RAPID ASSESSMENT – NEWBORN STABILIZATION UNIT (NBSU) In eight districts of Assam (Charaideo, Dibrugarh, Golaghat, Jorhat, Majuli, Sivasagar, Tinsukia, and Kamrup Rural (November – 2020) Acronyms CHC: Community Health Center IMR: Infant Mortality Rate IPE Global: Infrastructure Professionals Enterprise Global FBNC: Facility Based Newborn Care FRU: First Referral Unit F-IMNCI: Facility based Integrated Management of Neonatal and Childhood Illness FBNC: Facility Based New born Care HCP: Health Care Providers LBW: Low Birth Weight KMC: Kangaroo mother Care MO: Medical Officer NBCC: Newborn Care Corner NBSU: Newborn Stabilization Unit NHM: National Health Mission NMR: Neonatal Mortality Rate NSSK: Navjat Shishu Suraksha Karyakram PHC: Primary Health Center PT: Phototherapy QI: Quality Improvement RW: Radiant Warmer RMNCH+A: Reproductive, Maternal, Newborn, Child health & Adolescent Health SNCU Special Newborn Care Unit USAID: United States Agency for International Development 1 Table of Contents Executive Summary ............................................................................................... 3 Background ........................................................................................................... 4 Objectives of the rapid assessment ...................................................................... 5 Process adopted .................................................................................................... 5 Findings ................................................................................................................. 8 Lay Out and Area: Space available in NBSUs .......................................................... 9 Beds available in NBSUs ....................................................................................... 10 Human Resource .................................................................................................. 11 Essential Equipment in NBSUs ............................................................................. 12 Services in NBSUs ................................................................................................. 14 Recommendations .............................................................................................. 15 Annexure 1: NBSU Tool for Rapid Assessment ..................................................... 20 Annexure 2: District-wise Findings ....................................................................... 25 Annexure 3: Summary table - Availability of space and resources in 34 NBSUs ... 29 2 Executive Summary The Government of India (GoI) introduced the Facility Based Newborn Care (FBNC) guidelines in the year 2011for management of small and sick newborns at three levels of care. Various assessments have shown that while Newborn Care Corner (NBCCs) and Special Newborn Care Units (SNCUs) have largely been operationalized, there has been suboptimal implementation of NBSUs across the country. A rapid assessment of NBSUs was undertaken by IPE Global at the request of NHM Assam, under USAID’s Project Vriddhi, with the aim of determining the functioning of NBSUs in order to support the Government of Assam to strengthen NBSUs as per national guidelines. The assessment was conducted in 34 NBSUs, selected out of 55 existing NBSUs as per selection criteria, in eight districts of Assam. Districts covered included the seven upper Assam districts of Charideo, Dibrugarh, Golaghat, Jorhat, Majuli, Sivasagar and Tinsukia, as per the Vriddhi project mandate in Assam, and Kamrup Rural, that was included at the behest of the Assam government. The assessment was conducted online by interviewing 51 personnel including facility in-charges, medical staff and block officials using a rapid assessment tool. The rapid assessment reveals that 3 (9%) NBSUs have an area of 400 sq. ft. or more as recommended in the draft 2020 FBNC guidelines, 9 (27%) NBSUs have an area of 300 sq. ft. or more while 7 (20%) NBSUs have area less than 200 sq. ft. which is inadequate for an NBSU. The earlier recommendation of 200 sq. ft. or more space, as per the 2011 FBNC guidelines, is available in 18 (80%) NBSUs. Only 6 (18%) NBSUs have the recommended 4 beds. For operationalization of any NBSU adequate staffing consisting of 1 medical officer and 4 designated NBSU nurses is a pre-requisite. The 34 NBSUs are staffed with 28 medical officers and 66 nurses, averaging to around 2 nurses per facility. Of these nurses, 27 are full time NBSU nurses. While 4 facilities do not have a medical officer, none of the NBSUs have 4 full time designated nurses. The assessment also highlights capacity building needs with 9 (32%) medical officers being trained in FBNC and 8 (12%) nurses having undertaken the training. A minimum of 4 functional