Home-based Newborn Care Project - Nipccd

Replicating
The Home-Based Newborn Care
in India
New evidence from 12 sites
and
implications for national policy
ICMR
Report of the convention
th
New Delhi,10 August 2006
SEARCH PFI

Convention organised by :
- Indian Council of Medical Research, New Delhi.
- SEARCH, Gadchiroli
- Population Foundation of India, New Delhi
Published by :
SEARCH
Society for Education Action and
Research in Community Health
Gadchiroli , Maharashtra, India.
Pin : 442 605
Ph.no. 91-7138-255407
Fax no. 91-7138-255411
e-mail: search@satyam.net.in
website : www.searchgadchiroli.org
Printed by : Amey art, Nagpur

Contents
A. Background and Objectives of the Convention 1
B. Proceedings 2
Inaugural session 2
Purpose of the Convention 2
Key Note Address 3
Inaugural Address 4
Chairperson’s Remarks 4
C. Scientific Session 5
Home-based Newborn Care and the ANKUR Study 6
The ICMR Study 9
D. Health Education Film Release 14
E. Second Session 14
National Rural Health Mission and the HBNC 14
Training 15
Dialogue with CHWs 16
F. Concluding Session 17
G. Statement of the Convention 18
Programme 20
List of Participants 22
Glimpses 26

Report of the Convention
Replicating the Home-Based Newborn care in India
New Evidence from 12 sites and implications for national policy
A) Background and objectives of the convention
1.1 million neonates die every year in India. Major fraction of the infant and child deaths occur
during the neonatal period. The National Population Policy aims at bringing down the infant
mortality rate to < 30 per 1000 live births. Besides, India is also committed to achieve the
Millennium Development Goal of reducing child mortality to two-thirds by 2015.
The Gadchiroli study on Home-based Newborn Care (HBNC) (1993-98) conducted by SEARCH,
an NGO in Maharashtra, was a major breakthrough towards finding a way to reduce the IMR in
India. In 2001, the Government of India considered a national scaling up of this approach, and
decided to test its replicability before scaling up. Thus, two replication studies were planned.
SEARCH launched the ANKUR project on the replication of HBNC by NGOs in Maharashtra. The
Indian Council of Medical Research (ICMR) launched another study of replicating HBNC
through the Government systems.
After five years, the ANKUR study has been completed with its final results ready, and the ICMR
study has completed the baseline study, selection and training of workers to provide HBNC, and
the piloting of sepsis management.
A one-day convention on “Replicating the Home Based New-Born Care in India: New Evidence
from 12 sites” was held at the PHD House, New Delhi on August 10, 2006 from 10:00 AM to 6:00
PM. The event was organised jointly by SEARCH, ICMR and Population Foundation of
India (PFI).
Objectives of the convention
1) To share the methods of replication and the results observed in (a) the first level of scale-up
in the seven sites in Maharashtra in the ANKUR study , and , (b) the interim findings of the
five site study by the ICMR in of Bihar, Maharashtra, Orissa, Rajasthan and Uttar Pradesh.
2) To release the training package and the film developed by SEARCH for training village
health workers on HBNC
3) To create an opportunity for the policy makers to meet the community health workers from
the ANKUR and ICMR project sites.
4) To create an environment for decision by the policy makers and donors.
1

B) Proceedings
Inaugural Session :
Purpose of the convention : Mr. A. R. Nanda, Executive Director, PFI
Mr. A. R. Nanda welcomed the participants on behalf of the organizers i.e. SEARCH, ICMR and
PFI, and explained the purpose of the convention. He said
“The IMR in India is 58 (SRS, 2004). Annually 1.1 million neonatal deaths occur in India the
largest number in any single country. Therefore, there is an urgent need to find new solutions
which are feasible and which have been proven in field trials. The SEARCH, Gadchiroli model of
Home-based Newborn Care (HBNC) started as an intervention research in 1988. It has gone
through rigorous processes of research, openness and transparency. It was published in the
Lancet in 1999. This study has shown that by training a community health worker, neonatal care
can be provided at home and the newborn mortality can be reduced by nearly two-thirds. This was
a major breakthrough emerging from India. Both the Lancet and Time magazine have hailed this
study as a global milestone in medical research. This study changed the outlook towards newborn
care and neonatal mortality. Reducing the neonatal mortality appeared a realistic possibility not
only in India but also in other developing countries. Certain countries of Africa have already
explored the possibility of replicating this model and sought the help of SEARCH.
In 2001, the Government of India had the option of adopting the HBNC model for immediate
national scaling up. But the question was will it succeed elsewhere? Unproven solutions are often
pushed in the policies and programs under various pressures, but they fail to deliver. This is one
reason for the failure of many large scale programmes. Another reason is that sound, detailed
methods are not worked out and field tested. Hence, the Health Ministry decided to let this method
of HBNC pass through a replication cycle before adopting it in national programme. Replication
and field testing at other places would make the methods and conclusions more robust. That is
why the ANKUR project in Maharashtra and ICMR trial in five states were launched in 2001 and
2003 respectively. Both used the standard package of interventions which was proved in the
Gadchiroli trial, and the methods of selection of community health workers, training, supervision
and the management standardized by SEARCH.
The national policy makers and many in the civil society organizations have been eagerly waiting
for the results and the products from these two studies. In this context, this one day meet has been
organized so as to present these findings and the products
The ANKUR study with its final results
T he ICMR trial with its interim results
Products for training of community health workers and health education.
2

