Improving Newborn-child survival in India Technical Advisory Group Consultation “Book of Proceedings”

1. Improving Newborn-child survival in India Technical Advisory Group Consultation “Book of Proceedings” Dr. Rajiv Tandon Senior Advisor-MNCHN Save the Children, India r.tandon@savethechildren.in +91-98111-03305

2. Maternal health in India

4. Status of Child Health in India • Nearly 2 of 8 million U5 deaths per year, in India – the highest anywhere in the world, 50% within their first month of life (LBW !!), majority of deaths are preventable • More than half of the children die in just 7 Indian states - Uttar Pradesh, Madhya Pradesh, Rajasthan, Chhattisgarh, Bihar, Jharkhand and Orissa • More then 100 million U5 undernourished (8.5million - SAM) • Only half U5 receive routine immunisation • India ranks • 171st of 175 countries in Public Health Spending • 119th of 169 countries in Human Development Index • 73rd of 78 countries as the best place to be a mother • 67th of 84 countries in Global Hunger Index URGENTLY NEED TO FOCUS ON NB & CS & UNDERNUTRITION!!!!!!

5. Comprehensive obstetric care • Treatment of severe newborn & child illness Referral Level Care “Outside” Health Service Interventions • Basic preventive services (ANC, immunization, etc.) • Primary treatment of MNCH illness (IMNCI, basic essential and emergency obstetric care) • Counseling 1st level - Private Services 1st level - Public Services Operational Framework Barriers, constraints, facilitating factors • Transport of complicated deliveries and sick children • Organization for ANC & immunization • Community oversight and monitoring • etc. • ANC • Immunization • AWW, ASHA, supervision & supply • Health information • Private provider training • etc. >60% of Deaths Community Health Interventions Community linkages to health services Public Private Care delivered in the community • 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. Family practices

6. When do Newborn Babies die? ICMR 2004

7. “Where” to provide care? Place of Death Place of birth Private hospital Home Govt hospital ICMR HBYI study, 2005 NCMH, 2005

8. Technical Advisory Group Consultation • Objective: Developing strategic breakthroughs needed to achieve a dramatic reduction in newborn & child mortality in India • 125 people/organisations – cross section of leading experts in Government, Academia, Corporates, Civil Society Organizations, Donors • 3 day participatory process, facilitated (OST) • 40 group work reports, prioritization of key objectives & action plans (Book of Proceedings) • 39 personal statements of commitments for action

9. Key barriers to achieving positive MNCHN outcomes in India • Inadequate total funding & critical funding gaps • Significant gaps between policy & program implementation (multiple fragmented efforts) • Lack of access for the poorest & most vulnerable communities: girls, urban poor, minorities, disabled, Dalits, tribals, migrants • Poor quality of services • Insufficient numbers, role definition, capacity building, supervision of frontline healthcare workers/supervisors

10. Key barriers to achieving positive MNCHN outcomes in India (contd.) • Lack of coordination between Ministries & departments (and service providers) • Lack of champions, platforms & institutions for consensus building & joint actions • Lack of governance (Corruption) & mismanagement of funds & processes • Insufficient community ownership, participation, monitoring • Inadequate data to inform decision making & weak HMIS • Lack of awareness (among the middle class) of challenges for the poor

11. What needs to be done to improve newborn and child survival in India?TAG recommendations

12. India needs: • Increased investment for greater access to MNCHN services • Convergence between government departments & stakeholders for holistic, effective, equitable implementation • Strengthened human resources, with special emphasis on frontline health workers (newborn care, nutrition) • Enhanced accountability for responsible governance • Enhanced quantity, quality and availability of data to inform decision-making • United social movementcommitted to bringing about a dramatic reduction in child mortality

13. 1. Increased investment for greater access to MNCHN services • Increase overall budget allocation for health to 3% GDP. • 5% (if drugs and chronic diseases-related costs get special focus) • Allocate 25% for newborn & child health • Link MNCHN indicators to economic growth indicators • Introduce budget tracking tools and social audits • Enhance access to vulnerable communities: women, Dalits, tribals, disabled, religious minorities, conflict-affected and remote communities, migrants, (250 highest need districts) • Launch National Urban Health Mission

14. 1. Increased investment for greater access to MNCHN services (contd.) • Technical & operational consensus for scaling up MNCH through a continuum of care, “Deconstruct to Reconstruct” a non branded, evidence based, cost effective model at scale – “Adaptation process” • Fiscal devolution policy – at districts/Block levels (Role of DMs/BDOs) • Develop gold standards for Quality of care • Develop and implement Block level health service delivery plans and resource hubs • Invest in human resources for health • Invest in infrastructure and new technology (ICT) • Actualize Right to Food & Nutrition • JSY to include MNCHN services

15. 2. Convergence between government departments and stakeholders for holistic, effective implementation • Develop champions & leaders for MNCH at all levels • Form and actualize a MNCH coalition (Multi-stakeholder) • Continuum of Care (HH, community, referral, FRU) for MNCH • Establish role clarity between departments & programs (HFW, PHED, WCD, RD) • Coordinate state PIP planning, targeting, implementing, monitoring & budgeting across departments

