10th November, 2016
Bihar Technical Support Program (BTSP) Geographic and Demographic snapshot of Bihar
Density Range Up to 630 Density Range 631- 880 Division 9 Density Range 881 - 1130 Density Range 1131 - 1380 West Districts 38 Champaran Density Above 1380
Sub Divisions 101 East Sitamarhi Champaran Gopalganj Sheohar Blocks 534 Madhubani Siwan Supaul Kishanganj Muzaffarpur Araria Panchayats 8408 Darbhanga Saran Samastipur Saharsa Revenue Village 45,103 Vaishali Purnia Buxar Begusarai Khagaria Katihar Bhojpur Patna Population (2011) 104 million Nalanda Bhagalpur Arwal Lakhisarai Munger Rohtas Jehanabad Rural Population 89% (India avg: 61%) Bhabua
Nawada Jamui Banka Per Capita Income $335 p.a (India: $914) Aurangabad Gaya
Population 1,106 /sq Km Density Left Wing Extremist affected 921/1000 males Districts Sex Ratio (India: 943) East Champaran Rohtas Literacy Rate 63.8% (India: 73%) Aurangabad Female Literacy Jehanabad 53% (India: 65%) Rate Arwal Gaya Decadal Growth 25.1% (India: 17.6%) Jamui Rate (Percentage)
2 Snapshot of key RMNCH+A indicators in Bihar (1/4)
Maternal Mortality Ratio (MMR) Total Fertility Rate (TFR)
531 4 3.7 3.6 3.5 3.4 3.2 371 312 398 261 301 219 208 2.68 2.5 2.4 2.4 2.3 2.3 254 212 178 167
NFHS 05- SRS 2010 SRS 2011 SRS 2012 SRS 2013 SRS 2014 SRS 97-98 SRS 01-03 SRS 04-06 SRS 07-09 SRS 10-12 SRS 11-13 06 India Bihar India Bihar
Neo Natal Mortality Rate (NMR) Infant Mortality Rate (IMR)
49.1 48 44 43 42 42 39.8 47 44 42 43 40 39 39 31 29 28 28 27 33 31 26 29
NFHS 98- NFHS 05- SRS 2010 SRS 2011 SRS 2012 SRS 2013 SRS 2014 SRS 2010 SRS 2011 SRS 2012 SRS 2013 SRS 2014 99 06 India Bihar India Bihar
Source:: SRS, NFHS 3 Snapshot of key RMNCH+A indicators in Bihar (2/4)
% 0-5 yrs children underweight Children aged 12-23 months (weight for age) Fully Immunized (%)
69.9 55.9 43.9 65.6 64.5
NFHS 05-06 NFHS 15-16 AHS 10-11 AHS 11-12 AHS 12-13
Kala-Azar cases in Bihar
16036
10730 7615 6280
2012 2013 2014 2015
Source:: SRS, NFHS, DLHS, AHS
4 5 Health and nutritional goals and status
Indicator India Bihar Bihar Vikash Current status Trend (Year & source) Mission- Goal (2021) Maternal Mortality Ratio (MMR) 167 312 261 219 208 <100 (Per 1 lakh live births) (SRS 11-13) * (SRS 04-06) (SRS 07-09) (SRS 10-12) (SRS 11-13) Infant Mortality Rate (IMR) 39 48 44 43 42 <27 [0-1 year] (Per 1000 live births) (SRS 2014) (SRS 2010) (SRS 2011) (SRS 2012) (SRS 2014) Neonatal Mortality Rate (NMR) 26 31 29 28 27 16 [0-28 days] (Per 1000 live births) (SRS 2014) (SRS 2010) (SRS 2011) (SRS 2012) (SRS 2014) Early NMR 27 [within 7 days of Birth] 20 25 23 22 (SRS 2014) (SRS 2011) (SRS 2012) (SRS 2014) (Per 1000 live births) (SRS 2010) Under 5 Mortality Rate 45 64 59 57 53 <35 (Per 1000 live births) (SRS 2014) (SRS 2010) (SRS2011) (SRS 2012) (SRS 2014) Total Fertility Rate (TFR) 2.3 3.7 3.6 3.5 3.2 2.4 (SRS 2014) (SRS 2010) (SRS 11-12) (SRS 12-13) (SRS 2014) Full Immunization 65% 65.6% 66% 81 % 82.73% 95% (RSOC 2012-13) **(AHS 12-13) ***(WHO) (WHO) ****(HMIS) * SRS-Sample Registration System, **AHS- Annual Health System, *** WHO- World Health Organization, **** HMIS- Health Management Information System, ‘’ RSOC- Rapid Survey on Children
5 RMNCH interventions target the ‘window of opportunity’
Defining sharply, what ASHAs and AWWs should do during the 1,000 day window of opportunity
-9 months -6 months -3 months 0 (birth) +6 months +12 months +18 months +24 months
Birth preparedness Delivery PNC EBF, FP Complementary Feeding, FP