Questions which begged answers from this meet were:
1. Can this method be implemented at other places by other organizations?
2. Can the interventions in the home-based newborn care be delivered by an ASHA like
community health worker ?
3. What training inputs and equipments are required to deliver the HBNC? Are the
methods of training effective and robust?
4. What are the community acceptance, coverage and impact of the HBNC in different
types of settings?
5. What are the problems faced?
6. What precautions should be taken to ensure successful replication? And finally
7. Should this method be adopted for scaling up in the National Rural Health Mission, so
that the IMR is reduced to less than 30 in next five years?
Key Note address: Mr. P. K. Hota,
Secretary, Health and Family Welfare, Govt. of India
Mr. P. K. Hota addressed the audience by mentioning that Dr. Bang's unique effort needed
propagation and it was an achievement of lifetime dedication. He said, “The challenges of
reduction of child and neonatal mortality continue to be before us. Some states have achieved
such reduction but in a limited and uneven manner. The major states like UP, Bihar, MP and Orissa
have very high child mortality but the new states like Chattisgarh and Jharkhand are showing
comparatively better results. We have to understand the hidden challenges and these should be
brought in to open. Civil society must challenge the governance structures. Apart from
technologies and strategies, how do we create alliances and awareness in the concerned
states? This is also a challenge.
Dr. Bang's experiment is memorable. To scale it up in different states with poor governance in
health sector will be a great challenge and these aspects need to be kept in mind and addressed.
How do we create values and whether issues of poor governance can be overcome in states like
Bihar and UP. are the questions that must be faced How to make it replicable with community
participation is more important than technological sophistication. More than mechanical issues,
ownership among the community needs to be created.”
He concluded the address by mentioning that the great experiments like Dr. Bang's model should
reach the deprived people in the states where mothers and children still remain voiceless and this
model would do wonders for them.
3

2. IMNCI has been taken up already by the government in few states. How can one scale
the HBNC model without disturbing the IMNCI?
3. Asphyxia and sepsis mortality in HBNC is controlled by technology administered in
small pilot areas. To replicate it throughout the nation will take a lot more time in
introduction and this problem needs to be addressed.
4. How to ensure the availability of working weighing machines in each
village?
5. Are we ready to introduce zinc? Zinc administration needs careful attention.
6. In many regions the number of neonatal tetanus deaths is high . So this problem
should be addressed
7. Experience of countries which have succeeded in reducing neonatal and infant
mortality needs to be looked at.
8. Program for neonatal screening and program for genetic disorders also need to
be thought of.
9. There is a need to focus on area/ region specific issues. e.g. Malaria is a major
concern in MP and prevalence of malaria during pregnancy is very high .
Prof. Ganguly concluded his remarks by pointing out that most of the programs were rural
based and did not focus on slums. He pointed out that by 2015, a major proportion of the
population will shift from rural habitat to the city slums and hence there was a need
to focus on the city slums.
C. Scientific Session
1. The Gadchiroli field trial and the methods and results of the ANKUR were presented
by Dr. Abhay Bang.
2. Methods and the interim results from the five site national level trial by ICMR were
presented by Dr. Malabika Roy.
5

Inaugural Address: Dr. Syeda Hameed,
Member, Planning Commission, Govt. of India
Addressing the distinguished guests and audience Dr. Hameed shared that she has known Dr.
Bang since she joined the Planning Commission and she was aware of the work that SEARCH
was doing in Gadchiroli. The health workers who work at the grassroots can help and support the
newborn and mother at home and work towards providing the newborn the care needed at birth.
Though government was emphasizing institutional delivery, still in many states, in the rural areas
most of the deliveries were performed at home. At times it was very difficult for the pregnant
women to reach the government or private institutions and it was even more difficult in the hilly
areas. She felt that many people experimented pilots on newborn care but, SEARCH, Gadchiroli
had made a niche for itself.
th
She further said that during the midterm appraisal of the 10 five year plan it was found that many
targets were not achieved. Planning commission was working towards achieving the targets and
she felt that new and innovative initiatives which were tried by various organizations would
help achieving these targets.
According to her, the Home-based newborn care was a home-spun solution which had emerged
from the grassroots and showed that there was a way of giving home based care to the new born
child which would enable the newborn child to survive. “We are fighting against new born deaths
and trying to find new paths and new experiments”, she said. She congratulated SEARCH, ICMR
and PFI for taking up the initiative and creating a pressure on the policy makers to address the
issue of child mortality and adapt new experiments and pilots. She said, “These are the
visionaries, who are imaginative and have shown that there can be positive outcomes to new
initiatives”. She welcomed the initiative of SEARCH and wished success for the experiment.
Chairperson's Remarks: Prof. N. K. Ganguly
Director General, ICMR
Addressing the audience, Prof. Ganguly said that it was an important event for everybody present
and mentioned that as Mr. Nanda believed, neonatal deaths could be prevented only if we reached
the homes and perhaps it would be possible for the HBNC initiative to achieve this by
reaching homes across the country.
He said that since the stage of scaling up of the HBNC approach has been reached, many new
questions would need to be addressed. He pointed out some issues. These are given below:
1. Although the training module which has been fine tuned and closely supervised is
available, will it be possible for the states to take up such an extensive 31 days
training , when replication is attempted ?
4

1. Home-based Newborn Care and the ANKUR Study :
Dr. Abhay Bang, Director, SEARCH
Dr Abhay Bang, led the participants through the details of the various components of the original
Gadchiroli field trial and beyond which resulted in steep and sustained reduction in the NMR and
IMR and also maternal morbidities. He pointed out that the HBNC approach was evidence based
and low cost option to achieve the national goal of reducing the IMR to

