Rapid Assessment – Newborn Stabilization Unit (Nbsu)

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

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

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.

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.

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 of HR, infrastructure, equipment and admission practices. • Identify priority areas for operationalizing NBSU and strengthen functioning

Process adopted Project Vriddhi began activities in the state of Assam after approval of its microplan of activities by the government of Assam in early October 2020. Following communication to the districts on IPE Global activities, including the rapid assessment of NBSUs, relevant district and block officials were contacted by the state team for necessary approvals and assistance to undertake the rapid assessment. Lists of NBSUs in the district, those NBSUs reporting admissions in the last five months and contact details of relevant authorities in the NBSU facilities were obtained. Simultaneously, the national technical team prepared a data collection tool for the rapid assessment based on the national FBNC guidelines and key global standards.

The assessment of NBSUs was conducted online, through telephonic interviews, due to the COVID 19 pandemic from 16-20 October by Vriddhi project staff. Key personnel interviewed for the rapid assessment included 16 Medical Officers and 20 Nurses of NBSUs and 15 Block Program Managers (BPMs)/Assistant BPMs in eight districts, that is, 7 districts of upper Assam including Charideo, Dibrugarh, Golaghat, Jorhat, Majuli, Sivasagar, Tinsukia and Kamrup Rural using a

Rapid Assessment Tool (Annexure 1). A total of 51 personnel were interviewed. Medical Officer In-charge (I/C) of the facility, Medical Officer I/C of the NBSUs and Staff Nurses deputed in the NBSUs were interviewed telephonically. Support from the respective Block Program Managers and Assistant Block Program Managers were also sought as per the requirement for relevant information. Key components for which data was collected included infrastructure, space, human resource and capacity, equipment, drugs and services. Following data collection, data cleaning, data analysis and report writing completed the process. The information in the report will be relevant to strengthen NBSUs to achieve standards of 3 to 5 operational NBSUs that achieve key standards.

Selection process of NBSUs for Rapid Assessment

There a total of 203 NBSUs in Assam as per state records (Table 1).

Table 1: District-wise distribution of NBSUs in Assam

S. No District No. of S. No District No. of NBSU NBSU 1 Baksa 4 17 Jorhat 10 2 Barpeta 12 18 Kamrup Metro 3 3 Biswanath 6 19 Kamrup Rural 9 4 Bongaigaon 3 20 Karimganj 5 5 Cachar 14 21 Karbianglong 1 6 Charaideo 4 22 Kokrajhar 6 7 Chirang 1 23 Lakhimpur 8 8 Darrang 4 24 Majuli 2 9 Dhemaji 5 25 Morigaon 9 10 Dhuburi 8 26 Nagaon 13 11 Dibrugarh 13 27 Nalbari 9 12 Dimahasao 1 28 Sivasagar 5 13 Goalpara 8 29 Sonitpur 6 14 Golaghat 6 30 Tinsukia 6 15 Hailakandi 2 31 Udalguri 2 16 Hojai 4 32 West Karbianglong 14

Out of the 55 NBSUs available as per state records in eight districts, 32 were shortlisted which were found to be reporting admissions in last 5 months along with all NBSUs located in FRUs

6 irrespective of the reporting status, that is, 3 additional NBSUs. One NBSU located in a hospital that has been converted to a Covid Care Centre was excluded from the desk review (Figure 1).

Figure 1: Selection process for Rapid Assessment

Of the 34 NBSUs assessed, 47% were located in FRUs, 32% were in non- FRU CHCs and 21% were in PHCs. As per the district-wise break-up, almost half the NBSUs assessed were from Dibrugarh and Kamrup Rural districts (23% from each district) while the other districts had a lower share of NBSUs (Table 2).

Table 2: Location of NBSUs selected for rapid assessment

District NBSUs NBSUs Facility where NBSU is located per district selected for assessment FRU CHC PHC Charaideo 4 2 1 1 Dibrugarh 13 8 1 5 2 Golaghat 6 3 1 2 Jorhat 10 4 2 2 Majuli 2 1 1 Sivasagar 5 2 1 1 Tinsukia 6 6 3 1 2 Kamrup Rural 9 8 6 2 Total 55 34 16 11 7 Location of NBSUs by facility (%) 47% 32% 21%

Findings The findings were interpreted as per the national guidelines standards for NBSUs given below.

