Challenges in programme implementation some lessons for Indian Child Health and Nutrition Programmes

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1 Challenges in programme implementation some lessons for Indian Child Health and Nutrition Programmes

2 India will achieve MDGs in child mortality Not do as well in maternal mortality Under nutrition or micronutrient deficiency - poverty, hunger

3 In general, these trends indicate greater success in areas where supply side solutions can have an impact, but not in areas where demand issues are big barriers.

4 Key maternal and child health and nutrition indicators in selected Asian countries Indicator India China Indonesia Bangladesh Pakistan Under-five child ( 2006 ) mortality Neonatal mortality ( 2004 ) Maternal mortality ( 2005 ) % 21.8% 28.6% 47.8% 41.5% ( ) Stunting Underweight ( ) 43.5% 6.8% 19.7% 39.2% 31.3% Anaemia in women 15- ( ) 49 years 51% 19.9% 33.0% 33.2% 27.9% GNI per capita ( 2006 $, Int (PPP, Population living <1 $ /day (PPP, Int $, ( % % 41.3% 17.0% 61.0% 90.9% 90.4% 47.5% 49.9% ( ) Adult literacy

5 Percentage of adequacy of inputs in District Hospitals, FRUs, and CHSs in India, Facility Survey 2003 No. of facilities ( N ) surveyed Percentage adequately equipped * Infrastructure Staff Supply Equipment Percentage of DHs utilized as referral ( 370 ) DH ( 1882 ) FRU ( 1625 ) CHC Source: Report of: India Facility Survey 2003, IIPS, Dec 2005, Bombay * Adequately equipped means has at least 60% of specified inputs (infrastructure, staff, supplies, equipment)

6 An enterprise for child health, nutrition and development with attention to supply and demand issues. Some of its components are excellent but the whole never works.

7 Programme Implementation Slow absorption of new solutions Failure to scale up effective pilot programmes Lack of innovative solutions unmet needs Zn and ORS Double fortified salt Conditional cash transfer concepts Public private partnership New vaccines RUTF Community Rx of diarrhea and/ pneumonia Growth promotion and Rehabilitation of severe malnutrition Vitamin A, Iron folic acid, exclusive breast feeding, antenatal care Postnatal check ups for mother and baby. Immunization Effective care at birth Nutrient intake by pregnant women, adolescents and 6m 2 years old children Generating demand for preventive, curative services

8 Barriers to scaling up of health interventions Community and household levels Lack of information, women s education, physical, financial, women s decision-making power Health services delivery level Shortage of qualified staff, weak technical guidance, programme management and supervision, inadequate supplies, equipment and infrastructure, poor accessibility Health sector policy and strategic management level Weak and centralized system for planning and management, weak drug policies and supply system, inadequate regulations, lack of intersectoral action and partnership, weak incentives to use inputs efficiently and respond to user needs and preferences, reliance on donor funding Public policies cutting across sectors Government bureaucracy, poor communication and transport Infrastructure Environmental characteristics Governance and overall policy framework Corruption, weak government, weak laws, political instability and insecurity, low priority to social sectors, weak structure for public accountability and opportunities for public opinions, lack of free press Physical environment Climatic and geographic predisposition, physical environment unfavourable to service delivery

9 Programme design failure illustration ICDS as an instrument for improved nutrition under 2 years ANMs and traditional birth attendants for effective care at birth

10 Policy and Governance failure Who is responsible for designing policies, plans and programmes for nutrition in India? What is our nutrition policy?

11 Good ideas must not only sound good but they must be scalable and shown to have impact Efficacy Program Gap in research Reprogram Gap in research Neonatal care example

12 Institutional framework for public health is fragmented, weak, with large gaps Centres of excellence in implementation research

13 Lack of an effective feed back loop Too much information collected that was seldom used to shape/reshape policy or To design/redesign programmes

14 Leadership and Stewardship at national, state, district level The programme policies and strategy team are unstable, poor in handling evidence, or plan, lack critical expertise. Evidence of programmes not working well, not well received Demand generation solutions were less often on the agenda

15 Human resource for public health Density Diversity Skills Location

16 International agencies synergy

17 Innovation Interesting Developments IMCI to IMNCI Asha s JSY, Chiranjeevi Attention to human resource and infrastructure in NRHM Greater civic society participation in policy making or programme feed back

18 The way forwards Initiating excellence in program delivery must lead to enduring change with continued improvements and innovation till the programme delivery enterprise works as a whole Improvements must be founded on evidence (implementation research) and experience