He then described the ANKUR project, its objectives, study design, methods and presented the
results were presented. At 7 replication sites, the coverage of HBNC was 85%, reduction in the
NMR 51% and in the IMR 47%. Beneficiary satisfaction was 93%.
Research Questions
1. Can the HBNC be replicated ?
- By NGOs ? Project ANKUR
- By Government ? ICMR study
2. How : methods and tools ?
3. What will be the effectiveness ?
4. Cat it be integrated with other MCH
interventions ?
rd
% Coverage of mothers and newborns in the 3 year of intervention
7
Nasik Rural
ANKUR Project sites in Maharashtra
Rural
Sangli
Baseline (1998-2000)
Osmanabad Rural
Yavatmal
Tribal
Effect on the IMR
Intervention 3rd year
(2004-2005)
Rural
Nagpur
U.Slum
Tribal
Gadchiroli SEARCH HQ
Study Sites in ANKUR
Villages : 91, Slums : 6
Population : 88, 311
Liberal estimate
(2004-2005)

Conclusions of ANKUR
1) HBNC can be replicated by NGOs.
2) Methods and tools of replication have been field tested and are effective. These
can be used by others.
3) HBNC is feasible and acceptable in 3 types of setting (tribal, rural and urban slums) with
some modifications which were made in the tribal and urban slums.
4) HBNC was effective in reducing NMR, IMR and CMR by nearly half in above 3 types of
settings (combined).
5) HBNC can be combined with the MCH interventions.
6) The HBNC package, as structured and tested in ANKUR, appears suitable for
incorporating in the government health programme.
Limitations of HBNC when replicated
Tools developed for replicating HBNC are :
How can the ANKUR pattern fit into the NRHM
It is a process intensive approach and needs careful attention to quality
Training (31 days) and field supervision are required
Some difficulties of coverage in tribal areas with small dispersed hamlets.
The activity was conducted by the NGOs, the community used and valued it but the
community ownership was not strong.
It was not possible to sustain it without financial support.
Health education material: Flip chart and film
Training manual and material
Record system and MIS
8

Four reports on ANKUR
Four reports on ANKUR have been prepared. These are:
1. ANKUR study report
2. Report on the Training for Home-based Newborn Care
3. Process Documentation of ANKUR by the Tata Institute of Social Sciences, Mumbai
4. Case study of ANKUR by the Indian Institute of Management, Ahmedabad
2. The ICMR study : Dr. Malbika Roy,
Coordinator, Reproductive Health & Nutrition Div, ICMR.
Dr Malabika Roy presented the interim results of the “Home-based Management of Young Infants”
project. She pointed out that the strategies and methods were identical to those used in the
Gadchiroli field trial. The major difference was that the ICMR study was being implemented
simultaneously through two arms. In one arm the services were provided by the CHWs (similar to
ASHAs) and in the other, through the existing Aangawadi workers so that comparison of the
effectiveness could be made. The ICMR study is being conducted in 5 states (Rajsthan, UP, Bihar,
Orissa and Maharashtra). Each site has a population of 60,000 in the health services arm, 60,000
in the ICDS arm and 60,000 in the control area. The activities completed so far were: The baseline
estimates of mortality rates, study of knowledge and practices in population, selection and training
of workers by using the training package developed by SEARCH and piloting of sepsis
management by use of injection gentamicin by CHWs. The project has entered into the
intervention phase.
9
Replication sites in India

Interim findings
1. Prospective recording of newborn deaths revealed that 39 percent of deaths occurred on
the day of birth. Verbal autopsy study indicated that around 33 percent newborn deaths
were due to sepsis. Any intervention package needs to cover these two, namely the day
of birth and the sepsis, adequately.
Timing of neonantal deaths (n=1521)
2. 20 Master trainers were trained at SEARCH Gadchiroli. By April 2005, 548 village
workers [ 278 Shishu Rakshaks (SR) and 270 Aanganwadi Workers (AWWs)] have been
trained by these master trainers.
3. The training of CHWs was effective. The skills including complex skills such as birth
asphyxia management and injections were transferred to SRs satisfactorily. The
evaluation at the end of the training showed that the majority of SRs (70.5 %) acquired
desired level of competence in delivering newborn survival interventions. AWWs were
yet to achieve desired level of competence.
4. The AWW arm performed poorly as compared to the Shishu Rakshak (comparable to
ASHA) arm, suggesting that the ASHA will be more suitable than AWW
5. HBNC interventions except injection treatment began in all areas after completion of
training , through workers found suitable on evaluation.
6. Piloting of intervention with injection antibiotic was done in SR arm. During the piloting
period SRs have successfully treated sepsis cases using injectable antibiotics. There
was no adverse effect during piloting. So far 163 cases of neonatal sepsis have been
managed by the Shishu Rakshaks. The case fatality was low; comparable to the
case fatality in the Gadchiroli field trial. .
Causes of neonatal deaths (n=258)
Congenital
malformation
5.4 %
Prematurity
15.2 %
Not established
14.7 %
7. Community acceptance of the Shishu Rakshaks was satisfactory
10
Others
10.7 %
Infection
33.2 %
Birth Asphyxia
20.9 %

Proportion of Srs/ AWWs with score 70% and above in the
final evaluation after training
Proportion of home deliveries attended by
SRs and AWWs
11