radiant warmers as per 2020 guidelines are available in 5 (15%) NBSUs and a minimum of 3 functional radiant warmers as per 2011 guidelines in 12 (35%) NBSUs. A minimum of 2 functional phototherapy units are available in 19 (56%) NBSUs and a minimum of 1 functional unit in 30 (88%) NBSUs. It is important for NBSUs to keep admissions overnight in order to provide appropriate care for sick and small newborns nearer to their residence and to reduce the workload on SNCUs. Night admissions are being done in 14 (41%) NBSUs, mainly for night deliveries and being shifted out with the mother or being sent to the SNCU within 24 hours. Hence it is recommended to build capacity of NBSU staff, redistribute and re-organize human resource (HR), equipment and drugs so as to fully operationalize a minimum of one NBSU per district initially and aim for strategically operationalizing 3 to 5, as per the district size and requirement, with the allocation of additional resources including HR as necessary. 3 Background Although the neonatal mortality rate has reduced from 35 in 2008 to 23 in 2018 (SRS), it is still far from the NHP goal of 16 by 2025 and the INAP goal of single digit NMR by 2030. As per government data, more than 26 million babies are born annually of which 15-20% are pre-term and low-birth weight (LBW). In India, 78% of neonatal deaths occur within first week of life, the major causes being prematurity and LBW (48%), birth asphyxia and trauma (13%), pneumonia (12%), sepsis (5.4%), congenital anomalies (4%) and diarrhoea (3%), more than 80% of which are preventable. This highlights the importance of continued investments in providing facility based newborn care (FBNC) to small and sick newborns. To provide FBNC, nearly 900 Special Newborn Care Units (SNCUs), more than 2,500 Newborn Stabilization Units (NBSUs) and 20337 Newborn Care Corners (NBCCs) have been established. Though large investments have been made in expanding FBNC structures in the country, the quality of care provided as per international standards, adherence to national guidelines and optimal provision of care and utilization as per the three tier system envisaged remain areas of concern. Additionally, adherence to the recently released WHO’s ‘Standards for improving the quality of care for small and sick newborns in health facilities, 2020’ and the revised national ‘FBNC Operational Guidelines, 2020’ (draft guidelines under finalization), must be ensured. NBSUs at the sub district level serve as an important link between SNCUs at the district level and NBCCs in the health facilities. If appropriately operationalized, they serve to reduce delays in initiation of appropriate care for sick and small newborns including for emergencies and for minor ailments thereby improving outcomes, help in stabilizing sick newborns before referral to the SNCUs, prevent overloading of SNCUs at the district level, provide care closer to home and reduce the cost of care. However, the implementation of FBNC has been uneven, and these critical middle tier NBSUs are not functional as envisaged. To enhance the support towards care of sick and small new-born at sub-district level, as per the Government of Assam, a rapid assessment of NBSUs was undertaken by IPE Global, under USAID’s Project Vriddhi, in order to develop a strategy to further operationalize NBSUs and strengthen their functioning as per the key standards for NBSUs recommended in the national FBNC guidelines and as per global standards. 4 IPE Global has prior experience of operationalizing 15 NBSUs in four states of Jharkhand (5), Uttarakhand (4), Punjab (3), Haryana (3) in 9 Aspirational Districts through USAID’s Vriddhi project. The model adopted for NBSU Operationalization includes: Gap analysis conducted jointly with states and remedial actions undertaken as below. • Human resource (HR) and logistics issues have been strengthened with state support and capacity building of staff posted at NBSUs with Vriddhi Support • Data recording and reporting mechanism are also strengthened Training has been completed and data flow has started from NBSUs operationalized, HR has been mobilized in 3 states and infrastructure and logistics has been strengthened in 4 states. In consultation with NHM Assam, the rapid assessment of NBSUs was conducted in eight districts of Assam, that is, seven districts in upper Assam which included all five project districts where IPE Global has been working in since October 2020 and two newer districts, along with Kamrup Rural. Objectives of the rapid assessment The rapid assessment was conducted with the overall aim of determining the functioning of NBSUs in order to support the Government of Assam to strengthen NBSUs as per national guidelines. Specific objectives are to: • Assess current status