6 CARE initiated operations in Bihar in 2011, with focused implementation in 8 districts
With the support of BMGF, Integrated Family Health Initiative (IFHI), spearheaded by 8 focus districts • Patna CARE, was focussed on supporting GoB to improve family health outcomes across state. • Samastipur The core objective was to test and scale-up innovative and high impact interventions / • Begusarai solutions. • Saharsa • 2010-11: Implementation Design • Khagaria • 2011-13: Solutions implemented in 8 focus districts • Gopalganj • Ongoing measurement of Results and Outcomes • E. Champaran • W. Champaran • 2013 onwards: Scale-up of solutions across State by goverment
Focus on 8 Technical interventions Categories of solutions
1. Family planning, especially for healthy timing, spacing, and limiting of Outreach pregnancies 2. Skilled attendance at birth, meeting guidelines for quality care, and delivery of quality emergency obstetric care Facility 3. Immediate newborn care, with special emphasis on care for low birth weight infants 4. Management of asphyxia Local-level 5. Prevention and management of neonatal sepsis debottlenecking 6. Early and exclusive breastfeeding 7. Appropriate complementary feeding 8. Complete immunization Innovation
7 There were lessons learnt from IFHI by mid-2013
. Proof of concept established: the proposed solution levers had worked at a scale of ~28m population, given the level of facilitation provided:
• Clear upstrokes in a range of desired outcomes
• Clear associations between levels of effort of FLWs and desired outcomes
. GoB appetite for solution levers was strong, wished them to be scaled up (HSC, mentoring)
. Plenty of solution-specific lessons available for fine-tuning
. Initial experience with eight ‘twin’ districts suggested that scale up was likely to be more rapid than the effort involved in the original districts
. Clear system level deficiencies, which were not being significantly corrected with current efforts of BTAST and others
8 In addition to the lessons learnt, there were circumstances favoring TSU formation
Consistent political support from GoB to improve the health of women and children, exemplified most recently by the launch of the Human Development Mission (Manav Vikas Mission) under the chairmanship of Chief Minister in the state
The then recent launch of the government of India’s (GoI) RMNCH+A strategy
Success of the Ananya program in identifying strategies and solutions that support these goals
Request to the Foundation from GoB for support in the areas of nutrition and family planning
9 Combination of these conditions led to evolution of TSU
TSU approach
• Co-owning development goals with GoB given high degree of alignment with Maternal & child health and nutrition initiatives; sharp focus on desired results
• Create ownership and necessary environment within Health departments and programs to implement solutions and nurture innovation
• Providing techno-managerial and operational expertise Go Support and TSU B co-own • Creating necessary enabling environment to GoB to nurture interventions
MVM* goals • Working closely with other development partners in strengthening system components for better service delivery
Expected outcome
• Formally influence and support health department and ICDS at highest levels to shape effective policies and complement systemic changes in areas of human resources, supply chain, IT etc.
