A (Health) Systems Approach

for Tackling Anemia

From Programme Managers – perspective

Dr. Vani Sethi

5 December 2019
 PROGRAME
BASED ON LEARNINGS OF 20 YEARS
DESIGN

HEALTH SYSTEMS
FACILITATE+ STRENGTHEN+ HOLD ACCOUNTABLE

Nutrition Network Meeting

5 November 2019
What we those learnings?
1. Highest Political Commitment
2. Target setting and reviews at highest level
3. Interdepartment & partners’ synergy
4. No supply stock outs/ruptures
5. Focus on limited number of defined proven interventions
6. Public perception and constant communication is key
7. Schools as a platform; girls and boys - best advocates
8. Functional system of field supervision and rapid assessment
9. Clear financial norms
10. Open-mindedness for ongoing corrective action
 Nutrition Network Meeting
5 November 2019

6X6X6 strategy Results-based (Health) Systems building

blocks
 (Health) systems building blocks for AMB
Building block
1. Policy, guidelines,
Implementation Guidelines
2. Institutional mechanism
3. Financing
4. Demand Creation [Branding]
5. Leadership &Governance
6. Partnerships
7. Information Systems
8. Capacity strengthening
9. Supply system
10. Research & Policy Dialogue
What’s new?
• Defined strategy - 6X6X6
• Define KPI; defined process indicatos
• Defined financial norms
• At National- Programme Management Unit,
N/SCEARA, IEG, Tarang Hub, NCEARD
• Clear 11 Major Heads, Unit Cost, denominators
• States encouraged to budget
• Visibilizing the problem (T3) and programme (launch).
• Defined activities, standardized materials
• Highest level ownership (PMO, Part of JA/PA).
• Regularized review
• Sufficient scope for all partners to contribute.
• Academic/Technical Institutions brought in
• HMIS-based Dashboard and %-wise district reporting
• Defined process indicators
• Progress in public domain. Ranking of Districts
• Training - Standard materials and structure defined
• New dose, technical specifications, bottleneck analyses
• Effectiveness of new {how to} strategies; Policy briefs
Results framework for AMB

Impact Outcome Output Inputs

Six interventions 4 KPIs

Reduction in
(receipt of IFA
Anemia in Six Consumption of Process
and supply
beneficiaries IFA and Indicators
stock outs)
Improvement in Health systems
AMB DASH
diets building blocks
BOARD
Its been a Year:
Where are we will KPIs?
 What's the change – compared to pre-
AMB
HMIS 22.1.1: Girls (6–12 class) provided 4 IFA tablets in schools (%)
FY 2019-20 FY 2018-19
Q2 Q1 Q4 Q3 Q2
 % (Apr-Sept'19) (Apr-Jun'19) (Apr’18-Mar'19) (Apr-Dec’18) (Apr-Sept'18)
Andhra Pradesh 60.5        
Assam 42.5 0.3 49.9 35 39
Bihar 34.7 44.7 0.4 0 0
Chhattisgarh 35.4 39.6 50.5 43.9 25.2
Gujarat 22.5 16.9 36.7 35 43.3
Jharkhand 38 49.9 31.8 17.9 21.8
Karnataka 32 9.5 11.6 10.1 11.9
Madhya Pradesh 27.8 33.2 49.9 40.7 30.6
Maharashtra 48.4 44.6 57.5 35.2 33.2
Odisha 22.8 25.9 28.9 12 12.1
Rajasthan 2.1 1.1 3.5 2.3 2.2
Telangana 22.4 17.2 1.4 1.5 0.9
Uttar Pradesh 31.8 35.3 16 9.1 8.5
West Bengal 16.4 20.4 10.2 6.2 1.5

Pooled 14 States 31 27.3 23 16.2 15.1

www.anemiamuktbharat.in
 Its been an Year
Where are we with process indicators
Building block
1. Policy, strategy, Implementation
Guidelines

2. Institutional mechanism
3. Financing

4. Demand Creation [Branding]

5. Leadership &Governance

6. Partnerships

7. Information Systems
8. Capacity strengthening
9. Supply system
10. Research & Policy Dialogue
PROCESSES 1 PROGRAMME KICK START ACTIVITIES

State-level
District Nodal office Inter-ministerial sensitization
State Nodal office apointed across all sensitization meeting for AMB
Milestone appointed – Y/N districts meeting held – Y/N conducted – Y/N
Maharashtra Y Y Y Y
Madhya Pradesh Y Y Y Y
Bihar Y Y Y Y
Jharkhand Y Y Y Y
Assam Y Y Y Y
Chhattisgarh Y Y Y Y
Uttar Pradesh Y Y Y Y
Odisha Y Y Y N
Karnataka Y Y Y Y
Telengana Y Y Y Y
Rajasthan Y Y Y Y
Gujarat Y Y N N
Andhra Pradesh Y Y Y Y
West bengal N N N N
Total of States 13 13 11 10
PROCESSES 2 PLANS AND FINANCING- RENEWING FOCUS
Ensuring financing is NOT a constraint (planning, allocation, disbursement
and expenditure) to achieve KPIs