Table 3: Key standards for operationalizing NBSUs as per national guidelines

Standard FBNC Operational Guideline 2011 Draft FBNC Operational Guidelines 2020 Space and • CHC/FRU level • At subdistrict level (CHC/FRU) location • Within or in close proximity to the • Preferably in close proximity to maternity maternity ward ward • At least 200 sq. ft. floor space • 400 sq. ft. (100 sq. ft. per radiant warmer) Bed capacity • 4 bedded unit • 4-6 bedded unit Human • 1 doctor trained in F-IMNCI • 1 Medical Officer trained in FBNC, NSSK resource • 4 full time staff nurses trained in F- 2020 IMNCI • 4 staff nurses trained in FBNC, NSSK 2020 - one per shift Expected • Care at birth • Care at and after birth services at • Feeding support • Management of sick and small newborns NBSU • Care of sick newborn meeting admission criteria - Management of LBW > 1800 gms - Stabilization of newborns with - Phototherapy for emergency signs hyperbilirubinemia - Newborns with weight > 1800 gms with - Management of newborn sepsis feeding problem/fast breathing/ - Stabilization and referral of sick hyperthermia/jaundice/ sepsis newborns and very LBW - LBW 1500-1800 gms with no sign of - Referral services sickness • Immunization services - Newborns who cannot be transferred/referred - Newborns back-referred from SNCU Essential • Radiant warmer – 3 • Radiant warmer – 4-6 Equipment • Phototherapy Unit – 1 • Phototherapy Unit – 2 • Resuscitation equipment • Resuscitation equipment • For maintaining temperature • For maintaining temperature • General equipment • General equipment • Laboratory equipment • Laboratory equipment - Glucometer - Glucometer - 1 - Bilirubinometer - Pulse oximeter - 2 - Bilirubinometer - 1 • Essential drugs for care of normal and sick newborn

Following are the key findings from the rapid assessment -

Lay Out and Area: Space available in NBSUs

Table 4: Area-wise distribution of NBSUs

The findings revealed District NBSU area NBSU area NBSU area NBSU area that 20% of NBSUs < 200 200 to 300 to > 400 have space less than sq. ft. <300 sq. ft. <400 sq. ft. sq. ft. 200 sq. ft. which is the Charaideo 1 1 - - minimum required as per the 2011 FBNC Dibrugarh - 5 1 2 guidelines. Although Golaghat - 1 1 1 80% have a minimum Jorhat - 3 1 - of 200 sq. ft. space, Majuli - - 1 - only 9% have a Sivasagar - 2 - - minimum area of 400 Tinsukia 3 2 1 - sq. ft. that is required for a NBSU as per the Kamrup Rural 3 4 1 - revised draft 2020 Total NBSUs 7 (20%) 18 (53%) 6 (18%) 3 (9%) FBNC guidelines (Table 4 and Figure 2). Figure 2: Space for NBSUs

Beds available in NBSUs

Table 5: Bed-wise distribution of NBSUs

District < 3 beds 3 beds > 4 beds

Charaideo 2 As per the FBNC guidelines, NBSUs Dibrugarh 4 4 2 are 4 bedded units and may even Golaghat 3 be 6 bedded. Of the NBSUs Jorhat 3 1 1 assessed, 82% do not have 4 beds Majuli 1 1 (Table 5 and Figure 3). Sivasagar 2 Tinsukia 4 2 1 Kamrup Rural 3 5 1 Total NBSUs 18 (53%) 10 (29%) 6 (18%)

Figure 3: Availability of beds in NBSUs

82% NBAUs do not have 4 beds Table 6: Lay out of the NBSUs Other Lay out criteria of NBSUs S. Available Lay out Criteria While most (over 90%) of the No. % (No.) 1 Located in close proximity to maternal ward 91% (31) NBSUs were located in close 2 Hand Washing Area in NBSU 94% (32) proximity to the maternity ward 3 Elbow operated taps 68% (23) and had a hand washing area, 4 Area earmarked for Nursing Station 56% (19) other provisions were available 5 Separate Gowning Area 50% (17) in one-third to half of the NBSUs 6 Examination/Triage area 32% (11) (Table 6). 7 Space for mother’s education 44% (15) 10

Human Resource

As per the FBNC guidelines there should be 1 doctor and 4 full time nurses in each NBSU trained in F-IMNCI (2011 guidelines) and FBNC (2020 guidelines) Medical Officers Table 7: Training and Qualifications of Medical Officers Doctors are available in 82% Medical Officers (28) Total facilities and while 64% are trained on F-IMNCI, only Training F-IMNCI 18 (64%) FBNC 9 (32%) 32% are trained on FBNC Qualifications MBBS 10 (36%) (Table 7). Of these medical MD Paediatrics - 8 16 (57%) Paediatrician officers, 57% are DCH - 8 pediatricians. 4 facilities do DGO - 1 2 (7%) Others not have any medical MD Pathology - 1 officer. Nurses There are 66 nurses in 33 facilities Table 8: Availability and Training of Nurses averaging 2 nurses per facility. However, Nurses Available F-IMNCI FBNC only 41% (27 – refer to Table 8) of these Trained Trained nurses are designated to NBSUs full time In Facility 66 30 (45%) 8 (12%) with an average of less than 1 full time In NBSU 27 designated nurse to take care of 10 (37%) 5 (19%) newborns per NBSU. Of these NBSU nurses, 37% are trained on F-IMNCI and only 19% on FBNC. While 14% facilities have 4 nurses, none of the NBSUs have 4 nurses designated full time to the NBSU as per the government standards raising serious concerns regarding the care provided by NBSUs to admitted sick newborns. 50% of the facilities have 2 or more nurses while the other 50% have less than 2 nurses (Table 9). Kamalpur Model Hospital CHC in Kamrup Rural does not have any nurse and 11 NBSUs (32%) do not have any designated full time nurse. Table 9: District-wise Facilities and NBSUs with availability of Nurses