• Create an enabling environment which will eventually drive sustainable change
. *MVM- Manav Vikas Mission 10 Hypotheses and Nature of our support to GOB changed significantly over time based on learnings from eight districts
Going-in hypothesis New hypothesis with Initiatives carried New initiatives with scale in 8 districts scale up forward from 8 districts up
Improving quantity, quality, • Scaling up HSC level planning, review and learning Improving skills and CHWs FACILITIES equity & timeliness of CHW forums Improving quality of care beyond PHCs at performance of community Improving quality of care at PHCs through interactions with families through • ExpandingDHs focus / RHs of ~90K through RI service QI and delivery doctor sessions health workers to improve quality improvement and nurse mentoring home visits does drive behavior DH RHto includementoring products and is informationcrucial to improve around quantity, quality, equity & will improve intrapartum care and change but is under powered to diarrhea/ORS/Zinc,complications FP, IFA management etc and timeliness of interactions with provide more FP services consistently increase reach and coverage, • Monthly complementary feeding demonstrations families through home visits provision of comprehensive FP services hence need to consider through ICDS under the Child Malnutrition Free Bihar will drive behavior change OUTREACH PHC alternative plays Families campaign Integrating health into SHGs Formal will drive service uptake and Private ImprovingLeveraging pneumonia formal/informal-diarrhea private behavior change among PRIVATEProviders outcomesproviders willat population improve timelylevel requires & marginalized communities addressingappropriate barrierstreatment to ofcare childhood and SECTOR workinginfectious with diseases a large (diarrhea, proportion of Informal informalpneumonia) /formal providers Private Overcoming Strengthening Building Providers Improvinghealth system health systems (HR,leadership, critical supplies and infrastructure)accountability is essential to improvebarriers quality and of care+ but willculture be takenof focus care of+ by other withinDPs GoB provision of on outcomes through data policy guidance within GoB and monitoring GoB
..are critical to achieve and sustain results at scale
Schematic adapted from BMGF 11 Hypotheses and Nature of our support to GOB changed significantly over time based on learnings from eight districts
Going-in hypothesis New hypothesis with Initiatives carried New initiatives with scale in 8 districts scale up forward from 8 districts up
Improving• Scaling quantity, up QI processesquality, and nurse mentoring Improving skills and CHWs Other community equityacross & timeliness all PHCs of andCHW 56 DHs/RHs with refinements FACILITIES Improving services and QoC at facilities performance of community platforms Improving quality of care beyond PHCs at interactions(e.g., PRONTO with families simulations, through identification and became more central to our work both of health workers to improve DHs / RHs through QI and doctor homereferral visits doesof complications) drive behavior DH RH MNCH, FP and other PSTs. We needed to quantity, quality, equity & mentoring is crucial to improve change but is under powered to go beyond block PHCs for management of timeliness• Doctor of mentoring interactions in with56 DHs/RHs to improve complications management and increase reach and coverage, complications familiesmanagement will drive ofservice complications and C-sections provision of comprehensive FP services hence need to consider uptake• Added and emphasis behavior onchange identification and trackingSHGs of PHC alternativeLBW babies plays following continuum of care from facility Families IntegratingIntegratingto home healthhealth intointo SHGsSHGs Formal ImprovingLeveraging pneumonia formal/informal-diarrhea private workswill• Strengtheningdrive but GOBservice ownership uptakefacility basedand record keeping systems Private outcomesproviders willat population improve timelylevel requires & requiredbehaviorLearningfor change comprehensive collaborative among in 10 DHs to improve intra- Providers scalemarginalizedpartum play care, communities C-sections operations, and newborn addressingappropriate barriers treatment to care of childhoodand resuscitation through IHI Informal workinginfectious with diseases a large proportion (diarrhea, of informal /formal providers • Training and demand generation of comprehensive Private pneumonia) OvercomingFP services (Minilap/PPTL,Strengthening PPIUD, IUD) across 200 Building Providers Improvinghealthhigh systemvolume health systems facilities (HR,leadership, critical supplies and infrastructure)accountability is essential to + culture of focus + within GoB improve• barriersImproving quality and FPof care service but willquality be takenand informed care of bychoice other DPs provision of on outcomes through data policy guidance within GoB and monitoring
