCH Service providers: This activity is to (a) support mapping of Private Health Facilities for Accreditation to provide MCH services to develop a provider base for of quality services and (b) pilot implementation of Accreditation guidelines in 2 NIPI states (MP and Orissa). This activity is due to start in October 2010. Similar activity is planned for Rajasthan, UP and Bihar – to be completed by March 2011.

e. Capacity building of AYUSH practitioners in SBA / IMNCI skills: One of the common bottle necks in providing RCH services is lack of trained manpower especially in hard to reach areas. The retention rate of Medical Officers in PHCs is low. In this scenario, there are over 443,634 licensed Ayurveda and 216,858 Homeopathic practitioners in India. The course curriculum for AYUSH doctors is around 40% similar to MBBS. Many states (Maharashtra, Kerala, Gujarat to name a few) are already utilizing AYUSH doctors in PHCs and dispensaries to provide allopathic and primary health care. An estimated 12,000 such AYUSH practitioners are already in service, especially in tribal and hard-to-reach areas. Around twice this number are employed in states to provided traditional medical care in specified dispensaries. To address this paradox, it was proposed to build the capacity of AYUSH practitioners to provide RCH services.

i. A training program is being developed in NIPI states that have high MMR and IMR (Orissa, Rajasthan, and MP in first phase as these States are promoting AYUSH involvement in delivering SBA and ENBC services). Assessment of training need is ongoing from regular WHO budget.

ii. Similar activities and training of AYUSH in SBA skills as well as strengthening SBA pre-service training to follow GoI norms will be undertaken in NIPI states based on the assessment.

f. Supporting techno-managerial capacity building of Program Managers: Capacity building of district programme managers is planned for maternal health interventions in selected districts of NIPI States similar to the Child Health programme manager’s course. The training modules will include: (1) planning guidelines for district management for MNH, (2) programme review guidelines for MNH, (3) and IFC guidelines and training tools that will cater for a stronger link to community. This will be piloted in one district (Bharatpur) before the end of this year.

g. Operational Research: Iron Sucrose study proposed with PHFI and Lady Hardinge Medical College. Brief proposal enclosed. This will be submitted to OR committee for review.

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2.1.2 BUDGET SUMMARY

WHO – NIPI Activities: 2010-11 Proposed Budget

US$ Control of VPD - Expanding Measles Control activities: Budget Sub-Total 1,824,000

Accelerating Child Health interventions: Budget Sub-Total 450,000

a. Strengthening Pre-service IMNCI training b. Capacity building of district level Programme Managers in Child Health programme

review and management c. Community monitoring of MCH activities at village level d. Strengthening Essential Newborn Care (ENBC) e. Strengthening Management of Child Malnutrition:

Capacity Building of MOs/Nurses in management of SAM Children Strengthening Infant and Young Child Feeding education in medical

curriculum

f. Operational Research: to develop a community based model to address social determinants of under-nutrition in children (with INCLEN)

g. Operational Research: to study the ‘Impact of energy dense local diets on physiological recovery of children with severe acute malnutrition (SAM): multi-centric Study’ (DBT/ICMR-NIN)

80,000

60,000 20,000 10,000

10,000 10,000

100,000

160,000

Maternal Health: Budget Sub-Total 330,000

a. Strengthening Quality Assurance of RCH trainings - EmOC/LSAS trainings b. Strengthening SBA Training under NRHM c. Developing Implementation Model for Strengthening Maternal and Newborn

Health services d. Strengthening Accreditation of RCH Service providers e. Capacity building of AYUSH practitioners in SBA and IMNCI skills f. Supporting Techno-managerial capacity building of Program Managers. g. Operational Research: Iron Sucrose study

10,000 80,000 50,000

75,000 35,000 30,000 50,000

Total Budget 2,604,000

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2.2 UNOPS-LFA proposal on Pre Service Nursing Education Strengthening in Bihar The JSC in their IX meeting resolved to seek a detailed proposal with proper documentation be submitted by the Technical Agency JHPIEGO to the PMG for their review and further recommendation to JSC.

