Innovation Pilot Proposal by Uttar Pradesh Enhancing facility community processes to improve early eclusive 1. Contet, Rationale Problem Statement According to recent data from the Rapid Survey on Children (RSOC) 1, 38.7 % of Indian children under five years are stunted, 29.4 % are underweight 15.1 % are wasted. Over 50% of the child deaths are associated with malnutrition. Uttar Pradesh has the highest stunting rates in the country.in Uttar Pradesh, as per the RSOC (2014), 34.3% of children under five years old are underweight, 50.4% are stunted 10 % are wasted. About 74% of the children under five are anemic.early initiation of breast feeding is at 22.5% eclusive is 62.2%, only one third of children 6 to 8 months are provided timely complementary feeding. Infants who are not breastfed appropriately are at higher risk of both acute chronic malnutrition, sub-optimum is the underlying cause of 12% of deaths among children under five in the developing world 2. Despite the institutional delivery being 62.1% in Uttar Pradesh the early rate is 22.5%.This is a missed opportunity provides a platform for improving both early eclusive.an innovation pilot is therefore proposed to specificallyimprove early eclusive rates to reduce infant mortality improve infant child nutrition growth. 2. Objective To improve early initiation of in the project area by 10%. To improveeclusive rate in the area by 5%. 3. Intervention Description Scope of Innovation The innovation proposes to build improve services both at health facility at the community level to improve early eclusive. Geography The project will be implemented in one block of Barabanki district. The district is situated about 29 Kms East of Lucknow, infaizabad division. As per 2011 census, Barabanki has a population of 3,260,699. It is proposed that the intervention will be carried out in Nindura block of the district which has a population of 2,50,000. Time Frame The project will be implemented over a time period of one year, from Jan 201707 to Dec 2017. Target Audience Pregnant lactating women Husbs Mother in laws other family members Medical Staff- Medical Officer, AYUSH Doctor, Staff Nurse, ANM, Counsellor, Attendants from the Obstetric Gynaecological ward ICDS Staff-DPO, CDPO, Supervisors, AWW Program Strategy Delivery Modalities 1 RSOC 2013-14, Ministry of Women Child Development, Government of India 2 Black et al. (2008) Maternal Child Under nutrition: global regional eposures health consequences. Lancet 1
In order to promote early eclusive a three pronged approach will be adopted: A) Making the health facilities responsive to early initiation eclusive breast feeding. B) Breastfeeding Promotion Nutrition Training Centres (BPNTC) to be set up at the community level. C) Intensive counselling at the household level for adoption of early eclusive. The key behaviours that the project will focus on promoting include: Breastfed within the first hour after birth. o No newborns are givenpre-lacteal o All newborns are fed colostrum. All infants young children are breastfed on dem, day night. All infants are eclusively breastfed until 6 months of age Continue feeding during after illness. No children are fed with bottles pacifiers. A) Making the health facilities responsive to early initiation of breast feeding Inside the delivery room, a separate corner will be set up for ensuring within first hour of delivery. The staff nurse in-charge will provide requisite support to the mother for facilitating early. She will ensure that the colostrum is given to the child that no pre-lacteal feed is given difficulties in establishing are addressed. It is a common sight that the husb/mother in law/other family members who accompany the pregnant women for delivery, wer around the delivery room aniously waiting for the delivery to take place. Waiting area will be developed at apt location the opportunity will be used for dissemination of information related to importance of early eclusive. Activity A.1: Capacity building of service providers on importance of early eclusive. Activity A.2: Capacity building of ANMs/ICDS supervisors on lactation management. Activity A.3: Setting up breast feeding corners in the delivery room. Activity A.4: Developing waiting areas/wards for display of IEC material. Activity A.5: Setting up Audio-Video aids for dissemination of information.in the waiting area in the CHC/PHC also in the gynae wards Activity A.6: Sensitizing the CMO for review of early eclusive indicators during review meetings. Activity A.7: Supportive Supervision visits by the CMO/other staff to all the PHC/subcentre where delivery takes place. Activity A.8: Sensitization of medical staff attendants of private nursing home to promote early eclusive. B) Breastfeeding Promotion Nutrition Training Centres (BPNTC) to be set up at the community Activity B.1: Breastfeeding Promotion Nutrition Training Centres (BPNTC) will be set up at community (in the eisting AWC/Panchayat bhawan where required physical structure/space is available), for providing h holding support to the AWWs. Facilities at the BPNTC Counselling cum training area withdemonstration dolls, actual support/live demonstration, video facility, posters o Refresher for the AWW/ASHA on importance of early eclusive, correct attachment position while, solving difficulties e.g. less milk at 3 months, inadequate milk, epression storage of breastmilk to feed the baby when she is away to work, LBW babies including KMC, sick infants, when mother is unwell. 2