Number of Nurses in the Facility Number of Nurses in NBSU District > Four Three Two One Zero Four Three Two One Zero Charaideo 2 2 Dibrugarh 4 3 1 1 7 Golaghat 1 2 1 2 Jorhat 4 4 Majuli 1 1 Sivasagar 2 1 1 Tinsukia 1 3 2 1 3 4 Kamrup R 3 4 1 6 Total 5 (14%) 6 6 16 1 0 1 (3%) 2 (6%) 20 11 (18%) (18%) (47%) (3%) (59%) (32%) 11

None of the NBSUs have 4 full time nurses, only 1 NBSU has 3 and 2 NBSUs have 2 nurses highlighting the importance of filling these positions at the earliest to ensure operationalization. While 97% facilities (33 facilities) have a minimum of 1 nurse, only 23 NBSUs (68%) have a minimum of 1 designated nurse.

Figure 4: Availability and training of doctors and nurses

Essential Equipment in NBSUs

Radiant Warmers and Phototherapy Units A minimum of 3 functional radiant warmers and 1 functional phototherapy unit, which are necessary in NBSUs as per the 2011 FBNC guidelines, were available in 18 (53%) facilities. A minimum of 3 functional radiant warmers and 1 functional phototherapy unit were available in 12 (35%) facilities. Of the total 92 radiant warmers However, a minimum of 4 radiant warmers and 2 available in these 34 facilities, phototherapy units were available in only 5 (15%) NBSUs 74 (80%) are functional and of which is the recommendation in the draft 2020 guidelines. the total 62 phototherapy units A minimum of 4 radiant warmers and 2 phototherapy available, 53 (85%) are units were available and functional in 4 (12%) NBSUs functional. (Figure 5). The availability of radiant warmers and phototherapy units is shown in Table 10. Figure 5: NBSUs with availability of 4 radiant warmers and 2 phototherapy units

Table 10: District-wise availability and functionality of Radiant Warmers (RWs) and Phototherapy (PT) Units

District Radiant Warmers Phototherapy Unit Both Radiant Warmers & Phototherapy Unit

> 4 > 3 > 4 > 3 RW + RW + RW + RW + > 4 3 > 4 3 > 2 1 > 2 1 2 PT 1 PT 2 PT 1 PT Units Unit Units Unit Available Functional Available Functional Available Functional Charaideo 1 1 1 1 Dibrugarh 2 3 1 1 6 3 5 3 2 5 1 2 Golaghat 3 3 3 3 3 3 Jorhat 1 1 1 3 1 3 1 1 2 1 1 Majuli 1 1 1 1 1 1 Sivasagar 2 1 1 1 Tinsukia 1 1 1 1 3 1 3 1 1 2 1 2 Kamrup 1 4 1 2 5 3 3 3 1 5 1 3 Rural Total 6 12 5 7 23 11 19 11 5 18 4 12 (18%) (35%) (15%) (21%) (68%) (32%) (56%) (32%) (15%) (53%) (12%) (35%)

Other Essential Equipment Table 11: District-wise Availability of Essential Functional While the 2011 Equipment as per govt. standards guidelines mention the requirement of a District 1 2 Pulse 1 Pulse 1 glucometer and Glucometer Oximeter Oximeter Bilirubinometer bilirubinometer, the Charaideo 1 1 2020 draft guidelines Dibrugarh 4 3 also prescribe 2 pulse Golaghat 3 3 oximeters. The Jorhat 1 2 availability of essential Majuli equipment district- Sivasagar 1 wise is shown Table Tinsukia 5 1 11. For facility-wise Kamrup 3 availability, refer to Rural Annexure 2. Total 18 (53%) 1 (3%) 15 (44%) 1 (3%) General Equipment

ACs are available in only 6% (2) NBSUs and power backup in 68%. Essential general equipment such as refrigerators, voltage stabilizers and room heaters are functional in 35% (12 NBSUs), 38% (13) and 21% (7) NBSUs respectively. 13