..will be critical to achieve and sustain results at scale
Schematic adapted from BMGF 12 Hypotheses and Nature of our support to GOB changed significantly over time based on learnings from eight districts
Going-in hypothesis New hypothesis with Initiatives carried New initiatives with scale in 8 districts scale up forward from 8 districts up
Improving quantity, quality, Improving skills and CHWs Other community equity & timeliness of CHW performance of community platforms improving quality of care beyond PHCs at interactions with families through health workers to improve DHs / RHs through QI and doctor home visits does drive behavior DH RH quantity, quality, equity & mentoring is crucial to improve change but is under powered to timeliness of interactions with complications management and increase reach and coverage, families will drive service provision of comprehensive FP services hence need to consider uptake and behavior change SHGs PHC alternative plays Families Formal IntegratingIntegrating healthhealth intointo SHGsSHGs Private ImprovingLeveraging pneumonia formal/informal-diarrhea private workswill drive but GOBservice ownership uptake and Providers outcomesproviders willat population improve timelylevel requires & requiredbehaviorfor change comprehensive among PRIVATE addressingappropriate barrierstreatment to ofcare childhood and scalemarginalized• playLearning communities investment across 2 districts to improve SECTOR diarrhea / pneumonia outcomes across private and workinginfectious with diseases a large (diarrhea, proportion of Informal informalpneumonia) /formal providers public sector Private Strengthening Building Overcoming Providers Improvinghealth system health systems (HR,leadership, critical supplies and infrastructure)accountability is essential to improvebarriers quality and of care+ but willculture be takenof focus care of+ by other withinDPs GoB provision of on outcomes through data policy guidance within GoB and monitoring
..will be critical to achieve and sustain results at scale
Schematic adapted from BMGF 13 Our approach for RMNCHN changed significantly since inception based on learnings from 8 districts
Going-in hypothesis New hypothesis with Initiatives carried New initiatives with scale in 8 districts scale up forward from 8 districts up
•ImprovingHR support quantity, – rationalization quality, and policy changes Improving skills and CHWs Other community •equityStreamlining & timeliness supply of CHWchain – procurement guidelines, performance of community platforms improving quality of care beyond PHCs at interactionspharmacist with trainings families through health workers to improve DHs / RHs through QI and doctor •homeOperationalizing visits does drive PPP behavior cell and improved accreditation DH RH quantity, quality, equity & mentoring is crucial to improve changepolicies but is under powered to timeliness of interactions with complications management and •increaseStrengthening reach and NCH coverage, services through functional pediatric families will drive service provision of comprehensive FP services henceward need and SNCUsto consider at District Hospitals uptake and behavior change SHGs PHC •alternativeTA to GoB plays for integrated information systems through ICT Families • Planning and management support: PIP, budget and IntegratingIntegrating healthhealth intointo SHGsSHGs Formal expenditure tracking ImprovingLeveraging pneumonia formal/informal-diarrhea private workswill drive but GOBservice ownership uptake and Private • TA to strengthen procurement and distribution of supplies outcomesproviders willat population improve timelylevel requires & requiredbehaviorfor change comprehensive among Providers scalemarginalized play communities addressingappropriate barriers treatment to care of childhoodand Informal workinginfectious with diseases a large proportion (diarrhea, of informalpneumonia) /formal providers Overcoming Strengthening Building Private leadership, accountability Providers Improvinghealth system health systems+ (HR, critical supplies and infrastructure) is essential to improvebarriers quality and of care but willculture be takenof focus care of+ by other withinDPs GoB provision of on outcomes through data policy guidance within GoB and monitoring Health Systems ..will be critical to achieve and sustain results at scale