Strengthening of Nursing and Midwifery Pre-service Education in Bihar (SHS Bihar/NIPI Child Health Resource Network, UNOPS)

It has been observed in multiple assessment studies that the quality of Pre Service Education for Nursing Education in the state leaves much to be desired, with the educational infrastructure at the ANMTCs being in poor state and the ANMTC faculty having sub-optimal knowledge and clinical skills.

To address this gap of inadequate numbers of nursing staff and sub-optimal quality of PSE in the state, the Government of Bihar has realized the need and is willing to invest for the strengthening of the PSE for the Nursing and Midwifery cadre in the state, focusing especially on the existing ANMTCs which were defunct for almost one decade. Bihar Government has approval from NRHM (2010-11 PIP) to invest substantially in the infrastructure and HR requirements (Faculty and other Staff etc) for Nursing Education. Further, the State Government through a series of meetings Chaired by Principal Health Secretary, Health Secretary and Officer on Special Duty (OSD) have identified the need for technical assistance to help translate the improvement in the PSE. They sought inputs from the Nursing Advisor, Government of India and agreed to seek a proposal for Technical Assistance for PSE.

Jhpiego is an international non-profit health organization affiliated with Johns Hopkins University. For 35 years, Jhpiego has empowered front-line health workers by designing and implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care services for women and their families. JHPIEGO has technical expertise in reproductive, maternal and child health, FP and Pre Service Education for Nursing and Midwifery cadre. Presently, JHPIEGO is working closely with Indian Nursing Council for strengthening of ANMTCs in the states of Uttar Pradesh and Jharkhand.

A proposal from JHPIEGO was received by Bihar Government which proposes to provide technical assistance to Bihar Health Department in identifying an existing GNM school as state nodal centre and strengthen it using INC programmatic approach. The Nodal centre in turn to facilitate strengthening of the ANMTCs by Capacity building of the ANMTC tutors, Strengthening PSE by using educational standards (SBMR) and Network ANMTCs to compare progress and collectively solve implementation challenges. The approach will also include local assessment and an advocacy mechanism such as a technical and advisory group mechanism. Innovations that are tried and tested by Jhpiego in India and in other countries will be integral to the design of this approach. Some of the activities Jhpiego would engage in are listed below. These include but are not limited to:

1. To establish a nodal center of excellence for Pre- Service Education (PSE) for Nursing and

Midwifery Cadre in Bihar, to act as a resource center in the state for mentoring the process

of strengthening the GNM Schools and ANM Training centers.

2. To improve the educational standards and processes in the GNM schools and ANM training

centers by strengthening the educational infrastructure of these schools

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3. To strengthen the teaching skills of the faculty of the GNM Schools and ANMTCs by training

of the faculty in pedagogic courses with concurrent strengthening of the management and

supervision capacity of the faculty to improve overall management of the educational

processes in these schools.

4. To strengthen the process of clinical skill development of the GNM and ANM graduates by

strengthening of the clinical practice sites of the GNM Schools and ANMTCs with concurrent

updating of the knowledge and standardization of the clinical skills of the faculty in the

MNCH interventions.

The proposal was examined by competent authorities in the Bihar Health Department. The recommendations have been recorded duly through the meeting held on 28th April 2010 and Chaired by the Principal Health Secretary, Government of Bihar. The Nursing Advisor, Government of India through his letter dated 27th September, No. Z 28015/117/2010-N has positively responded with request for update on the Project Progress.

A sum of USD 780, 836 is proposed for the TA by JHPIEGO. (Detailed proposal with budget is attached as annexure).