Services in NBSUs

Essential Laboratory Services for NBSUs Laboratory tests were available in the NBSUs as below: • Complete blood count, ESR and CRP – 71% (24 NBSUs), • Serum bilirubin - 56% (19 NBSUs) • Blood grouping, Rh typing, and blood sugar – 97% (33 NBSUs). Essential Drugs and Consumables The availability of drugs that are essential for treating sick newborns in NBSUs such as Injection Potassium Chloride (35%), Chloramphenicol (21%), Aminophylline (35%), Phenobarbitone (44%) and Ampicillin/Cloxacillin (59%) is inadequate. IV fluid is available at all facilities. Mucuous extractor is available in 77% of the facilities, while pulse oximeter probes, suction machine tubes and nasal prongs are available in 32%, 68% and 71% of NBSUs respectively. Record keeping and IEC for NBSUs All the NBSUs maintained admission registers, referral registers were maintained in 79% and case record forms in 46% facilities respectively. While 75% had IEC posters, none of the NBSUs had IEC video material. Case Mix in NBSUs Regarding types of cases treated in NBSUs, majority of the NBSUs (91%) reported managing cases of prematurity/LBW, almost half are managing cases of hypothermia, asphyxia and jaundice (47%) while a third (33%) manage sepsis. Four of 34 NBSUs report having received 16 patients through reverse referral from SNCUs in the last three months to NBSUs for the continuation of antibiotic therapy. Admissions in NBSUs Deliveries in facility and admissions in NBSUs • April 2019 to March 2020 (12 months): • Total 25377 deliveries in 34 facilities (Average – 62 deliveries/month/facility) • Total 1852 admissions in 34 NBSUs (Average – 5 admissions/month/NBSU) • April 2020 to September 2020 (6 months - during COVID pandemic): • Total 10200 deliveries in 34 facilities (Average – 52 deliveries/month/facility) • Total 588 admissions in 34 NBSUs (Average – 3 admissions/month/NBSU) Overnight admissions in NBSUs • In only 41% of NBSUs (14 NBSUs) overnight admissions are done • Admissions in NBSUs are usually not kept for more than 24 hours.

• The admissions are looked after by general duty nurse at night if admitted, as full time nurses are mostly not available in the NBSUs at night. • Admissions are often for night deliveries where referral at night would be inconvenient. • In 59% of NBSUs, overnight admissions are not done. The day admissions are shifted either to the mother or SNCUs at night. N.B: For district-wise key findings, refer to Annexure 2.

Recommendations

Goal

• All districts should have 4 to 5 fully operational NBSUs preferably one in each FRU

Guiding principles for recommendations

• It is good to be ambitious but prudent to be realistic • The longer term aim should be to have 4 to 5 fully operational NBSUs in each district, depending on district size • Shorter term objective is to begin with strengthening a limited number of NBSUs for service provision where maximum key criteria are fulfilled. • Key service provision criteria include: • Adequate space for service provision as per standards • Adequate human resource for operationalization of NBSUs as per standards • Availability of essential equipment and drugs • 24 X 7 services for small and sick newborns including overnight stay • Stabilization of small and sick newborns prior to referral

Limitations and way forward

• As per the 2011 FBNC guidelines, none of the NBSUs meet the key standards. The draft FBNC guidelines of 2020 are even more stringent. • Area remains a constraint for creating NBSUs in facilities as per norms • Initially at least one fully operational NBSU may be created in each district • In the immediate and short term, human resource and equipment may be reorganised to make some NBSUs fully operational and the requirements for others may be included in the PIP. • In the longer term, fact finding government teams may visit facilities and identify NBSUs that may be made fully operational as per the norms to have 4 to 5 in each district. 15

Strategic Approach

Facilities should be taken up in a phased manner for strengthening, prioritizing facilities fulfilling key criteria for NBSUs

1. Low hanging fruit • Three facilities in Dibrugarh district (Table 12) where NBSUs are located have 1 doctor and 4 nurses in facility with NBSU area > 200 sq. ft. These may be prioritized for strengthening first. • State to ensure that there are 4 full time nurses in the NBSUs • Capacity building for the facility should be conducted at the outset • Initially glucometers, pulse oximeters and serum bilirubinometers may be procured for these facilities, to make these NBSUs fully operational while other equipment and drugs are procured. • Newborns fulfilling the admission criteria should be admitted at the NBSUs with no refusals, shifting out or referrals at night.

Table 12: First priority NBSUs: Availability of essential space, HR, equipment & services

Facility = 3 Area Facility NBSU Fn. Fn. Fn. Fn. Pulse Night (Dibrugarh) (sq. MO Nurse FT RW PT Gluco- oximeter admn ft.) Nurse Unit meter Moran state 256 1 4 1 1 2 0 1 No dispensary CHC Naharkutia CHC 400 1 4 1 1 2 0 0 Yes Namrup PHC* 225 1 4 1 1 1 0 0 No

* Though it fulfills the criteria mentioned, this may be replaced with a more strategic FRU/CHC as per government’s analysis, since Namrup is a PHC, and FRU/CHC remain priority for strengthening.