3. Discussion : Given below are the comments made, issues raised and responses by the
speakers:
In the present scenario, there are multiple village level workers in the villages. How to
ensure that duplication of work does not occur ? What will be the role of the ANMs,
AWWs and ASHAs ?
How in the government set up issues of non performance can be addressed, which
could be addressed in SEARCH ?
Dr. Bang: Roles are performed at different levels in the government set up if the job
descriptions are clearly spelt out Governance and accountability are major issues which
need to be addressed carefully. Perhaps we need to understand the processes of
motivation, reward and punishment, and governance followed in this model and transfer
these to the government system. These things cannot happen in isolation and need to go
hand in hand.
Dr. Bulbul Sood, - CEDPA: ANM has somehow lost its aims and is involved in many
activities. We need to think about a dedicated maternal and newborn care provider at the
community level.
Dr. Bang: A part of ASHAs time could be dedicated to the maternal and newborn care. With the
predefined job priority, ASHAs would do wonders for the community.
Dr. Tandon - USAID: “Gadchiroli model is a result of lifetime commitment of a certain
institution. We have seen what a committed organization can best achieve in certain areas
and we saw certain processes executed very systematically . The model has been scaled
up from 39 villages in Gadchiroli to 7 different areas of Maharashtra. It might be worthwhile
if those aspects could be very systematically evaluated. Scale up also needs a very
systematic process, it does not happen straight way. There are certain other softer aspects
which can be bottlenecks for any project and if these are addressed and then put in the
scaling up methodology; we might come out with the real answer”.
Poonam Muttreja : “ICMR and ANKUR studies happened in parallel. With the national
NMR and IMR being so high, how long are we going to wait for the scaling up of the HBNC
model? . How, without much delay, can we scale up the model ? Can we scale up the model
with the systems which are functional? What ICMR is planning to do?
Dr. Malabika: “ICMR has completed two years of the trial. The program will be finally
evaluated In early 2008. Supervision is a major issue for this trial. Presently the
supervisors are hired for the project and are a paid staff. ANMs or LHVs have been
included as supervisors but we found that because of other pressing priorities they did not
function as effective supervisors. But if we want to scale up HBNC. sustaining the
supervisors in an effective way within the existing health system will be a major concern. All
the five sites face different issues and problems. ICMR believes that the health workers
can be trained, skills can be transferred and community acceptance can be generated.
12

Dr. Bang: “ICMR trial may be able to answer the impact issue after two years. But with the
definitive results from the Gadchiroli and ANKUR trial, the impact on the NMR and IMR is no
longer in question. The crucial issue is the processes issue. The learning so far from the ICMR
study is that the community health workers can be selected and trained, skills can be
transferred , can perform her functions, can mange sepsis, and community also accepts them.
Hence, the process related issues have been already answered. Supervision in SEARCH,
ANKUR and ICMR was done by the hired ANMs, nurses or non-MBBS doctors. And if these
types of workers can function as supervisors, then ANMs in the Government setup should also
be able to function. But the ANMs need to be told about their job priority. Issue now is probably
not of research, but of implementation, management and taking certain crucial decisions at the
policy level. After the ANKUR and the ICMR study we don't need any more pilots; what we need
now is better and effective implementation”.
Dr. Harish WHO: “ANKUR, ICMR and IMNCI are three home based newborn care pilots that
are currently available and if we want to have a true insight, we need to look at all the three
packages carefully. In IMNCI, the community worker has to be trained for 8 fays in a year.,
UNICEF is facing lots of problem for the IMNCI training. Even after two and a half years,
UNICEF has not been able to implement the IMNCI program even in one full district.
SEARCH suggests 3 visits in the ANC period and 8 visits in the post-natal period for the
newborn. UNICEF suggests 3 visits and 6 visits respectively and the data shows that it is
difficult to motivate workers to make 6 visits. 1 or 2 visits are feasible but more than that is
difficult What is the number ofy the bare minimum visits which can be recommended?
Dr. Bang: In the subsequent research, SEARCH has found that 5 post-natal visits to the lowrisk
neonates and 13 to the high risk neonates are a better option.)
The non-recurring cost for HBNC in SEARCH was $ 125. Half of the cost was for
equipments and $ 80 was for training. This cost was of 1998-1999. What was the cost in
ANKUR and the ICMR.
Dr. Bang: In fact, the non-recurring cost was $ 155 and not 125. Similarly, the cost estimates
were for the period 2001-2003. (J. Perinatology Supplement, 2005)
In the ANKUR project, the model was integrated and implemented as the maternal,
newborn and child health program. What are the components that were in ANKUR for
maternal health ?
Dr. Bang: Health education during pregnancy, attending delivery, encouraging referral, postnatal
visits these all were present in the Gadchiroli study as well)
Dr. Harish also raised some concerns about the supportive supervision as it is key for the
success of the HBNC model and issues of the hand on experience for the health workers.
Mr. Nanda responded by mentioning that IMNCI did not go through the several years of
rigorous testing as that of HBNC. He said that the HBNC was an indigenous initiative which
has been field tested for 12 years. “It is unfair to compare it with the IMNCI. The IMCI was
13