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3.0 Progress on some decisions taken at IX JSC

3.1 Summary of WHO activities: a. Strengthening Control of Vaccine Preventable Diseases:

a. Strengthening Measles Control Activities in NIPI States

b. Accelerating Child Health Interventions:

a. Strengthening Pre-service IMNCI training b. Capacity building of district level Programme Managers in Child Health Programme

review and management c. Community monitoring of MCH activities at village level d. Strengthening Essential Newborn Care (ENBC) e. Strengthening Management of Child Malnutrition:

i. Strengthening Infant and Young Child Feeding education in medical curriculum ii. Capacity Building of MOs/Nurses in facility based management of SAM children

iii. Operational Research: Development of a community based model to address social

determinants of under-nutrition in children (with INCLEN) Study on impact of energy dense local diets on physiological recovery of

children with Severe Acute Malnutrition – a multi-centric study. (DBT/ICMR – NIN)

c. Accelerating Maternal Health Interventions:

a. Strengthening Quality Assurance of RCH trainings - EmOC/LSAS trainings. b. Strengthening SBA Training under NRHM. c. Developing Implementation Model for Strengthening Maternal and Newborn Health

services. d. Strengthening Accreditation of RCH Service providers. e. Capacity building of AYUSH practitioners in SBA and IMNCI skills. f. Supporting Techno-managerial capacity building of Program Managers. g. Operational Research: Iron Sucrose study [with PHFI and Lady Hardinge Medical College,

New Delhi] Presentation on progress will be made at PMG meeting.

3.2 UNICEF will continue with its catalytic support for IMNCI, FIMNCI, and EVM as per previous

JSC mandate and is following up on the Newborn Care Collaborating Centres, One Stop Shop for establishing and implementing SCNUs as per the IX JSC approvals. Presentation on progress will be made at PMG meeting.

3.3 UNOPS Programmes (LFA) concentrated its efforts in the Facility Development Plans

(FDP) for the MCH Centres in NIPI Focus Districts following the national discourse. The facilitation of the State Health Societies for implementing JSC approved interventions such as Yashodas, HBPNC, SNCU, Techno Managerial and Routine Immunization continues.

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Presentation on progress will be made by States and UNOPS LFA at PMG meeting.

3.4 UNOPS Secretariat Progress 3.4.1 Monitoring and Evaluation Strategy Monitoring and Evaluation Strategy has been developed and shared with the Royal Norwegian Embassy (RNE) and the 3 NIPI Partners viz., UNOPS, WHO, UNICEF for inputs and finalization of the same. The strategy focuses on all levels of monitoring- NIPI Secretariat, Partners’ interventions and Research Institutes. The M&E strategy focuses on monitoring NIPI at 3 levels. These are:

Level 3- Overall NIPI

Level2- Partners’ interventions

Level1- Programme management

In September 2010, all the NIPI Partners, NIPI Secretariat and RNE had a meeting to reach agreement on the M&E strategy. Thereafter, a meeting of the 3 Partners and NIPI Secretariat took place to finalize indicators for each Partner wherein consensus on a common programme progress format was reached. It was also agreed upon that semi-annual reports using this format shall be shared by the Partners with NIPI Secretariat on a 6 monthly basis. Any updates for PMG, JSC etc shall be shared prior to the scheduled meetings. These reports shall be shared by NIPI Secretariat with RNE. The draft version of the M&E strategy has also been shared with the Evaluability Team from NORAD and detailed inputs from them are awaited. 3.4.2 Gender Mainstreaming Promotion of gender equality (MDG 3) is an overarching principle of the Norway India Partnership Initiative (NIPI) which specifically is designed to contribute to the National Rural Health Mission (NRHM), towards achieving the goals of MDG 4 and 5. The Joint Steering Committee (JSC) in several meetings, has given direction to the three implementing partners (UNICEF, WHO and UNOPS) that measurable gender mainstreaming efforts must be made, across all NIPI interventions. The NIPI Mid Term Review (MTR) team observed that the current programs do not explicitly address gender issues or have strong gender component. As an overarching principle, gender mainstreaming processes need to firmly embedded into the initiatives, in order to avoid the risk of NIPI being viewed as taking token account of gender concerns. MTR, in their recommendations emphasized the need to have institutionalized mechanism for gender mainstreaming by identifying a gender champion within the NIPI. As a follow up of the direction given by the JSC as well as the recommendation of MTR, a ‘Gender Advisor’ has been identified within the NIPI Secretariat, from 01-09-10 . A draft NIPI gender mainstreaming action plan has been prepared which outlines the broad set of activities that would be taken up in this year for embedding the gender mainstreaming efforts into NIPI initiatives. A gender strategy will be finalized in consultation with the three partners in this quarter. Two day gender awareness training was conducted for the NIPI team at Manesar on 8 and 9 September 2010. The training was attended by 10 UNOPS State program teams and one