2. Minimal support requirement • Six facilities (Table 13) need minimal support, that is, 1 additional HR required • State to ensure that there are 4 full time nurses in the NBSUs • Capacity building for the facility should be conducted at the outset • Initially glucometers, pulse oximeters and serum bilirubinometers may be procured for these facilities, to make these NBSUs fully operational while other equipment and drugs are procured. • Newborns fulfilling the admission criteria should be admitted at the NBSUs with no refusals, shifting out or referrals at night. 16

Table 13: Second priority NBSUs: Availability of essential space, HR, equipment, services

Facility = 6 Area Facility NBSU Fn. Fn. PT Gluco- Pulse Night (District) (sq. MO Nurse FT RW Unit meter oximeter admn ft.) Nurse

Dibrugarh state 1200 0 3 2 2 2 1 1 No dispensary FRU (Dibrugarh) Naharani CHC 300 1 3 1 3 3 1 1 Yes (Dibrugarh) Panitola Block 250 0 4 1 1 1 0 0 No PHC (Dibrugarh) Rajgarh CHC 250 1 3 1 1 1 1 0 Yes (Dibrugarh) Dangori CHC 200 1 3 0 1 2 0 0 Yes (Tinsukia) Jagun Mini PHC** 336 1 3 3 1 2 1 1 No (Tinsukia) ** Though it fulfills the criteria mentioned, this may be replaced with a more strategic FRU/CHC as per government’s analysis, since Jagun MPHC is a PHC, and FRU/CHC remain priority for strengthening.

3. Adequate Space Requirements • Since area is a constraint and there are five additional NBSUs with at least 300 sq. ft. area but more than 1 recruitment is required (Table 14) • In addition to the previous 9 facilities, these 5 should be prioritized next for short term strengthening in 4 districts other than Dibrugarh and Tinsukia.

Table 14: Third priority NBSUs: Availability of essential space, HR, equipment, services

Facility = 5 Area Facility NBSU Fn. Fn. Fn. Fn. Pulse Night (District) (sq. MO Nurse FT RW PT Gluco- oximeter admn ft.) Nurse Unit meter SKMCH Bokakhat 600 1 2 2 3 2 1 1 No FRU (Golaghat) Dergaon CHC 300 0 1 1 3 2 1 1 No (Golaghat) Titabor FRU (Jorhat) 300 1 1 1 5 4 2 2 No Garmur SDCH FRU 300 1 1 1 4 1 0 0 No (Majuli) Kamalpur MH CHC 300 0 0 0 1 0 0 0 No (Kamrup R)

4. Reallocation of resources from NBSUs or additional space to be provided • In seven facilities (Table 15) where the area is less than 200 sq. ft, the resources may be reallocated to other NBSUs in the district to make them fully operational. Otherwise, more space should be allocated for these NBSUs.

Table 15: NBSUs with resources to be reallocated or additional space requirement

Facility = 7 Area Facility NBSU Fn. PT Fn. Gluco- Pulse Night (District) (sq. MO Nurse FT RW RW unit PT meter oxi- admn ft.) Nurse unit meter Patsaku PHC 168 0 1 1 1 1 1 1 0 0 No (Charaideo) Digboi CHC 150 1 2 0 2 2 1 0 1 1 No (Tinsukia) Doomdooma FRU 144 1 4 0 3 3 2 2 1 1 No (Tinsukia) Hapjan Block PHC 176 1 3 0 2 1 1 0 1 1 No (Tinsukia) Azara FRU 132 1 1 0 3 3 2 2 0 0 Yes (Kamrup Rural) Bezera CHC 196 1 2 0 3 1 3 1 0 0 Yes (Kamrup Rural) Rangia FRU 144 1 2 0 2 2 1 1 0 0 No (Kamrup Rural)

Vriddhi support towards strengthening

• Capacity building • Preparation of Monitoring framework • Supportive supervision

Government contribution required for NBSU strengthening

• Adequate staffing of NBSUs with doctors and full time nurses as per guidelines • Provision of essential equipment and drugs as per requirement • Monitoring, supervision and review of performance.

Summary of recommendations

Facilities to be taken up in a phased manner fulfilling key criteria for NBSUs

• Priority for immediate strengthening: NBSUs with adequate. area or more having a doctor and dedicated nurses 18

• FRUs to be prioritized where possible. • An NBSU in each district • A team to be deputed by the government to identify 3 – 5 facilities per district for strengthening on a longer term. A healthy competition may be started through an award system for best performing districts. • NBSUs with an area of less than 200 sq. ft. resources may be redistributed

Lets work together for Quality Standards……

Annexure 1: NBSU Tool for Rapid Assessment Facility Identification

Date of Assessment: ______CHC/SDH/FRU: ______District: ______

Name of the health facility: ______

Method of verification: Telephonic interview

1. New Born Stabilization Unit Lay out and area S.No. Components Yes No Remarks

1 Number of beds in the NBSU (give number)

2 At least Four-bedded stabilization unit

3 Rough estimate of the area (in sq. ft.)

4 Minimum 100 sq. ft. area per bed/radiant warmer

5 Located in close proximity to maternal ward

6 Hand Washing Area in NBSU

6.1 Elbow operated taps (Answer if 6 = Yes)

7 Area earmarked for Nursing Station

8 Separate Gowning Area

9 Examination/Triage area

10 Space for mother’s education

2. Human Resource If trained, type of Desig- Training Qualifi- training** S.No Type of Staff Number nated on NBC* Remarks cations (1=F-IMNCI, 2=FBNC, (Yes/No) (Yes/No) 3=NBSU,4=NSSK, 5=Others, specify)