field tested in some other country and the N (newborn) component added in India
without conducting any field trial to evaluate its effectiveness. The HBNC and IMNCI
can not be treated in the same manner while scaling up. HBNC has been repeatedly
shown to reduce the NMR and IMR; there is no such evidence from the IMNCI so far”
he said.
D. Health Education Film Release : The highlight was the screening of the first part
of the health education film “Nanhisi Jaan” which was launched at the hands of the only
surviving child, Swati, of the producer director (of the film) duo Abha Dayal and Puneet
Tandon who had met a tragic death in an accident just on the threshold of the completion
of the film. This film had been field tested extensively under ANKUR and ICMR project
and proved useful. This film gives messages to pregnant women and mother on newborn
care.
E. Second Session
National Rural Health Mission and the Home-based Newborn Care :
Address by Mrs. S. Jalaja,
Director, National Rural Health Mission, and Additional Secretary, Ministry of
Health and F W, Government of India
Addressing the audience, Mrs. Jalaja said, “It is an important day for the neonates in the
country. SEARCH and ICMR together have done an excellent job to address neonatal
mortality and bring excellent recommendations from their experiences. These studies show
that the grassroot workers can take care of the life of the neonates in the country.
The goal of NRHM is to achieve universal health care and , reduction in IMR, MMR and TFR in
the country. In the last one year, the mission has started institution building. National, state,
and district health missions have been set up. Decentralization at all level and intersectoral
convergence is the prime aim of NRHM. Under the NRHM, one ASHA is being introduced per
1000 population. ASHA will be a success only with functional health systems. ASHAs priority
will be able to bring down the TFR, NMR, IMR and do related work. ASHA will perform both
preventive and curative health activities.
Using HBNC provided through the community health worker , the NMR can be reduced.
ICMR in collaboration with SEARCH has been trying to replicate HBNC through health
system. Under NRHM, government is planning to train ASHAs in the HBNC. Norwegian
government has agreed to support the training of ASHAs in HBNC in five states. This can
make a dramatic change for the poor, underserved and unserved areas. As far as other
states are concerned, it was being suggested to train all the ASHAs in HBNC in a shorter
period of time through use of technology and later on the training may be strengthened
through capsules”.
14

She stated that even in Chattisgarh, through the Mitanins and direct interventions; the state
government had managed to reduce the neonatal mortality by more than 16 points in a short span
of time. “This gives hope that if energized adequately, even the government systems can work
effectively. It is a meaningful partnership between government and non government institutions to
bring down the neonatal mortality. It can not be done in isolation. Without compromising the
quality how to take it forward is the main challenge” she said.
The Training Manual: The SEARCH training manual 'How to train community Health Workers in
Home-based Newborn Care' was released by Mrs. S. Jalaja followed by a brief presentation on
the training manual.
Mrs. Priya Paranjpe of SEARCH made presentation on training under HBNC with emphasis on
training of CHWs. She explained the philosophy, design and contents of the manual. The highlight
of the training method was its stepladder approach and use of participatory methods of adult
learning. She emphasized that the training was community based and not hospital based. She
discussed the excellent results of end of training evaluation of CHWs wherein 92% of the trained
CHWs scored more that 70% marks and the mean score was 86%. She drew attention to the fact
that attitude of the trainee and not her educational qualification was important for transfer of
knowledge and skills. The results of ANKUR and the acknowledged satisfactory transfer of
knowledge and skills to CHWs under ICMR project evidenced the effectiveness of the manual and
“doability” of training.
Four levels of training ( new recruits)
A. Training of Project Managers 15 days
B. Training of Trainers/ Supervisors 43 days
C. Training of Community Health Workers 31 days
D. Training of Traditional Birth Attendants 6 days
15

Dialogue with the Community Health Workers
The lively dialogue between the participants and the 19 CHWs representing the Gadchiroli
site, 7 ANKUR field sites and 4 of the 5 ICMR project sites with the participants which followed
the training presentation was another highlight of the day. During this dialogue the CHWS
narrated their experiences in respect of difficulties faced by them and manner in which they
overcame these difficulties right from the stage of induction to actual provision of service in
the community. This dialogue brought out their triumphs and rare failures, increase in their
self-esteem and the empowerment brought about not only of the CHWs but also of their
families and the community. They answered the queries of the participants confidently and
declared unequivocally that though they had apprehensions initially they now had the support
of their families and acceptance of the communities in which they work and were proud that
they were contributing to the cause of saving newborn lives.
Felicitation:
The interaction with community health workers session was followed by felicitation of the
NGO heads and Principal investigators who had participated in the ANKUR project and ICMR
project respectively and also of workers from SEARCH Gadchiroli associated with the
projects. They were presented mementoes by Dr Vinod Paul of AIIMS and Mr. A.R. Nanda of
PFI.
16
No. Of CHWs
Final Evaluation of Training of CHWs
(n=92)
score score

F. Concluding Session
1. The Way Forward : Dr. Vinod Paul, Professor of Pediatrics, AIIMS
Addressing the audience, Dr. Paul said that it was a challenge as toi how can this initiative be
incorporated into the NRHM system,, what should be done for further learning and what were
the integrals aspects of the training .
He said, “We have enough evidence and the time and the opportunity have come that we
should think seriously for scaling up of the HBNC model. IMNCI is meant to be operating at
community level through ANMs or AWWs whereas the HBNC is proposed to be scaled up
through ASHAs. The two approaches can complement each other. In certain states may be
one approach would precede the other depending upon the status of the existing systems.
There is no incompatibility between the two approaches. He felt that home based newborn
care should be integrated with the child health and maternal health. He also pointed out that
government is promoting institutional deliveries and HBNC is not incompatible with
institutional care but the home deliveries and early discharge of the mother and newborn
were realities to be covered by HBNC. He also allayed the fears of problems arising out of
providing additional training to ASHA for HBNC. He suggested a need for concurrent
evaluation, learning and correction in the scaled up programme of HBNC.
Mr. Nanda read out the concluding statement emerging out of this convention. (Please see
section G at the end of this report)
Dr Ganguli who chaired the session said in his remarks that HBNC must be introduced at
least in one state and observed and monitored closely. Since lot of other players and
competing models were coming up we should proceed in such a way that we can provide
clear answers. Channelizing the available resources properly and in an inclusive manner
was necessary.
The programme ended with the vote of thanks by Dr Abhay Bang.
Gift from the CHWs : As the participants left the auditorium they were presented with a
shoulder bag (identical to one used by the CHWs when they make home visits for providing
care to the mother and the neonate) containing CHW kit as a message that having been
convinced that HBNC could be replicated successfully they might initiate action to save the
newborns in their respective regions.
6. Demonstration of CHWs’ skills : Stalls were in operation outside the auditorium where the
CHWs from ANKUR demonstrated the skills such as birth asphyxia management,
hypothermia management and injection. The participants observed these demonstrations
and interacted with the CHWs on one to one basis.
17