Schematic adapted from BMGF 14 Our approach for RMNCHN changed significantly since inception based on learnings from 8 districts
Going-in hypothesis New hypothesis with Initiatives carried New initiatives with scale in 8 districts scale up forward from 8 districts up
Improving quantity, quality, Improving skills and CHWs Other community •equityOn the & timelinessjob support of and CHW tools to strengthen leadership of performance of community platforms improving quality of care beyond PHCs at interactionsICDS and withHealth families at different through levels health workers to improve DHs / RHs through QI and doctor •homePeer visits to peer does influence drive behavior through TSU team presence DH RH quantity, quality, equity & mentoring is crucial to improve •changePlan for but leadership is under powered and management to development timeliness of interactions with complications management and increaseprograms reach for GoBand coverage,officials families will drive service provision of comprehensive FP services •henceUniversal, need tomodular consider program management trainings for uptake and behavior change SHGs PHC alternativeGoB leadership plays • Rewards and Recognition program (Bihar Swasth Seva Families IntegratingIntegratingRatan) healthhealth intointo SHGsSHGs Formal ImprovingLeveraging pneumonia formal/informal-diarrhea private workswill drive but GOBservice ownership uptake and Private outcomesproviders willat population improve timelylevel requires & requiredbehaviorfor change comprehensive among Providers scalemarginalized play communities addressingappropriate barriers treatment to care of childhoodand Informal workinginfectious with diseases a large proportion (diarrhea, of Private informalpneumonia) /formal providers Strengthening Building leadership, accountability Providers Improving health systems+ (HR,leadership, critical supplies and infrastructure) is essential to improve quality of care but willculture be takenof focus care of +by other withinDPs GoB on outcomes through data within GoB and monitoring
..will be critical to achieve and sustain results at scale
Schematic adapted from BMGF 15 Our approach for RMNCHN changed significantly since inception based on learnings from 8 districts
Going-in hypothesis New hypothesis with Initiatives carried New initiatives with scale in 8 districts scale up forward from 8 districts up
Improving quantity, quality, Improving skills and CHWs Other community equity & timeliness of CHW performance of community platforms improving quality of care beyond PHCs at interactions• Strengthening with families and systematizing through reviews with use of health workers to improve DHs / RHs through QI and doctor homedata visits through does drive dashboards; behavior other complementary tools DH RH quantity, quality, equity & mentoring is crucial to improve changelike but Mobile is under app poweredand web toportal for GoB officials at state, timeliness of interactions with complications management and increasedistrict reach and blockand coverage, level families will drive service provision of comprehensive FP services hence• Upskilling need to GoBconsider officials on use of data and developing uptake and behavior change SHGs PHC alternativeresult-orientation plays • Strengthening quality of care through clinical reviews at Families IntegratingIntegratingfacility levelhealthhealth intointo SHGsSHGs Formal ImprovingLeveraging pneumonia formal/informal-diarrhea private workswill drive but GOBservice ownership uptake and Private outcomesproviders willat population improve timelylevel requires & requiredbehaviorfor change comprehensive among Providers scalemarginalized play communities addressingappropriate barriers treatment to care of childhoodand Informal workinginfectious with diseases a large proportion (diarrhea, of informalpneumonia) /formal providers Strengthening Building Private leadership, accountability Providers Improving health systems+ (HR, critical supplies and infrastructure)accountability is essential to improve quality of care but willculture be takenof focus care of +by other withinDPs GoB on outcomes throughthrough datadata within GoB and monitoring