16. 2. Convergence between government departments and stakeholders for holistic, effective implementation (contd.) • Develop and implement integrated awareness campaigns & models of MNCH care • Establish clear linkages & referral mechanisms within & between departments & service providers • Mainstream NBCS into NDMA planning • Engage private sector providers

17. 3. Strengthened human resources, with special emphasis on frontline health workers • Increase fund allocation & number of frontline health workers (Global code of Practice on recruitment of health personnel) • Rationalize health worker placement & workload • Ensure equitable recruitment , selection process & cadre reviews • Clarify specific roles of ASHA, ANM (SBA), AWW • Build capacity of workers through comprehensive, participatory, skills-based training

18. 3. Strengthened human resources, with special emphasis on frontline health workers (contd.) • Place special emphasis on linking training & equipping them with supplies • Improve system of performance incentives & rewards • Develop & implement supportive supervisory methods & feedback mechanisms • Streamline reporting expectations, processes to address grievances • Develop state HR plan & create HR management cells • Establish block resource centers for ongoing capacity building

19. 4. Enhanced accountability for responsible governance • Rights based approach (redressal and punitive action) • Gender- Zero tolerance policy, gender budgeting in 12th - 5 year plan • Greater role of Gram Sabhas, peer leaders, hamlet representation • Increase awareness at community level of rights and entitlements (citizen charter, data triangulation) • Equip community-based monitoring structures (VHSC, PRI, SHG) with knowledge & tools needed to track services delivered & identify unmet needs and link them with BDOs • Civil society facilitated social audits, public hearings, information sharing

20. 4. Enhanced accountability for responsible governance (contd.) • Link funding to Program success (outlays to outcomes) • Increase financial transparency & timeliness of processes • Institutionalize minimum service guarantees & redressal mechanisms • Mobilize local & state media for public awareness on gaps in implementation & transparency within the health care system • Media as agent of change – Media Leaders Summit on MNCHN, National Media/Communications Consortium • Generate competitive governance states, districts & blocks

21. 5. Enhanced quantity, quality and availability of data related to the provision of MNCH services (encompassing technical, financial, and managerial data) to inform decision-making • Conduct thorough assessment of Health Management Information Systems , concurrent/impact evaluations • Invest in institutions and HR for MIS – COE, sentinel sites • Disseminate best practices in technical interventions/services, financial management, service supervision to key stakeholders including government & non-government institutions, health professionals & frontline workers & research institutions

22. 5. Enhanced quantity, quality and availability of data related to the provision of MNCH services (encompassing technical, financial, and managerial data) to inform decision-making (contd.) • Learn from best practices of southern states • Engage private sector - regulatory frameworks, ombudsman (avoid conflict of interest) • ICT – GIS, smart phones, UID, e/m health, rapid visual surveys, GPS, SMS (fund transfer), broadband tech. • Conduct study on feasibility and cost-effectiveness of various interventions • Determine denominators (Scandal of invisibility!!) • Rationalize unit of operationalisation - Block

23. 6. United social movement committed to bring about a dramatic reduction in child mortality • International solidarity and political pressure to make MNCHN a key priority within political agenda • Engage with National consortium of MNCH academia • Media mobilization to highlight scale of problem, issues, gaps, human stories • MDG4 tracking and update vis a vis other priority countries • Call for action to increase child health budget in the next fiscal year • Rights based mobilization demanding for legislation

24. Recent / upcoming developments • Union Health & Family Welfare Minister: Health Sector Priorities • National consultation on MDG 4 (SC India) - Shadow report • UN MDG Review Summit, New York • Global Strategy for Women’s and Children’s Health by 2010 • SG’s Call to Action • 2010 Countdown to 2015 Report • Public Hearing (SC India) • PMNCH partners meeting, Pledges to Action • Delhi Declaration • Newborn and Child Survival TAG (SC India) • Book of Proceedings • Approach Paper on Child Health, 12th Five Year Plan • Lancet Series • Towards Universal Health Coverage – 2020 in India

25. Recent / upcoming developments • UN Commission on Information and Accountability for Women and Children’s health (Harper and Kikwete), Geneva • Monitor, Review, Remedy • Working Groups for Results & Resources • Independent Expert group on MCH report to UNGA • Global Forum on Human Resources for Health, Bangkok • Strategies and targets to close the health worker gap • World Economic Forum, Davos • Global Polio Eradication funding gap addressed • G8: Paris, June • Health systems strengthening • UNGA : New York, September - Inform. & Accountability Commission report • G20:Cannes, November - Governance & innovative financing

26. Key recommendations and action steps • Increase budgetary allocations 3% (25% to NBCH) • Formation of a MNCH Coalition (Multi-stakeholder) • Civil society organizations (e.g. Save the Children) to input into 12th five year plan approach papers, be a part of the advisory, thematic and steering groups • Participation in the reviews of National Programs e.g. NRHM, ICDS, NREGA, SSA, TSC, MDM etc.

27. Key recommendations and action steps, contd. • Immediate operationalisation of the revised Newborn & Child Health policy & strategy (adequately costed & funded) • Regular high level oversight mechanisms for MNCH • National Health Commission (PM/Parliamentary committee with CSO) • Collaboration using Implementation Science to dramatically accelerate progress in meeting country needs for preventing maternal and newborn deaths • Institutions – platforms - champions!!!!

28. THANK YOU Thank you