Counselling case management o Counselling of pregnant/lactating women when required o Counselling husbs/mother in laws to motivate/support in early eclusive, wherever required o Case management of referred with problems e.g. breast engorgement, breast preference. C) Intensive counselling at the household level for adoption of early eclusive The intervention will focus on early identification of pregnant women, their registration counselling: Emphasis will be given on home visits to facilitate interpersonal counselling, a detailed home visit schedule will be developed at the AWC level. a. Breastfeeding promotion This activity will be carried by AWW, who will counsel all pregnant mothers in the 8 th 9 th month of pregnancy so that the mothers is aware ofthe importance of, commit to early eclusive institutional delivery. Mothers will also be briefed about the BPNTC centres at the sector level. b. Breastfeeding management AWW will follow up support mothers to maintain eclusive in the first si months continue for 24 months beyond. Supervisors will provide support to mothers on common difficulties encourage them to adopt optimal practices. All the complicated cases like the mothers having low supply of milk, breast engorgement, sore nipples, mastitis etc. will be followed up by supervisors till the difficulty is resolved. Activity C.1: Capacity development of frontline health workers on early eclusive interpersonal communication. Activity C.2: Development of home visit schedule for all the frontline workers. Activity C.3: Reaching families with timely accurate messages support for improved practices through interpersonal counseling during home visits by frontline workers. Activity C.3: Family counselling, comprising of pregnant women/lactating women, husb mother in law. Activity C.4: Supportive supervision by the supervisors ASHA Sangini. Activity C.5: Referral to BPNTC for lactation management as required. Stakeholders their Roles Responsibilities The project will be implemented in convergence with the Health department. Health department will be responsible for taking lead on the facility level intervention to support early initiation eclusive. ICDS will take lead on BPNTC centre, counselling by the AWW home visits. Development partners will also support in providing supportive supervision providing materials for training communication aids. District Magistrate/CDO will conduct monthly review of the project. Feasibility of Scaling up of the innovation The pilot will be implemented by the eisting Health ICDS system no additional manpower will be deployed for the pilot. The intervention will support in improving the indicators with minimal cost will present a model which can be easily replicated at scale. Convergence The proposed pilot aspires to demonstrate convergence between Department of Women Child Development Department of Health in Nidura block, district Barabunki towards the approved innovation. The project implementation plan for the pilot details activities in support of this convergence. 3
4. Results Framework with Indicators Outcome level Output level Indicator Baseline Endline Data Source Proportion of children born in the last 24 10% improvement Baseline months who were put to the breast within one hour of birth Endline Survey Proportion of infants 0 5 months of age who are fed eclusively with breast milk Number of Institutions having corners Number of Institutions where IYCF videos/iec material is displayed in the waiting area gynecological wards No. of medical officers/staff Nurse/ANMs trained on early eclusive counselling skills 5% improvement Baseline Endline Survey 0 17 corners at the CHC/PHC/Subcentre 0 17 facilities where delivery takes place ANM:31 MO :10 Report Report 80% trained Training Report No. of BPNTC centres set up in the project 20 BPNTC centres at area the Community Report level No. of AWW/ASHAs trained on IPC skills AWW :200 80% trained Training ASHAs :230 Report No. of pregnant women registered 90% registration of MIS pregnancy (Eisting) No. of pregnant women family 80% of all the members counselled on early initiation of deliveries taking Report its importance place at the facility No. of cases counselled at the BPNTC 30% of the pregnant Report lactating women No of home visits made for promotion of 70% of pregnant Home early eclusive lactating Visit women Register (Eisting) Frequency Once Once (Training will be completed in from 4-6 months, thereafter the format will only say completed) 4