..will be critical to achieve and sustain results at scale
Schematic adapted from BMGF 16 Not only hypothesis and nature of support, operational scale has also changed over a period of time
2011-2013 IFHI operation TSU Mode of operation
137 blocks 534 blocks
Solution scale-up across state 0.9m pregnant women 2.7m pregnant women
0.85m births/ year 2.55m births/ year
46,000 ASHA/ AWW 180,000 ASHA/ AWW
Intervention support 1,900 doctors 4,200 doctors
5,000 Grade A Nurses / ANMs 25,000 Grade A Nurses / ANMs
17 Given the level of co-ordination needed with state, TSU offered a structure designed providing support at all levels
TSU structure Healthcare hierarchy
Strategy formulation & technical support team
State level
State RMNCH+A unit (SRU) Nutrition Strategy Unit (NUS) District and block level
Ground support team State level Provides programmatic support, technical skilling, problem solving support and mentoring at block and district levels District and block level
Data collection and analytics team State level Puts in place processes to generate and analyse outcome and process data on community and facility-level services District and block level
18 CML Framework- What are we trying to do
Maternal, New Childhood born & Child Nutrition Pneumonia and Web Domains in Health Diarrhoea Platform for which we are real-time working Reproductive Strengthening data access Health/ Family Health System VL Planning
Geo-tagging
Tracking Progress of Output and Outcome level and geo intervention/solution spatial implemented by the system Input and Process level analysis and BTSP
Measurement Presenting Framework data to the Exploratory studies GoB at Deep Dives appropriate Assessment of Solutions level
19 Coverage of some of the major measurement efforts
Facility Assessment Age Groups All functional facilities of Bihar 0-2 months Infrastructure and HR: annual Equipment, supply, record
All Districts covered: 3-5 months keeping: bi-annual District Estimates and the state estimate 6-8 months 534 blocks across 38 Direct Observation of Delivery districts Measurements 9-11 months Pre and post mentoring Independent observation through 15,687 sample QoC size/age group 12-23 months a check-list Covered 400 facilities
78,435 respondents Facility Information System
Frequency: Bi- Data Quality Coverage: annual Assurance: During the period of mentoring
Coverage: population survey: LQAS+survey: populationCoverage: 15% back checks Granular case-wise data Covered 400 facilities
20 Family Planning
21 Contraceptive method mix
6-8 months age group 12-23 months age group 6-8 months age group (VHSND pilot blocks) Method R6 R7 Change R6 R7 Change R6 R7 Change
mCPR 13% 11% 18% 18% 12% 16%
IUD 0.4% 0.8% 0.6% 0.7% 0.3% 1.9%
Injectable 0.3% 0.5% 0.4% 0.7% 0.3% 1.1%
OCP 1% 1% 1.3% 0.3% 1.1% 1.1%
Condoms 1.3% 1.1% 1.3% 1% 1.4% 1.1%
TL 10.2% 7.5% 13.8% 14.1% 8.9% 11%
0.7% 0.7% Uptake of 0.4% PPIUCD 0.3% 0.3% R6 0.2% 0.2% across age 0.1% 0.1% 0.1% 0.1% R7 groups 0.0% 6-8 mo. 6-8 mo. 6-8 mo. 12-23 mo. 12-23 mo. 12-23 mo. (30 EH sites) (PPIUCD sites) (30 EH sites) (PPIUCD sites)
Source: LQAS R6 (May – Sept 2014) and R7 (Sept – Nov 2015)
22 Systematic planning and activation of FP services in public facilities is beginning to show increase in service uptake
Method Mix Clinical FP Services Method Mix Non-Clinical FP Services
= 43,612 = -21,599
4047265 4025666 307471 = 17,074
263859 262810 245736
= 25,451 = 107,660
61947 726490 618830 36496
IUCD PPIUCD FS Condom (In pc) OCP (In cycles)
Apr 2014 – 4,30,723 50,910 5,41,462 53,72,668 8,41,359 Mar 2015
April to Dec, 2014 April to Dec, 2015 April to Dec, 2014 April to Dec, 2015
23 Availability of consumables (incl. FP-related consumables) at facilities have shown improvement
% availability of drugs and commodities at facilities
98%
88% 82% 79% 71% 69% 70%71% 61% 63% 64%
51% 47% 46%
Cap. Amoxicillin Magnesium Inj. Oxytocin Condoms OCP Pregnancy kit IUCD Sulphate CFA R1 CFA R2
Source: CFA Round 1 data (April to June 2015); CFA Round 2 data (Dec 2015 to Jan 2016) Note: Availability calculated as (1-% stockout) 24 Maternal Health
25 AMANAT trainings have significantly improved clinical practices at facilities (1/2)
Handing washing with water and soap Did not apply Fundal pressure * (before delivery) *
91% 86% 81% 71%
Non-AMANAT facilities AMANAT facilities Non-AMANAT facilities AMANAT facilities
10 IU Oxytocin administered Any dose of Oxytocin administered (within 1 minute of delivery) * (after delivery) *
91% 78%
53%
14%
Non-AMANAT facilities AMANAT facilities Non-AMANAT facilities AMANAT facilities