Medical officer 1. (Recommended:1)

Staff nurses 2. (Recommended: one in each shift – total 4)

If trained, type of Desig- Training Qualifi- training** S.No Type of Staff Number nated on NBC* Remarks cations (1=F-IMNCI, 2=FBNC, (Yes/No) (Yes/No) 3=NBSU,4=NSSK, 5=Others, specify)

Support Staff: Nursing orderly, sweepers, security personnel. 3. Yes No (Recommended: one in each shift - can be from hospital pool)

* NBC – New born care (MO and Nurse must be trained in F-IMNCI/FBNC/NBSU) **F-IMNCI = Facility based Integrated Management of Neonatal and Childhood Illness, FBNC = Facility Based New born Care, NBSU = New Born Stabilization Unit training, NSSK = Navjaat Shishu Surakhsha Karyakram.

3. Equipment Functional Essential Items S.No. Number (No. Remarks (recommended amounts are in brackets) functional) 1. Radiant warmer (4-6 depending on bed no.) 2. Phototherapy unit (2 recommended) 3. Self-inflating bag (500ml - 1) 4. Self-inflating bag (250ml - 1) 5. Masks (size 0 – 2 sets) 6. Masks (size 1 – 2 sets) Neonatal Laryngoscope set (preterm & term 7. blades - 2) 8. Suction pump electrical (1) 9. Suction pump foot operated (1) 10. Digital thermometer (4-6) 11. Low flow oxygen nasal cannula (as per need) 12. Oxygen source - cylinder 13. Oxygen concentrator 14. Blender 15. Weighing scale digital (1) 16. Glucometer (1) 17. Stethoscope (4-6) 18. Wall clock (1) 19. Pulse oximeter (2) 20. Room Thermometer (1) 21. Bilirubinometer (1)

Functional General Equipment Number (No. Remarks functional) 1. AC 1.5 Tonne 2. Generator set 25 KVA 3. Refrigerator (1) 4. Voltage stabiliser Main Line 5. Room heater (Oil filled – 2) 6. Bed side lockers (4) 7. Fowler Beds for mothers (4-6) 8. KMC chairs (2) 9. Sterilising Drum 10. Electric Steriliser

4. Essential Laboratory Services Remarks (Facility/ Laboratory Services Yes No Outsourced) 1. Complete Blood Count (CBC) 2. ESR and CRP 3. Serum Bilirubin 4. Blood grouping and Rh typing 5. Blood Sugar

5. Drugs & Consumables (in the NBSU) S.No. Drugs Yes No Remarks 1. IV Fluid therapy - 10% Dextrose, Normal saline 2. Inj. Potassium chloride 3. Inj. Ampicillin/Cloxacillin 4. Inj. Gentamicim/Amikacin 5. Inj. Cefotaxime 6. Inj. Chloramphenicol 7. Inj. Aminophylline 8. Inj. Vitamin K 9. Inj. Phenobarbitone

S.No. Drugs Yes No Remarks 10. Inj. Phenytoin 11. Inj. Dopamine/Dobutamine

12. Dee Lee Mucous Extractor (6 to 8)

13. Pulse oximeter probes 14. Suction machine tubes 15. Nasal Prongs & Masks of different Sizes 16. Endotracheal tubes (2.5, 3 & 3.5 non-cuffed)

6. Admission Profile – April 2019 to September 2020 Month Inborn Outborn Birth Outcome Total Total Weight deliveries admission Male Male < > Discharged in facility in NBSU Female Female Referred Lama Died 2500 2500 From April 2019 to March 2020

From April 2020 till September 2020

7. Record Keeping S.No. Record Available Remarks (Yes / No) 1. Admission Register 2. Referral Register 3. IEC Material: Posters 4. IEC Material: Videos 5. Case Recording Forms 5.1. Case Recording Forms are being filled (Answer if 5 = Yes)

8. Types of cases treated in NBSU (to understand conditions treated in NBSU in last three months) a. Prematurity/LBW b. Sepsis c. Jaundice d. Any other cases, specify______23

9. Is there reverse referral Are neonates from SNCU (higher Centres) admitted in NBSU? a. Yes/No b. If 9a = Yes, how many such cases were admitted in the last 3 months? ______c. If 9a = Yes, what are the common reasons for such admissions? ______

10. Overnight stay of newborns in the NBSU Are admitted newborns kept in the NBSU overnight or are they shifted out? a. Yes, they are kept in the NBSU overnight b. If 10 a. is yes, who looks after the newborn at night if there is no designated nurse at night in the NBSU______c. No, they are shifted out at night.