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representative from UNICEF and a representative from Royal Norwegian Embassy. The WHO representatives could not join the training. The training was facilitated by an external gender trainer. Day one of the training was observed by a representative from the Ministry of Health and Family Welfare, Government of India as well as a two representative of Royal Norwegian Embassy. The UNOPS state program teams from MP, Orissa, Bihar and Rajasthan developed draft gender action plan and presented the same. 3.4.3 Operations Research In accordance with the decisions taken at the 9th Joint Steering Committee, the Operations Research Committee has been reconstituted and the Operations Research component has been handed over to the NIPI Secretariat. Since the 9th JSC, 2 meetings of the reconstituted ORC have been held in the months of July and August 2010. In the 1st meeting of the ORC (1 July 2010), a decision was taken to have a sub group of the Operations Research Committee with Indian Council of Medical Research (ICMR) as the Chair. The mandate of the sub group is to finalize the research agenda, review research proposals under operations research before sharing these with all the ORC members for final approval. Since July 2010, two meetings of the sub group ORC have been held with the focus being on preparation of a list of research priorities for operations research, list of external evaluators comprising experts on subject matter and research methodologies and review of any new proposals. There are two proposals currently being reviewed by the Sub Group ORC. It has also been proposed to have a National consultative workshop in October 2010 with all relevant stakeholders from National, State and District levels to finalise the research priorities. With regards to the two ongoing studies- ANSWERS/ FAFO and PHFI- updates have been shared with the ORC members during the 2nd ORC meeting held in August 2010. Suggestions have been made by all members to the research organizations for strengthening the studies further. The financial aspects of these studies are still being managed by the Royal Norwegian Embassy (RNE) in line with the agreements entered into by these agencies and RNE. However, NIPI Secretariat is responsible for oversight of research studies. All reports shall be shared with the NIPI Secretariat which in turn will share these with RNE.

Operations Research administration transferred to NIPI Secretariat following JSC directive in its IXth JSC meet in June ’10.

ANNEXURES

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NPSP supported Measles Surveillance

2006 (Surveillance initiated)

2007 (Surveillance initiated)

2010 (Surveillance initiated)

2009 (Surveillance initiated)

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Training of Trainers for Measles SIAs

SIA: MCV1 <80%: 14 states

RI: MCV1 > 80%: 17 states

2nd opportunity of Measles vaccine:

State specific Delivery strategies

MCV1: Coverage of Measles containing vaccine per DLHS-3; CES-06 for Nagaland

MCV1 coverage national average : 69%

Annexure 1 Request for support from NIPI for strengthening measles surveillance and control activities in selected NIPI states Background WHO-National Polio Surveillance Project (NPSP) provides technical support to Govt. of India (GoI) and the state Governments in polio eradication, accelerated measles control and routine immunization strengthening activities. Through its extensive network of field officers, NPSP currently supports state governments to conduct outbreak based measles surveillance with laboratory investigation in 8 states: Andhra Pradesh, Gujarat, Madhya Pradesh, Karnataka, Kerala, Rajasthan, Tamil Nadu and West Bengal. Of these states, two are NIPI states (Madhya Pradesh and Rajasthan). Outbreak-based measles surveillance has evolved in a phased manner and expansion of this model of surveillance will continue in step with the planned phases of measles catch-up vaccination campaigns. In addition, WHO and NPSP, along with other partner organizations, are also supporting GoI to plan and implement measles catch-up campaigns in 14 low performing India states. Four of these states are NIPI focus states – Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. These campaigns will immunize 134 million children (9 months – 10 years of age) between 2010 and 2012 and help India reduce measles mortality by 90% by 2013 as compared to 2000 estimates. NPSP also supports Union and State governments to strengthen routine immunization activities through a range of strategic inputs including curriculum development and training of medical officers and health staff, program monitoring and feedback and improving AEFI management and surveillance. This proposal details out priority activities currently supported by WHO NPSP and for which NIPI funding would be utilized during the next 6 months. Beyond this period, measles control activities – surveillance and catch-up vaccination campaigns – are likely to expand but ultimately depend on Govt of India decisions. Additional NIPI support during this expansion phase could be considered at this time. Budget and activity components (October 2010 – March 2011) 1. Apportioned costs for WHO-NPSP field offices: NPSP maintains a network of field offices with technical and support staff. This network is primarily maintained for supporting Govt. of India in its polio eradication activities. Costs for supporting other program outputs are apportioned to the

ANNEXURES

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operational costs for the units. All activities are undertaken in coordination with Central and State Governments. In the budget below we have apportioned 15% of the operational costs of the units likely to be involved in measles control activities. 2. Measles outbreak surveillance: Continuation and expansion of measles surveillance in the NIPI states (Bihar, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh).

Specific technical assistance related to:

Training workshops (State and District Level)

Operational support related to outbreak and case investigations

Printing and dissemination of guidelines

This activity is done in collaboration with Integrated Disease Surveillance Project (IDSP) of Govt. of India and hence needs their concurrence.

WHO also provides laboratory support to measles surveillance activities through a network of WHO accredited national laboratories in these states. Laboratory costs have not been included in the budget submitted below.

3. Measles immunization campaigns: Continued technical support to measles catch-up campaigns in Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. This includes:

Developing training material

Conducting training of trainers and other trainings

Supporting and evaluating district level preparedness for the catch-up campaigns

Supporting injection safety and AEFI surveillance and management

Monitoring the quality of the catch-up campaigns 4. Routine Immunization strengthening

Technical support to monitor routine immunization training of medical officers

Expansion of RI monitoring through

Training of medical officers

Institutionalization of feedback Conclusion Expansion and continuation of these activities to assist the Government are contingent upon continued concurrence of GoI and availability of funding to support inputs by NPSP. The budget for which funding is required is given below.

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Annexure 2 Budget (in USD) for accelerated measles control activities in NIPI states

* The budget line titled “Technical support through NPSP field offices” is essentially to support Surveillance Medical Officers in the NIPI focus states. The number of SMO unit offices in the NIPI states is given below for information. As accelerated measles control activities increase – initiation of Measles Vaccine 2nd dose, strengthening of RI through monitoring and actionable feedback and enhanced laboratory supported surveillance – so too will the proportion of an SMO’s time and resources devoted to these activities. What was budgeted for accelerated measles control is 15% of the unit running costs, with the understanding that this will vary based on GoI and State-level decisions associated with accelerated measles control activities.

NIPI focus State Number of districts Number SMO unit offices

Bihar 38 35

Madhya Pradesh 50 14

Orissa 30 6

Rajasthan 34 8

Uttar Pradesh 71 75

Activity components Annual NPSP budget for NIPI focus states for 1

year or for total activity

NIPI funding requested for ongoing NPSP activities

for period Oct ’10 – Mar ’11

Technical support through NPSP field offices*

Technical Assistance to Measles control and RI activities: Operational costs for SMO unit 8,560,000 1,284,000

Sub-total for technical support through NPSP Offices

8,560,000 1,284,000

Technical support to Measles outbreak surveillance

Training and workshops (State and District Level) & Printing and dissemination of surveillance guidelines

282,000 71,000

Outbreak and case investigations 112,000 28,000

Sub-total for measles outbreak surveillance 394,000 99,000

Technical support to Measles SIA & RI activities

Development of Training Guidelines and National and state level coordination meetings and Training: Includes Training of Trainers, District level workshops, AEFI training etc.