Source: 2015 DoD in Non-AMANAT facilities and AMANAT facilities * Statistically significant (p<0.05) 26 Referral protocols have shown improvement (additional improvement in AMANAT facilities) with better supervision and referral tracking mechanism (Purnia district example)
% complications identified
8.3% 8.8%
5.3% Apr'15 4.2% 3.7% Jul'15 2.3% Oct'15 0.7% 0.2% 0.3%
AMANAT facilities Non-AMANAT facilities Total For Oct’15, N = 6299
% cases that reached DH with Referral slip/ written advice vs cases that reached DH
71.4% 75.9% 72.7% 74.2%
47.4% Apr'15 33.3% Jul'15 Oct'15 0.0% 3.3% 2.4%
AMANAT facilities Non-AMANAT facilities Total For Oct’15, N = 62
% cases that reached DH with initial stabilization as per SOP vs cases that reached DH
64.3% 62.0% Apr'15 37.1% Jul'15 24.2% 28.9% 8.3% Oct'15 0.0% 3.3% 2.4%
AMANAT facilities Non-AMANAT facilities Total For Oct’15, N = 62
Note: No. of births in April 2015 = 3969, July 2015 = 5090, October 2015 = 6299
27 New Born Health
28 Essential newborn care practices at facilities have shown marked improvement – AMANAT facilities have shown higher increase (1/2)
Skin-to-skin 39% 32% 31% R6 care (STSC) at 14% 20% 20% 18% 20% R7 birth All deliveries* Public facility deliveries* AMANAT facilities * Non-AMANAT facilities* (Public, Private, Home) N=14290 N=13905 N=8357 N=7882 N=1112 N=831 N=7245 N=5419
81% 70% 74% 73% 70% 74% 56% 57% Early Initiation R6 of Breast R7 Feeding (EIBF) All deliveries Public facilities* AMANAT facilities* Non-AMANAT facilities* (Public, Private, Home) N=15671 N=15471 N=9092 N=8622 N=1207 N=892 N=7885 N=5935
91% 94% 93% 97% 91% 94% 66% 68% Weighed at R6 Birth R7
All deliveries * Public facilities* AMANAT facilities * Non-AMANAT facilities* (Public, Private, Home) N=15153 N=15064 N=8722 N=8333 N=1160 N=866 N=7562 N=5751
Source: LQAS R6 (May – Sept 2014) and R7 (Sept – Nov 2015) * Statistically significant (p<0.05) Values related to AMANAT & Non-AMANAT are based on 78% of data 29 Essential newborn care practices at facilities have shown marked improvement – AMANAT facilities have shown higher increase (2/2)
93% 86% 71% 60% 37% R6 Dry cord care 26% R7
Public facility deliveries* Private facility deliveries* Home deliveries*
N=8160 N=7306 N=2065 N=1946 N=4165 N=3909
For deliveries in Public facilities, Dry This drop can be attributed to increase in Cord Care continued at home * application of various reagents to the cord after beneficiary returns home
51%
31% 33% 23% 16% 13% 10% 7%
N=8160 N=7306 Mustard Oil Talcum Powder Gentian Violet R6 R7 R6 R7
Source: LQAS R6 (May – Sept 2014) and R7 (Sept – Nov 2015)
* Statistically significant at p<0.05 30 vLBW tracking intervention has led to marked increase in accurate identification of vLBW babies and direct reduction in mortality of identified vLBWs
% live births identified as vLBW Identified vLBW babies advised %vLBW families with at least 1 babies for extra care at hospital FLW visit in 1st week of delivery 5.2% 46% 4% 34%
2% 15% 18%
Prior to structured Post introduction Expected intervention of intervention Prevalence R1 R2 R1 R2 (Feb to Apr-15) (Sept to Oct-15) (Based on FIS data) (After adjustment) (After adjustment)
LBW babies who died within 3- %vLBW babies who were not KMC at facilities for vLBW 27 days bathed before 48 hrs of delivery babies
9.73% 51% 7.84% 41% 14.5% 8.3%
R1 R2 R1 R2 R1 R2
1 - vLBW implies babies with birth weight <= 2000 gms R1 - Before Intervention (Feb to Apr-15) N=1408 2- Expected prevalence is from Facility Information System (FIS): this estimation is on the basis of observation of large number of deliveries by nurse mentors working in facilities of rural Bihar R2 - Post intervention (Sept to Oct-15) N= 1664 31 Nutrition
32 Practice of Exclusive Breast Feeding and Initiation of Complementary Feeding has shown improvement
EBF and CF practices**
76%
67% 65% 61%
52%
46% 46% 42%
Exclusive Breast Feeding (0-2 Exclusive Breast Feeding (3-5 Initiation of Complementary Initiation of Complementary months) months) Feeding (6-8 months) Feeding (6-8 months) in VHSND pilot blocks R6 R7 N=15687 N=15649 N=15687 N=15649 N=15687 N=15649 N=643 N=639
Source: LQAS R6 (May – Sept 2014) and R7 (Sept – Nov 2015)
** Statistically significant at p<0.05 33 Frequency of complimentary feeding has improved significantly while other feeding practices (min. dietary diversity and min. acceptable diet) have remained stagnant
Age appropriate frequency of feeding ** Age appropriate quantity of feeding (in ml.)