TRACK ACT TRACK ACT TRACK

Track FY 2019 – Advocate and Track Advocate and Track

20 Planning and support disbursement support utilization
allocation Inclusion of missing efficiency – gaps
Inclusion of 45
efficiency budget items and Time, Amount, Track KPIs –
minor heads in
activities in Equity Quarter 4
11 major and 45 FY 2020-21
Supplementary PIP
minor heads (State financial proposed PIP as Advocate for
2019–2020
PIP/ROP; cost records) part of state timely
Advocate timely officers trainings allocation for
norms/rate Track KPIs –
disbursement and FY 2020–21
contracts, state implementation of Quarter 3
validation budgeted activities November 2019
Track KPIs September– – March 2020 April–June
October 2019 November – 2020
– Quarter 1
December 2019
Track KPIs –
July–August
Quarter 2
2019

Phase-1 Phase-2 Phase-3 Phase-4 Phase-5

PROCESSES 2 PLANS AND FINANCING- RENEWING FOCUS

Major bottleneck found was in “planning stage” itself

Only 36% of the required budget proposed

Requirement (to achieve 100%

Proposed (PIP) What was approved? (RoP)
KPI coverage for 14 States)

INR 20.87 billion INR 7.42 billion INR 5.74 billion

-64% -22%
Gap between Gap between
proposed amount approved
and required amount and
amount to achieve -72% proposed
100% KPI amount

Gap between approved

amount and required
amount
PROCESSES 1 PLANS AND FINANCING- RENEWING FOCUS

1. Jharkhand had no planning Gap.

2. Lowest Gaps in Chattisgarh and Maharashtra.
3. Highest in U.Pradesh and Gujarat
% gap in Madhya Pradesh -41
States
Planning
Maharashtra -19
Andhra Pradesh -47 Odisha -44
Assam -37 Rajasthan -36
Bihar -43 Telangana -48
Chhattisgarh -19 Uttar Pradesh -87
Gujarat -65 West Bengal -61
Jharkhand 9 Total -64
Karnataka -61
Action : Advocacy and support for inclusion of missing elements and
support in planning using developed excel-based planning tool
PROCESSES 2 PLANS AND FINANCING- RENEWING FOCUS

Most states did not budget for all AMB major/minor heads,
especially, drug and warehouse logistics, HR at state level
ASHA M&E / Service Researc Program Drug & AMB State
Procur Capacity IEC/
SN Major head Incenti Printin Deliver h/ Managem Warehouse Excellence Innovation
ement Building SBCC
ves g y Surveys ent Logistics Unit/HR
Minor
  17 7 3 1 4 6 2 1 1 1 2
heads
Andhra
1 Partial No No No Partial No No No No No No
Pradesh
2 Assam Partial Yes Yes Partial Partial Partial No No No Partial No
3 Bihar Partial Yes Partial Partial Partial Partial No Partial No No No
4 Partial Yes Yes Yes Yes Partial No Yes No Partial Yes
Chhatisgarh
5 Gujarat Partial Partial Yes Partial No Partial No No No No No
6 Jharkhand Partial Yes Yes No Partial Partial No Partial No No No
7 Karnataka Partial No No Partial Partial Partial No No No No No
Madhya
8 Partial Partial Yes No Partial Partial Yes No No No Yes
Pradesh

9 Maharashtr Partial Yes Yes Partial Partial Partial No Yes No No No

a
10 Odisha Partial Partial No No Partial Partial No No No No No
11 Rajasthan Partial Yes Partial Partial Partial Partial No Yes Yes No No
12 Telengana Partial Partial Partial Partial Partial Partial No Partial No No No
Uttar
13 Partial No Partial Partial Partial Yes No No No No No
Pradesh
West
14 Partial Partial Partial Partial Partial No No No No No No
Bengal
PROCESSES 3 CAPACITY BUILDING

Training module State Resource Training load No. of Training

develope pool of master assessed and batches of achievemen
contextualised for trainers trained – training plan in trainings t versus
Milestone state- Y/N Y/N place– Y/N completed f load (%)
Maharashtra Y Y Y N N
Madhya Pradesh Y N Y N N
Bihar Y Y Y N N
Jharkhand N Y Y N N
Assam N N Y N N
Chhattisgarh N N Y N N
Uttar Pradesh N N N N N
Odisha N N Y N N
Karnataka N N N N N
Telengana N N N N N
Rajasthan N N N N N
Gujarat N N N N N
Andhra Pradesh N N N N N
West bengal N N N N N
PROCESSES 4 DEMAND GENERATION
PROCESSES 4 DEMAND GENERATION
PROCESSES 4 DEMAND GENERATION

AMB
AMB Communic
Communica ation
tion Package District
Package printed and State media outdoor District
adapted distributed plan media plan community media
and to health approved approved plan approved
State available in facilities and and and implemented
communication/IE State and ANM, implemente implement especially for
C plan developed language- ASHAs- d for a full ed for a full hard to reach
Milestone for the year- Y/N Y/N Y/N yea-Y/N year- Y/N villages- Y/N)
Maharashtra Y Y N Y N N
Madhya Pradesh Y Y Y N N Y
Bihar N Y Y N N N
Jharkhand N Y N N N N
Assam N Y N Y N N
Chhattisgarh Y N Y N N N
Uttar Pradesh Y Y Y N N N
Odisha Y Y Y N N N
Karnataka N N N N N N
Telengana N N N N N N
Rajasthan N Y Y N N N
Gujarat N N N N N N
Andhra Pradesh N N N N N N
West bengal N N N N N N
PROCESSES 5 SUPPLY
PROCESSES 6 PARTNERSHIPS

UNDP

Nutrition International

Alive and Thrive

Evidence Action

IPE Global

UNICEF

New Concept
AIIMS-Delhi

IEG-Delhi

Lady Irwin