G. Statement of the Convention
The Home-based Newborn Care approach was developed by SEARCH in Gadchiroli district
in the 90's. It dramatically reduced the NMR and IMR in the rural community. In view of its
potential significance to India, two replication trials were launched. The ANKUR project
(2001-2005) replicated the approach of Home-Based Newborn care at 7 sites through the
NGOs in Maharashtra. The ICMR replication study completed the baseline studies, selection
and training of CHWs, piloting of sepsis management and has begun the intervention phase
at 5 sites in 5 states.
The methods, results and the products from these trials were presented in the one day
convention, “Replicating the Home Based Newborn Care in India: New Evidence from 12
Sites” organized jointly by the Indian Council of Medical Research, SEARCH, Gadchiroli, and
th
the Population Foundation of India on 10 August 2006 in New Delhi. The meeting was
addressed by Dr. Syeda Hameed, Member Health, Planning Commission, Mr. P. K. Hota,
Secretary, Health and Family Welfare, Government of India, Mrs. S. Jalaja, Additional
Secretary and Director, National Rural Health Mission, Dr. Vinod Paul, Professor, AIIMS,
representatives from ICMR and was chaired by Dr. N. K. Ganguly, Director General, Indian
Council for Medical Research.The methods, results and experiences of replicating the Homebased
Newborn Care were presented from Gadchiroli, 7 sites in ANKUR and 5 sites in the
ICMR study. These were followed by questions and discussion.
The meeting concludes that :
1. The replication of HBNC was field tested in 12 different sites. The methods of replication
and training were feasible and effective. These could now be considered ready for
adaptation in the National Rural Health Mission. The ASHAs and other similar
community based workers and ANMs should be trained to provide the HBNC.
2. The HBNC is a process sensitive approach. Hence, to be effective, its contents as well as
the methods of selection, training, supervision and management should be carefully
planned and meticulously followed. The difficulties and constraints faced during
replication trials have to be attended to.
3. The ICMR baseline study showed that
A. Infection is the most frequent (33%) cause of neonatal deaths
b. 40 percent of the neonatal deaths occur on the day of birth, and
c. Most of the deaths due to preterm and birth asphyxia occur on the day 0-3. In view of
these, it is necessary that the neonatal care package should ensure
i. Presence of a trained care provider at the time of birth in home deliveries, and
during the period immediately following, and
ii. Prevention and management of neonatal infections.
18

4. The approach was feasible to introduce in the pilot sites in five states in the ICMR study
and was effective in reducing the NMR, IMR and CMR in the rural and tribal areas as
well as in the urban slums in the ANKUR project. The impact of HBNC the NMR reduced
to the low level of 23 and the IMR to around 30 suggests that, irrespective of the place of
delivery and proportion of institutional deliveries, the HBNC is useful in areas with the
IMR higher than 30.
5. The HBNC package in ANKUR study was integrated with child survival interventions
such as pneumonia and diarrhea management and nutrition education. The two sets of
interventions complemented each other, resulting in near 50 % reduction in the NMR,
IMR and the CMR. Similarly, the incidence of postpartum maternal morbidities reduced
and the referral of mothers and sick neonates increased. These facts strongly favour
that the HBNC be integrated with the maternal and child health interventions and that a
continuum of care should be ensured which includes the care at home as well as, when
necessary, care in hospitals.
6. Training alone is not enough. Ingredients of good implementation (onsite mentoring and
supervision, motivation building, kits, and supportive community) are essential to
achieve the desired health outcomes. There is an urgent need to systematically develop
an enabling framework for ASHAs in regard to HBNC.
7. An administrative and legal facilitation is necessary to enable the state governments,
other authorities and NGOs implement this package of interventions.
8. We should move forward with the implementation of HBNC approach through ASHA
and/or similar other workers.
a. As a part of the NRHM and under the Indo-Norway partnership initiative in 5 states
(Uttar Pradesh, Madhya Pradesh, Rajasthan, Bihar and Orissa) as advised by
Secretary, Health and Family Welfare and Director, NRHM.
th
b. Also as a part of the 11 five year plan this has to be included as recommended by
Dr. Syeda Hameed, Member Health, Planning Commission
9. The HBNC should be suitably enlarged to include key evidence-based maternal and
child health messages or skills required at the home or community.
10. An independent mechanism and necessary resources to establish a system of
concurrent evaluation to plough back the lessons learnt from the early implementation
.
The time has now come that, based on the evidence and learning from Gadchiroli, ANKUR
and the ICMR studies , the HBNC is taken up for scaling and without further should not
delay further.
19