485,000 86,000

Monitoring of RI and SIA activities & coverage evaluation survey plus end of activity report

1,892,000 206,000

Deployment of NPSP field staff & hiring of external consultants

1,191,000 149,000

Sub-total for SIA & RI 3,568,000 441,000

Grand Total 12,522,000 1,824,000

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Annexure 3

Maternal Health: Synopsis of Iron Sucrose study proposed with PHFI and Lady Harding Medical College. Hypothesis: Will treating pregnant women with severe and moderate anaemia with intravenous Iron therapy improve maternal and neonatal outcomes compared to oral treatment? Problem addressed: Iron deficiency is the commonest cause of anaemia during pregnancy in developing countries. Moderate to severe anaemia has several adverse maternal and fetal consequences. Current preventive and treatment measures involve the administration of oral iron preparations. Programs using oral iron supplements have failed to improve indicators of maternal morbidity and mortality to a large extent due to the poor bioavailability, tolerance and compliance associated with oral iron preparations. Intravenous administration of iron may rapidly correct hematologic indices of maternal anaemia and thereby improve maternal and foetal outcomes. Research question: This trial is designed to provide reliable evidence on the safety and effectiveness of IV iron sucrose compared to oral iron therapy in the treatment of moderate and severe iron deficiency anaemia among pregnant women in India in improving maternal and neonatal outcomes.

Burden: Maternal mortality ratio in India is among the highest in the world estimated at 254 deaths for every 100,000 live births. Census data from India (1997-2003) attribute 20% of maternal deaths directly to anaemia and 20 % to indirect causes of anaemia which includes haemorrhage and sepsis. Prevalence of anaemia was not different in pregnant women supplemented (88.1%) with oral iron compared to those not supplemented (87.5%), suggesting that oral supplements are not effective in improving haematologic indices of anaemia. Need for the trial: Iron deficiency is the cause in 95% of anaemia during pregnancy. Though the net requirement of iron for an expectant mother is 600mgs, she should be able to mobilize 1200mg of iron during the course of her pregnancy. A combination of adequate dietary provision of iron, and mobilization from adequate pre-pregnancy iron stores (300mg) is adequate to meet this demand. While mild anaemia and moderate anaemia detected early in pregnancy can be corrected by oral iron therapy, they are ineffective in severe anaemia and moderate anaemia detected in the later part of the pregnancy. Poor compliance and poor bio-availability of oral iron can be attributed for its ineffectiveness. There is a strong epidemiological evidence linking maternal anaemia to maternal mortality. Hence there is a need for alternative safe and effective therapeutic strategy for women with anaemia <8gms of Hb who report late in their pregnancy. Intramuscular(IM) route of iron therapy improves iron stores better and faster than oral iron, but IM administration is extremely painful and has high rates of systemic reactions. Among the IV preparation Ferrous sucrose has the best tolerance and has low allergenic effect (0.002%) due to slow release of elementary Fe from the complex. Therefore iron sucrose has the potential to be an important treatment option in pregnant women with moderate and severe anaemia. Centre: Department of Obstetrics/Gynaecology, Lady Harding Medical College, New Delhi. Proposed Budget: 50, 000 US$

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Annexure 4

Strengthening pre service education for Nursing and Midwifery Cadre in Bihar (Detailed proposal attached) Executive Summary

The State Health Government of Bihar, under the flagship of NRHM, is committed towards promoting the right of every citizen especially the rural woman and child for availability and access to quality health care. State aims at minimizing regional variations in the areas of Reproductive and Child Health including population stabilization through integrated, focused and participatory interventions. Meeting unmet demands of the target population, and provision of assured, equitable, responsive quality services are central to the programme strategies.