Annexure 2: District-wise Findings

Table A: Availability of space and resources in NBSUs in Charaideo

Facility Patsaku PHC Sonari SDCH FRU Area (sq. ft.) 168 200 Medical Officer 0 1 Facility Nurse 1 1 NBSU Full time/designated Nurse 1 1 Radiant Warmer 1 2 Functional Radiant Warmer 1 2 Phototherapy Unit 1 2 Functional Phototherapy Unit 1 2 Functional Glucometer 0 1 Functional Pulse Oximeter 0 1 Functional Serum Bilirubinometer 0 0 Night Admission No Yes

Table B: Availability of space and resources in NBSUs in Dibrugarh

Facility Dibrugarh Moran Moran Naharani Naharkutia Namrup Panitola Rajgarh state state Tiloi CHC CHC PHC Block CHC dispensary dispensary CHC PHC FRU CHC Area (sq. ft.) 1200 256 224 300 400 225 250 250 Medical Officer 0 1 1 1 1 1 0 1 Facility Nurse 3 4 1 3 4 4 4 3 NBSU Full time 2 1 1 1 1 1 1 1 Nurse Radiant Warmer 2 3 4 3 3 2 2 4 Functional (Fn.) 2 1 4 3 1 1 1 1 Radiant Warmer Phototherapy 2 2 4 3 2 1 1 2 Unit Fn. Phototherapy 2 2 2 3 2 1 1 1 Unit Fn. Glucometer 1 0 1 1 0 0 0 1 Fn. Pulse 1 1 0 1 0 0 0 0 Oximeter Fn. Serum Bilirubinometer Night Admission No No Yes Yes Yes No No Yes

Table C: Availability of space and resources in NBSUs in Golaghat

Facility Dergaon Sarupathar SKMCH Bokakhat CHC CHC FRU Area (sq. ft.) 300 200 600 Medical Officer 0 1 1 Facility Nurse 1 1 2 NBSU Full time Nurse 1 1 2 Radiant Warmer 3 3 3 Functional Radiant Warmer 3 3 3 Phototherapy Unit 2 3 2 Functional Phototherapy Unit 2 3 2 Functional Glucometer 1 1 1 Functional Pulse Oximeter 1 1 1 Functional Serum Bilirubinometer 0 0 0 Night Admission No No No

Table D: Availability of space and resources in NBSUs in Jorhat

Facility Kakojan Mariani PHC Teok FRU Titabor Block PHC FRU Area (sq. ft.) 200 200 200 300 Medical Officer 0 1 1 1 Facility Nurse 1 1 1 1 NBSU Full time Nurse 1 1 1 1 Radiant Warmer 2 2 3 6 Functional Radiant Warmer 2 2 2 5 Phototherapy Unit 2 1 2 4 Functional Phototherapy Unit 2 1 2 4 Functional Glucometer 0 0 0 2 Functional Pulse Oximeter 0 1 1 2 Functional Serum 0 0 0 0 Bilirubinometer Night Admission No No No No

Table E: Availability of space and resources in NBSUs in Majuli

Facility Garmur SDCH FRU Area (sq. ft.) 300 Medical Officer 1 Facility Nurse 1 NBSU Full time Nurse 1 Radiant Warmer 4 Functional Radiant Warmer 4 Phototherapy Unit 1 Functional Phototherapy Unit 1 Functional Glucometer 0 Functional Pulse Oximeter 0 Functional Serum Bilirubinometer 0 Night Admission No

Table F: Availability of space and resources in NBSUs in Sivasagar

Facility Demow CHC KSHS Nazira SDCH FRU

Area (sq. ft.) 200 200 Medical Officer 1 1 Facility Nurse 1 1 NBSU Full time Nurse 0 1 Radiant Warmer 2 2

Functional Radiant Warmer 1 1 Phototherapy Unit 2 2 Functional Phototherapy Unit 2 1 Functional Glucometer 1 0 Functional Pulse Oximeter 1 0 Functional Serum Bilirubinometer 0 0 Night Admission Yes Yes

Table G: Availability of space and resources in NBSUs in Tinsukia

Facility Dangori Digboi Doomdooma Hapjan Jagun Magherita CHC CHC FRU Block Mini PHC FRU PHC Area (sq. ft.) 200 150 144 176 336 224 Medical Officer 1 1 1 1 1 1 Facility Nurse 3 2 4 3 3 2 NBSU Full time 0 0 0 0 3 1 Nurse Radiant Warmer 2 2 3 2 2 4 Fn. Radiant Warmer 1 2 3 1 2 4 Phototherapy Unit 2 1 2 1 1 2 Fn. Phototherapy 2 0 2 0 1 2 Unit Fn. Glucometer 0 1 1 1 1 1 Fn. Pulse Oximeter 0 1 1 1 1 0 Fn. Serum 0 0 1 0 0 0 Bilirubinometer Night Admission Yes No No No No Yes