150 131 111 99
86% 68%
38% 39% 6-8 months 9-11 months
Benchmark Benchmark 6-8 months 9-11 months value = 200 ml value = 300 ml N=15669 N=15648 N=15663 N=15648
Children receiving minimum dietary diversity Children receiving minimum acceptable diet
20% 20%
15% 14% 15% 15% 13%
10% 10% 10% 6% 6% 6% 6% 5% 5%
0% 0% 6-8 months 9-11 months 6-8 months 9-11 months N=15687 N=15649 N=15687 N=15649 N=15687 N=15649 N=15687 N=15649 LQAS R6 Source: LQAS R6 (May – Sept 2014) and R7 (Sept – Nov 2015)
LQAS R7 ** Statistically significant at p<0.05 34 Seasonal trends: Exclusive Breastfeeding
Exclusive Breastfeeding 100%
90%
80%
70% R2-R5 60%
50%
40% R6 30%
20%
10%
0% 0th month 1st month 2nd month 3rd month 4th month 5th month R2-IFHI R3-IFHI R4-IFHI R5-IFHI R6-IFHI R6-IFHI-Twin (8) R6-Non-IFHI (22) R6-Twin+Non-IFHI (30) EBF indicators provide the clearest indication of the considerable impact of season. The best EBF rates are seen in round R2 and R5 (both from winter), and the worst in R6 (peak summer). As seen in the next two slides, there are two main offending fluids: plain water and animal milk. The prevalence of feeding of plain water is entirely a function of season, as evinced by the non-linear changes across rounds, and is a mirror image of the overall EBF curves on this page. Animal milk feeding patterns represent a steady replacement of mother’s milk with age, with only minor seasonal change, largely limited to the 3+ months group.
35 Seasonal trends: Giving water
Plain water given in the previous 24 hours 100%
90%
80%
70%
60% R6 50%
40%
30%
20% R2-R5
10%
0% 0th month 1st month 2nd month 3rd month 4th month 5th month R2-IFHI R3-IFHI R4-IFHI R5-IFHI
R6-IFHI R6-IFHI-Twin (8) R6-Non-IFHI (22) R6-Twin+Non-IFHI (30)
36 Seasonal trends: Giving Animal milk
Animal or formula milk given in the previous 24 hours 100%
90%
80%
70%
60%
50%
40% R6 30% R2-R5 20%
10%
0% 0th month 1st month 2nd month 3rd month 4th month 5th month R2-IFHI R3-IFHI R4-IFHI R5-IFHI
R6-IFHI R6-IFHI-Twin (8) R6-Non-IFHI (22) R6-Twin+Non-IFHI (30)
37 Visceral Leishmaniasis
38 Historical Visceral Leishmaniasis Incidence in Bihar
39 Interventions for VL Elimination
IRS Spray
Early Complete Diagnosis Treatment VL Elimination
KA-MIS Surveillance
40 Effectiveness of IRS Spray
Proportion of HHs covered 100.0% 81.5% 72.5% 73.7% 80.0% 69.4% 67.4% 62.5% 28.6% 52.4% 60.0% 33.4% 33.3% 36.2% 29.5% 12.3% 27.4% 40.0% 52.9% 20.0% 40.1% 35.1% 36.1% 36.3% 37.9% 40.3% 0.0% DDT SP DDT SP 2014 R1 2014 R2 2015 R1 2015 R2 2016 R1
Completely sprayed
Squads reach a high proportion of HH, Less than 10% HH refuse spraying, and similar for DDT and SP even this has come down with SP 100% 85% 86% 80% 90% 15% 80% 9.4% 9.0% 10.2% 10% 60% 5.6% 40% 20% 5% 0% 0% R II 2015 R 1 2016 R II 2015 R 1 2016 R II 2015 R 1 2016 R II 2015 R 1 2016 DDT SP DDT SP
41 IRS as main intervention for elimination
100% 2.5
80% 2
60% 31% 1.5 33% 35% 12% 27%
40% 1 IRS Coverage IRS 48% 20% 45% 40% 0.5 32% 32% 35% 36% 37% 10,000) (per Incidence
0% 0 2011 2012 2013 2014 R1 2014 R2 2015 R1 2015 R2 2016 R1 Completely Sprayed Partially Sprayed Incidence of VL
Projections of IRS coverage for 2012 and 2013 were made based on linear regression modelling using district level coverages of 2014 to 2016, by which point monitoring support had increased considerably It is assumed that the 2012 coverage was typical of years since the appointment of KTS and VBDC under World Bank support.
Source – CML Survey
42 Thanking all who are supporting our work in Bihar…
Donor
Lead Partner
Partners
Sub Grantees
43