ICMR SEARCH
Gadchiroli
REPLICATING HOME-BASED NEWBORN CARE IN INDIA
9.30 AM : Registration
Session 1 : Inauguration
Chair : Prof. N K Ganguly, Director General, ICMR
10.00 AM : Welcome and Purpose of the Meeting
10.10 AM : Keynote Address
10.25 AM : Inaugural Address
Mr. A R Nanda, Executive Director, PFI
Mr. P K Hota, Secretary Health & Family Welfare, Govt. of India
Dr. Syeda Hameed, Member, Planning Commission, Govt. of India
10.40 AM : Chairperson's Remarks by Dr. N. K. Ganguly
10.55 AM : Tea Break
11.10 AM : Home-based Newborn Care and the ANKUR project
Dr. Abhay Bang, Director, SEARCH
12.00 PM : ICMR Study : Newborn care study results through a 5-sites
12.15 PM : Discussion
12.45 PM : Lunch
New Evidence from the 12 Sites
th
Date: 10 August 2006, New Delhi
Programme
Dr. Malavika Roy, Coordinator Reproductive Health & Nutrition, ICMR
1.20 2.10 PM : Film : Nanhi Si Jaan : A health education film prepared by Late Abha
Dayal and Puneet Tandon, with the lead role by Late Deena Pathak.
20
PFI

ICMR SEARCH
Gadchiroli
Session 2 : Concluding Session
2.20 PM : Address by Ms. S Jalaja, Additional Secretary, Ministry of Health & Family
Welfare Newborn Care and the Director, National Rural Health Mission
2.35 PM : Release of the Training Manual Ms. Jalaja
Training Manual and training strategy SEARCH Ms. Priya Paranjpe
2.50 PM : Voices from the field : Community Health Workers share their experiences
4.00 PM : Felicitation of the project leaders
4.20 PM : Way Forward for Newborn Care Programms : Opportunities, Challenges and Tasks
4.35 PM : Closing Remarks
Dr. Vinod Paul, Professor, Dept. of Pediatrics, AIIMS
Mr. A. R. Nanda
4.45 PM : Chairperson's Remarks
Dr. N. K. Ganguly
5.05 PM : Vote of Thanks
Dr. Abhay Bang
5.15 PM : Close of the Workshop/Tea
5.15 6.00 PM : The participants can visit the Home-based Newborn Care stalls, see the
demonstration of skills and have dialogue with CHWs.
21
PFI

List of Participants
1 Dr. Syeda Hmeed Member Health, Planning Commission, Govt. Of India
2 Mr. P.K. Hota Secretary, Health and Family Welfare, Govt. Of India
3 Mrs. S. Jalaja Additional Secretary, Health and Family Welfare,
Govt. Of India
4 Mr. Amarjeet Sinha Joint Secretary, Health and Family Welfare, Govt. Of India
5 Mr. Shiv Kumar Member, National Advisory Committee, Govt. Of India
6 Dr. Namshum Narika Deputy Commissioner, Training , Ministry of Health and
Family Welfare Govt. Of India
7 Dr. N.K. Ganguly Director General , ICMR
8 Dr. N.K. Sethi Advisor Health, Planning Commission, Govt. Of India
9 Dr. N.C. Saxena I C M R
10 Dr. Sangeeta Saxena Asst. Commissioner, Child Health , Ministry of Health and
Family Welfare Govt. Of India
11 Dr. Sandeep Asst. Commissioner, Child Health , Ministry of Health and
Family Welfare Govt. Of India
12 Dr. Satish Saluja Secretary, National Neonatology Forum
13 Dr. M.B. Mathur President, National Neonatology Forum
14 Dr. Vinod Paul Professor of Pediatrics, AIIMS , New Delhi
15 Dr. S.P. Yadav Director FW, Govt. Of Rajsthan
16 Dr. Sunder Raman SHRC, Govt. of Chattisgarh
17 Dr. Hogiraj Sharma Dir-PH & FW, Govt. of Madhya Pradesh
18 Dr. Abhay Bang SEARCH, Gadchiroli, Maharashtra
19 Dr. Anju Sinha Division of RHN, ICMR
20 Dr. Adarsha Sharma Chetna
21 Dr. Aparajita Gogoi White Rebbon Alliance, India
22 Dr. Arti Srivastav KGMU, Lucknow, Utter Pradesh
23 Dr. Ashok Dyalchand IHMP, Pachod, Maharashtra
24 Dr. Bapu Selokar NIWCYD, Nagpur, Maharashtra
25 Dr. Bhalchandra Sathe Rugna Seva Prakalp, Miraj, , Maharashtra
26 Dr. Balbul Sood CEDPA
27 Dr. Chauhan Additional District Hhealth Officer , Maharashtra
28 Dr. Chellani ICMR
22