Table H: Availability of essentials in NBSUs in Kamrup Rural

Facility Azara Bezera Boko Hajo Kamalpur Rangia Rangia Sualkuchi FRU CHC FRU FRU MH CHC FRU MH FRU FRU Area (sq. ft.) 132 196 216 210 300 144 200 240 Medical Officer 1 1 1 1 0 1 1 1 Facility Nurse 1 2 1 1 0 2 2 1 NBSU Full time 0 0 1 0 0 0 0 1 Nurse Radiant Warmer 3 3 3 3 1 2 4 2 Fn. Radiant 3 1 3 2 1 2 4 2 Warmer Phototherapy 2 3 2 3 1 1 2 1 Unit Fn. Phototherapy 2 1 2 0 0 1 2 1 Unit Fn. Glucometer 0 0 1 1 0 0 1 0 Fn. Pulse 0 0 0 0 0 0 1 0 Oximeter Fn. Serum 0 0 0 0 0 0 0 0 Bilirubinometer Night Admission Yes Yes No Yes No No Yes Yes 28

Annexure 3: Summary table - Availability of space and resources in 34 NBSUs selected for rapid assessment S. Area Facility NBSU FT2 Fn.4 PT5 Fn. PT Gluco- Pulse Night No District Facility (sq. ft.) MO1 Nurse Nurse RW3 RW unit unit meter oximeter admn6 1 Charaideo Patsaku PHC 168 0 1 1 1 1 1 1 0 0 No 2 Sonari SDCH FRU 200 1 1 1 2 2 2 2 1 1 Yes 3 Dibrugarh Dibrugarh state dispensary FRU 1200 0 3 2 2 2 2 2 1 1 No 4 Moran state dispensary CHC 256 1 4 1 3 1 2 2 0 1 No 5 Moran Tiloi CHC 224 1 1 1 4 4 4 2 1 0 Yes 6 Naharani CHC 300 1 3 1 3 3 3 3 1 1 Yes 7 Naharkutia CHC 400 1 4 1 3 1 2 2 0 0 Yes 8 Namrup PHC 225 1 4 1 2 1 1 1 0 0 No 9 Panitola Block PHC 250 0 4 1 2 1 1 1 0 0 No 10 Rajgarh CHC 250 1 3 1 4 1 2 1 1 0 Yes 11 Golaghat Dergaon CHC 300 0 1 1 3 3 2 2 1 1 No 12 Sarupathar CHC 200 1 1 1 3 3 3 3 1 1 No 13 SKMCH Bokakhat FRU 600 1 2 2 3 3 2 2 1 1 No 14 Jorhat Kakojan Block PHC 200 0 1 1 2 2 2 2 0 0 No 15 Mariani PHC 200 1 1 1 2 2 1 1 0 1 No 16 Teok FRU 200 1 1 1 3 2 2 2 0 1 No 17 Titabor FRU 300 1 1 1 6 5 4 4 2 2 No 18 Majuli Garmur SDCH FRU 300 1 1 1 4 4 1 1 0 0 No 19 Sivasagar Demow CHC 200 1 1 0 2 1 2 2 1 1 Yes 20 KSHS Nazira SDCH FRU 200 1 1 1 2 1 2 1 0 0 Yes 21 Tinsukia Dangori CHC 200 1 3 0 2 1 2 2 0 0 Yes 22 Digboi CHC 150 1 2 0 2 2 1 0 1 1 No 23 Doomdooma FRU 144 1 4 0 3 3 2 2 1 1 No 24 Hapjan Block PHC 176 1 3 0 2 1 1 0 1 1 No 25 Jagun Mini PHC 336 1 3 3 2 2 1 1 1 1 No 26 Magherita FRU 224 1 2 1 4 4 2 2 1 0 Yes 27 Kamrup Azara FRU 132 1 1 0 3 3 2 2 0 0 Yes 28 Rural Bezera CHC 196 1 2 0 3 1 3 1 0 0 Yes 29 Boko FRU 216 1 1 1 3 3 2 2 1 0 No 30 Hajo FRU 210 1 1 0 3 2 3 0 1 0 Yes 31 Kamalpur MH CHC 300 0 0 0 1 1 1 0 0 0 No 32 Rangia FRU 144 1 2 0 2 2 1 1 0 0 No 33 Rangia MH FRU 200 1 2 0 4 4 2 2 1 1 Yes 34 Sualkuchi FRU 240 1 1 1 2 2 1 1 0 0 Yes 1 MO: Medical Officer 2 FT: Full time/designated 3 RW: Radiant Warmer 4 Fn: Functional 5 PT: Phototherapy 6 Admn: Admission

Key considerations for prioritizing strengthening of NBSUs To be taken up for immediate strengthening, i.e. within the next 3 months subject to provision of adequate HR, essential equipment and drugs To be taken up for short term strengthening, i.e. within the next 3 to 6 months subject to provision of adequate HR, essential equipment and drugs To be taken up for longer term strengthening, i.e. within 6 months to 1 year subject to provision of adequate HR, essential equipment and drugs Not to be considered for strengthening – area less than 200sq. ft.