State of Bihar has made move towards achieving the vision with decline in important MCH indicators:

MMR from 371 ( 2001-2003) to 312 ( 2004-06) IMR from 61 ( 2005) to 56 per 1000 live births ( 2009) Total Fertility Rate (TFR) from 4.3 to 3.9

.1 To achieve the desired level of availability and access of the quality services, the state has put in a lot of efforts in recruitment of Basic Health Worker/Auxiliary Nurse Midwife and establishment of a network of a community health link worker (ASHA-Accredited Social Health Activist). But still a large gap exists in the requirement and the present availability of these health workers, with only 6000 ANMs in place in the state, compared to the need for 11694 ANMs.

Additionally, it has been observed in multiple assessment studies that the quality of PSE in the state leaves much to be desired, with the educational infrastructure at the ANMTCs being in poor state and the ANMTC faculty having sub-optimal knowledge and clinical skills.

To address this gap of inadequate numbers of nursing staff and sub-optimal quality of PSE in the state, the Government of Bihar has realized the need and is willing to invest for the strengthening of the PSE for the Nursing and Midwifery cadre in the state, focusing especially on the existing ANMTCs which were defunct for almost one decade . Jhpiego , is an international non-profit health organization affiliated with Johns Hopkins University. For 35 years, Jhpiego has empowered front-line health workers by designing and implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care services for women and their families. JHPIEGO has technical expertise in reproductive, maternal and child health, FP and Pre Service Education for Nursing and Midwifery cadre. Presently, JHPIEGO is working closely with Indian Nursing Council for strengthening of ANMTCs in the states of Uttar Pradesh and Jharkhand.

The proposal from JHPIEGO proposes to provide technical assistance to Bihar Government in identifying an existing GNM school as state nodal center and strengthen it using INC programmatic approach. The Nodal center in turn will facilitate strengthening of the ANMTCs by Capacity building of the ANMTC tutors, Strengthening PSE by using educational standards (SBMR) and Network ANMTCs to compare progress and collectively solve implementation challenges. The approach will also include local assessment and an advocacy mechanism such as a technical and advisory group mechanism. Innovations that are tried and tested by Jhpiego in India and in other

1 Source: State of Bihar, NRHM PIP for year 2010-11 Link:

http://mohfw.nic.in/NRHM/Annual_Plan_Final.htm#

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countries will be integral to the design of this approach. Some of the activities Jhpiego would engage in are listed below. These include but are not limited to:

5. To establish a nodal center of excellence for Pre- Service Education (PSE) for Nursing and

Midwifery Cadre in Bihar, to act as a resource center in the state for mentoring the process

of strengthening the GNM Schools and ANM Training centers.

6. To improve the educational standards and processes in the GNM schools and ANM training

centers by strengthening the educational infrastructure of these schools

7. To strengthen the teaching skills of the faculty of the GNM Schools and ANMTCs by training

of the faculty in pedagogic courses with concurrent strengthening of the management and

supervision capacity of the faculty to improve overall management of the educational

processes in these schools.

8. To strengthen the process of clinical skill development of the GNM and ANM graduates by

strengthening of the clinical practice sites of the GNM Schools and ANMTCs with concurrent

updating of the knowledge and standardization of the clinical skills of the faculty in the

MNCH interventions.

Jhpiego Corporation

PRIME:

Proposal Name: Strengthening Pre Service Education for Nursing and Midwifery Cadre in Bihar

Period of Performance: 1 December 2010 – 30th November 2012

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LINE ITEM SUMMARY

Line Item Year 1 Year 2 Total

Personnel $131,892 $136,148 $268,040

Fringe Benefits $7,977 $8,296 $16,273

Travel $85,617 $64,354 $149,970

Equipment $0 $0 $0

Materials and Supplies $15,194 $1,713 $16,907

Contractual $0 $0 $0

Other Direct Costs $104,113 $101,966 $206,079

Indirect Costs $64,821 $58,746 $123,567

Fixed Fee $0 $0 $0

TOTAL COSTS $409,613 $371,223 $780,836

Notes:

- Other direct costs includes: Program activities, Office allocation and service centre costs.