29 Dr. Deepti Chirmulay Path, India
30 Dr. Druv Mankad VACHAN, Nasik , Maharashtra
31 Dr. G.K. Malik ICMR
32 Dr. Harish Kumar NPO IMNCI, WHO
33 Dr. J.L. Mishra CMHO, Santa
34 Dr. J.P. Mishra Programme Advisor , ECTA
35 Dr. Jenny Ruducha Public Health Specialist, New Delhi
36 Dr. Kumudha Aruldas Additional Director, PFI
37 Dr. Laila C. Varkey Consultant, India
38 Dr. Lalita Kaliban Gandhigram, Tamilnadu
39 Dr. Lalitendu Jagatdeo PFI, New Delhi
40 Dr. Malabika Roy Coordinator, RHN, ICMR
41 Dr. P.P. Paranjpe SEARCH, Gadchiroli
42 Dr. Pankaj Shukla Civil Surgeon, Vidisha, Madhya Pradesh
43 Dr. Partho Halder UHRC Representative, India
44 Dr. Poonam Muttreja Director MacArthur Foundation, New Delhi
45 Dr. Poshali Majumdar Cini, Indian
46 Dr. R.K. Aggarwar IGNOU, Department of Distance Education, New Delhi
47 Dr. R.P. Srivastav CMHO, Dist Umaria
48 Dr. R.P. Singh Patna
49 Dr. Rajiv Tandon Senior Advisor (Child Survival) ,USAID
50 Dr. Rajani Ved Public Health Consultant, New Delhi
51 Dr. Ramnik Ahuja CII
52 Dr. Reeta Rasaily ADG Division of RHN, ICMR
53 Dr. Rekha Karat Rugna Seva Prakalp, Miraj, Maharashtra
54 Dr. S. Bhargava
55 Dr. S. Ramji Prof. Dept of pediatrics MAMC, New Delhi
56 Dr. S.V. Adhish NIHFW, New Delhi
57 Dr. S.R. Sarwade MGIMS , Sewagram, Maharashtra
58 Dr. S.S. Gupta MGIMS , Sewagram, Maharashtra
59 Dr. Sanjay Baitule SEARCH, Gadchiroli, Maharashtra
60 Dr. Saraswati Swain NIAHRD, Cuttack
61 Dr. Satish Gogulwar Amhi Amachya Aarogyasathi, Gadchiroli, Maharashtra
23

62 Dr. Shanti Ghosh Public Health Expert
63 Dr. Sharad Iyengar ARTH, Udaipur, Rajasthan
64 Dr. Sreela Das ICRW
65 Dr. Vandana Prasad Chaukhat
66 Dr. Vasanti Krishnan ARC, New Delhi
67 Dr. Vikram Rajam World Bank
68 Dr. Vishwahjeet Kumar SNL/Save the Children, US
69 Dr. H.K. Das Orissa
70 Dr. Jaya NIHFW
71 Dr. Sreela Das Gupta ICRW
72 Dr. Veena Sinha CMHO, Patna, Bihar
73 Dr. A. Mishra
74 Mr. A.R. Nanda Executive Director, PFI, New Delhi
75 Mr. Ajay Bhardhwaj AVNI, Representing FOGSI
76 Mr. Amita Kulkarni SRUJAN, Yavatmal, Maharashtra
77 Mr. Anil Naxine MGIMS, Sewagram, Maharashtra
78 Mr. Arun Dalvi Sahyog Nirmitee, Osamanabad, Maharashtra
79 Mr. C.V.S. Prasad Demographer, Senior Consultant, AC Neilson
ORG MARG
80 Mr. Debabrato PFI, New Delhi
81 Mr. Dyaneshwar Bawane NIWCYD, Maharashtra
82 Mr. Francis PFI, New Delhi
83 Mr. Harishankar Sharma
84 Mr. Hemant Pimpalkar SEARCH, Gadchiroli
85 Mr. Jitendra Bais Amhi Amachya Aarogyasathi, Gadchiroli, Maharashtra
86 Mr. K. G. Venkat PFI, New Delhi
87 Mr. K. L. Rao PFI, New Delhi
88 Mr. Kalyan Roy Deccan Herald
89 Mr. Kannake NIWCYD, Nagpur, Maharashtra
90 Mr. Kisan Gayakwad VACHAN, Nagpur, Maharashtra
91 Mr. M.S. Bharambe MGIMS , Sewagram, Maharashtra
92 Mr. Mahesh Deshmukh SEARCH, Gadchiroli, Maharashtra
93 Mr. Neera Arun SOSVA, Delhi
94 Mr. OM M Batermn USAID
24

95 Mr. Ramkant Kulkarni Sahyog Nirmitee, Osamanabad, Maharashtra
96 Mr. S.S.Negi PFI, New Delhi
97 Mr. Shakti Ranjan Patra NIHARI
98 Mr. Shyam Thapa SNL, US
99 Mr. Uday Singh Patna, Bihar
100 Mrs. Priya Paranjpe SEARCH,Gadchiroli
101 Ms. Deepa Deshpande Amhi Amachya Aarogyasathi, Gadchiroli, Maharashtra
102 Ms. Deepa Nag MacArthur Foundation VHAI
Chaudhary
103 Ms. Gyotika Barwah RRC
104 Ms. Ira Raj Guru SMILE Foundation
105 Ms. Kusum Gadpayle SEARCH, Gadchiroli
106 Ms. Leela Gomti
107 Ms. Maitree Padhi NIAHRD, Orissa
108 Ms. Meena Batra SMILE Foundation
109 Ms. Nalini Nayak NIAHRD, Orissa
110 Ms. Nishi Agrawal KGMU, Lucknow, Utter Pradesh
111 Ms. Rahat Bahl CHETNA
112 Ms. Rajshree Thorat ISSUE, Nagpur, Maharashtra
113 Ms. Razia Pendse WHO
114 Ms. Sangmitra Bharose ISSUE, Nagpur, Maharashtra
115 Ms. Shlini Singh Lucknow, Utter Pradesh
116 Ms. Shrabanti Sent PFI, New Delhi
117 Ms. Usha Rai
118 Ms. Vani Sethi UHRC India, Lady Irwin College
119 Ms. Yogini Dolke SRUJAN, Yavatmal, Maharashtra
25

Glimpses
26