5. Project Implementation Plan (maimum one year of implementation) Program activities Stakeholder meetingfor project planning Official Communication s by Director ICDS/ MD NHM/DG Health Family Welfare to District to project eecution Identification of CHC/PHC/ subcentre Identification of BPNTC centres Development of Monitoring/MIS tools Identification of Trainers Modificationof Training module/job aids Planning for use of Audio-Visual Aids Procurement of Equipment Goods [LED TVs, demonstration dolls, reclining beds for the corners, curtains, chairs for waiting area]. Months Prep phase Delivery of intervention Delivery assessment 1 2 3 4 5 6 7 8 9 10 11 12 Responsibility JPC Director ICDS/DG Health/MD NHM CMO/DPO Barabanki DPO/CDPO Barabanki State in consultation with World Bank JPC World Bank (Consultation with Development Partners)/State Govt. World Bank (Consultation with Development Partners)/State Govt. Director ICDS Project roll Out Director ICDS 5
Program activities Orientation of District/Block supporting partners DM, CDO, DPM, Nurse Mentor, TSU, UNICEF etc Finalization of Baseline agency tools Months Prep phase Delivery of intervention Delivery assessment 1 2 3 4 5 6 7 8 9 10 11 12 Responsibility World Bank (Consultation with Development Partners)/State Govt. Baseline Survey Identified Agency Capacity building of service providers on importance of early eclusive Capacity building of service providers on IPC At Facility JPC Trainers Trainers Setting up CMO breast feeding corners in the delivery room Display of MO Audio-Video in the waiting area the wards Counselling of ANM pregnant lactating women for early eclusive Breastfeeding ANM Complication Management to promote Eclusive At Community Setting up of DPO 6
Program activities BPNTC in the community level Registration of pregnant women Motivation of pregnant women/familyo n early breast feeding eclusive Counselling on Lactation Management at BPNTC Refresher/h s on training on Early Eclusive of AWW/ASHA at BPNTC Home visits for Counselling Home visits for follow-up Supportive Supervision for problem solving Review meetings Project End Months Prep phase Delivery of intervention Delivery assessment 1 2 3 4 5 6 7 8 9 10 11 12 Responsibility X AWW/ASHA/ANM X AWW/ASHA/ANM X ICDS Supervisor/ANM X ICDS Supervisor/ANM X AWW/ASHA X AWW/ASHA X DPO/CDPO/Spervi sor/ ANM/MO/CMO X DM/JPC End line Survey Identified Agency Dissemination discussion on scale-up JPC 7
6. Monitoring EvaluationPlans 6A: Routine Monitoring of progress The following mechanisms will be used for program monitoring: a. Management Information System MIS used in the ICDS system the Health HMIS will be used for reviewing the early, registration of pregnant women counselling on early eclusive. This block is also the ICT- RTM block hence the data generated through the CAS software will also be used for reviewing of the indicators. b. Supportive Supervision Supportive supervision will be an important aspect of performance management quality improvement. Main objective of the supportive supervision will be to motivate frontline health workers to improve quality of program delivery. The supervision visit will perform two functions: (1) to monitor improve quality, (2) to assess performance in relation to quantity (home visits made by the AWW). MO/CDPO/LHV/Supervisors will provide supportive supervision to improve performance of frontline health workers support in quality delivery of services by utilizing data to address challenges, proper record keeping, timely report submission motivation. c. Review Mechanism review meeting will be held jointly by the Health ICDS at the block level to assess the progress of the innovation identify gaps propose solutions. d. Quarterly review Meeting Quarterly Review meeting will be held at the State/District level to review the progress provide the needed support for successful implementation of the project. 6B: Evaluation A baseline end line assessment in the proposed geography will be undertaken to assess the etent to which the intervention has led to changes in -related behaviours. Specifically, the key behaviours that the survey will focus on, will include: Proportion of children born in the last 24 months who were put to the breast within one hour of birth. Proportion of infants 0 5 months of age who are fed eclusively with breast milk. The survey will be undertaken amongst a rom sample of mothers in the 200 AWCs in the block. A control block will be identified similar survey will be taken up in control block also. The same survey instrument will be used, change will be observed over time. 7. Budgets Component Cost in INR Remarks Setting up of 8,50,000 Breastfeeding Corners (17 centres) Development of 5,00,000 Waiting area/gynecological Ward Setting up of 30,00,000 BPNTC(20 centres) Development 10,00,000 Printing of Training Modules Adaption of Audio- 5,00,000 Visual Aids Training 10,00,000 Program 5,00,000 Monitoring 8
Component Cost in INR Remarks Evaluation 20,00,000 (Baseline/End line) Dissemination 2,50,000 Miscellaneous 10,00,000 Total 1,05,50,000 9